I’ll see you and I’ll raise you 96 hours…
Then there was that time when 96 hours turned into two years…
A couple of (relatively – you know me!) quick thoughts relative to Emergency Management for your consideration as we start the slide from Spring to Summah (which has pretty much happened everywhere, but the calendar can sometimes hold sway).
First off (and I suspect this will not necessarily be a big surprise to you folks as a working concept), our friends in Chicago (in their infinite wisdom and grace) will allow response to the pandemic to be used to meet the response activation/testing requirements outlined in the Emergency Management chapter.
The specific “asks” are to make sure you include an evaluation of performance in the six critical areas (communications, resources & assets, safety & security, staff responsibilities, utility systems, patient clinical & support activities) in whichever documentation format, etc., your organization has deemed appropriate. (Be mindful that if you use the prototypical AAR format, you may have to “tease out” the six critical TJC functions—I think they’re in there, but it would seem they don’t always “jump out” at the surveyors).
You can also use the pandemic response for both required exercises as long as you reflect the community integration piece for the one evaluation and the facility-based piece for the second evaluation (or do both for both—it’s all good). I think we can all agree that the last two years have tested our response capabilities in ways that we might never have imagined, but we kept the doors open and took care of the patients, despite the challenges. If that’s not preparedness, I’m not sure what is. You can see the published FAQ : https://www.jointcommission.org/standards/standard-faqs/hospital-and-hospital-clinics/emergency-management-em/000002335/
Item No. 2 is just a recap of where we are relative to the 96-hour rule/scenario; they’ve not yet updated the FAQ for this standard to reflect all accreditation programs just yet (as of mid-day on May 26, 2022, it was ambulatory and behavioral health EM chapters that were referenced), but I think we can intuit that there will be some re-publishing of EM FAQs in the wake of the newly minted EM chapter.
As we wait for the update of the FAQs, this article at the Accreditation Quality Center will give you something upon which to hang a regulatory hat or two; particularly if someone is looking for 96-hours’ worth of stuff. https://www.accreditationqualitycenter.com/articles/what-know-about-96-hour-rule-em-operations.
The important dynamic of this whole thing is not so much the having of 96-hours’ worth of stuff, but rather knowing when things are starting to get tight on the availability side of things, for when you need to start making the “tough” decisions about preparing for evacuation. If we have learned nothing else these last two years, it is that healthcare has an enormous capacity for improvisation when it comes to keeping the doors open – bravo a tutti!
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 firstname.lastname@example.org.