EIIP Virtual Forum Presentation — March 26, 2008

Joint Commission Emergency Management Standards Revisited
Healthcare Facility Accreditation Requirements for 2008

James L. Paturas, CEM, EMTP, CHS-IV, CBCP, FACCP
Deputy Director for Clinical Services
Yale New Haven Center for Emergency Preparedness and Disaster Response

Amy Sebring
EIIP Moderator

The following version of the transcript has been edited for easier reading and comprehension. A raw, unedited transcript is available from our archives. See our home page at http://www.emforum.org

[Welcome / Introduction]

Amy Sebring: Good morning/afternoon everyone. On behalf of Avagene and myself, welcome to the Virtual Forum! We are glad you could join us today.

Today's topic is titled "Joint Commission Emergency Management Standards Revisited." The reason we say 'revisited' is that we first addressed this topic during November of 2000. If you are interested in some additional background and history, you may want to check out that transcript at http://www.emforum.org/vforum/lc001122.htm.

Now it is my pleasure to introduce today's guest. James L. Paturas is the Deputy Director of the Yale New Haven Center for Emergency Preparedness and Disaster Response, (YNH-CEPDR) which provides coordination of emergency preparedness for Bridgeport Hospital, Greenwich Hospital, Yale-New Haven Hospital, Yale-New Haven Children's Hospital and Yale-New Haven Psychiatric Hospital.

He also serves as Director of the state designated Connecticut Center of Excellence for Bioterrorism and Emergency Preparedness at the Yale New Haven Health System and Associate Director for the Pan American Health Organization (PAHO) / World Health Organization (WHO) designated International Collaborating Center for Emergency Preparedness and Disaster Response (ICCEPDR).

Mr. Paturas has served as author, editor and contributor on over 30 medical texts and publications with a primary focus on emergency medicine and disaster preparedness. His professional activities are numerous and you can find additional biographical information on today's Background Page, [ http://www.emforum.org/vforum/080326.htm ] however, I would like to mention that he is currently serving on FEMA's National Advisory Council.

This is the second time we have been privileged to have Jim as a speaker. Last time was a little over a year ago, when he spoke about his program at the Yale New Haven Center. Also, please note that there is a link to the revised Standards that we will be discussing today, at http://www.naphs.org/documents/EmergencyMgtStandardsFinal.pdf.

Welcome back Jim and thank you for being with us today. I now turn the floor over to you to start us off please.


Jim Paturas: Thank you Amy. Since 2001 the Joint Commission has visited and debriefed a significant number of health care organizations that were impacted by a variety of events. This includes floods, utility outages, terrorist attacks, and hurricanes. The Joint Commission realized that hospitals can no longer plan for a single event. They need to be prepared to demonstrate sufficient flexibility to respond effectively to combinations of escalating events.

Based on these findings, the 2008 Joint Commission Environment of Care – Emergency Management standards continue to reflect the need to take an "all-hazards" approach to emergency preparedness. The rationale behind this approach is that is fosters both a flexible and effective response to a variety of events.

The 2008 standards also allow for a "scalable" approach to manage events that can involve variability in type, intensity, and duration for an individual hospital, numerous organizations or the community as a whole.

The standards continue to emphasize the importance of pre-planning and evaluation through drills, exercises and other methods of testing. New for this year is the need to develop plans for events where the hospital should not anticipate community support.

While the extent of the 2008 standards implementation can seem daunting to a hospital or healthcare facility, many of the elements contained in the standards are refinement of previously existing standards. There has been an attempt to refine and bring greater clarity to those that have existed.

Standard EC.4.10 has been replaced by standards EC.4.11 through EC.4.18. While these standards are new, many of the existing expectations have been relocated or moderately edited. Edits were made in response to organizations requesting clearer guidance in their emergency management planning efforts.

It is important that organizations have an understanding of their capabilities in meeting the six critical functions during varying conditions when their facility’s infrastructure, the community’s infrastructure, or both are compromised. Each of these six critical areas supports an "all hazards" approach that is not new but reorganized.

The six critical functions are:

• Communicating during emergency conditions.

• Managing resources and assets during emergency conditions.

• Managing safety and security during emergency conditions.

• Defining and managing staff roles and responsibilities during emergency conditions.

• Managing utilities during emergency conditions.

• Managing clinical activities during emergency conditions.

