Why Do Emergency Management Reviews?

Past surveys regarding emergency management have been deemed just another hurdle to overcome to meet regulatory needs. The standards were merely seen as a checkbox to fill. Recently with the pandemic, we’ve realized the processes put in place are there for a reason and many hospitals adjusted accordingly.

As you can imagine, emergency management is a trending topic during accreditation surveys. There will continue to be a focus on emergency management now and in the future as additional regulations are added. This raises the question, are emergency management reviews even necessary? The answer is YES!

In the past, many hospitals just concentrated on the haz-mat portion of the review and did drills based upon decontamination situations. Partially, this was due to the increased concern of global accessibility of biological/chemical agents. Additionally, grants were given to increase Hospital Emergency Response Teams which also dictated the focus.

Now with hospitals being completely retooled to deal with pandemics for such a long period of time, your entire EM process will come under scrutiny during the emergency management session. So here are some areas to check on during your EM review:

1. Look at your disaster privileging process and ensure everything is being done correctly. Remember the individual must be validated within 72 hours and make sure that the correct government identification was used during the initial privileging process.
2. Ensure your policies on air handling maintenance are current and correct. Follow up on your PM schedule to make sure that it matches what your policy says.
3. Identify the areas that have been overlooked in emergency management. Specifically focus on parts that were underutilized or not utilized at all and make sure they are up to date (i.e. 1135 waiver process).
4. Make sure your after-action reports for the pandemic are correct. This will be a focal point during your survey and will be validated.
5. Ensure you have plenty of documentation of your correspondence with local and state agencies to meet (EM 02.02.01 EP 22). At this time everyone has had correspondence with local coalitions, so you will be expected to present it.
6. Update your HVA to make sure it is current prior to your annual evaluation. This will demonstrate that you are already actively improving upon your EM program.

The key with surveys is being able to accurately show through documentation that your program is in place and active. Not just an area always talked about with no action. Remember to utilize a third party if you can to help with an extra set of eyes during these busy times. A third party will also keep you from searching for items related to a regulatory standard. Utilize every resource available to you and make sure your network of individuals are well versed in the field to help you stay on course. Utilizing your resources keeps you from reinventing the wheel.

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