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Only dimly aware of a certain unease in the air: Thoughts on succession planning and other EManations

Lately, as I field questions from folks regarding potential survey vulnerabilities relating to emergency management, I keep coming back to the importance of succession planning. And, interestingly enough, I’ve found that succession planning can have a very big impact on other processes in the physical environment.

Certainly, the most critical aspect of succession planning revolves around insuring that you have sufficient numbers of prepared competent incident command staff—in this age of frequent shifts in organizational leadership, etc., you can hit some really lean times when it comes to having appropriately knowledgeable folks in the bunker with you during emergency response activities. And with this recent spate of emergency response activations lasting days instead of hours and weeks instead of days, you really need to have enough bench strength to move folks in and out of roles, getting them a little downtime, etc. I think it is only natural(ly unnatural) to rely on a fairly finite cadre of individuals who you know can “bring it,” regardless of what’s going on, but I think the challenge as we move forward is to expand on those core folks and move towards access to incident command staff across all shifts. If you think of it in terms of a basic continuity of operations plan (after all, you need folks to be able to continue operations), a seamless philosophy, etc., would seem the best strategy. And, to that end, I have a question for you folks out there in radioland—do you have a standardized approach to providing education to your incident command folks? Is it the basic FEMA and associated stuff? Or have you found something else? I’d be really keen to hear what you’re doing to ensure reasonable competence, etc., in your response activities.

Another way in which succession planning can have an impact on general compliance are those instances in which critical processes are “owned” by one individual in an organization. And when that individual takes time off, or even leaves the organization, sometimes the stuff they were doing falls through the cracks. I can’t tell you how many times I’ve run into instances when eyewash checks, fire pump tests, preventive maintenance for equipment, etc., went undone because the person responsible didn’t (or wasn’t able to) make a handoff. As you can probably figure out, surveyors are not going to look too kindly upon these kinds of gaps and with the threshold for findings being at such a low point, you really only need a couple of “drops” before you’re looking at survey troubles. I would imagine that those of you with work order systems can engineer a failsafe into the process so if someone is off, it’s easy to discern that the activity needs to be reassigned. But what if you pay to send someone to school to learn how to maintain a certain piece (or pieces) of equipment and that individual leaves the organization and you (potentially) without a service contract for the equipment in question because you brought it “in house”? These are all real life examples of how the best laid plans of facilities/safety professionals can go astray. Specialized knowledge and skill is rather a premium at the moment and you want to be sure you have processes in place that will withstand attrition (in all its glories).

Next week, I want to talk a little bit about how folks are managing construction projects. You know me: I never miss an opportunity for some ponderings…

’Tis the season…for more emergency management goodness!

Recognizing the somewhat hyperbolic nature of this week’s headline (you need only listen to current news/weather feeds to be able to determine that emergencies are not quite as seasonal as perhaps they once were…), I did want to share one more emergency management-related nugget with you (I do try to mix things up, but until I start seeing some “hard” survey results—or some regulatory panjandrum makes some sort of announcement, I’m going to keep seeding this space with various and sundry bits of stuff), this coming to us from the left coast, aka California.

While I have little doubt that you Californians in the audience are familiar with the California Department of Public Health (CDPH—four scary letters, though perhaps not as scary as OSHPD for the facilities folks in Cali) requirements for workplace emergency plans (which is highlighted in this month’s CDPH Occupational Health Watch), I think that there might well be some useful information for folks in other parts of the country (I have found, over some few years of experience, that regulatory tsunamis can start in California and find their way to all manner of locales). To be honest (and why else would we be here?), the plan elements required (or at least the ones the surveyors want to see) by the usual regulatorily-inclined suspects, are frequently not quite as useful from an operational preparedness/mitigation/response/recovery standpoint (they provide a useful structure for the aforementioned quartet, but when it comes down to doing the do, again, sometimes not so much).

At any rate, the Cal/OSHA Emergency Action Plan requirements, provide (at least in my mind—feel free to disagree) a good basic sense of the pieces to have in place that are not necessarily as patient-focused. When the fecal matters starts impacting the rapidly rotation turbine blades, it’s important to have a structure in place that addresses the employee aspect, particularly for those of you with offsite non-clinical operations (billing, finance, HR, etc.: a lot of folks don’t have enough space at the main campus for all the moving pieces that constitute a healthcare organization). So, here’s the California stuff (and please feel free to share any good stuff your state might have on the books—this is all about getting prepared and staying prepared—every little bit helps):

(b) Elements. The following elements, at a minimum, shall be included in the plan:

(1) Procedures for emergency evacuation, including type of evacuation and exit route assignments;

(2) Procedures to be followed by employees who remain to operate critical plant operations before they evacuate;

(3) Procedures to account for all employees after emergency evacuation has been completed;

(4) Procedures to be followed by employees performing rescue or medical duties;

(5) The preferred means of reporting fires and other emergencies; and

(6) Names or regular job titles of persons or departments who can be contacted for further information or explanation of duties under the plan.

