April 28, 2017 | | Comments 0
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Remembering it wasn’t fair outside…

First off, a mea culpa. It turns out that there was an educational presentation by CMS to (nominally) discuss the final Emergency Preparedness rule, with a focus on the training and testing requirements (you can find the slide deck here; the presentation will be uploaded sometime in the next couple of weeks or so) and I neglected to make sure that I had shared that information with you in time for you to check it out. My bad!

That said, I don’t know that it was the most compelling hour I’ve ever spent on the phone, but there were one or two (maybe as many as three) aspects of the conversation that were of interest, bordering on instructive. First off, when the final rule speaks to the topic of educating all staff on an annual basis, the pudding proof is going to be during survey when staff are asked specific questions about their roles in your plan (presumably based on what you come up with through the hazard vulnerability assessment—HVA—process). Do they know what to do if there is a condition that requires evacuation? Do they know how to summon additional resources during an emergency? Do they know what works and what doesn’t work as the result of various scenarios, etc.? This is certainly in line with what I’ve seen popping up (particularly during, but not limited to, CMS/state surveys)—there is an expectation (and I personally can’t argue against this as a general concept) that point-of-care/point-of-service staff are competent and knowledgeable when it comes to emergency management (and, not to mention, management of the care environment). As I’ve noted to I can’t tell you how many folks, the management of the physical environment, inclusive of emergency preparedness/management does not live on a committee and it is not “administered” during surveillance rounds or during fire drills. Folks who are taking care of the patients’ needs to know what their role is in the environment, particularly as a function of what to do when things are not perfect (I’ll stop for a moment and let you chew on that one for a moment).

Another expectation that was discussed (and this dovetails a wee bit with the last paragraph) is that your annual review of your emergency preparedness/management process/program must include a review of all (and I do mean all) of the associate/applicable policies and procedures that are needed for appropriate response. So far (at least on the TJC front—I’m less clear on what some of the other accrediting organizations (AO)—might be doing, though I suspect not too very far from this. More on the AO front in a moment), the survey review of documentation has focused on the emergency plan (or emergency operations plan or emergency response plan—if only a rose were a rose were a rose…), the exercise/drill documentation, HVA, and annual evaluation process. But now that the gauntlet has been expanded to include all those pesky policies and procedures. I will freely admit that I’m still trying to figure out how I would be inclined to proceed if I still had daily operational responsibility for emergency management stuff. My gut tells me that the key to this is going to be to start with the HVA and then try to reduce the number of policies and procedures to the smallest number of essential elements. I know there are going to be individual response plans—fire, hazmat, utility systems failures, etc.—is it worth “appendicizing” them to your basic response plan document (if you’ve already done so, I’d be interested to hear how it’s worked out, particularly when it comes to providing staff education)? I’m going to guess that pretty much everybody addresses the basic functions (communications, resources and assets, safety and security, utility systems, staff roles and responsibilities, patient care activities) with the structure of the E-plan, which I guess limits the amount of reviewable materials. There was a question from the listening audience about the difficulty in managing review of all these various and sundry documents and the potential for missing something in the review process (I am, of course, paraphrasing) and the response was not very forgiving—the whole of it has to be reviewed/revised/etc. So, I guess the job is to minimize/compact your response plans to their most essential (the final rule mentions the development of policies and procedures, but doesn’t stipulate what those might be) elements and guard them diligently.

The final takeaways for me are two in number. Number 1: Eventually, there will be Interpretive Guidelines published for the Emergency Preparedness final rule, but there is no firm pub date, so please don’t wait for that august publication before working towards the November implementation deadline. Number 2: While there is an expectation that the AOs will be reviewing their requirements and bringing them into accordance with the CMS requirements, there is no deadline for that to occur. Something makes me think that perhaps they are waiting on the Interpretive Guidelines to “make their move”—remembering it’s not going to be fair any time soon. I think the important dynamic to keep in mind when it comes to our friends at CMS (in all their permutations) is that they are paying hospitals to take care of their patients: the patients are CMS’ customers, not us. Which kind of goes a ways towards explaining why they are not so nice sometimes…

A bientot!

Entry Information

Filed Under: CMSEmergency managementHospital security


Steve MacArthur About the Author: Steve MacArthur is a safety consultant based in Bridgewater, 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 stevemacsafetyspace@gmail.com.

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