Center for Improvement in Healthcare Quality Newsletter
February 2022

CIHQ-ARS Article

Top 5 Emergency Preparedness Challenges During a Survey

By: Don Roush
It’s 0730 and you just arrived at the hospital to begin work. As you are getting out of your car you get a text informing you that your accrediting organization is on their way to the hospital to conduct a full accreditation survey of the hospital. Are you prepared for their arrival? This is not an uncommon scenario when it comes to being surveyed. The difference is how you have prepared for such an event. One of the challenging parts of a survey is how information is presented to the surveyors so that they have a clear understanding of how the hospital is performing and meeting the expectations of the programs you have put in place. That is why it is important to be ready for almost anything when it comes to emergency management. Here is an outline of the 5 most challenging emergency preparedness standards that hospitals face during surveys:
  1. Your hospital is required to conduct two drills a year. One drill must be a full-scale exercise that is community-based, or when a community-based exercise is not accessible, an individual, facility-based. The second exercise can be a second full-scale exercise that is community-based or individual, facility-based or a tabletop exercise. A tabletop exercise must include group discussion led by a facilitator, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. The challenge for most hospitals is not performing the drills but analyzing the hospital's response to the exercises. Each drill must be evaluated, and if deficiencies or opportunities are identified they must be tracked and corrected. In other words, each item identified must be closed out within a reasonable amount of time. Be sure that all off-site locations participate in at least one of these drills (if possible) or performs one drill specific to their location.
  2. Documentation pertaining to the emergency operation plans and programs are required to be reviewed, updated, and documented at predetermined frequencies as shown below:
    • As necessary throughout the year at least every two years:
      • Contact information for incoming new staff and departing staff and any other changes to information for those individuals and entities on the hospital’s contact list as necessary and every two years
      • Names and contact information for staff, entities providing services under arrangement, patients' physicians, other hospitals and critical access hospitals, and volunteers must be reviewed and updated as necessary and every two years
      • All contact information for Federal, State, tribal, regional, and local emergency preparedness staff, and other sources of assistance as necessary and every two years
      • Emergency preparedness training must be documented for all staff, individuals providing services under contract arrangement, and volunteers. The documentation must include the specific training that is consistent with their expected role as well as the methods used for demonstrating knowledge of the training program initially and every two years.
    • Updated and reviewed at least every two years:
      • Emergency preparedness plan
      • Communication plan
      • Hospital training programs
    • Documentation that must be maintained for least three years:
      • All testing and implementation records of the Emergency Preparedness Plan
  3. The emergency preparedness plan addresses patient population, including, but not limited to, persons at-risk, the type of services the organization can provide in an emergency, and continuity of operations including delegations of authority and succession plans.
  4. The hospital must develop and implement policies and procedures that address alternate sources of energy to maintain the following:
    • Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions
    • Emergency lighting
    • Fire detection, extinguishing, and alarm systems
    • Sewage and waste disposal
  5. A system to track the location of on-duty staff and sheltered patients in the hospital's care during an emergency. If on-duty staff and sheltered patients are relocated during the emergency, the hospital must document the specific name and location of the receiving facility or other location.
Expect surveyors to randomly question hospital staff about your emergency management program; such as asking a new employee how he or she would respond to a tornado warning or what department specific emergency preparedness training they have had. Remember the key is to have staff actively involved in hospital exercises. By keeping pace with these challenges, you can expect your accreditation surveys to go more smoothly, and your hospital can operate more successfully if a disaster was to strike.