TJC introduces new EM survey process

The Joint Commission’s (TJC’s) new Emergency Management (EM) Chapter went into effect last year. Although the standards have changed, the overriding concepts remain the same. The program following an “all-hazards approach” was reviewed in the September 2022 Health Facilities Management article titled “Comprehensive emergency management programs.” 

 Hospitals should note that 49 of the 60 (down from 124) elements of performance (EPs) require written documentation. Further details of the EPs can be found in the American Society for Health Care Engineering’s Emergency Management Checklist.

Another change is a new four-part survey for EM sessions. The sessions are 60-90 minutes and focus on how effectively an organization’s multidisciplinary team uses its emergency operations plan:

Part 1. The team describes how real events over the past 12-36 months impacted the organization, how it used its hazard vulnerability analysis and how the six critical areas were used to prepare for these events.

Part 2. The team demonstrates robust planning and preparedness efforts. The hospital describes emergency exercises it recently conducted, which should be based on past experiences, known risks and hazards, and recent changes to its emergency operations. Hospitals should be prepared to describe these exercises as occurring at the frequencies of one annual operations-based exercise; and one annual exercise of choice, either an operations-based or discussion-based exercise.

Part 3. The discussion and documentation provided by the team should demonstrate a comprehensive program for staff education and training. The program must include initial and ongoing EM education for all staff and specific education for the incident command roles.

Part 4. The new EM standards require a comprehensive evaluation by the multidisciplinary EM committee, with recommendations and opportunities for improvement forwarded to senior leadership for action. This ensures the organization applies lessons learned to mitigate the effect of future emergencies.

Edward M. Browne CHFM, CHC, FACHE, EC/LS consultant, Joint Commission Resources.