(c) Alarm System.

(1) The employer shall establish an employee alarm system which complies with Article 165 (link to that info here).

(2) If the employee alarm system is used for alerting fire brigade members, or for other purposes, a distinctive signal for each purpose shall be used.

(d) Evacuation. The employer shall establish in the emergency action plan the types of evacuation to be used in emergency circumstances.

(e) Training.

(1) Before implementing the emergency action plan, the employer shall designate and train a sufficient number of persons to assist in the safe and orderly emergency evacuation of employees.

(2) The employer shall advise each employee of his/her responsibility under the plan at the following times:

(A) Initially when the plan is developed,

(B) Whenever the employee’s responsibilities or designated actions under the plan change, and

(C) Whenever the plan is changed.

(3) The employer shall review with each employee upon initial assignment those parts of the plan which the employee must know to protect the employee in the event of an emergency. The written plan shall be kept at the workplace and made available for employee review. For those employers with 10 or fewer employees the plan may be communicated orally to employees and the employer need not maintain a written plan.

 

I hope this provides you with some useful (and perhaps even thoughtful) information as we roll through emergency year 2018. I am hoping for a time of minimal impact for communities this year (I think we had just about enough last year), but the oddness of the weather patterns over the past couple of months gives me pause. (I live in the Boston area and Houston and its environs had snow before we did!)

Emergency Management Monkeyshines: All Things Must Pass…

Sometimes like a kidney stone, but nonetheless…

Before we dive into this week’s “content,” I have a thought for you to ponder as to the nature of basing future survey results on the results of surveys past (rather Dickensian, the results of surveys past): Recognizing that authorities having jurisdiction (AHJ) always reserve the right to disagree with any decision you’ve ever made or, indeed, anything they (or any other AHJ) have told you in the past, how long are existing waivers and/or equivalencies good for? Hopefully this ponderable will not visit itself upon you or your organization, but one must be prepared for any (and every) eventuality. Which neatly brings us to:

In digging around past emails and such, I noticed that I had not visited the Department of Health and Human Services Healthcare Emergency Preparedness Gateway in rather a while and what to my wondering eyes should appear but some updated info and a link to CMS that I think you’ll find useful. So, the current headlines/topics:

  • Considerations for the Use of Temporary Care Locations for Managing Seasonal Patient Surge
  • Pediatric Issues in Disasters Webinar
  • 2017 Hurricane Response – Resources for Children with Special Health Care Needs
  • Supporting Non-resident/Foreign Citizen Patients
  • A new issue of The Exchange newsletter
  • A link to the CMS Emergency Preparedness Final Rule surveyor training (you can find the information available to providers here). Unfortunately, the post-test is not available to providers, but sometimes it’s like that.

It is my intent over the next little while to check out the education package, so I will let you know if I have any grave reservations about the content, etc., or if I think you need to earmark it for priority viewing.

So, kind of brief this week, but I’m sure there’ll be more to discuss in the not too distant future. And so, with the end of wintah on the horizon, I wish you a moderately temperate week!

Lazy days of autumn: CMS does emergency management (cue applause)!

I suppose you could accuse me of being a little lazy in this week’s offering, but I really want you to focus closely on what the CMS surveyors are instructed to ask for in the Emergency Management Interpretive Guidelines (more on those here; seems like forever ago), so I’ve done a bit of a regulatory reduction by pulling out the non-hospital elements (I still think they could have done a better job with sorting this out for the individual programs) and then pulling out the Survey Procedures piece—that’s really where the rubber meets the road in terms of how this is going to be surveyed, at least at the front end of the survey process.

I suspect (and we only have all of recorded history to fall back on for this) that as surveyors become more comfortable with the process, they may go a little off-topic from time to time (surprise, surprise, surprise!), but I think this is useful from a starting point. As I have maintained right along, I really believe that you folks have your arms around this, even to the point of shifting interpretations. This is the stuff that they’ve been instructed to ask for, so I think this is the stuff that you should verify is in place (and, really, I think you’ll find you’re in very good shape). There’s a fair amount of ground to cover, so I will leave you to it—until next week!

BTW, I purposely didn’t identify which of the specific pieces of the Final Rule apply to each set of Survey Procedures. If there is a hue and cry, I will be happy to do so (or you can make your own—it might be worth it to tie these across to the requirements), but I think these are the pieces to worry about, without the language of bureaucracy making a mess of things. Just sayin’…

Survey Procedures

  • Interview the facility leadership and ask him/her/them to describe the facility’s emergency preparedness program.
  • Ask to see the facility’s written policy and documentation on the emergency preparedness program.
  • For hospitals and critical access hospitals (CAH) only: Verify the hospital’s or CAH’s program was developed based on an all-hazards approach by asking their leadership to describe how the facility used an all-hazards approach when developing its program.

