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Healthcare emergency preparedness guidelines: TJC vs. CMS

For the past nine months, the healthcare industry has been reviewing and implementing emergency preparedness plans to meet a November 2017 deadline set by CMS (the Centers for Medicare / Medicaid Services). Most hospitals receive accreditation under the Joint Commission, and many emergency planners are wondering what the difference is between the JC and CMS guidelines.

The purpose of the guidelines

Discussions first started after Hurricane Katrina hit New Orleans — patients at Memorial Hospital faced unnecessary suffering and even death while on-site officials scrambled to get help from the outside world.  The CMS planning process took several years, but when Hurricane Sandy hit the East Coast, there was a renewed sense of urgency to complete the Final Rule, published last September.

CMS set out to create a:

“Comprehensive, consistent, flexible, and dynamic regulator approach to emergency preparedness that incorporates lessons learned and proven best practices.” 42 CFR parts 403, 416, 418, 441, 460, 482 – 486, 491, 494

The guidelines focus on safeguarding human resources, maintaining business continuity, and protecting physical resources.  The planning is broken down into four programs: risk assessment and planning, policies and procedures, a communication plan, and training and testing.  They apply to 17 provider and supplier types. A list of the facilities and their individual requirements under the CMS guidelines can be found here. (pdf)

Currently, there is concern about meeting the guidelines, 58% of respondents during a recent poll said they weren’t ready yet but expected to meet the November deadline, another 7% said they were concerned about the meeting the deadline.

The joint commission vs. CMS guidelines

Since the publication of the CMS Final Rule for Emergency Preparedness Guidelines, many people have wondered about the differences and what hospitals now need to do.  The Joint Commission responded to the guidelines at a conference in April saying they would match the CMS standards.  In a webinar just a week later an official from CMS said,

“If you’re accredited through the Joint Commission, you’ll be surveyed as through the usual accrediting process, but it’s important to note the Joint Commission standards will have to meet or exceed the CMS Final Rule.” ~ Caecilia Blondiaux

There is one critical area where The Joint Commission exceeds CMS.  CMS requires one active drill and one tabletop drill per year, but The Joint Commission requires two active drills.  Another important difference is that CMS requires tracking of information during an incident that involves the outside community.  The Joint Commission requires log information for any incident so their surveyors can review the information.  Please note, as we wait for 1) the final guidelines from the Joint Commission and 2) the Interpretive Guidelines from CMS that these differences are subject to change. 

Webinar for emergency preparedness guidelines

We recently hosted a webinar that compared and contrasted the differences between CMS and TJC.  We talked about several aspects of the new guidelines including:

  • Contacting & Tracking Staff During an Incident
  • Communicating with the Local Community
  • Documenting Incidents When They Occur
  • Working with Unique Populations
  • HIPAA Compliance During an Incident
  • and, Is The Deadline Real?

We invite you to review the on-demand webinar, download the slides, or visit our CMS Emergency Preparedness Resource Library to learn more about meeting the deadline.


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