Emergency Preparedness

Citation

TJC EM.09.01.01

The hospital has a comprehensive emergency management program that utilizes an all-hazards ap...

The hospital must maintain a written, comprehensive, all-hazards emergency management program that includes leadership accountability, risk assessment, and preparedness activities.

Citation

TJC EM.11.01.01

The hospital conducts a hazard vulnerability analysis utilizing an all-hazards approach.

The hospital must conduct and document a facility-based hazard vulnerability analysis using an all-hazards approach to identify and prioritize potential threats.

Citation

TJC EM.12.01.01

The hospital develops an emergency operations plan based on an all-hazards approach.

The hospital must maintain a written all-hazards emergency operations plan that includes procedures for surge capacity, evacuation, sheltering, and resource management.

Citation

TJC EM.12.02.01

The hospital has a communications plan that addresses how it will initiate and maintain commu...

The hospital must maintain a communications plan that includes contact lists, reporting procedures, and methods for sharing patient information during emergencies.

Citation

TJC EM.12.02.03

The hospital has a staffing plan for managing all staff and volunteers during an emergency or...

The hospital must develop a staffing plan to manage personnel and volunteers during emergency incidents, including methods for contact and role integration.

Citation

TJC EM.12.02.05

The hospital has a plan for providing patient care and clinical support during an emergency o...

The hospital must have procedures for sharing patient information and transferring patients to other facilities to maintain continuity of care during emergencies.

Citation

TJC EM.12.02.07

The hospital has a plan for safety and security measures to take during an emergency or disas...

The hospital must implement a system to track the location of staff, volunteers, and patients during emergency events, including relocations or evacuations.

Citation

TJC EM.12.02.09

The hospital has a plan for managing resources and assets during an emergency or disaster inc...

The hospital must maintain a plan for tracking, monitoring, and replenishing essential resources and assets during and after an emergency incident.

Citation

TJC EM.12.02.11

The hospital has a plan for managing essential or critical utilities during an emergency or d...

The standard addresses a hospital plan for maintaining essential or critical utility systems during an emergency or disaster incident.

Citation

TJC EM.13.01.01

The hospital has a continuity of operations plan.

The standard addresses a hospital continuity of operations plan for maintaining essential business functions and leadership authority during disruptions.

Citation

TJC EM.15.01.01

The hospital has an emergency management education and training program.

The standard addresses hospital emergency management education and training for staff, arranged-service personnel, and volunteers.

Citation

TJC EM.16.01.01

The hospital plans and conducts exercises to test its emergency operations plan and response...

The standard addresses hospital exercises to test emergency operations plans and response procedures, including documentation of exercises and incidents.

Citation

TJC EM.17.01.01

The hospital evaluates its emergency management program, emergency operations plan, and conti...

The standard addresses hospital review of emergency exercises, disaster incidents, after-action reports, improvement plans, and periodic updates to emergency management documents.

Citation

TJC IM.11.01.01

The hospital plans for continuity of its information management processes.

The hospital must maintain policies and procedures to ensure the availability and security of medical records during emergencies and system interruptions.

Citation

TJC NPG.03.01.01

Hospital leaders provide oversight and support of the emergency management program.

Hospital leadership must provide oversight and support for the emergency management program, including the appointment of a qualified lead and the establishment of a multidisciplinary committee.

Citation

TJC NPG.03.02.01

The hospital develops an emergency operations plan based on an all-hazards approach.

The hospital must maintain an all-hazards emergency operations plan that includes a scalable incident command structure and designated authority for activation.

Citation

TJC NPG.03.02.02

The hospital has a communications plan that addresses how it will initiate and maintain commu...

The hospital must implement a communications plan to maintain contact with staff, patients, and community partners during emergency or disaster events.

Citation

TJC NPG.03.02.03

The hospital has a staffing plan for managing all staff and volunteers during an emergency or...

The standard addresses written emergency staffing procedures for staff, volunteers, volunteer licensed practitioners, disaster privileges, and staff support needs.

Citation

TJC NPG.03.02.04

The hospital has a plan for providing patient care and clinical support during an emergency o...

The standard addresses emergency planning for patient care and clinical support, including procedures for non-patient individuals and coordination for unidentified or deceased patients.

Citation

TJC NPG.03.02.05

The hospital has a plan for safety and security measures to take during an emergency or disas...

The standard addresses hospital planning for safety and security measures and coordination with community security agencies during emergencies or disasters.

Citation

TJC NPG.03.02.06

The hospital has a plan for managing resources and assets during an emergency or disaster inc...

The standard addresses written planning for managing resources and assets during emergencies, including evaluation of up to 96 hours of hospital self-sufficiency.

Citation

TJC NPG.03.03.01

The hospital has a disaster recovery plan.

The hospital maintains a written disaster recovery plan addressing damage assessments, restoration of critical systems and essential services, return to operations, and family reunification coordination.

Citation

TJC NPG.03.04.01

The hospital has an emergency management education and training program.

The hospital maintains emergency management education and training, including duty-specific training for incident command staff.

Citation

TJC NPG.03.05.01

The hospital plans and conducts exercises to test its emergency operations plan and response...

The hospital plans and conducts exercises to test emergency operations and response procedures, including annual exercises for covered freestanding outpatient care buildings when not included in hospital exercises.

Citation

TJC NPG.03.06.01

The hospital evaluates its emergency management program, emergency operations plan, and conti...

The hospital evaluates its emergency management program and related plans and forwards after-action reports and improvement recommendations to senior leaders for review.

Citation

TJC NPG.05.02.01

The hospital implements processes to support preparedness for high-consequence infectious dis...

The hospital must implement protocols for identifying, isolating, and managing high-consequence infectious diseases, including staff training and infection control measures.

Citation

TJC NPG.11.03.01

The hospital manages utility systems.

The hospital manages utility systems, including written procedures for utility disruptions and emergency backup policies for essential medication dispensing equipment and medication refrigeration.

Citation

TJC PE.03.01.01

The hospital designs and manages the physical environment to comply with the Life Safety Code.

Requires the hospital to design and manage its physical environment to comply with the Life Safety Code, including fire safety documentation, fire control plans, and construction-related safeguards.

Citation

TJC PE.03.02.01

The hospital protects occupants during periods when the Life Safety Code is not met or during...

Requires the hospital to implement interim life safety measures, including fire watches, alternative exits, surveillance, drills, and training, when Life Safety Code deficiencies cannot be immediately corrected or during construction.