Survey Procedures

  • Verify the facility has an emergency preparedness plan by asking to see a copy of the plan.
  • Ask facility leadership to identify the hazards (e.g., natural, man-made, facility, geographic, etc.) that were identified in the facility’s risk assessment and how the risk assessment was conducted.
  • Review the plan to verify it contains all of the required elements.
  • Verify that the plan is reviewed and updated annually by looking for documentation of the date of the review and updates that were made to the plan based on the review.

 

Survey Procedures

  • Ask to see the written documentation of the facility’s risk assessments and associated strategies.
  • Interview the facility leadership and ask which hazards (e.g., natural, man-made, facility, geographic) were included in the facility’s risk assessment, why they were included and how the risk assessment was conducted.
  • Verify the risk assessment is based on an all-hazards approach specific to the geographic location of the facility and encompasses potential hazards.

Survey Procedures

Interview leadership and ask them to describe the following:

  • The facility’s patient populations that would be at risk during an emergency event
  • Strategies the facility (except for an ASC, hospice, PACE organization, HHA, CORF, CMHC, RHC, FQHC and end stage renal disease (ESRD) facility) has put in place to address the needs of at-risk or vulnerable patient populations
  • Services the facility would be able to provide during an emergency
  • How the facility plans to continue operations during an emergency
  • Delegations of authority and succession plans

Verify that all of the above are included in the written emergency plan.

Survey Procedures

Interview facility leadership and ask them to describe their process for ensuring cooperation and collaboration with local, tribal, regional, state, and federal emergency preparedness officials’ efforts to ensure an integrated response during a disaster or emergency situation.

  • Ask for documentation of the facility’s efforts to contact such officials and, when applicable, its participation in collaborative and cooperative planning efforts.
  • For ESRD facilities, ask to see documentation that the ESRD facility contacted the local public health and emergency management agency public official at least annually to confirm that the agency is aware of the ESRD facility’s needs in the event of an emergency and know how to contact the agencies in the event of an emergency.

Survey Procedures

Review the written policies and procedures which address the facility’s emergency plan and verify the following:

  • Policies and procedures were developed based on the facility- and community-based risk assessment and communication plan, utilizing an all-hazards approach.
  • Ask to see documentation that verifies the policies and procedures have been reviewed and updated on an annual basis.

Survey Procedures

  • Verify the emergency plan includes policies and procedures for the provision of subsistence needs including, but not limited to, food, water and pharmaceutical supplies for patients and staff by reviewing the plan.
  • Verify the emergency plan includes policies and procedures to ensure adequate alternate energy sources necessary to maintain:

o Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions;

o Emergency lighting; and,

o Fire detection, extinguishing, and alarm systems.

  • Verify the emergency plan includes policies and procedures to provide for sewage and waste disposal.

 

Survey Procedures

  • Ask staff to describe and/or demonstrate the tracking system used to document locations of patients and staff.
  • Verify that the tracking system is documented as part of the facilities’ emergency plan policies and procedures.

 

Survey Procedures

  • Review the emergency plan to verify it includes policies and procedures for safe evacuation from the facility and that it includes all of the required elements.
  • When surveying an RHC or FQHC, verify that exit signs are placed in the appropriate locations to facilitate a safe evacuation.

 

Survey Procedures

  • Verify the emergency plan includes policies and procedures for how it will provide a means to shelter in place for patients, staff and volunteers who remain in a facility.
  • Review the policies and procedures for sheltering in place and evaluate if they aligned with the facility’s emergency plan and risk assessment.

 

Survey Procedures

  • Ask to see a copy of the policies and procedures that documents the medical record documentation system the facility has developed to preserves patient (or potential and actual donor for OPOs) information, protects confidentiality of patient (or potential and actual donor for OPOs) information, and secures and maintains availability of records.

 

Survey Procedures

  • Verify the facility has included policies and procedures for the use of volunteers and other staffing strategies in its emergency plan.

 

Survey Procedures

  • Ask to see copies of the arrangements and/or any agreements the facility has with other facilities to receive patients in the event the facility is not able to care for them during an emergency.
  • Ask facility leadership to explain the arrangements in place for transportation in the event of an evacuation.

 

Survey Procedures

  • Verify the facility has included policies and procedures in its emergency plan describing the facility’s role in providing care and treatment (except for RNHCI, for care only) at alternate care sites under an 1135 waiver.

 

Survey Procedures

  • Verify that the facility has a written communication plan by asking to see the plan.
  • Ask to see evidence that the plan has been reviewed (and updated as necessary) on an annual basis.

 

Survey Procedures

  • Verify that all required contacts are included in the communication plan by asking to see a list of the contacts with their contact information.
  • Verify that all contact information has been reviewed and updated at least annually by asking to see evidence of the annual review.

 

Survey Procedures

  • Verify that all required contacts are included in the communication plan by asking to see a list of the contacts with their contact information.
  • Verify that all contact information has been reviewed and updated at least annually by asking to see evidence of the annual review.

