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 onsite 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:

1. Communications both internal and external to community care partners,

state/federal agencies
2. Supplies Adequate levels and appropriateness to hazard vulnerabilities
3. Security Enabling normal hospital operations and protection of staff and
property
4. Staff Roles and Responsibilities within a standard Hospital Incident
Command Structure
5. Utilities Enabling self-sufficiency for as long as possible with a goal of 96
hours
6. 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 plans appropriateness, adequacy,
and the effectiveness of logistics, human resources, training,
policies, procedures, and protocols. Exercises should stress the
limits of the organizations emergency management system. The
goal of this testing is to assess the organizations 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 organizations 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 organizations
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 communitywide 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.