Some behavioral health organizations got a surprise during their surveys this past year in the Environment of Care review. They received Requirements for Improvement related to their hazard vulnerability analysis and their emergency management drills. The issue was not that they had overlooked doing the emergency management drills. They had actually done the required number and type of drills they had always done in the past. The issue was that the drills they conducted were not related to the priorities they had identified on their HVA.
For example, one organization had identified a hostage situation as one of their potential emergencies in their HVA. Their program was located in a high crime area and a neighboring organization had recently gone through a hostage stand-off. The organization carried out two emergency management drills during the year: one for a severe snowstorm and one for a utility failure (same ones they had conducted the previous year.) The surveyor reviewed their EOC Committee minutes and asked if they had drilled on the hostage situation. Since they had not, he cited them as out of compliance with the following standard: EC.4.20 EP 6: "The organization regularly tests its emergency management plan. Planned exercises are realistic and related to the priority emergencies identified in the organization's hazard vulnerability analysis." (In the Hospital Manual, it's standard EM.03.01.03 EP 5.)
So, the take-away is to make sure that your drills relate back to the priorities that you identified in your HVA. Once you've identified a disaster scenario as a potential for your organization, you must develop a response plan and then conduct a drill on that response plan.
It's also important to remember that all emergency management drills must be critiqued. This is another area where organizations sometimes get caught short during surveys. What we're seeing on our clients' surveys is that surveyors are not just looking for a description of the drill in the EOC minutes. What they want to see is a documented critique of the drill which identifies:
- What worked well during this drill?
- What didn't work so well?
- What are the opportunities for improvement?
These results then need to be reviewed by the EOC Committee and adjustments made as needed to the Emergency Management plan.
It should be noted that Joint Commission standards do allow for an actual emergency to take the place of an emergency management drill. However, the response to that actual emergency must be critiqued in the same manner as a real drill. Too often, organizations overlook this part when counting their real emergency as a drill.
Finally, keep in mind that the HVA must be reviewed and updated annually. If needed, it should be modified based on any new emergency management issues that have been identified over the past year.
If you subscribe toTJC's Environment of Care News, see the September 2008 issue for the article "How to Perform a Hazard Vulnerability Analysis."