Policies and Procedures for Continuity: CMS Rule
Many healthcare facilities are in the process of updating their emergency preparedness plans to meet the Center for Medicare and Medicaid Services (CMS) deadline later this year. In a series of blog posts, we’ll address each of the key areas covered in the new CMS emergency preparedness requirements. This post looks at policies and procedures that are needed to comply with the CMS emergency preparedness rule.
The first critical step for any healthcare organization engaged in emergency management is risk assessment. An all-hazards assessment of probable risks faced by a facility provides the foundation for all the steps that follow.
The second step, discussed in detail below, is creating policies and procedures based on that risk assessment, so documented emergency plans—like the Emergency Operations Plan (EOP) or Continuity of Operations Plan (COOP)—respond to identified needs.
1. Meeting subsistence needs
One of the critical emergency preparedness lessons from Hurricane Katrina was the importance of providing for the subsistence needs of those who had been sheltered in place. Stores of subsistence needs—food, water, medical supplies, and pharmaceuticals—must be maintained at appropriate levels. A well-cataloged inventory can track supply levels and expiration dates to avoid waste.
2. Maintaining safe and sanitary conditions
The provisions need to be kept available for emergency situations when the power is out and water isn’t running. An alternate power source is critical for maintaining the appropriate temperature for heat- or cold-sensitive supplies. Policies and procedures should also address emergency lighting, fire detection and extinguishing, and managing waste, including sewage, solid waste, recyclables, chemical, biomedical waste, and waste water.
3. Keeping track of patients and staff
Being able to locate critical personnel is essential in a disaster situation. Documenting staff location in the event of evacuation ensures continuity of care and helps manage human resources in a time of flux. Though CMS removed a requirement for facilities to track patient location after an emergency, hospitals must have a clear record of their location during an emergency.
Most importantly, healthcare providers must be able to share the information with patients’ family and friends as well as emergency responders and agencies. The CMS emergency preparedness rule allows facilities to choose whether to share that information electronically or via hard copy, but the reality is that real-time information management on a large scale is best managed by an electronic solution.
4. Preserving and sharing patient records
Care teams must have ready access to patient records to maintain continuity of care, even when a patient is transferred to another facility or alternate care site. The CMS rule requires that facilities’ emergency preparedness plans include procedures to secure the availability of these records. As with patient location, the CMS emergency preparedness rule does not require that this information be saved or accessed electronically, but most facilities will find it efficient to do so, especially since the CMS requirements explicitly state that record keeping and sharing must be compliant with HIPAA, even in an emergency.
5. Providing continuity of care in multiple scenarios
A hazard vulnerability analysis (HVA) will help facilities identify the circumstances under which patients and staff will evacuate, when they will shelter in place, and when they will receive patients from other facilities. Policies and procedures should make clear the criteria for deciding which personnel and patients will shelter in place when those circumstances arise. Apart from the needs already listed, facilities must anticipate alternate means of communication and alternate staff roles. A centralized virtual communication center and database of certifications/skills can help facilitate quick decisions and deployment of resources when the usual chain of command is disrupted.
6. Collaborating effectively with community partners
All facilities must have a plan to address medical surges, including policies and procedures addressing the use of volunteers and, for facilities that provide continuous care, receiving patients from other facilities. The emergency preparedness plan must also address the role of the hospital under an 1135 waiver, when certain Medicare, Medicaid or Children’s Health Insurance Program (CHIP) requirements may be waived during a public health emergency to make it easier to use and staff alternate care sites. CMS states explicitly that they want to encourage providers to collaborate with local officials and facilities to plan a community-wide response to assure continuity of care.
CMS took pains to explain that they intentionally did not provide detailed requirements for policies and procedures. Instead, they are asking facilities to rely on a thorough assessment of their location, staff, and patient population to determine the measures that would be most effective.
Read our white paper Continuity of Operations Planning (COOP) for Healthcare Organizations for a clear explanation of how an emergency plan based on an accurate risk assessment can support continuity of care.
Upcoming: Our ongoing series on CMS emergency preparedness will focus on communications.
Terry Zysk, CEO of LiveProcess, has more than two decades of experience in leading organizations that provide innovative solutions to the healthcare industry.