Joint Commission Revises Emergency Management Standards for Hospitals and Critical Access Hospitals

PUBLISHED: Nov 2, 2017
Relevant to: Critical Access Hospitals, Hospitals

The Joint Commission (TJC) has created 21 new Emergency Management (EM) requirements for their deemed Hospital and Critical Access Hospital accreditation programs in response to the Centers for Medicare & Medicaid Services' (CMS) final rule on emergency preparedness issued in September 2016. TJC will begin surveying for these new requirements on November 15, 2017.

Links to the prepublication standards are provided below. In summary, Hospitals and Critical Access Hospitals must ensure the following:

  • The emergency plan is reviewed, updated and tested at least annually.
  • The emergency plan includes a facility and community based all hazards risk assessment.
  • The emergency plan includes specifics for emergency preparedness training.
  • The communications plan includes names and contact information for key individuals as well as primary and alternate means for communicating with the key personnel and entities
  • The communications plan describes method(s) for sharing information and medical documentation for patients under the hospital's care and also for evacuated patients.
  • The communications plan includes a method to provide information about the general condition and location of patients under the facility's care, as permitted by law and regulation.
  • The communications plan includes a method for providing information about the hospital's occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.
  • Additional policies and procedures specifically address plans for evacuating patients to alternative care sites, emergency power systems, sewage and waste disposal, training for all staff.

Included with today’s notice is a selection of policies related to these new requirements. For additional relevant policies please see MCN Healthcare’s Emergency Management and Bioterrorism Manual.

Want to read the full alert and receive alert emails?

Browse Additional Alerts