J
oint Commission Standard EM.03.01.03 requires organiza- tions to conduct regular emergency exercises that fully evalu- ate their Emergency Operations (Management) Plans—
verifying appropriateness, adequacy, and effectiveness. Historical- ly, organizations across all programs struggle to meet this standard’s requirements—and for the first half of 2014, it has the highest percentage of noncompliance of any Joint Commission standard.
The following checklist distills the EPs in this standard. It’s de- signed to help your organization improve how it tracks emergency exercises and how it evaluates performance on those exercises. You can use it to verify compliance and guide how you conduct your emergency exercises.
unless otherwise indicated in parentheses after the task description.
Download this tool at: https://www.jcrinc.com/assets/1/7/ECN0415_checklist.xls
TASK | Completed | In Progress | Completion Date | TASK | Completed | In Progress | Completion Date | |
Before the Drill | During the Drill | |||||||
Drill Timing | Communication | |||||||
Conduct an Emergency Operations Plan/Emergency Management Plan exercise twice per year (AHC, CAH, HAP, LAB, NCC) [Note: Actual emergencies can take the place of emergency exercises.] | Review and verify internal communication | |||||||
Staff communication | ||||||||
Patient communication | ||||||||
Content is clear and appropriate | ||||||||
Conduct an Emergency Operations Plan/Emergency Management Plan exercise once per year (BHC, OBS, OME) | ||||||||
Review and verify external communication | ||||||||
Vendors/suppliers | ||||||||
Contracted providers | ||||||||
Drill Characteristics | ||||||||
Other health care organizations | ||||||||
Address likely disasters, such as those outlined in the hazard vulnerability analysis | ||||||||
County emergency operations | ||||||||
Local government | ||||||||
Stress organization preparedness limits to uncover potential gaps | ||||||||
Police | ||||||||
Local public health department | ||||||||
Include an influx of simulated patients in at least one exercise (AHC, CAH, HAP, OBS) | ||||||||
Fire department | ||||||||
Resources and Assets | ||||||||
In at least one exercise, include an escalating event in which the local community cannot support the health care organization (CAH, HAP) | ||||||||
Monitor how the organization allocates and mobilizes medications | ||||||||
Monitor how the organization allocates and mobilizes supplies, medical and nonmedical, including personal protective equipment | ||||||||
Include communitywide drill participation in at least one exercise (CAH, HAP) | ||||||||
Do not use tabletop drills, except when simulating the community portion of an escalating drill | ||||||||
Monitor how the organization allocates and mobilizes transportation | ||||||||
Drill Responsibility | ||||||||
Safety and Security | ||||||||
Assign one person to monitor and document drill performance and improvement opportunities Name: Title: | ||||||||
Verify that security is appropriate and in place, internally and externally | ||||||||
Conduct rounds, if possible, noting safety hazards | ||||||||
Staffing | ||||||||
Confirm that there are unambiguous staff roles and responsibilities, including for licensed independent practitioners | ||||||||
Confirm that staff, including licensed independent practitioners, understand and can fulfill their roles and responsibilities | ||||||||
Make sure that the individual is knowledgeable the exercise’s goals and expectations | ||||||||
(continued on page 11)
Compliance Checklist for EM.03.01.03 (continued from page 10)
TASK | Completed | In Progress | Completion Date | TASK | Completed | In Progress | Completion Date | |
Utilities | Seek input from staff involved in the exercise about what went well and what might be potential improvement areas | |||||||
Check that utilities are functioning properly | ||||||||
Check that staff understand and can execute emergency shut-down procedures | ||||||||
Document deficiencies and improvement opportunities | ||||||||
Patient Care | Share deficiencies with the environment of care improvement team | |||||||
Make sure clinical activities continue and are not compromised | ||||||||
Create a plan to address any deficiencies before the next drill | ||||||||
Make sure support activities continue and are not compromised | ||||||||
Ensure that interim measures are in place until the deficiency is resolved | ||||||||
After the Drill | ||||||||
Evaluation | Respond to problematic issues identified in the exercise | |||||||
Evaluate the drill using a multidisciplinary process (including physicians) | Make any necessary modifications to the Emergency Operations Plan/Emergency Management Plan | |||||||
EC