13 steps to compliance with new regulations
Here’s a "to do" list for compliance with the new Emergency Medical Treatment and Active Labor Act (EMTALA) regulations for hospital outpatient facilities, compiled by Larry B. Mellick, MS, MD, FAAP, FACEP, chair and professor for the department of emergency medicine at the Medical College of Georgia in Augusta:
1. Identify hospital off-campus service sites that will fall under the new legal requirements.
2. Send notifications and specifics of the new requirements to any facility or organization that is located off the main hospital campus and has been determined under this statute to be a department of the hospital.
3. Since most administrators in these locations will not completely understand EMTALA, provide a brief but complete synopsis of the law.
4. Set up a "legal hotline" within your institution to answer general questions concerning EMTALA or the new requirements.
5. Create a hospital task force to review areas of risk within the institution and to develop general guidelines for protocol development.
6. Consider establishing an EMTALA "czar" to oversee these activities within the institution and assist with enforcement if necessary.
7. Develop information resources within the institution of staff knowledgeable in EMTALA who might act as "internal consultants." Consider enlisting the risk management department to provide this service.
8. Ask legal services to develop a "boiler plate" transfer agreement for those patients needing to be transported to another hospital because of the gravity of their condition.
9. Identify individuals at each of these off-campus locations to take overall leadership and responsibility for EMTALA education, training, and oversight.
10. Allow each site to develop its own drafts of protocols and transfer agreements within a clearly defined deadline.
11. A task force should be created at each off-campus location to format these EMTALA policies and protocols. These drafted protocols should be presented and reviewed by the hospital EMTALA task force to ensure compliance and completeness.
12. Develop plans for annual review of compliance and to establish mandatory annual reviews of protocols and policies and staff education.
13. Plan for appropriate EMTALA signage for patients and staff at each of these locations.
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