All-Hazards Risk Assessment: CMS Emergency Preparedness Rule
[Originally posted April 3, 2017, this post has been updated to reflect clarifications released February 2019 and revisions proposed September 2018.]
CMS requires an all-hazards approach
A fundamental requirements of the CMS emergency preparedness rule is the approach to risk assessment. CMS requires that healthcare facilities employ an all-hazards approach.
“An all-hazards approach is an integrated approach to emergency preparedness planning that focuses on capacities and capabilities that are critical to preparedness for a full spectrum of emergencies or disasters.” (S&C:17-17-ALL)
Key aspects of an all-hazards approach to risk assessment include:
- Developing plans that are flexible and scalable enough to adapt to a wide variety of disasters
- Focusing on the continuity of essential services that must remain consistent regardless of the disaster
- Assessing the risks most likely to affect an individual facility and community
That last point is key: during the comment phase of CMS emergency preparedness rulemaking, some healthcare leaders expressed concern that an all-hazards approach to emergency preparedness would be too broad. Writing a detailed plan for every single possible emergency would be too much work for any facility, with little benefit.
It’s important to note that the all-hazards approach applies to risk assessment, not to drafting policies and procedures. The emergency management team analyzes possible scenarios and develops a plan based on the areas of highest risk. A coastal Florida hospital doesn’t need to prepare for a blizzard, and a Minnesota long-term care facility doesn’t have to worry about hurricanes. Ransomware could hit any acute, post-acute or ambulatory care facility.
Assessing risk means both examining the likelihood of particular scenarios—severe weather disasters as well as pandemics or terrorist attacks—and evaluating the extent to which they will impair a facility’s operations and essential services.
Clarification to the rule in Appendix Z also emphasized the need to add “emerging infections diseases” to the definition of an all-hazards approach. According to CMS’ Quality, Safety, and Oversight group:
“CMS determined it was critical for facilities to include planning for infectious diseases within their emergency preparedness program. In light of events such as the Ebola virus and Zika, we believe that facilities should consider preparedness and infection prevention within their all-hazards approach.”
A Hazard Vulnerability Analysis (HVA) provides a straightforward way to complete a risk assessment. The HVA assesses a facility’s current level of emergency preparedness and the human, property, and business impact of multiple hazards. The hazard vulnerability analysis can help quantify the level of risk and the severity of impact, so preparedness efforts address the most important potential emergencies.
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Continuity of operations and community collaboration
Other requirements related to risk assessment necessitate that emergency preparedness plans address continuity of operations, in both the healthcare facility and the community. Key criteria include:
- Addressing the essential services that will be provided by the healthcare facility in an emergency in the written plan
- Documenting the chain of command and responsibility, including succession and delegation planning
- Establishing a process for cooperation and collaboration with local, tribal, regional, state and federal emergency preparedness officials, to facilitate integration during large-scale events
Other key elements of risk assessment for CMS emergency preparedness compliance
CMS also calls out the need to focus on at-risk patient populations when creating an emergency plan. That group includes patients who are medically at risk, such as people with disabilities, pregnant women, children, and senior citizens, and patients who are at risk for non-medical reason. The latter group would include patients from distinct cultural or religious backgrounds, as well as patients with limited English proficiency. This emphasis on unique patient populations underscores the importance of each healthcare facility developing an emergency management plan tailored to its location and its role in the wider community.
LiveProcess Emergency Manager is a proven system for emergency preparedness planning, mass notification and mobilization, real-time coordination and tracking. Hospitals and health systems, ambulatory centers, home health agencies, nursing homes, and public agencies use Emergency Manager to prepare for and respond to disaster events and for everyday coordination.
Some hospitals and healthcare facilities will already have some of these plan elements in an Emergency Operations Plan (EOP), especially where there is overlap with Joint Commission guidelines. Others facilities may need more help. In either case, templates and tools designed for emergency management planning can make compliance with the CMS emergency preparedness rule easier.
- Use this CMS Emergency Preparedness Checklist
- Next blog post: Hospital Readiness for Likely Threats: CMS Emergency Preparedness.
- LiveProcess delivers on CMS emergency preparedness rule for hospitals.
- Continuity of Operations Planning (COOP) for Healthcare Organizations
- How LiveProcess helps hospitals, health systems, and healthcare coalitions prepare for disasters
- LiveProcess can help your healthcare organization across all phases of emergency management, including planning, mobilization, coordination & collaboration, and tracking.
- More blog posts about CMS emergency preparedness