Transcript Val Verde Regional Medical Center Del Rio, Texas
Survey Readiness Emergency Preparedness: Contingency Planning for Whatever Happens
Carol Tuminaro, RN, MBA, HRM Senior Manager, Clinical Operations May 16, 2012
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5 Carol Tuminaro, RN, MBA, HRM Senior Manager, Clinical Operations With over 15 years of healthcare consulting, Carol’s clients value her in depth knowledge of risk management, quality/process improvement, core measures, survey processes, regulatory requirements and accreditation standards. Carol identifies critical issues to help hospitals achieve compliance with state and Joint Commission accreditation standards, as well as CMS Medicare Conditions of Participation regulations. Carol provides health care organizations with practical suggestions and tools to help clients achieve compliance, maintain readiness for unannounced regulatory and accreditation surveys and respond to any identified deficiencies. Carol earned her master’s degree from Rosary College, St. River Forest, IL; and her bachelor’s degree from The College of Saint Francis, Joliet, IL. Carol is certified in Healthcare Risk Management and Quality.
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Greetings and Introductions
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The Four Phases of Emergency Management
Mitigation Usually occurs before an emergency Preparedness Usually occurs before an emergency Response Occurs during and after an emergency Recovery Occurs during and after an emergency
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Emergency Management
An “emergency” is defined as “an unexpected or sudden event that significantly disrupts the organization’s ability to provide care, or the environment of care itself, or that results in a sudden, significantly changed or increased demand for the organization’s services”
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Emergency Management
A “disaster” is a type of emergency that, due to its complexity, scope or duration, threatens the organization’s capabilities and requires outside assistance to sustain patient care, safety, or security functions.
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The HVA and EOP
HVA – A Hazard Vulnerability Analysis Identifies the potential emergencies Identifies the likelihood that they will occur Identifies the consequences of the event EOP – Emergency Operations Plan Based on information in the HVA An EOP is developed by the: o Hospital Leadership Team o Physician Leaders
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The HVA and EOP
The EOP should be designed to provide care to patients for 96 hours Review the HVA and EOP Annually
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Hospital Command Center
Remaining prepared for a disaster and survey: As part of the Emergency Operations Plan: Create a HCC cabinet that contains essential supplies: Design this cabinet to be mobile (on wheels) Store this cabinet in a safe place Keep this cabinet locked when not in use to ensure supplies are not removed
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Being Prepared for Survey
The surveyor will ask the Safety Officer: How did the organization create its HVA?
o Multidisciplinary team o A committee meets annually to review the document and makes necessary changes Who is involved in the HAV committee?
o Senior Leadership o Community Partners Local Police and Fire Department, other Emergency Preparedness Personnel Other healthcare and community organizations
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Keep Manuals/Plans up to Date
Update manuals/plans as regulatory standards change Assure that appropriate staff are educated to the changes in the plans Do not refer to staff by name in these documents, refer to positions, i.e. Plant Manager not Tom Smith Plans are multidisciplinary in nature with teams from several disciplines Example: The Emergency Operation Plan command structure needs to be integrated and consistent with the community’s command structure.
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For Emergency Management
In an effort to remain readiness prepared the organization must be able to show surveyors documentation regarding their ongoing ability to manage these areas: Communication Resources and assets Safety and Security Staff responsibilities Utilities Patient clinical and support activities
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To Ensure Emergency Readiness
Review and Update Mutual Aid Agreements Letters of support from vendors in the community o Where will you get portable water o Who will supply personal hygiene products Agreements with community organizations o Alternative locations to house patients such as schools or churches Agreements for assistance from neighboring States These need to be reviewed / revised annually
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Keep Readiness Activities Robust
The EOP includes a documented inventory of the available resources to ensure ongoing communication. This list includes the following: Cell phones Landlines Bulletin boards Fax machines Satellite phones Amateur Radio Operators
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Keep Readiness Activities Robust
The EOP includes a documented inventory of the available resources and assets. This list includes the following: PPE- personal protective equipment Water Food Fuel Medical supplies Generators
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Survey Readiness
Be prepared to provide the surveyor with: A written inventory of the resources for each of the six critical areas of Emergency Management mentioned in slide #14 A description of the processes to initiate and terminate response and recovery efforts A list of alternative care sites, how these were chosen and in what situations they would be put into use Instances / drills when these sites were utilized
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Staff Preparedness
Nursing should be prepared to discuss: The top emergencies, identified in the organization’s HVA plan How the organization has prepared to manage these situations What is her/his role in any of these emergency situations How are they informed of the identified emergencies in the HVA and their role in responding