The following represent the new standards and because many of the standards have not changed I will list only the new elements that have been included under the Environment of Care section.


The organization plans for managing the consequences of emergencies.


• When developing its emergency operations plan, the organization communicates its needs and vulnerabilities to community emergency response agencies and identifies the capabilities of its community in meeting their needs.


The organization develops and maintains an Emergency Operations Plan.


The organization develops and maintains a written Emergency Operations Plan (EOP) that describes an "all-hazards" command structure for coordinating six critical areas within the organization during an emergency.

• The EOP identifies the organization’s capabilities and establishes response efforts when the organization cannot be supported by the local community for at least 96 hours in the six critical areas.

NOTE: The "96 hour rule" does not require hospitals to be able to sustain themselves without community support for 96 hours. It does not require hospitals to increase their fuel storage capacity, medical supply stores, food and provisions capacity and any other activity that it out of their routine to meet this requirement. It also requires hospital leaders and planners to understand and recognize the limitations of their resources, assets, utility systems and supply chain to stand alone for 96 hours.


The organization establishes emergency communications strategies.


• The organization plans for ongoing communication of information and instructions to its staff once emergency response measures are initiated.

• The organization plans for communicating with external authorities once emergency response measures are initiated.

• The organization plans for communicating with patients and their families during emergencies, including notification when patients are relocated to alternative care sites.

STANDARD EC.4.14 - The organization establishes strategies for managing resources and assets during emergencies.


• Potential sharing of resources and assets with health care organizations outside of the community in the event of a regional or prolonged disaster.

STANDARD EC.4.15 - The organization establishes strategies for managing safety and security during emergencies.


• The organization establishes internal security and safety operations that will be required once emergency measures are initiated.

• The organization identifies the roles of community security agencies (police, sheriff, national guard) and defines how the organization will coordinate security activities with these agencies.

• The organization identifies process that will be required for managing hazardous materials and waste once emergency measures are initiated.

• Controlling the movement of individuals within the health care facility during emergencies.

STANDARD EC.4.16 - The organization defines and manages staff roles and responsibilities.


• Staff are trained for their assigned roles during emergencies.

• The organization communicates to Licensed Independent Practitioners their roles in emergency response and to whom they report during an emergency.

STANDARD EC.4.17 - The organization establishes strategies for managing utilities during emergencies.


• Fuel required for building operations or essential transport activities.

STANDARD EC.4.18 - The organization establishes strategies for managing [patient] clinical and support activities during emergencies.


• Clinical services for vulnerable populations served by the organization, including patients who are pediatric, geriatric, disabled, or have serious chronic conditions or addictions; personal hygiene and sanitation needs of its patients; the mental health service needs of its [patient]s; and mortuary services.

• The organization plans for documenting and tracking patients’ clinical information.

STANDARD EC.4.20 - The organization regularly tests its emergency operation plan.


• At least one exercise a year is escalated to evaluate how effectively the organization performs when it cannot be supported by the local community.

NOTE: Tabletop sessions are acceptable in meeting the community portion of this exercise.

• During planned exercises, the hospitals monitor the six critical areas. What has been added in the 2008 standards are the need to include safety and security, staff roles and responsibilities and utility systems.

That completes the traditional EOC EM standards.

While most of the emergency management standards can be found in the Management of the Environment of Care section there are a number of disaster related elements that have been included in other sections. Therefore, depending on the organizational and reporting structure within your hospital, it is important that the Emergency Management Coordinator and or the Emergency Management Committee be aware of these and have a method for ensuring that the standards are in place and that they are being monitored. These include:

STANDARD IC.6.10 - The hospital prepares to respond to an influx of infectious patients.


• The hospital determines its response to an influx or risk of an influx of infectious patients or refers to other facilities/resources.

• If the hospital will continue to accept or treat patients, then the hospital has a plan for managing an ongoing influx of potentially infectious patients over an extended period.

• Determines how to keep abreast of current information about the emergence of epidemics and new infections, which may result in the hospital activating its response (i.e. syndromic surveillance).

• Determines how it will disseminate critical information to staff and other key practitioners.

• Identifies recourses in the community (through local, state and/or federal public health systems) for obtaining additional information and access to resources (ECS/MRC).

STANDARD HR.1.25 - The hospital may assign disaster responsibilities to volunteer practitioners.


