JCAHO Proposes Revisions to Its Disaster Preparedness Standards

  1. Home
  2. News & Insights
  3. JCAHO Proposes Revisions to Its Disaster Preparedness Standards

On May 13, 2005, the Joint Commission on Accreditation of Healthcare Organizations ("JCAHO") proposed revisions to the emergency management procedures for hospitals found in the Comprehensive Accreditation Manual for Hospitals. If approved, JCAHO anticipates adopting the proposed changes by 2007. Some of the key proposed changes to the JCAHO standards address the following:

  • Hospital Drill Requirements. The current JCAHO Standard EC.4.20 requires hospitals to conduct test drills every four to eight months. Under the suggested revisions to this standard, hospitals will only need to conduct drills to test their emergency response procedures once per year. In addition, the new standards require hospitals associated with community-wide disaster response plans to conduct at least one community-wide drill per year. The new provisions also establish requirements for drill conditions, performance criteria, and test monitoring for the drills.
  • Expansion of Privileges to Unlicensed Personnel. The current JCAHO Standard MS.4.110, which will be renumbered as HR.4.35, allows hospitals to grant privileges during disaster situations to doctors and other licensed practitioners not credentialed with that hospital. Under the proposed JCAHO Standard HR.1.25, hospitals will establish mechanisms for granting disaster privileges to unlicensed volunteers, such as medical technicians and support staff.
  • Confirmation of Identity. The current JCAHO Standard MS.4.110 requires hospitals to develop a mechanism for hospital staff to identify volunteers, address the verification process as a "high priority," and confirm the volunteer's identity as soon as the immediate disaster situation is under control. Under the proposed sections HR.1.25 and HR.4.35, hospitals will be required to verify a volunteer's identity within 72 hours after receiving the identification documentation (unless communication disruptions prevent verification).
  • Plan Activation. Proposed sections HR.1.25 and HR.4.35 create a new requirement under which a hospital is not permitted to grant disaster privileges until after the hospital activates its emergency management plan and determines that it is unable to handle the immediate patient care demands.

If adopted, these revisions proposed by JCAHO will impose new requirements on a hospital's disaster preparation procedures and policies. Before undergoing a JCAHO certification audit, a hospital may want to confirm that it complies with the latest requirements of the JCAHO standards. Please contact the Reinhart Health Care Department if you have any questions or if we may assist you concerning this matter.


Related Practices