 

Survey Procedures

  • Verify the communication plan includes primary and alternate means for communicating with facility staff, federal, state, tribal, regional and local emergency management agencies by reviewing the communication plan.
  • Ask to see the communications equipment or communication systems listed in the plan.

 

Survey Procedures

  • Verify the communication plan includes a method for sharing information and medical (or for RNHCIs only, care) documentation for patients under the facility’s care, as necessary, with other health (or care for RNHCIs) providers to maintain the continuity of care by reviewing the communication plan.

o For RNCHIs, verify that the method for sharing patient information is based on a requirement for the written election statement made by the patient or his or her legal representative.

  • Verify the facility has developed policies and procedures that address the means the facility will use to release patient information to include the general condition and location of patients, by reviewing the communication plan

 

Survey Procedures

  • Verify the communication plan includes a means of providing information about the facility’s needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee by reviewing the communication plan.
  • For hospitals, CAHs, RNHCIs, inpatient hospices, PRTFs, LTC facilities, and ICF/IIDs, also verify if the communication plan includes a means of providing information about their occupancy.

 

Survey Procedures

  • Verify that the facility has a written training and testing (and for ESRD facilities, a patient orientation) program that meets the requirements of the regulation.
  • Verify the program has been reviewed and updated on, at least, an annual basis by asking for documentation of the annual review as well as any updates made.
  • Verify that ICF/IID emergency plans also meet the requirements for evacuation drills and training at §483.470(i).

 

Survey Procedures

  • Ask for copies of the facility’s initial emergency preparedness training and annual emergency preparedness training offerings.
  • Interview various staff and ask questions regarding the facility’s initial and annual training course, to verify staff knowledge of emergency procedures.
  • Review a sample of staff training files to verify staff have received initial and annual emergency preparedness training.

 

Survey Procedures

  • Ask to see documentation of the annual tabletop and full scale exercises (which may include, but is not limited to, the exercise plan, the AAR, and any additional documentation used by the facility to support the exercise.
  • Ask to see the documentation of the facility’s efforts to identify a full-scale community based exercise if they did not participate in one (i.e., date and personnel and agencies contacted and the reasons for the inability to participate in a community based exercise).
  • Request documentation of the facility’s analysis and response and how the facility updated its emergency program based on this analysis.

 

Survey Procedures

  • Verify that the hospital, CAH, and LTC facility has the required emergency and standby power systems to meet the requirements of the facility’s emergency plan and corresponding policies and procedures
  • Review the emergency plan for “shelter in place” and evacuation plans. Based on those plans, does the facility have emergency power systems or plans in place to maintain safe operations while sheltering in place?
  • For hospitals, CAHs, and LTC facilities which are under construction or have existing buildings being renovated, verify the facility has a written plan to relocate the EPSS by the time construction is completed

For hospitals, CAHs, and LTC facilities with generators:

  • For new construction that takes place between November 15, 2016 and is completed by November 15, 2017, verify the generator is located and installed in accordance with NFPA 110 and NFPA 99 when a new structure is built or when an existing structure or building is renovated.  The applicability of both NFPA 110 and NFPA 99 addresses only new, altered, renovated or modified generator locations.
  • Verify that the hospitals, CAHs and LTC facilities with an onsite fuel source maintains it in accordance with NFPA 110 for their generator, and have a plan for how to keep the generator operational during an emergency, unless they plan to evacuate.

 

Survey Procedures

  • Verify whether or not the facility has opted to be part of its healthcare system’s unified and integrated emergency preparedness program. Verify that they are by asking to see documentation of its inclusion in the program.
  • Ask to see documentation that verifies the facility within the system was actively involved in the development of the unified emergency preparedness program.
  • Ask to see documentation that verifies the facility was actively involved in the annual reviews of the program requirements and any program updates.
  • Ask to see a copy of the entire integrated and unified emergency preparedness program and all required components (emergency plan, policies and procedures, communication plan, training and testing program).
  • Ask facility leadership to describe how the unified and integrated emergency preparedness program is updated based on changes within the healthcare system such as when facilities enter or leave the system.

 

To close out this week’s bloggy goodness, Diagnostic Imaging just published a piece on emergency preparedness for radiology departments that I think is worth checking out: http://www.diagnosticimaging.com/practice-management/emergency-preparedness-radiology . Imaging services are such a critical element of care giving (not to mention one of the largest financial investment areas of any healthcare organization) that a little extra attention on keeping things running when the world is falling (literally or figuratively) down around your ears. I think we can make the case that integration of all hospital services is likely to be a key element of preparedness evaluation in the future—this is definitely worthy of your consideration.

