SSR Compliance and Facilities Management Articles

TJC Strengthens Leadership Accountability for Emergency Management

By David Stymiest, PE, CHFM, CHSP, FASHE

In the July 2014 issue of Joint Commission Perspectives, TJC officially issued new and revised leadership requirements intended to provide “a clearer description of leadership-level oversight of emergency management.”  The new and revised elements of performance are all effective January 1, 2014. 

• Within Leadership Standard LD.04.01.05 (the standard requiring effective management of programs, services and departments) TJC added a new EP-12 that requires the organization to identify a leader to be accountable for implementation of the 4 phases of emergency management, the 6 critical areas of emergency management, hospital-wide collaboration, and collaboration with community-response partners. This new EP is scoring category A.
• Within Standard EM.03.01.01 (the standard requiring evaluation of the effectiveness of emergency management planning activities) TJC added a new EP-4 requiring that planning reviews be forwarded to senior (vice president and officer level) leadership for review.  This new EP is scoring category A.
• Within Standard EM.03.01.03 (the standard on evaluating the EOP effectiveness), TJC modified EP-13 (the EP requiring evaluation of all exercises and responses to actual emergencies) to require that relevant input from staff at all affected levels also be considered.  Within the same standard, EP-15 regarding communication of emergency management deficiencies and opportunities for improvement was modified to require communication of this information to senior leadership.
• And finally, within Leadership Standard LD.04.04.01 (the standard requiring that leaders establish performance improvement priorities) TJC added a new EP-25 that requires senior leaders to direct implementation of selected hospital-wide improvements in emergency management based on three listed considerations.  This new EP is scoring category A.

In explaining the reasoning behind the above changes, TJC stated “hospitals plan and respond more effectively when accountability for hospital-wide emergency management is assigned to leadership at a high level of the organization.”  Since many hospitals consider the performance improvement activities for each year in January of that calendar year, SSR recommends that these changes be discussed in the near future to ensure that required activities have been completed on time.  Besides appearing in Perspectives, the full text of these new requirements will also appear in 2013 Update 2 to the Comprehensive Accreditation Manual for the hospital and critical access hospital programs as well as in the fall 2013 Joint Commission online manual update.