Joint Commission wants to see new effort on terrorism plans
Cooperating with other local providers now a big focus for surveyors
Health care providers must step up their preparations for terrorist attacks and other disasters, according to a new Joint Commission on Accreditation of Healthcare Organizations directive that says past requirements for emergency preparedness are not enough in the post-Sept. 11 era.
In the immediate aftermath of the attacks, the Joint Commission urged providers to review their emergency preparedness plans and update them in light of the new threats. But as the health care community took a closer look, the organization determined that previous standards were inadequate and recently added a new requirement to EC.1.4, the standard requiring each organization to have an emergency management plan.
Added to the "intent" section, that new clause calls for cooperation among health care organizations on a local level. The addition is prefaced by a stark explanation that it is needed because of "the experiences of health care organizations responding to the September 2001 terrorist attacks in New York City and Washington, DC."
This is the text of the new requirement:
"Cooperative planning among health care organizations that, together, provide services to a contiguous geographic area (for example, among hospitals serving a town or borough) to facilitate the timely sharing of information about:
- essential elements of their command structures and control centers for emergency response;
- names, roles, and telephone numbers of individuals in their command structures;
- resources and assets that could potentially be shared or pooled in an emergency response;
- names of patients and deceased individuals brought to the organizations to facilitate identification and location of victims of the emergency."
Robert Wise, MD, vice president in the division of research at the Joint Commission, tells Hospital Peer Review that the organization had been reviewing EC.1.4 for some time in an effort to improve how providers respond to disasters. Based on incidents such as major storms, the researchers already were starting to think that local cooperation among providers needed improvement. The New York terrorist attack made that a certainty.
"As we changed our assumption that these types of large-scale attacks were highly likely in major metropolitan areas, we found that the thing that was still missing in some cities was some type of cooperative planning among health care organizations," he says. "If you’re going to have a disaster hit at a communitywide level, something that large, it’s not going to work to have each organization trying to decide what to do on their own."
Wise notes that the new language has been added only to the intent section of the standard, meaning it is technically not a new part of the standard. The revision also states that the addition is only "clarified language, not additional requirements." But Wise says that distinction is irrelevant. Surveyors will check for compliance with this new clause.
"This is viewed as an important part of the emergency management standard," he says. "We will want to see evidence of this later on. This is a change in a requirement; it’s not important whether it’s in the intent or the standard."
Almost all providers will have to revamp their emergency management plans in light of this new requirement, he says. The Joint Commission wants to see providers develop an extensive, detailed coordination plan with each other before disaster strikes, and Wise emphasizes that this needs to be more than the type of plan that currently exists for mutual aid, diversions, disaster drills, and disaster plan activation. Much of the new work will involve administrative coordination among providers, which could prove challenging, he says.
"The system needs improved coordination, cooperation, and planning throughout the entire health care delivery system," Wise says. "We thought it was so important that we decided to bring it up to a standards level. This is important. People need to act on it immediately."
Information-sharing is a key goal
In the past, much of the disaster coordination among local providers has been of a practical nature, with the main goal being that limited health care resources be mobilized for a large number of victims. While that remains a concern, Wise says the New York experience illustrated the need for more information-sharing among providers during the disaster and afterward.
"One of the things that completely overwhelmed the hospitals in New York was that there was no central place for names of the people admitted or the several thousand who died," he says. "So you had all these people going from hospital to hospital to hospital looking for their husband, or mother, or daughter. We hope not to see that again."
Wise praises the overall preparation of hospitals in the New York City area, saying it was nearly impossible for anyone to anticipate a disaster of the type and magnitude that struck on Sept. 11. But now it’s not so hard to imagine that type of disaster happening again, so providers must learn from the experience and plan accordingly, he says. A centralized databank for the community, with all local providers inputting information and consolidating it, would greatly improve the community’s response, Wise says.
The other issues cited in the new requirement also deal with sharing information among providers — elements of your command structure, contact information for key people, and resources that could be pooled or shared. Sharing that kind of information may sound easy at first, but Wise cautions that you could run into problems once you try to do it. Handing over information may not be easy, especially in communities where providers are in strong competition with each other.
"Part of the problem is that hospitals are in tough shape financially, a very competitive environment, and most see the hospital down the road as a major competitor," he says. "In some places, it will require a culture change to sit down and work together. I think that they will embrace it in spirit, but clearly the issue is in the details. How do they take something that is philosophically well within their mission and make that happen within a highly competitive business environment?"
Wise suggests that the best strategy might be to work within existing structures such as local hospital councils or state hospital associations.
Joel Mattison, MD, physician adviser in the department of utilization management and quality assurance at St. Joseph’s Hospital in Tampa, FL, agrees with that strategy. Most communities already have some local committee that helps coordinate disaster response among health care providers, so they are the natural choice for coordinating the newly required information exchange.
However, Mattison cautions HPR readers not to underestimate the obstacles they might encounter when trying to comply with the new Joint Commission directive. Sharing information often will prove more difficult than cooperating in patient care, he says. It is unlikely that hospital administrators or clinicians will be able to just pick up the phone, call a competitor across town, and work out a shared computer database, for instance.
"Even if no one is looking for an excuse for avoiding this, you’ll run into a lot of practical problems," he says. "Will your different information systems be able to mesh? Will there be fear of commercial espionage? No one ever admits that they fear that, but everyone does."
Confidentiality will be another major concern. Can one hospital share information with other facilities, or with a community database, without violating patient confidentiality? And Mattison anticipates that hospitals might have to upgrade their data collection systems, "so that you have computer terminals everywhere. If you’re going to get this information in the system quickly, you can’t wait for data entry at the end of the day."
Plan solo effort and cooperation at same time
Wise says the Joint Commission saw another lesson emerge from the Sept. 11 attacks, something the organization has seen at countless other disasters of various types. No matter how well your hospital has planned to cooperate with other providers during a disaster, you’ll probably be on your own for a while. That means your emergency management plan must take both scenarios into account.
"We’ve heard and learned that at the time of the emergency, the hospital has to assume it is going to be on its own for the first 72 hours," Wise says. "So you have to plan for all this cooperation, but you may be isolated at first. In New York, the police shut down streets, communication was disrupted, and the city lost its emergency operations center, so coordination by the city was severely hampered. You have this very interesting problem where the hospital has to say, I’m going to be on my own and need to be capable of sustaining our services for that time.’ But you still need to plan for the cooperation that is so important afterward."
Expect challenges and hard work
Wise acknowledges that hospitals and other health care providers may find this new requirement challenging. If you don’t, he says, either your community has a truly superior system in place already or you’re underestimating what the Joint Commission expects. The required work — setting up a central community database, for example — can be expensive, so the Joint Commission is working closely with federal officials to find funds. Some of the money allocated by Congress after the terrorist attacks might be made available to health care providers for this type of improvement, he says.
Hospitals will be challenged to comply with the new Joint Commission directive, but the work will be easier if administrators remember why they’re doing it, Mattison says.
"Those people wandering around New York looking for people, that’s the kind of thing that will make hospitals cooperate when other things wouldn’t. We all remember seeing that, and we don’t want it in our community," he says. "That will motivate even those people who usually don’t cooperate very well."
(Editor’s note: For more information on preparing for terrorism and other disasters, see the Joint Commission’s publication Perspectives. The December 2001 issue is a special report on emergency management and contains a wealth of useful information. The issue is available on-line for free at www.jcrinc.com/subscribers/perspectives.)
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