Fall On Me: Keeping Emergency Management Changes in Perspective

As I was ruminating on a topic for this week’s conversation, the October issue of Perspectives came zipping over the electronic transom, and I think there is just enough stuff here to cobble together a relatively cogent offering to you all out there in the blogosphere (that’s right—after 10+ years, I’m working on cogency—who’d a thunk…)

First up is the announcement of proposed changes to the Emergency Management chapter (I say proposed, because the indication is that these changes still require approval by CMS) with an intended survey implementation date of November 15, 2017 (when the Emergency Management final rule takes full effect). From my experiences with folks, I still don’t think they’re barking up a tree for which we cannot (collectively) provide a reasonable response, but if you’re interested in what they think they need to change in the standards, the list of additions includes consideration of:

  • Continuity of operations and succession plans
  • Documentation of collaboration with local, tribal, regional, state, and federal EM officials
  • Contact information on volunteers and tribal groups
  • Documented annual training of all new/existing staff, contractors, and volunteers
  • Integrated health care systems
  • Transplant hospitals

Again, I don’t see anything that strikes me as being particularly daunting, though there’s still a fair amount of angst relative to these changes (as is the case with anything that changes). I know there’s been some consternation relative to managing Memorandums of Understanding (or Memoranda, if that be your preference) and Alternate Care Sites, but I think the important thing to keep in mind is that the journey to the Final Rule started back when the 2008 TJC standards were in full bloom. And I suspect that those of you who have been doing this for a while recall those heady days of focus on MOU’s, ASC’S, COOP’s and the like, concepts that have really kind of faded into the operational ether as the efficacy of those approaches has yielded wildly inconsistent levels of preparation. For some folks, MOU’s, ASC’s and COOP’s are essential, but I’ve also seen evidence that when the feces is striking the rapidly rotating blades, it is often the group that shows up first with the closest thing to cash that has access to resources. When you think about it, things like MOU’s are only an agreement to do the best one can under the circumstances—that’s why the interface with local and regional EM authorities is so very important. At any rate, next we’ll chat a bit about what the CMS survey instructions involve and why I think you folks are going to be in pretty good shape. I am curious as to whether or not there is an intent to modify the emergency response exercise requirements to more closely mirror the Final Rule—I guess all in the fullness of time.

Moving on to other Perspectives topics, it would seem that last month’s Clarifications and Expectations column was indeed the last official communication under George Mills’ direction. The column is on hiatus for the moment—I guess we’ll have to wait and see whether November brings it back (though oy could certainly make the case that EC-EM-LS topics are taking up a fair amount of space in the monthly Perspectives, Clarifications and Expectations columns notwithstanding).

There is a new Sentinel Event Alert (#58!) regarding issues relating to inadequate hand-off communications; the reason I mention it here is that, while the focus in Perspectives is very much on the clinical side of things, I think there is more than a little crossover into the safety / physical environment realm. I’m just planting the seed here, but I suspect that I will have more thoughts on this in the coming little while.

Finally (for this week), there is a piece on Workplace Violence as a function of screening for early detection of risk to harm self or others. I suspect that this may be a harbinger of next steps as it relates to how organizations are managing at-risk patients, particularly as a function of the current focus on ligature risks. In recognition that all the risks that are not medically/clinically necessary have removed, if you don’t have a pretty robust screening process in place, it makes it very challenging to manage the risks that remain. At any rate, I’d keep an eye on this one—much as they’ve been peeling the Infection Control “onion” over the past couple of years, I think this is how they’re going to expand focus in the behavioral health realm.

But, as a subset of that, I did want to muse a bit on those instances when entities that were thought of as “friendly” turn out (under certain circumstances) to be not so much. I suspect that most of you saw the news item back in July regarding the nurse working in the ED of a hospital in Salt Lake City, UT, who was forcibly arrested by local police for not acquiescing to a request that was not allowed by organization policy (if you missed it, you can see some of the story here or here.) I mention this only to point out that the management of this stuff is not always simple (OK, it pretty much never is simple), but this does offer up yet another facet to how facilities safety and security professionals have to proactively advocate for staff (and patient) safety. Some of the images of the arrest are most harrowing and definitely beg the question of how this came to pass in this day and age (or maybe it’s not as questionable an outcome as perhaps it might once have been). At any rate, it’s always important to periodically review what I refer to as the “rules of engagement,” particularly when it comes to interacting with law enforcement folks. If our folks can’t be protected from our “friends,” then what shot do we have against an unknown/unknowable “foe.”

Plan be nimble, plan be quick

As we have discussed (pretty much ad nauseum) in this hallowed hall of electrons, there is likely to be a renewed (and I don’t mean renewed in a healthful way, this would be more like a subscription to a magazine that someone sent you as a prank) interest/scrutiny in how you and your organization are complying with all these lovely (and pesky, can’t forget pesky) new emergency management considerations. But there is one word of caution that I wanted to inject into the conversation, and while it probably doesn’t “need” to be said, I try not to leave any card unplayed when it comes to compliance activities.

