December 21, 2011 | | Comments 6
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If they don’t know by now…you must be remarkably emergency-free

Lately, I’ve encountered some consternation relative to emergency management, specifically EM.02.02.07, for communicating in writing to each licensed independent practitioners their role in an emergency and to whom they would report in an emergency.

From my experiences, there are any number of ways to demonstrate compliance with this performance element, and to be honest, I’ve not heard of any Joint Commission surveyors “pushing” on this issue, but it could certainly be a vulnerability. One way folks comply with this standard is through credentialing and/or re-credentialing, making use of a process that is already in place. I’m presuming that you have e-mail access for your medical staff members, in which case a simple summary of their duties/roles in an emergency response activation would suffice. Another thought would be handouts at your regularly scheduled medical staff meetings, though, depending on attendance, this might be a tough one to sell if you have a particularly picky surveyor. Anything along these lines would be quite adequate as a demonstration of compliance with this standard.

By the way, the standard does not specify a frequency, so–at least for the moment—you need only document one communication of this nature. It would certainly be appropriate to inform medical staff of substantive changes in their roles, etc., but that would not be considered a standards-based requirement.

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Filed Under: Emergency management


Steve MacArthur 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 Briefings on Hospital Safety. Contact Steve at

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  1. We’ve been told by consultants that email notification (including a 72 hour limit on observation of competence during disasters)is not acceptable to TJC. We put the wording into our EOP, Med Staff Policy and By-Laws (all 3 places are necessary) to cover all the bases, and then give paper copies to med staff.

  2. Great idea to incorporate into the Med Staff Policy and By-Laws. In lieu of paper copies, I wonder if you could pass out pocket cards and briefly cover during new employee orientations and once a year during staff meetings?

  3. I will agree with Robert and Mitch. We included in our Med Staff Policy and By-Laws as well as our EOP. Our last JC survey (August 2009)included a few questions on this process.

  4. I have been in the Healthcare setting now for 31yrs,and in this time i have never seen a life safety specialist working for a hospital til now.TRINITAS REGIONAL MEDICAL CENTER in Elizabeth N.J has two full time life safety specialist in their hospital.They cover everything from life safety 101 codes,nfpa,osha,EPA,and ADA to make sure they are in complience.
    I think that having full time LSS in a HOSPITAL is something CMS or Joint Commission Should look at as far as requiring a hospital to have.What do you think?

  5. We have a Safety Officer and a Life Safety Specialist at our facility and with the new emphasis on Life Safety, it is prudent and recomended to have a full time LSS at the hospital. Previously at our facility, the function was performed by a consultant with our facility folks doing the actual corrections as budgets allowed. With the expertise in the facility we can prioritize deficiencies and correct them adequately and be better prepared for the upcoming 2 day life safety visit from Joint Commission.

  6. I am a Nurse manager and we have payed for life safety consultants to survey my hospital prior to JC survey.But as always we get hit for life safety issues and OSHA,ADA issues and that’s because most consultants are not familiar with OSHA,ADA,EPA,etc. They only focus on life safety issues and that’s questionable.
    The fact that Trinitas has 2 LSS and they focus not only on life safety but also on EPA,OSHA,ADA etc is a big plus for them. One problem most facilities have is to find qualified person to do this task. To pay a consultant is a risk you have to take and hope they do a good job. Yes I do agree that CMA should make all hospitals have a full time LSS on site and to make sure they cover all aspects of safety not just life safety 101. And I believe that if JC sends a consultant to my hospital or any in NJ for that matter they should be familiar with ADA,OSHA,EPA etc. Codes.

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