by Joseph V. Bellino, MS, CHPA, CHEM
Accreditation Advisor

On any given day, hospitals must be prepared to manage whatever emergency situation comes their way. From tornado and earthquake recovery to active shooter situations and cybersecurity threats, regulations and standards are established to cover a wide range of circumstances. During this global pandemic, when stress levels are high, adherence to requirements set in place by the Centers for Medicare & Medicaid Services (CMS) Conditions of Participation: Emergency Preparedness can feel particularly daunting.   

To quickly and effectively manage emergencies when they happen, I’ve identified five of the most challenging components of the emergency preparedness requirements for health care organizations, along with recommendations for how to succeed most effectively in each of these areas.

  1. Engage leadership in the emergency operation plan (EOP) development. How an organization responds and recovers from a disaster starts with the EOP. In addition to using an all-hazards approach that focuses on capacity and capabilities, the most effective plans are built with all hospital and department leaders, including medical staff, actively participating in its development. Challenges such as a process for evacuation, sheltering in place and medical record preservation, availability, and confidentiality can be addressed most efficiently and effectively with leadership involvement. The plan must be regularly reviewed, maintained and updated at least every two years.
  2. Have a self-sustainability plan. The first four days of a disaster are critical. Organizations must be able to demonstrate a self-sustainability plan of their capabilities for the first 72 to 96 hours following activation of the EOP. The extreme difficulty of sustaining health care delivery is evident in our current response to the COVID-19 pandemic. We have learned how vulnerable the supply chain is when the entire world is involved in an emergency. Re-examine your 72-to-96 hour plans based on the review of recent events and how well the organization responded to them.
  3. Conduct a hazard vulnerability analysis (HVA). In order to identify risks that are most likely to have an impact on your health care facility and community, completing an HVA is a critical step. A CMS requirement, this process assesses the probability of each type of event, the risk that it would post and your organization’s current level of preparedness.
  4. Conduct robust drills. Hospitals are required to conduct two emergency exercises or drills annually. In order to be most effective, drills should involve the community to help build local support and confidence in your health care organization. In addition to engaging the community, drills should focus on a likely scenario that includes an escalating event that challenges the routine resources of the organization. Conducting robust, realistic emergency exercises ensures a higher level of preparation for all parties.
  5. Understand the licensed independent practitioner (LIP) process. Prior to an event that requires additional staffing, health care organizations must understand and be prepared to implement the process for granting disaster privileges to LIPs. Mandatory steps in this process include: written identification of the party responsible for granting disaster privileges; two forms of ID from each LIP prior to eligibility; privileges are granted upon EOP activation; and clear differentiation between volunteer and other LIPs, perhaps through a separate and distinct identification badge.

To recap, involve leadership and key stakeholders in the emergency planning to ensure robust development of all requirements; not just to satisfy regulatory approval, but because it’s the right thing to do. Don’t neglect reviews of plans, inventories and objectives. A plan only works if it’s current, so remember to keep it fresh.

Finally, Vizient is here to help. Visit our COVID-19 resources page and know that we are always available to help you prepare — ideally before disaster strikes again.

About the author. Joseph Bellino has more than 30 years of leadership experience in health care safety, security, environment of care, emergency management, hospital law enforcement, facilities, and construction. He also served as a safety officer, volunteer firefighter and a certified fire inspector. Additionally, Bellino served as a narcotics detector dog handler in the U.S. Air Force, and a municipal police officer where he developed community crime prevention programs, as well as budgeted and implemented a police canine program. He rose to the rank of police chief, and also served as a special agent at the Department of Justice. He served for 10 years as a member of several Department of Homeland Security and Health and Human Services committees and was co-chair of the Joint Advisory Working Group on health care security.