There’s nothing I like more than questions from the studio audience, so this week I thought I’d field a question on one of those risks that never seems to go away completely, as much because there are not very many specific requirements. So, let’s consider abduction drills.
The current situation at this particular organization involves what I think is a pretty good cross-section of activities: campus-wide drills, suspicious person(s) on the unit drills, mother/baby-specific drills, as well as random quizzing of staff throughout the organization on their role(s) in the infant abduction policy (they have to answer 10 questions about the policy), and a monthly operational test of the infant security alarm system. Again, I think that’s a very good start to things. But it does sort of beg the question as to what requirements exist? Well, dear reader, I beg you, please read on.
Strictly speaking, The Joint Commission (TJC) does not have a great deal that could be characterized as requirements in this regard. EC.02.01.01 EP #9 requires hospitals to have written procedures that can be acted upon in the event the hospital experiences any security incident, including abductions of infants of pediatric patients. That’s pretty much all there is in the standards. I’m presuming that you have a written procedure for responding to an infant and/or pediatric abduction incident, so we’re off to a good start. [more]
Could I have a volunteer from the audience?
Whilst working in the upper part of the Midwest, I found an interesting take on how one might gather volunteers to help out as “victims” when conducting an emergency response exercise that calls for said victims (“paper” patients are OK in a pinch, but isn’t it way more fun/realistic to have some flesh-and-blood types to run through the process?) In this particular area, high school students, in order to fulfill their obligations for graduation, are charged with participating in X number of community service hours during their (hopefully) four-year stint. If I may opine for a moment, I think the community service idea is way cool and with any luck, might bring back the whole “taking care of each other” mindset that seems to have fled screaming into the night. I see way too much trash dumped by roadsides, etc., to think that we are accelerating as a culture toward a positive destination . . . but I digress.
At any rate, a process was set up with the schools that allowed for participation in emergency exercises to count toward the community service requirement. How cool is that? I don’t know if you have such a program in your neck of the woods, but I think it’s definitely worth checking out. And if you’re already doing this, how come you didn’t share it with the group? Shame, shame, shame…
By now, I suspect that most of you have heard about some of the “editorial” changes that will be taking effect in a couple of weeks—just in time for the Independence Day festivities, though I don’t know that this should result in much in the way of fireworks.
So the first item revolves around the whole business occupancy as emergency services provider and/or community-designated disaster receiving station, which I suppose is a concern for some folks. But I can’t think of too many folks with business occupancies that provide emergency services or (even less likely I’m thinking) community-designated disaster receiving stations, and even if you do, why would you not include these locations in your regular exercise schedule? Again, something of which to be mindful, but I shouldn’t think would be a problem as long as you’re paying attention. Which leads me to the “other” point, otherwise known as Note 4 under EM.03.01.03, which appears to pile on a bit when it comes to your post-emergency exercise activities.
As with so many of the more intricate meanderings of the Joint, as far as I’m concerned, this merely clarifies what was already implied in the standard. To be honest, the exercise section of the Emergency Management chapter is actually kind of useful (along with the standards covering the management of volunteer practitioners during an emergency—that is a very well-crafted set of standards/expectation and can actually assist folks in identifying appropriate strategies, but I digress).
My interpretation of the whole EM.03.01.03 magillah is that it is a clear move to a classic performance improvement cycle: You do an exercise, you identify improvements, implement the improvements, use the next exercise to evaluate the changes, identify more improvements, implement them, use the next exercise to evaluate those changes, and so on. Where this can be tricky is when you’re “playing” with the community because they will almost invariably have a different agenda for the exercise than the hospital will, so the hospital then has to become creative in building their improvements (and the evaluation thereof) of that drill. Sometimes the improvements are so broad-ranging that they will easily “fit” in any scenario, but others maybe not so much. The other point to keep in mind (and this dovetails very nicely with the recent blog item on interim gas measures) is that if you cannot implement an identified improvement prior to the next drill, you are supposed to identify interim measure to “bridge the gap” until implementation (the “note” for EM.03.01.03, EP 16 states that when modifications requiring substantive resources cannot be accomplished for the next response exercise, interim measures are put in place until final modifications can be made). As far as I’m concerned the “requirement” in the new note already existed as EP 17, which requires subsequent exercises to reflect the modifications and interim measures identified in previous exercises. They’ve changed the language some (and perhaps made it more clear, but I thought that what they had was clear enough. It may be that they did no one favors by burying it at the end of the chapter and decided to move it to a position of greater prominence. All we have is conjecture at this point. So, my advice would be to utilize your organization’s performance improvement model to track exercises and performance therein and keep the ball rolling.