Over the years (officially 16 of consulting—time flies!) I have found that sometimes (OK, maybe more frequently than sometimes), the prettiest plans, policies, procedures, etc. end up falling to the ground in demonic spasms because they did not accurately reflect the practice of the organization. The general mantra for this is “do the right thing, do what you say, say what you do,” but sometimes it’s tough to figure out exactly what constitutes “the right thing” (as opposed to “The Right Stuff,” natch). When it comes to emergency preparedness, response, recovery, etc. probably the single most important aspect of the plan (at least I think it’s an aspect—if you can think of a better descriptor, please sing out!) is that it is flexible enough to be able to react to minute-by-minute changes that are (frequently) the hallmark of catastrophic events. I think anyone who has worked in healthcare for any length of time has seen what happens to a rigid structure, be it policy, plan, expectations, buildings, flora and fauna—whatever, when things get to swirling around in intense fashion—things start to pull apart (figuratively and/or literally) and sustaining your response becomes that much more difficult.

So, as we “embrace” the challenges of the changes, I would encourage you to think about how you’ll maintain (and test during exercises) that flexibility of response that will give you enough wiggle room to weather the storms (of outrageous and other fabulous fortune). Exercise scenarios can push (or be pushed) in any number of directions (strangely, it is very much like real life)—make sure you take full advantage of those folks in the Command Center—if they’re not sweating—turn up the heat!

It’s not funny how we don’t talk anymore

A mixed bag of stuff this week (dig, if you will, a picture: sleigh full of regulatory madness), including the Perspectives coverage of the Emergency Management standards. But first, a little musing to usher in the change of the seasons.

The nature of my work/vocation requires me to travel a fair amount—and I am not whining about that—it’s my choice to continue to do so, and I understand that if the travel gods are displeased, there is no point in kvetching, but I digress. One of my favorite travel pastimes is watching fellow travelers as they navigate the various and sundry obstacles that one might encounter as they complete the check-in/TSA gauntlet, etc., after which, they generally “crash” in the gate areas or airline clubs. One of the most fascinating/disturbing trends (and I suspect you’ve probably witnessed this yourselves—perhaps even in your own homes) is groups of people (even families!) staring at their devices…and saying not a word to each other. I can’t help but think that if we can’t (or I guess more appropriately, don’t) converse in our private lives, it’s going to have a not-so-good impact on discourse in the workplace. We are better when we are talking—and even technological isolation is still isolation-y.

Hopping down from the ol’ soapbox, just a quick couple of words on the Emergency Management stuff in Perspectives. Interestingly enough (almost to the point of being strangely enough), it appears that folks responding to emergencies have found that the EM standards facilitate effective response—go figure! While I am certainly glad to hear that, I’m not necessarily surprised, mind you. After all, the basic tenets of small “e” emergency management are what inform the big “E” Joint Commission chapter, so if there’s stuff that doesn’t lend itself to response, recovery, etc., I would hope that it would have been expunged by now. Another area of emphasis in the article is the importance of collaboration with the community and other health providers when you are dealing with a significant emergency (as an aside, the CMS final rule also highlights the importance of that collaboration), which (once again) makes a great deal of sense from a practical standpoint. The article closes out with some links to useful information; I’d encourage you to check them out once the stockings are hung by the chimney with care:

Finally, to close out this epistle, I would encourage you to climb into the wayback machine and revisit those halcyon days of Sentinel Event Alert #37 and the management of emergency power systems, etc. My gut tells me that e-power is going to continue (if not increase) to be a focal point for pretty much any and all regulatory systems and the advice provided in SEA #37 relative to evaluating your e-power capabilities, assessing the reliability of normal power, etc., can only become more timely as our reliance on technology grows at an almost exponential rate. We certainly don’t want to get caught unawares on the e-power front and I’d be willing to bet that there have been some changes in the technology infrastructure in your place that might be significant enough for some analysis. At any rate, some more links to peruse once you’ve laid out the cookie and milk for that right jolly old elf:

Beyond that, I hope that we all get a chance to turn off the technology for a bit over the next couple of weeks (and I mean that in the best possible way—I am no Luddite!) and allow some real-time reflection with our family, friends and, indeed, the world at large.

Here’s hoping that 2017 rings in the return of civil discourse!

Gathering gobs of Grinchiness

As the ol’ Physical Environment Portal remains barren of new goodies (maybe we will awake the morning of December 25 and find crisply wrapped interpretations under the tree—oh, what joy for every girl and boy!), we will turn yet again to the annals of Perspectives to mayhap glean some clarity from that august source of information. I suspect that as the December issue is chock-a-block full of life safety and emergency management goodness, we’ll be chatting about the contents for a couple of sessions. First, the big news (or what I think/suspect is the news that is likely to have the most far-reaching implications for survey year 2017): a survey process change relative to the evaluation of Interim Life Safety Measures. Actually, I should note that, as the changes were effective November 17, 2016, those of you experiencing surveys ‘twixt then and the end of the year will also be subject to this slight alteration.

