Just a quick look at social media or at a news resource can make you keenly aware of the threats healthcare workers and patients could face from Mother Nature and human-caused incidents. With epidemics, extreme weather, active shooters, and so many other dangers, the best chance for a successful outcome will come with preparation.

One way to better prepare for an emergency is through performing practice drills. The brain learns by repetition, so drills performed on a routine basis will help the necessary actions become second nature. By conducting post-drill evaluations, you can determine the readiness of staff and the organization to respond to a crisis.

Part of your emergency planning should come from conducting a Hazard Vulnerability Analysis. This will help you identifying the probability and risk potential for adverse events.

ACHC Standards

The Accreditation Commission for Health Care (ACHC) Standards Manual addresses emergency preparedness for office-based surgery centers:

Standard 07.00.01: Emergency Management

The organization must comply with all applicable federal, state, and local emergency preparedness requirements. The organization must develop and maintain an emergency preparedness program that meets the requirements of this chapter through an all-hazards approach.

The emergency management program must include:

• Planning (including a risk assessment and Hazard Vulnerability Analysis for emergencies).
• Written plan, along with written policies and procedures.
• Training and testing.

Standard 07.00.02: Hazard Vulnerability Analysis

The organization conducts a documented, facility-based, and community-based risk assessment (i.e., Hazard Vulnerability Analysis) to ascertain not only conceivable threats and disasters that could affect the organization’s ability to operate facilities or to provide services to its patients, but also the probability of those events occurring.

The organization must identify likely hazards for its community service area (e.g., natural disaster; bioterrorism threats; disruption of utilities such as water, sewer, electricity, communications, and fuel; nuclear accidents; industrial accidents; and other likely mass casualty events) and develop appropriate responses that will ensure the safety and well-being of patients.

The HVA must be documented and reviewed by the governing body for relevancy and accuracy annually.

The organization must share its HVA with its community partners to help set priorities with the HVA. Community partners may include:

• Department of public health.
• Department of public safety.
• Department of public works.
• Local municipality representatives.
• Other government agencies.
• Community organizations.
• Other healthcare organizations.

Standard 07.00.03: Emergency Operations Plan

A written Emergency Operations Plan (EOP) must be developed, maintained, and made available to the staff for crisis preparation and response.

• The EOP must be based on the priorities established in the current Hazard Vulnerability Analysis (HVA) and must include strategies for addressing emergencies identified in the HVA.
• Policies and procedures for emergency management are based on the EOP and the HVA.
• The EOP must be integrated into the organization’s Quality Assurance Performance Improvement (QAPI) plan.

Standard 07.02.01: Emergency Training

The organization must develop and maintain training that is based on the Emergency Operations Plan and related policies and procedures.

The organization must:

• Provide initial training in emergency management policies and procedures to all new and existing staff and to individuals providing on-site services under an arrangement consistent with their expected roles.
• Provide emergency management training annually and whenever the emergency plan is significantly updated.
• Maintain documentation of all emergency management training.
• Demonstrate staff knowledge of emergency procedures.

Standard 07.02.02: Emergency Exercises

These are the emergency exercise requirements for office-based surgery centers:

• The organization must conduct quarterly fire exercises.
• The organization must conduct one exercise (in addition to the fire response exercises) annually to test the emergency plan.
• If the organization experiences an actual natural or human-caused emergency that requires activation of the emergency plan, the organization may use the event to meet the requirements for an emergency exercise if the organization prepares an evaluation and after-action improvement plan after the event.

Tips for Compliance

Meaningful participation helps everyone understand their role in handling an emergency.

• Look for barriers during your drills, and develop steps to avoid them.
• Ensure leadership is involved.
• Invite your local city or county emergency responders and subject matter experts.
• Evaluate your drill response, develop your after-action plan, and update your Emergency Operations Plan, as necessary.
• Eliminate any unnecessary steps from your plans.

Resource

Healthcare organizations often develop their own Hazard Vulnerability Analysis (HVA) tools. Here is one example: https://www.fhca.org/facility_operations/hazard_vulnerability_analysis_tool

Here to Help

For access to the most recent ACHC Office-Based Surgery Accreditation Standards Manual, contact your Account Advisor or email us at [email protected].