Just a quick look at social media or at a news resource can make you keenly aware of the threats healthcare workers and patients could face from Mother Nature and human-caused incidents. With epidemics, extreme weather, active shooters, and so many other dangers, the best chance for a successful outcome will come with preparation.

One way to better prepare for an emergency is through performing practice drills. The brain learns by repetition, so drills performed on a routine basis will help the necessary actions become second nature. By conducting post-drill evaluations, you can determine the readiness of staff and the organization to respond to a crisis.

Part of your emergency planning should come from conducting a Hazard Vulnerability Analysis (HVA). This will help you identify the probability and risk potential for adverse events.

ACHC Standards

Accreditation Commission for Health Care (ACHC) Standards Manuals address emergency preparedness for deemed and non-deemed ambulatory surgery centers.

Standard: Emergency Preparedness/Management (15.00.01, deemed; 07.00.01, non-deemed)

The organization must comply with all applicable federal, state, and local emergency preparedness requirements. The organization must develop and maintain an emergency preparedness program that meets the requirements of this chapter through an all-hazards approach.

The emergency management program must include:

• Planning (including a risk assessment and Hazard Vulnerability Analysis for emergencies).
• Written plan, along with written policies and procedures.
• Communication.
• Training and testing.

Standard: Hazard Vulnerability Analysis (15.00.02, deemed; 07.00.02, non-deemed)

The organization must conduct a documented, facility-based, and community-based risk assessment (i.e., Hazard Vulnerability Analysis) to ascertain not only conceivable threats and disasters that could affect the organization’s ability to operate facilities or to provide services to its patients, but also the probability of those events occurring.

Before establishing an Emergency Operations Plan, the organization must assess risk (i.e., conduct HVA) based on an all-hazards approach. All-hazards planning does not specifically address every possible threat but ensures that organizations will have the capacity and capability to address a broad range of related emergencies.

The organization must share its HVA with its community partners to help set priorities with the HVA. Community partners may include:

• Department of public health.
• Department of public safety.
• Department of public works.
• Local municipality representatives.
• Other government agencies.
• Community organizations.
• Vendors.
• Other healthcare organizations.

Standard: Emergency Operations Plan (15.00.03, deemed; 07.00.03, non-deemed)

A written Emergency Operations Plan (EOP) must be developed, maintained, and made available to the staff for crisis preparation and response.

• The EOP must be based on the priorities established in the current Hazard Vulnerability Analysis and must include strategies for addressing emergencies identified in the HVA.
• Policies and procedures for emergency management are based on the EOP and the HVA.
• The EOP must be integrated into the organization’s Quality Assurance Performance Improvement (QAPI) plan.

In addition, for deemed ambulatory surgery centers, the EOP must be based on and include a documented facility-based and community-based risk assessment that uses an all-hazards approach and undergoes review every two years. The EOP must be reviewed with the community’s emergency response agencies to synchronize responses to common emergency events.

Standard: Emergency Training (15.03.01, deemed; 07.02.01, non-deemed)

The organization must develop and maintain training that is based on the Emergency Operations Plan and related policies and procedures.

The organization must:

• Provide initial training in emergency management policies and procedures to all new and existing staff and to individuals providing on-site services under an arrangement consistent with their expected roles. Additional training for volunteers, consistent with their expected roles, is required for deemed organizations.
• Provide emergency management training when the emergency plan is significantly updated; plus, provide training annually for non-deemed and biennially for deemed organizations.
• Maintain documentation of all emergency management training.
• Demonstrate staff knowledge of emergency procedures.

Standard: Emergency Exercises (15.03.02, deemed)

Here are the emergency exercise requirements for deemed ambulatory surgery centers:

• The ambulatory surgery center must develop and maintain a testing program (exercises) based on the Emergency Operations Plan, the Hazard Vulnerability Assessment, the organization’s policies and procedures, and the organization’s communication plan. The testing program must be reviewed and updated annually.
• An ambulatory surgery center must participate in two emergency exercises per calendar year to test the Emergency Operations Plan. Each exercise (disaster drill) is to be planned by the oversight committee on emergency management and implemented to build competencies in staff.
  • The ASC must conduct two exercises per year to test the emergency plan.
  • The ASC must participate in a full-scale exercise that is community-based or, when a community-based exercise is not accessible, an individual facility-based exercise. If the ASC experiences an actual natural or human-caused emergency that requires activation of the emergency plan, the ASC is exempt from engaging in one community-based or individual facility-based full-scale exercise for one year following the onset of the actual event.
  • The ASC must participate in a second exercise of its choice: an individual facility-based functional exercise; a drill; or a tabletop exercise.
  • The ASC must analyze the organization’s response to and maintain documentation of all drills and emergency events, and the ASC must revise its emergency plan as needed.

Standard: Emergency Exercises (07.02.02, non-deemed)

Here are the emergency exercise requirements for non-deemed ambulatory surgery centers:

• The organization must conduct one exercise (in addition to the fire response exercises) annually to test its Emergency Operations Plan.
• If the organization experiences an actual natural or human-caused emergency that requires activation of the emergency plan, the organization may use the event to meet the requirements for an emergency exercise if the organization prepares an evaluation and after-action improvement plan after the event. The organization still must conduct quarterly fire exercises.

Tips for Compliance

Meaningful participation helps everyone understand their roles in handling an emergency.

• Look for barriers during your drills, and develop steps to avoid them.
• Ensure leadership is involved.
• Invite your local city or county emergency responders and subject matter experts.
• Evaluate your drill response, develop your after-action plan, and update your Emergency Operations Plan, as necessary.
• Eliminate any unnecessary steps from your plans.

Resource

Healthcare organizations often develop their own Hazard Vulnerability Analysis tools. Here is one example: https://www.fhca.org/facility_operations/hazard_vulnerability_analysis_tool

Here to Help

For access to the most recent Ambulatory Surgery Center Accreditation Standards manual, including the manual for deemed status surveys that becomes effective on October 31, 2022, contact your Account Advisor or email us at [email protected].