• The hospital identifies in writing the individual(s) responsible for assigning disaster responsibilities.

• The hospital describes in writing a mechanism (for example, direct observation, mentoring and clinical record review) to oversee the professional performance of volunteer practitioners who are assigned disaster responsibilities.

• Primary source verification of licensure, certification or registration (if required by law and regulation to practice a profession) begins as soon as the immediate situation is under control, and is completed within 72 hours from the time the volunteer practitioner presents to the organization.

• The hospital oversees the professional practice or services of volunteer practitioners.

• The hospital makes a decision (based on information obtained regarding the professional practice of the volunteer practitioner) within 72 hours related to the continuation of the disaster responsibilities initially assigned.

• The hospital has a mechanism to identify volunteer practitioners that have been assigned disaster responsibilities (ECS/MRC).

• For volunteer practitioners to be assigned disaster responsibilities, the hospital obtains for each volunteer practitioner at a minimum, a valid government-issued photo identification issued by a state or federal agency (e.g. drivers license or passport) and at least one of the following:

- Primary source verification of licensure, certification or registration (if required by law and regulation to practice a profession) (i.e. MRC).

- Identification indicating that the individual is a member of a Disaster Medical Assistance Team (DMAT*), or MRC, ESAR-VHP, or other recognized state or federal organizations or groups.

- Identification indicating that the individual has been granted authorization to render patient care, treatment and/or services in disaster circumstances (such authority having been granted by a federal, state or municipal entity).

- Identification by current organization member(s) who possesses personal knowledge regarding the volunteer practitioner's qualifications.

STANDARD HR.2.20 - Staff and licensed independent practitioners describe or demonstrate their roles and responsibilities relative to safety.


• Staff and licensed independent practitioners as appropriate, can describe or demonstrate procedures such as use of PPE, evacuation, etc. to follow in the event of an incident

STANDARD IM.2.30 - Continuity of information is maintained.


• The hospital has a business continuity / disaster recovery plan for its information systems.

• For electronic systems, the business continuity / disaster recovery plan included the following:

- Contingency plans for operational interruptions (hardware, software or other systems failures).

- A back-up system (electronic or manual) business continuity/recovery plan.

- The plan is tested periodically as defined by the hospital (or in accordance with law or regulation) to ensure that the business interruption back-up techniques are effective.

- The business continuity / disaster recovery plan is implemented when information systems are interrupted.

Lastly, beginning in January 2009 the Joint Commission will be establishing the Emergency Management standards as part of their own chapter that is currently titled Emergency Management. In the draft document that was disseminated the Joint Commission has taken the HR 1.25 elements and incorporated them into the new chapter. They recently posted on their website a call for "comment" on the proposed chapter elements. They are accepting these comments via the web, email or direct mail. The focus of the review should concentrate on the following:

Do any of the proposed standard revisions appear to contain new requirements?

Are the proposed standard revisions clear?

Are the proposed standard revisions applicable to your service area or setting? (please state your service area or setting)

Are the proposed standard revisions essential to quality and safety of care in your service area or setting?

Are there any requirements proposed for deletion that should be retained?

As you can see the Joint Commission continues to evolve the emergency management standards and make them a high priority for hospitals and healthcare organizations. Thank you for taking the time out of your busy schedules to spend with us today.

Amy Sebring: Thanks very much Jim. Now, to proceed to your questions or comments. If you already have direct experience with incorporating these standards into your planning efforts, we would be interested in hearing about that as well.

[Audience Questions & Answers]

William Cumming: Mr. Paturas, perhaps you could discuss whether your hospitals are profit making or non-profit hospitals? Does this impact the planning and preparedness activity? Funding stream? Annual budget or grants?

Jim Paturas: The YNHHS is a NPO 501C3 organization. It does impact the planning in that over the past six years we have been standardizing our plans, education, drills and ongoing assessments. Funding comes from a variety of sources from the state, feds, private and health system.

Amy Sebring: Jim will you follow up please more generically on how the Joint Commission standards impact hospitals generally?

Jim Paturas: The JC standards are currently in about 5,000 hospitals nationwide. That leaves about 1,000 or so that use CMS [Centers for Medicare & Medicaid Services] for their accreditation.

Gail Meyer: Do all six critical areas need to be exercised in every drill?

