Changes to the 2014 Acute Care Hospital Manual on Emergency Management Compliance. January 30, 2014 Brad Keyes, CHSP

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1 Changes to the 2014 Acute Care Hospital Manual on Emergency Management Compliance January 30, 2014 Brad Keyes, CHSP

2 The New Manuals Why did we make changes to the old standards? Corrected some errors Eliminated some duplication Wanted to make the standards more relevant and meaningful and arranged in a fashion that makes sense Wanted to emphasize certain requirements of the Emergency Management process 2

3 The Administrative Surveyor As in past years, the Administrative surveyor will be evaluating the hospital s compliance with the Emergency Management chapter 3

4 The New Manuals For the new 2014 Acute Care manual, we separated out the standards from the old chapter 11: New Chapter 9: Emergency Management New Chapter 11: Physical Environment New Chapter 13: Life Safety 4

5 The Acute Care Manual The previous Acute Care manual Chapter 11 had 91 written standards on physical environment, life safety and emergency management compliance After relocating Emergency Management to its own Chapter 9, the new chapter has 16 written standards on Emergency Management compliance, and seven (7) of them are new requirements 5

6 The Acute Care Manual The new Emergency Management chapter is organized into 3 different sub-sections: Planning Response and Recovery Evaluation and Education 6

7 Emergency Operations Plan Was Was called Disaster Plan or Emergency Preparedness Plan The organization writes an EOP and reviews it on an annual basis and makes adjustments based on lessons learned during actual emergency events and during planned exercises. 7

8 Emergency Operations Plan The EOP is based on the priorities established in the annual Hazard Vulnerability Analysis (HVA), and the EOP is reviewed with the community s emergency response agencies to synchronize responses to common emergency events. 8

9 Emergency Operations Plan The concept of the EOP is it has to address all of the standards in chapter 9 This means the EOP has to explain how the hospital intends to meet the requirements of each individual chapter 9 standard, starting with and ending with (14 sections) 9

10 Emergency Operations Plan The EOP does not have to be titled the Emergency Operations Plan but there are specific requirements in the new standard that are new and must be complied with. NOTE: You will be evaluated on whether or not you have an EOP until July 1, 2014; Then after July 1, 2014 you will be expected to comply with all the requirements of this standard. 10

11 Emergency Hazard Vulnerability Analysis (HVA) New standard The HVA provides for an assessment to ascertain conceivable threats and disasters that could affect the ability to operate the facilities of the organization, or to provide services to their patients, and the probability of those events occurring. 11

12 Emergency Hazard Vulnerability Analysis (HVA) All facilities where patient care and treatment is provided are required to have an assessment conducted for threats, including facilities which the hospital may not own but where they provide treatment for their patients. 12

13 Emergency Hazard Vulnerability Analysis (HVA) The hospital may choose to create a single Hazard Vulnerability Analysis (HVA) that applies to all of the sites of the hospital, or an individual Hazard Vulnerability Analysis (HVA) for each of their locations 13

14 Emergency Hazard Vulnerability Analysis (HVA) Other details are required in this new standard There is no set HVA template or system that the hospital must use, but the HVA must be documented and conducted annually This standard will not be enforced until July 1,

15 Emergency Safety & Security Was (partially) This standard requires the EOP to have a comprehensive process to provide for the safety and security of the patients, staff and visitors during an emergency event. Not a new requirement 15

16 Emergency Supplies Was This standard requires the EOP to have a plan and a process to ensure supplies and equipment are stored, maintained, and ready for immediate use in the event of an emergency. Not a new requirement 16

17 Emergency Supplies All supplies and equipment designated for emergency response are documented, and reviewed and updated semi-annually. Other details are required in this standard 17

18 Emergency Utilities Was and This standard requires the EOP to provide for the continuation of emergency power, fuel, medical air, gas, and vacuum, and potable water during an emergency event. Not a new requirement Other details are required in this standard 18

19 Emergency Utilities At a minimum, the quantity of fuel maintained for the emergency generators must be at least a 26 hour supply, as required by NFPA 72 (1999), for the fire alarm system. 19

