JCAHO Issues

Your JCAHO inspector will be looking at your Hazard Vulnerability Analysis (HVA) for completeness and accuracy. Have you addressed all of your vulnerabilities? Have you planned exercises around these vulnerabilities? What have you done to mitigate those potential problems? Have you adequately documented these mitigation strategies?

A key component of any emergency plan is the inclusion of action plans which are critical for a successful response to a disaster, whether it be man made (chemical, biological, radiological, nuclear or explosive (CBRNE)), or natural (hurricane, tornado, earthquake). If your plan is well written, all inclusive, and tests all the high risk events identified in your Hazard Vulnerability Analyses, then your response should be effective.

Those healthcare facilities accredited with The Joint Commission are also required to follow Environment of Care (EC) Standards. There are seven EC standards which require written plans, performance standards and annual reviews. A complete review and critique of these plans, with recommendations for improvement are available with our service.

Variety of Incidents

Does your plan address an adequate variety of emergencies? We provide consultation in emergency preparedness by determining whether your plan clearly addresses: 1) natural, 2) man made or 3) technological events in your facility or in your community.

Staffing Issues

Have you anticipated and planned for staffing solutions during a disaster? A very important part of your emergency plan involves the notification of staff of site. Your plan should address exactly how staff are notified, how long will it take for staff to arrive and what alternatives are there if staff cannot respond to the disaster. Will your security staff be adequate and available should a major disaster occur in your area? How quickly can you secure your facility after being notified of a major disaster? Is your clinical staff adequately protected and informed during a disaster? Have you consider alternative sites to move patients, staff and your incident command center? All of these key questions (and more) should be thought-out and included in your disaster plan.

Communications, After Action Reports and Debriefings

We have found that the communication section of every disaster plan is extremely important. Communication is required through out the entire drill/exercise and extends through the de-briefing/critique that follows. What de-briefings have you developed to handle staff needs after the event? Have you established a format for your after action report?

Identified problems need to be addressed and written assignments for improvement should be tracked. Improvement to your ERP is continuous. There will always be changes to the plan. Plan activation and documentation of the improvements and changes from after-action reports will demonstrate a commitment to continuous quality improvement of your overall response plan.

Emergency Management

Disaster readiness is an integral part of the overall response capabilities of the organization. Testing your plan by conducting disaster drills in a community-wide approach and then critiquing and debriefing those leaders involved will make for a better planned response to the next disaster. Implementation of the Incident Command System will allow the appropriate leaders to make decisions based on knowledge of the event. The ICS approach will allow for a comprehensive response to almost any disaster event.

Before the next disaster occurs which involves your facility, allow us to review and comment on your existing disaster plans. We will provide the most current approach to determine what critical areas in your plan need to be adjusted in order to meet the JCAHO, EC Standards. Our expertise in the field will offer specific examples and recommendations for improving your emergency plan. Ultimately, we would be preparing your facility for both internal and external disasters. The end result would be a plan for all hazards in your area that would be comprehensive and functional for staff. The end result will improve patient care, preserve of life and promote patient safety.