Jim Paturas: Yes, in a recent discussion with the Joint Commission, they made it clear that the six critical elements must be covered in each exercise.

Scott Tanner: What do you see as the significance of the Joint Commisssion pulling the EM standards out of the EOC chapter to "stand alone"? Is it solely to consolidate all the EM related elements?

Jim Paturas: In speaking with the Joint Commission, the separation of the EM standards sends a message of their continued importance by the Joint Commisssion and sends a message to hospital and healthcare leadership that it must remain a priority for them also.

Heartbeat_Beacon: Could you expand on the term "syndromic surveillance" please?

Jim Paturas: Syndromic surveillance is the ability to use real-time data sources to track the flow and impact of emerging infectious diseases.

Becky Grizzle: If the hospital is small and rural, how stringently do the standards have to be met, when it appears some target larger urban settings.

Jim Paturas: One of our system hospitals is a small 150 bed community hospital, and when the Joint Commission does their site visit (probably next week) they are held to the same standards.

Scott Cormier: Jim, I'd like to encourage the attendees to carefully review the Emergency Management Standards Improvement Initiative. While we're all adapting the new standards that came into effect Jan 1 of this year, the improvement suggestions seem to change some of these standards. As a large for profit system (HCA) the Joint Commission requirements don't change for us, although the Stafford Act does have somewhat of an impact.

Jim Paturas: I agree with the suggestion about the Improvement Initiative.

[http://www.jointcommission.org/Standards/SII/ . Scroll to end of table for Emergency Management Standards ]

William Dunne: In the past our institution has utilized an Emergency Management Plan with Performance Improvement Initiatives. How should this be reflected (if at all) in the new standards? Should performance improvement only be initiated by exercise feedback?

Jim Paturas: During two recent site visits, the Joint Commission first used the EM PII to review where the facility was, is, and is planning to be. They then conducted a discussion-based tabletop exercise to test the hospitals understanding of its plans.

Tom Bowman: My question pertains to using DMAT personnel or MRC personnel as volunteer practitioners during a disaster; is the intent for the hospital to cover the liability for the volunteer provider?

Jim Paturas: Hopefully not. In some states (i.e. CT) a bill was passed that stated that once a declared disaster was in effect all members of the emergency credentialing program would become members of the MRC and as such have liability and workers comp coverage.

Ric Skinner: A survey I and my colleagues conducted last summer with the support of the Business Continuity Planning Workgroup for Healthcare Organizations revealed little standardization across hospitals & healthcare facilities re: with whom and where in the organization EM/DP/DR responsibilities are placed. Have you found a similar trend?

Jim Paturas: Yes, traditionally many DR programs are still run out of the IT departments. In some cases they have consolidated all EM/BCP/DR related activities under one department.

Anthony Barton: How will JCAHO survey the EM standards?

Jim Paturas: We just completed two site visits in the last six weeks and have one left. In each case, the first part of the site visit followed the traditional approach of the seven EOC areas being together and discussion of their plans including PII. They then excused most of the members and conducted a discussion-based tabletop with the key members of the command /ICS/ HICS staff. In each case it took approximately three hours of time.

J. R. Thomas: Mr. Paturas, does the JCAHO make any specific recommendations or requirements for children in a hospital setting?

Jim Paturas: The Joint Commission does require that organizations manage clinical services for vulnerable populations; that includes children.

Dawn Rougeux: Just to be absolutely clear about volunteers: if a volunteer is an MRC or ESAR-VHO volunteer (and the State has done primary source verification of credentials), then a hospital is not required to do another primary source verification. Correct?

Jim Paturas: Based on the Joint Commission standard, I believe it is the responsibility of the hospital to do a source verification within 72 hours of the event. The Joint Commission also wants to see this referenced in the Medical Staff bylaws.

Matthew Butler: Just to clarify, tabletop exercises are acceptable to the the Joint Commission if we address all six elements?

Jim Paturas: At this time tabletop exercise can only be used to support the community involvement portion of the hospital responsibility. It cannot be used as one of the two required events. There apparently is some discussion at the Joint Commission to reevaluate this.

Rich Henry: We had our Joint Commission survey in February and a physician conducted the EC portion -- not the Life Safety surveyor like we expected. It lasted an hour with the focus on EM but it wasn’t that difficult. With the addition of the new EM chapter do you think that will change to a dedicated EM surveyor?