20 Emergency Utilities For installations in seismic areas, compliance for maintenance of fuel supply for generators must comply with chapter 3 of NFPA 110 (1999 edition). You will need to know if you are in a seismic area. 20

21 Emergency Decontamination Was This standard requires the EOP to provide how the hospital arranges for the chemical, biological and radioactive decontamination Not a new requirement Other details are required in this standard 21

22 Emergency Decontamination The hospital must have a decontamination plan onsite if they receive patients for emergency treatment They cannot rely solely that the decontamination will be conducted offsite by local community authorities 22

23 Emergency Personal Protective Equipment Was This standard requires the EOP to provide how the hospital stores and maintains Personal Protective Equipment, and distributes them during the event of an emergency. Not a new requirement Other details are required in this standard 23

24 Emergency Nutritional Needs Was This standard requires the EOP to provide for methods to ensure the nutritional needs of patients and personnel during an emergency event. Not a new requirement Other details are required in this standard 24

25 Emergency Communication Was This standard requires the EOP to provide for written procedures and methods on how the hospital communicates with staff and outside agencies that have a functional role with the hospital s response and recovery phases during an emergency event. 25

26 Emergency Communication There are many new requirements in this standard, therefore: This standard will not be enforced until July 1,

27 Incident Command Center New standard This standard requires the EOP to provide for the identification where the hospital s incident command center will be located. The EOP ensures essential equipment and support is intact and maintained for use in directing and controlling response and recovery operations. The EOP provides for a process for activation of the incident command center, and how it is operated. 27

28 Incident Command Center The concept of an Incident Command Center is not (or should not) be new to any hospital, but HFAP standards had never requested any accountability of having one Therefore This standard will not be enforced until July 1,

29 Emergency Triage Was This standard requires the EOP to provide for the triaging of victims during an emergency event and includes identification tags, placement of patients, notification of physicians, and preliminary diagnosis of patients Not a new requirement Other details are required by this standard 29

30 Emergency Evacuation New standard This standard requires the EOP to provide for a written Emergency Evacuation Plan which identifies when and how the patients will be evacuated from the facility. The Emergency Evacuation Plan is integrated with the community emergency response plan This standard will not be enforced until July 1,

31 Volunteer Management New standard This standard requires the EOP to provide for a volunteer management plan that assigns, trains, and supervises volunteers during an emergency event Other details are required in this standard This standard will not be enforced until July 1,

32 Business Continuity New standard This standard requires the EOP to include a continuity planning component which identifies key clinical and business functions and the strategies required to recover them with minimal disruption to clinical operations during the recovery phase of an emergency. This standard will not be enforced until July 1,

33 Emergency Exercises Was This standard requires the EOP to provide separate emergency exercises to be performed twice per year. No specific period of time between the exercises Each exercise is to be planned by the oversight committee on emergency management and implemented to build competencies in staff. 33

34 Emergency Exercises Each exercise must be based on one of the identified priorities in the Hazard Vulnerability Analysis (HVA). At least one of the exercises shall include the community. Eliminates the specific requirement for WMD exercises 34

35 Emergency Education Was This standard requires the EOP to provide an educational program on activities, assignments and duties each staff member is responsible for during an emergency event. Other details required for this standard 35

36 Summary of Standards not to be enforced until July 1, 2014: Emergency Operations Plan Hazard Vulnerability Analysis Emergency Communications Incident Command Center 36

37 Summary of Standards not to be enforced until July 1, 2014: Emergency Evacuation Volunteer Management Business Continuity 37

38 Changes to the 2014 Acute Care Hospital Manual on Emergency Management Compliance Questions? Brad Keyes, CHSP (815) Office (815) Cell 38

39 Certificate of Attendance Awarded 1.0 contact hours Changes to the 2014 Acute Care Hospital Manual on Emergency Management Compliance A 60 minute audio-conference January 30, 2014 Beverly Robins Director of Accreditation and Certification Brad Keyes, Presenter Keyes Life Safety Compliance, LLC

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