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Staff Preparedness
Provide training to staff to ensure their emergency ready at home to allow them to assist at work Ensure they have access to supplies to allow their families support while they report to work Child care areas / older adult care for staff’s families to keep them safe while they report to work
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Disaster Preparedness
Disaster Privileging: Does the EOP identify: Who is responsible for granting disaster privileges to volunteer licensed independent practitioners Does the documentation from the drills contain: A process to assess the performance of the volunteer LIP to determine if the facility will continue to grant disaster privileges to these individuals
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Disaster Preparedness
Review plans and processes annually Evaluate if there are any new threats to the facility (i.e. a new chemical plant in the area) Meet with community organizations on an annual basis to review the HVA and EOP Document any changes Include a review of the HVA and EOP in ALL employee competency/inservices held annually Review all Disaster Drills with ALL staff to ensure awareness and understanding of the processes
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Conduct Mock Tracers
Interview staff at all levels of the organization to ensure there is understanding of roles they have if a disaster occurs Specifically perform a mock interview with: The incident commander who is prepared to respond to: o How is the command center activated, set up and equipped Incident Command Team Members o What are their roles o Where are they stationed
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Conduct Mock Tracers
Staff on patient care units o Where is the command center located o Who is stationed there o What is their responsibility during a disaster Safety Officer o How was the HVA created o How is the HVA used to define mitigation and preparedness activities o How is the content and recommendations communicated and coordinated within the community
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Conduct Mock Tracers
Chief of Medicine o Who is responsible for granting disaster privileges to volunteer licensed independent practitioners o How and where does the organization document this responsibility o How does this process work, when and who can be granted disaster privileges o How is their licensure verified o Who is responsible for oversight of the care they provide o How are the volunteers identified
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Annual Review
One final reminder:
Perform an annual review of the HVA to ensure it remains appropriate, add any new threats, new industry or activities in the community Perform an annual review of the EOP, again identifying any new threats/issues in the community
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Keep Information in Front of Staff
Post survey readiness information Posters in patient care areas Bulletin boards Streaming television Electronic bulletin boards Pay check stuffers Laminated cards to attach to ID badges Cafeteria table tents
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Prepare for Staff Participation
Consider who from your organization will participate in each session Document the staff member’s name and phone number on a grid Identify meeting locations that will accommodate the size of the group Educate your staff about these sessions as well!
Develop your “plan B” in case key staffers might not be available
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Watching and Waiting…
With rare exceptions, surveys will be unannounced Stay in touch with local colleagues to gain insight into surveyor patterns (i.e. State surveyors) Designate a staff member to check the TJC website daily CONSTANT survey readiness is key
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Plan for the Arrival Process
Develop a procedure that outlines what should be done and by whom when surveyors arrive Staff at hospital entry points should be fully competent on this process Who do they contact first, second, third? Provide office extensions and cell phone numbers (with second and third back-ups) Assure that surveyors are positively identified (picture IDs) Notification of the rest of the hospital Drill this process
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Surveyor Arrival
Greet surveyor(s) Verify identity
Readiness Guide
Responsible Staff Comments
Ask them to wait Validate authenticity of survey (if you have this option) Look at picture ID to ensure they are from the accrediting agency Location: Contact: ____________________ Phone number:___________ (staff contact who has this ability/authority)
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References
Survey Activity Guide for Health Care Organizations (2012). The Joint Commission. Accessed from the web on April 28, 2012: www.tjc.org
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New Joint Commission Standards (Clinical and Environment of Care)
July 18, 2012 11:00 a.m. CST
Be Prepared to Meet National Patient Safety Goals
September 19, 2012 11:00 a.m. CST
Environment of Care – Issues You Should Plan to Avoid
November 14, 2012 11:00 a.m. CST
Register at www.QHRLearningInstitute.com
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Upcoming Programs
QLI WILL ENTER THIS INFO
Register at www.qhrlearninginstitute.com
7/18/2012 – New Standards (Clinical and Environment of Care) New Joint Commission Standards (Clinical and Environment of Care) – Jamie Cox & Darlene Evans 9/19/2012 – National Patient Safety Goals – Be Prepared to Meet National Patient Safety Goals – Jamie Cox 11/14/2012 – Hot Topics in Environment of Care Environment of Care – Issues You Should Plan to Avoid – Carol Tuminaro
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Thanks for Attending!
Intended for internal guidance only, and not as recommendations for specific situations. Readers should consult a qualified attorney for specific legal guidance.
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