So, effective 11/17/16 (the 46th anniversary of the recording of Elton John’s landmark live album 11/17/70—coincidence? Probably…), the evaluation of your ILSM process (inclusive of the policy, any risk assessments, etc.) will be expanded to include discussion of how, and to what extent, ILSMs will be implemented when there are LS deficiencies identified during your survey that (presumably) cannot be immediately corrected, based on your ILSM policy. Sounds pretty straightforward, but it does make me wonder how the LS surveyor is going to have enough time to review your documentation, thoroughly survey your facility, and then sit down to review any LS findings and discuss how your ILSM policy/process comes into play. I have to tell you, when I first read this, my thought immediately went to “one more day of LS surveying to endure for any reasonably-sized hospital” and, taking into consideration all the other changes going on, while I hope I am incorrect, it does make me wonder, wonder, wonder. Also, the ILSM(s) to be implemented until the deficiency is resolved will be noted in the final survey report, so it probably behooves you to have a process in place to be able to FIFI (find it, fix it) every LS deficiency as it is encountered—and since everything counts with the abolition of the “C” performance elements, you know what you probably need to do.

At any rate, with the announcement that we can expect full coverage of the ILSM standard, there was also a note that an additional performance element has been added to provide for any additional ILSMs you might want to use that are not specifically addressed in the other performance elements for this standard. I’m not exactly sure how this would play out from a practical standpoint; maybe you could specifically include in your policy a provision for checking exit routes in construction only when the space is occupied, etc. As near as I can remember, the only instance I can think of somebody being cited for having an ILSM in their policy that did not precisely reflect the performance elements in the standard was back when the EP regarding the prohibition of smoking was discontinued from the standard; there were a few persnickety surveyors who cited folks for not having removed that from their policy (persnickety is as persnickety does), but that’s all I can think of.

Next week, we’ll chat a bit about some of the pending changes to the Life Safety chapter wrought by the adoption of the 2012 Life Safety Code®. In a word, riveting!

Oh, what fresh hell is this?

Much as 2016 has laid waste to the pantheon of pop culture, so has it decimated the status quo in the realm of facilities and safety management. While this year has brought “pleasures” expected (adoption of the 2012 edition of the Life Safety Code®) and unexpected (the demise of the Plan for Improvement process), it appears that the wheels (gears?) that drive this regulatory machine are not yet done churning out new stuff for us to ponder.

As you’ve probably heard by now, last week CMS finally dropped the mike on the federal requirements relating to emergency management and the healthcare world. (Press release can be found here; link to the final rule–the hospital requirements start on p. 584 of this oh so fabulous 651-page document. Monsieur Needle, please meet Monsieur Haystack…zut alors!)

Let’s do a quick run-through of the four primary components:

  • You have to have an emergency preparedness plan that must be reviewed and updated at least annually.
    • The plan must be based on, and include, a documented facility-based and community-based risk assessment, utilizing an all-hazards approach.
    • The plan must include strategies for addressing emergency events identified by the risk assessment, utilizing an all-hazards approach.
    • The plan must address patient population, including, but not limited to, persons at-risk; the type of services the hospital has ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.
    • The plan must include a process for cooperation with the various AHJs’ efforts to maintain an integrated response during a disaster or emergency situation, including documentation of the hospital’s efforts to contact such officials, and when applicable, its participation in collaborative and cooperative planning efforts.
  • Develop emergency preparedness policies and procedures that must be reviewed and updated at least annually. The policies and procedures must address the following:
    • The provision of subsistence needs for staff and patients, whether they evacuate or shelter in place, include, but are not limited to the following:
      • Food, water, medical, and pharmaceutical supplies.
      • Alternate sources of energy to maintain the following:
        • Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions.
        • Emergency lighting.
        • Fire detection, extinguishing, and alarm systems.
        • Sewage and waste disposal.
        • A system to track the location of on-duty staff and sheltered patients in the hospital’s care during an emergency. If on-duty staff and sheltered patients are relocated during the emergency, the hospital must document the specific name and location of the receiving facility or other location.
        • Safe evacuation from the hospital, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s); and primary and alternate means of communication with external sources of assistance.
        • A means to shelter in place for patients, staff, and volunteers who remain in the facility.
        • A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains the availability of records.
        • The use of volunteers in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated healthcare professionals to address surge needs during an emergency.
        • The development of arrangements with other hospitals and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to hospital patients.
        • The role of the hospital under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials.
      • Develop and maintain an emergency preparedness communication plan that must be reviewed and updated at least annually, which includes names and contact information for the following:
        • Staff
        • Entities providing services under arrangement
        • Patients’ physicians
        • Other hospitals and CAHs
        • Volunteers
      • The communications plan must also include contact information for the following:
        • Federal, state, tribal, regional, and local emergency preparedness staff
        • Other sources of assistance
      • The communications plan must identify primary and alternate means for communicating with the following:
        • Hospital’s staff
        • Federal, state, tribal, regional, and local emergency management agencies
      • The communications plan must provide a method for sharing information and medical documentation for patients under the hospital’s care, as necessary, with other healthcare providers to maintain the continuity of care.
      • The communications plan must provide a means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii).
      • The communications plan must provide a means of providing information about the general condition and location of patients under the facility’s care as permitted under 45 CFR 164.510(b)(4).
      • The communications plan must provide a means of providing information about the hospital’s occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.
    • Develop and maintain an emergency preparedness training and testing program that is reviewed and updated at least annually.
      • The training program must provide for:
        • Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role
        • Emergency preparedness training at least annually
        • Maintenance of documentation of the training
        • Demonstration of staff knowledge of emergency procedures
      • The testing program must provide for:
        • Participation in a full-scale exercise that is community-based or when a community-based exercise is not accessible, an individual, facility-based. If the hospital experiences an actual natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in a community-based or individual, facility-based full-scale exercise for one year following the onset of the actual event.
      • Conduction of an additional exercise that may include, but is not limited to the following:
        • A second full-scale exercise that is community-based or individual, facility-based
        • A tabletop exercise that includes a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan
      • Analysis of the hospital’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the hospital’s emergency plan, as needed.

