You aren’t mandated to develop departmental disaster plans

There is no Joint Commission requirement for you to have department-level emergency management plans, unless you have determined through your drilling and evaluation process that there are sufficient complexities to warrant that additional level of planning.

Based on Joint Commission standards, the only requirement is for each organization to have an emergency operations plan that includes:

• An incident command structure
• Planning, mitigation, response, and recovery strategies
• Components to reflect the management of the six key areas (communications, staffing, resources and assets, safety and security, patient care services, and utility systems)

Beyond that, the expectation is that the granularity of your process reflects the complexities of the organization. So you may be able to respond appropriately to an emergency with a monolithic plan — as long as you can demonstrate that this is indeed the case through planned exercises, actual events, the hazard vulnerability analysis process, and ultimately the annual evaluation of the emergency management program.

You may have adjuncts for certain areas of the hospital, though to be honest, I can’t think of anything off the top of my head that wouldn’t fit in under one of the programmatic elements noted above.