If there weren’t challenges…

…it really wouldn’t be an event that requires emergency response.

Somehow over the last little while, the fundamental nature of what constitutes an emergency and, even more importantly, what an appropriate response looks like, appears to have morphed over time. Now we seem to embrace the expectation that whatever happens, hospitals are going to be right on top of things (in a way that, frankly, doesn’t seem to apply to them that would sit in judgment, but that might be something of an editorial comment). But really, can you imagine what would have happened a year ago when pretty much everybody else was working from home, suspending normal operations, etc. (in full recognition that healthcare facilities don’t have the option of opting out of such things)? Now a lot of folks (and no, I’m not going to name names—if you don’t know, then it’s probably just as well) are playing catch-up and generating a wee bit of chaos as they get back to it. Happy happy, joy joy!

At any rate, I do hope that all the surveyors out there kicking the EM tires are paying close attention to some of the information contained in the CMS updates to the emergency preparedness requirements, including:

• It’s OK for your response process to be the same for multiple risks/hazards
• Your HVA/program must address each type of hazard, but your policies and procedures can indeed be consolidated (can you imagine how many binders you would need?!?)
• It is not the job of the surveyor to analyze the appropriateness of the identified risks; their job is to make sure that your program (including policies and procedures) align with your risk assessments (speaking of your risk assessments, they must be demonstrably facility-based/community-based and they must include staffing considerations; emerging infectious disease planning must be in the mix—no surprise there)
• It is OK (and certainly much more effective) to have each organization’s EM person “show” the requested elements as opposed to surveyor “browsing” of the plan, etc. (the CMS guidance encourages the use of crosswalks to more quickly/readily identify where the component pieces “live”)
• It is also OK to have your documentation in whatever format makes sense: hard copy, electronic, etc.

I think these are fairly representative of a common-sense approach to surveying compliance with the EM standards; I guess we’ll see how things unfold in the field…

Just a few odds and ends to wrap things up:

• They encourage the use of the ASPR-TRACIE checklists; lots of good stuff there and well worth poking around and discovering.
• Emergency power—you have to have what is required by the Life Safety Code® (LSC)/COP for your facility; but please remember that any additional emergency power considerations must be maintained in accordance with the LSC (and, by extension, NFPA 110 et al). I think some folks have this sense that anything not required by the LSC/110 combo can be maintained in whatever fashion they like. This seems to be drawing a line in the sand that they’re not buying it (again, I guess we’ll see what happens in the field—maybe anything that is not LSC-related isn’t offered up for scrutiny); also, they do not allow extension cords to directly connected to generators; generator must interface with facility through transfer system.
• Functional exercises, mock disaster drills and workshops can be used to count towards the activation requirements (by the way, long-term care facilities are on the hook for annual education; everyone else can go with biannual).
• Inpatient facilities need to have two years of documentation present; outpatient facilities have to have four years available.
• Emergency plans are expected to evolve (mutate?) over the course of a long-term event (and I think we know a little something about that…), your plan should include provisions for monitoring guidance from public health.
• Your plan must include provisions for tracking staff when electronic payroll systems, etc., not available—for example, power outages, etc. consider check-in procedures for on-duty and off-duty staff.
• Your plan must include a process for communicating with the various AHJS (and, boy howdy, aren’t there an awful lot of those kicking around); as well as provisions for surge planning. As for staffing, while the use of volunteers is optional, there is an expectation that you will have a process for managing them. Over the years, I’ve run into any number of folks that were not at all inclined to deal with volunteer practitioners, but I think the days when that was a reasonable decision point are rapidly fading into the distance.
• Your plan must also include a process for evacuating patients that refuse to do so; I figure there must be some empirical information that drove the inclusion of this in the guidance. I’m presuming that you have a process already for dealing with recalcitrant individuals, including patients, so I don’t know that this breaks any ground.

Now that I’ve finished typing this, I really don’t see a lot that I would considering troubling or, indeed, troublesome. I would imagine that a lot of this stuff has become rather more hard-wired than not over the past 15 months or so, if it were not already. I think there were a lot of common lessons learned, though the “equation” for “solving” the challenges is probably unique to every organization (unless you’re part of a system in which the facilities are virtually identical). From a compliance standpoint, I think you folks should be OK, but please reach out if you feel otherwise.

So, with June bearing down on us, I trust that you all continue to be well and are staying safe. See you next week!

About the Author: Steve MacArthur is a safety consultant with The Greeley Company in Danvers, Mass. He brings more than 30 years of healthcare management and consulting experience to his work with hospitals, physician offices, and ambulatory care facilities across the country. He is the author of HCPro's Hospital Safety Director's Handbook and is contributing editor for Healthcare Safety Leader. Contact Steve at stevemacsafetyspace@gmail.com.