JCAHO Compliance

a guide for understanding jcaho standards, core measures, compliance, and accreditation.

What is JCAHO?

The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) sets standards for healthcare organizations and issues accreditation to those organizations that meet those standards. JCAHO conducts periodic on-site surveys to verify that an accredited organization substantially complies with Joint Commission standards and continuously makes efforts to improve the care and services it provides.

JCAHO Emergency Management Standards

Joint Commission standards of care for Disaster Preparedness and Response has evolved from studies of significant disasters over the last five years. JCAHO guidance centers on managing consequences to; provide safe and effective patient care during an emergency, clearly defining staff roles, training those roles and responsibilities; and sustaining staff competencies over time. There are six focus areas for hospitals to demonstrate they have proper plans and response mechanisms to a disaster. During planned exercises, the [organization] monitors, at a minimum, the following six critical areas:

  • Communications – both internal and external to community care partners, state/federal agencies
  • Supplies – Adequate levels and appropriateness to hazard vulnerabilities
  • Security – Enabling normal hospital operations and protection of staff and property
  • Staff – Roles and Responsibilities within a standard Hospital Incident Command Structure
  • Utilities – Enabling self-sufficiency for as long as possible with a goal of 96 hours
  • Clinical Activity – Maintaining care, supporting vulnerable populations, alternate standards of care

Recent disaster studies since 2005 have exposed difficult challenges. Maintaining the medically frail is difficult requiring major focus. Keeping hospital beds open and available is vital in participating in and meeting community responsibilities. Scare resources against high demand of oxygen, vents, dialysis, pharmacy and home health care necessitate a broader scope of approach to planning, mitigation, response and recovery efforts.

Response Systems’ team of medical experts can help your organization define policy, procedures and planning tools based on the scenarios your facility and community is most likely to encounter.

Rationale for EC. 4.20 – The organization regularly tests its emergency operations plan

Periodic testing of an emergency operation plan enables organizations to assess the plan’s appropriateness, adequacy, and the effectiveness of logistics, human resources, training, policies, procedures, and protocols. Exercises should stress the limits of the organization’s emergency management system. The goal of this testing is to assess the organization’s preparedness capabilities and performance when systems are stressed during an actual emergency.

Exercises should be developed using plausible scenarios that are realistic and relevant to the organization. Events should be based on each organization’s HVA. Exercises should also validate the effectiveness of the plan and identify opportunities to improve.

This standard will assist health care organizations to test their emergency operation plan, identify deficiencies, and take corrective actions to continuously improve the effectiveness of their EOP. Only a thorough and objective evaluation of performance during an emergency management event or planned exercise will demonstrate how effective the organization’s planning efforts have been.

It is important to communicate the strengths and weaknesses of the performance revealed by the exercise to all levels of the organization, including administration, clinical staff, governing body, and those responsible for managing the patient safety program.

JCAHO accreditation / Elements of Performance

  • The [organization] tests its Emergency Operations Plan twice a year, either in response to an actual emergency or in a planned exercise.
  • (CAH, LTC) [Organizations] that offer emergency services or are community-designated disaster receiving stations conduct at least one exercise a year that includes an influx of actual or simulated [patients].
  • At least one exercise a year is escalated to evaluate how effectively the organization performs when it cannot be supported by the local community.
  • [Organizations] that have a defined role in the community-wide emergency management program participate in at least one community-wide exercise a year.

How Response Systems can help your organization with JCAHO

Response Systems key personnel have lived through the JCAHO assessment. We will look at your Emergency Management Program and Emergency Operations Plans for compliance. We will point out areas where proof of performance may be required during the visit. Let us help you be compliant and ready for the Joint Commission review.

For more information about JCAHO visit www.jointcommission.org