To be honest, at first blush, I don’t see anything of particularly dire consequence (feel free to disagree; I’m always up for some civil—or uncivil—discourse) unless you’ve done a less-than-complete job of documenting your communications with the various and sundry AHJs (“The plan must include a process for cooperation with the various AHJs’ efforts to maintain an integrated response during a disaster or emergency situation, including documentation of the hospital’s efforts to contact such officials, and when applicable, its participation in collaborative and cooperative planning efforts.”). In fact, it will be interesting to see if TJC backs off of their caveat that tabletops don’t count towards the annual exercise requirement though, as you can see, the tabletop must include some very specific elements.

There is some additional language relating to provisions for stand-by and emergency power that includes providing for generator locations when you build new or renovate (who wants an emergency generator that could end up under water?); maintaining fuel sources during an emergency; testing components in accordance with requirements, etc., but, again, I’m not seeing a lot of indigestion-inciting language. I suppose it is possible that, at the end of all this (I mean, what’s left to tweak), there will be enough certainty in the regulatory fabric to promote a consistent application of the standards, etc. during surveys. Wouldn’t that be nice…

As plain as the nose on your emergency response plan…

Periodically, the whole concept of adopting plain language codes for emergency response plan activities/activations percolates to the top of somebody’s to-do list (I’d much rather embrace the concept of the to-don’t list, but that’s a discussion for another day). There was a little bit of that (more by inference than anything else) in the CMS follow-up report to the hospital response to Superstorm Sandy. Jeez Louise, that seems like eons ago…

This discussion always seems to engender a lot of back and forth, mostly regarding the balancing act of providing enough information to direct an appropriate response and not providing enough information to cause a panic. I recognize both sides of the argument, but I must say that I haven’t seen a lot of data to support a wholesale change, particularly as it would require a fair amount of education (and yes, I know that just because something requires education, etc., is not enough to forego adopting a new strategy, etc.). But I will also say that, depending on your organizational palette when it comes to emergency notification, all the different codes relative to workplace violence, active shooter, emergency assistance calls, etc., may well benefit from a more succinct announcement.

Recently, the Texas Hospital Association has weighed in with a recommendation to its members to adopt plain language codes, including a sample policy, an implementation timeline, and some examples (you can find that information here). It appears that there’s a move away from the (fairly standard, though not quite universal) Code Red designation for a fire alarm activation to the plainer language (though somehow not quite as sexy) “fire alarm activation.” It does appear that medical emergencies will remain as the (again, fairly standard, not quite universal) Code Blue (I guess that one’s gotten enough play on medically-oriented TV programs to have become part of the vernacular—where are the TV shows about safety in hospitals?!?), but there are some other terms that are worth of consideration. I don’t know that there’s necessarily a groundswell of support, but sometimes Texas can be something of a bellwether, so it may be a good opportunity to look at the possibilities, particularly if you haven’t in a while.

That said, I have two (relatively moderate) concerns. One being we are still waiting on the unveiling of the CMS final rule on all things emergency management; I had thought perhaps that pursuit had become somewhat dormant, but with the adoption of the 2012 edition of NFPA 99 excluding the chapter on emergency management, I think we have to believe that something regulatory this way comes. At any rate, will CMS push for some standardized notification language, particularly as a function of a focus on interoperable communications capabilities? I think that card has been dealt, I guess we’ll have to see how it gets played.

The other concern is the overarching concept of interoperable communication capabilities; I, for one, do not recommend you go about changing anything in terms of notification until you have some talk-time with the local emergency response authorities. They may or may not feel like they have a stake in this discussion, but you want to be absolutely certain that any modifications you might be entertaining will not somehow fly in the face of established protocols, language, etc. Isolationism, particularly when it comes to emergency management, is not likely to be a winning strategy as it usually requires the cooperation of disparate resources. So don’t forget to keep the community folks in the loop—you never know when they might come in handy!