Jim Paturas: As you know, we are always at the whim of a particular surveyor. Since there are over 500 surveyors and they have a broad area to cover (in terms of the various standards), it is hard to get any one individual familiar with just EM. I have not heard anything to date, but would not be surprised if we see this kind of transition in the future.

Scott Tanner: I understand that there are stricter interpretations coming in 2009 for the Leadership Chapter as well. Hospital leaders will be required to demonstrate their involvement in the EM program as opposed to just knowing that it exists. This is a good opportunity for us, EM professionals, to educate our hospital leaders and have them provide the active role required for the EM plans and processes to succeed. I remind our staff that every person is an emergency manager and many are uncomfortable with the seemingly new role and expectations. Are others seeing this?

Jim Paturas: That is correct. Not only will they be required to be more involved in EM, but they will also be held accountable. It is my understanding that this requirement for hospital leadership will be across the board for all of the standards.

Scott S Thresher: We had a recent JC tracer accomplished in Feb with the new standards. I have addressed the areas and had a plan of action to become fully compliant. The surveyor was satisfied with this response and realized the new standards became effective Jan 1, 2008.

Jim Paturas: I have heard a similar story. I also heard (but not verified) that after June of 2008, the surveyors will hold institutions to the standards more closely than they are now because of the Jan 1, 2008 date.

Craig Kampmier: What differences do you see in the application of EM standards in LTC facilities vs. hospitals, aside from the obvious, i.e. hospital emergency departments, hospital bed availability?

Jim Paturas: Drills and exercises for one.

William Dunne: There is lots of anxiety around the 96 hours concept. Could you provide an example of how to address this for a specific area (i.e., supplies, water)?

Jim Paturas: What the Joint Commission has made clear is that they want institutions to identify where their points of failure are. As an example if your facility can only support water disruption for 60 hours, then that is OK, so long as your next step is to consider how you will function without it. Will you relocate or evacuate?

Amy Sebring: Or shut down? Right?

Jim Paturas: Possibility.


Amy Sebring: That's all we have time for today. Thank you very much Jim for an excellent job. We hope you enjoyed the experience once again and we really appreciate it. Please stand by just a moment while we make a couple of quick announcements.

Before we adjourn, please take a moment now, or after you review the transcript to Rate today's session and/or write a review or post your comments. You can access the form either from today's Background Page or from our home page. If you do not have time to write a short review or comment, then please just take a moment to do the rating. It should take less than a minute, and will assist future visitors to our site to find useful information.

We are pleased to announce THREE new Partners today: The Stoneybrook Group; POC: Ric Skinner, GISP, Chief Innovator & Spatialist. Ric's Website is http://www.healthgisguy/. "The Stoneybrook Group was established to provide innovative consulting services to hospitals, healthcare and healthcare preparedness sectors at the local, regional and national levels."

Ric would like to make a short announcement at this point. Go ahead please Ric.

Ric Skinner: Thanks, Amy. As I mentioned earlier, a survey conducted last summer on healthcare preparedness at US healthcare facilities revealed little or no standardization and considerable confusion on Hazard Vulnerability Analysis methods and processes.

A new survey on HVA is underway and can be accessed at http://www.surveymonkey.com/s.aspx?sm=AdxUKB_2baOksoeRFW0JPksw_3d_3d. Please participate and pass along the link to others. The results of previous surveys are at http://www.bcpwho.org.

Amy Sebring: Our next new partner is Readiness Resource Group, Inc.; URL: http://www.readinessresource.net; POC: Robert J. Coullahan, President; "Providing solutions for enterprise resilience and infrastructure security."

Our third new partner is Ingham Regional Medical Center (IRMC); URL: http://www.irmc.org; POC: Byron Callies; "Ingham Regional Medical Center, Lansing, Michigan is a community-based, university-affiliated teaching hospital, rated among the top 5% nationally among non-government, acute care hospitals by HealthGrades for quality care and clinical excellence."

Welcome to you all! Becoming an EIIP Partner is a way to show your support for what we do, and possibly help us to keep the services we provide available to you. It is easy to do; see the link to Partnership for You from our home page, and complete the simple form provided.

Thanks to everyone for participating today and all the excellent questions! We stand adjourned but before you go, please help me show our appreciation to Jim for a fine job.