As to how this may impact organizational resources (or the lack thereof), I don’t know that I’m prepared to throw that towel in just yet. I see far too much procrastination when it comes to emergency management efforts; it’s almost always part of someone’s job, but not the primary part, so accountability for emergency planning slides down the hierarchy. Part of it is, from a historical basis, most hospitals don’t have to deal with what I will loosely describe as “overwhelming” events, so it becomes a cost- (or risk-) benefit analysis. We have to devote our resources towards the stuff that’s most important. Now I’m certainly not prepared to say organizations feel that emergency preparedness is not important, but when you don’t have the resources to even make critical infrastructure improvements (which can actually increase the likelihood of an overwhelming event), you spend more time fixing stuff, putting out fires, etc. As I’ve noted in more places than I care to think, emergency preparedness is a journey not a destination. We will never get to a point where we can look back and say that we’ve done all we can (unless, of course, the Mayans are correct about next year, then maybe, just maybe we won’t have to worry as much about this stuff).
The “best” result you can really expect from an emergency response exercise is the identification of questions or issues that you can’t immediately resolve. That’s where you find your real improvement opportunities and/or vulnerabilities. There will always be quick fixes, but to find a real process opportunity—that’s real gold.
A client of mine recently happened upon one of these opportunities. (Now this may be something you’ve already dealt with—and good for you. Everybody comes to these things in their own way, form, time, etc. But if this is a concept you’ve not really addressed, then it’s something to consider for future exercises.)
The general scenario was one that resulted in an influx of patients. One of the downstream events during the exercise was that the ICU was directed by Incident Command to plan for the admission of pediatric and other patients who wouldn’t be considered typical to the populations served in the ICU. In the course of the exercise, concerns were raised by the ICU staff regarding how this “shift” would be accounted for in hospital policy, what happens to existing policies for “normal” operations, and the recognition that staff caring for these patients do not necessarily have demonstrated competencies relative to the needs of these patient populations. This finally led to the question of the accountability/liability of the hospital and any individual practitioner responding to the immediate needs.
As you can readily see, there are a lot of complications involved here, some of which are working in opposition. First we’ll start with Joint Commission requirement EM.02.02.11, EP 4, which requires the hospital to have a strategy for managing an increase in demand for clinical services for certain vulnerable populations, including pediatrics. Fortunately (I’m choosing to be optimistic about this), that’s pretty much all The Joint Commission says about it: we have to have a process, but how that process works is entirely up to us. The next complication is going to be under what circumstances would we need to plan for such an event? Would it be an emergency of such far-reaching consequences that the “normal” rules are suspended? In such a case, we may have a little leeway (note the “may” – more on that in a moment) in terms of how we emergently manage these patient populations, though I suspect that it will be of fairly limited duration (we could certainly look to post-Katrina New Orleans of an example of how “bad” things can get and there’ll still be someone to jump ugly on your decisions after the dust has cleared).
Part of our due diligence, now that the question is raised, is to consult with the state board of registration of nursing to see if they have any guidance. Clearly, we could get in a situation in which baseline competencies and scope of practice might be exceeded. From a risk management perspective, we need to have a very, very clear understanding of what that can and cannot mean. I can’t imagine that the question hasn’t been pondered by someone at the state level, maybe not quite as succinctly as this, but it’s a question that can equally apply to any and every healthcare organization in the state (not to mention the country, but I guess I just did). The other part of the due diligence would be to try and craft some basic expectations/competencies to be used as a framework during emergent events. I don’t know how much you could set up ahead of time (and I suppose from a compliance perspective, one would have to consider the merit of Memorandums of Understanding with healthcare organizations that may have ready access—and would be willing to share—to some of these “other” resources).
At any rate, this is something for which there is a regulatory expectation of planning and identification of response capabilities. Although the requirement does not force us to “have” these resources, it does require that we have a plan for managing such a situation should it arise.
The surveyor cadre is not particularly knowledgeable about the practical application (and implications, for that matter) of federal level emergency management activities.
There is a broad-based Joint Commission requirement for organizations to comply with applicable local, state, and federal laws and regulations, but even the National Incident Management System and Hospital Incident Command System only truly become “requirements” when [more]
I wrote an article for HCPro’s sister company, HealthLeaders Media, about a trial going on in New Orleans that, believe it or not, may connect a patient death following Hurricane Katrina to poor emergency generator system design.
How many times have you either personally experienced or read about post-drill critiques that recommend infrastructure changes due to emergency power concerns? I hear about it [more]
I was discussing emergency management scenarios involving a bomb threat and whether such exercises needed to include the movement of actual patients. [more]
I was recently asked whether fire drills could count towards The Joint Commission’s requirements for emergency management tests under EM.03.01.03.
I suppose if you evaluated a fire drill to the extent called for under [more]
After months of development, we’re happy to announce our new Emergency Preparedness Solutions series, which we think you’ll like.
The highlight for me, because it’s something I’ve wanted to see us publish for a long time, is a collection of 80 paper patients that are customizable to your hospital’s drill or triage efforts. [more]
I suspect that the reason The Joint Commission doesn’t (or perhaps even can’t) require infant abduction drills under EC.02.01.01 is that not everyone has to manage the security of those at-risk populations.
My take on this concern is that Joint Commission officials have tried to create standards and performance elements that can be applied [more]