New Joint Commission Quick Safety Issue Addresses Emergency Management

PUBLISHED: May 23, 2018
Relevant to: All Healthcare Organizations

The Joint Commission (TJC) has published a new Quick Safety Issue that reviews the need for continuity of operations planning (COOP) when health care organizations are faced with an emergency management situation such as natural disaster, industrial accident, cyberattack.

COOP strategy is a fundamental part of a comprehensive emergency management planning program, with emergency management planning focusing on individuals affected by the emergency and COOP focusing on the operation of the organization. “The goal is to protect the organization’s physical plant, information technology systems, business and financial operations, and other infrastructure from direct disruption or damage so that it can continue to function throughout or shortly after an emergency.”

According to TJC, best practice in continuity of operations planning includes, but is not limited to:

  • Ensuring a continuity of facilities and communications to support organizational functions.
  • Having a succession plan in place that lists who replaces the key leader(s) during an emergency if needed
  • Having a delegation of authority plan that describes the decisions and policies that can be implemented by authorized successors.

TJC reports that initial survey results from their new Emergency Management requirements under the Centers for Medicare & Medicaid Services (CMS) Emergency Management Final Rule indicate that continuity of operations planning is an area where TJC-accredited organizations need to focus. TJC proposes the following safety actions for organizations to consider:

  • Succession and delegations:
    • Organizations must ensure that there is a documented leadership succession as well as delegations of authority should it be needed.
  • Essential functions:
    • Organizations should identify the “…essential functions, capabilities, and assets that must be protected for the organization to survive a disaster.”
  • Mitigation
    • Organizations should identify how mitigation activities will be implemented. Mitigation priorities should be determined through an assessment of an organizations risks and the organization’s role in community response and recovery.
  • Communications:
    • Communication plans should include areas like staff reporting structures, communication with local command structure, communication with patients, support staff, vendors, suppliers and community resources.
  • Recovery:
    • Recovery planning should include determining which individuals are authorized to initiate the recovery phase, how recovery objectives will be prioritized, determining workforce adaptations, restoration of critical building systems, records, supplies.

A link to the quick safety issue is provided below. Also include with today’s notice are a selection of example policies related to various aspects of continuous operations planning.

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