Hospital Emergency Management: Oversight?

by DR. JAMES “JIM” BLAIR, COL RET, ARMY AMEDD January 21, 2011
We have seen in our earlier articles that the folks who design and construct today's hospitals show little regard for the built- in known vulnerability mitigation which promotes risk reduction for looming known natural and man-made threats.
It also appears that these threats to healthcare organizations enjoy little attention from those who populate the leadership ranks (Administration/Boards).
Effective oversight of the non-federal healthcare industry has always been challenging. In a free pluralistic healthcare sector, governance is a fragmented and complex undertaking. Even so, the National Congress with its committee structure is expected to pass laws which promote safe and secure delivery of care to the trusting public. The Executive Branch, through its Federal Agencies is tasked to promulgate rules and regulations which are intended to faithfully carry out the intent of Congressional guidance. The Judicial Branch is left to determine liability and promote a level playing field. The several States are responsible for the health and safety of their citizens.
The Department of Health and Human Services (DHHS) through its various Agencies and Offices is responsible for the oversight of quality and safety of the nation’s healthcare delivery system. A pivotal role and responsibility is placed with the Centers for Medicare and Medicaid Services (CMS). Healthcare providers who seek eligibility for reimbursement of care for their federal beneficiaries must be qualified through a “Deeming Status” (DS) process. Hospitals voluntarily request DS, it is not required to function as a hospital but is required for federal reimbursement for such care. Many think that the lack of strong oversight contributes to the Public Healthcare Sector being the soft underbelly of All Hazards Readiness.
Simple enough, theoretically, Accreditation from one of CMS's contractors, external evaluations mechanisms is the basis for not only federal reimbursement but, acts as a seal of approval and verification that quality, safe and secure care “goes on here”. In many instances it is used as, due diligence, on which insurers and credit lending industry' base their rates and evaluate their risks.
The Joint Commission (TJC) formerly (JCAHO) is one of several organizations with “Deeming Authority” and for many years has had a near monopoly on hospital accreditation.
At first glance the external evaluation mechanisms appear to be the “narrow point in the funnel”. In theory, a TJC survey or other contracted CMS survey groups act as a “trip wire” for obvious patient and work-site dangers which are the primary responsibility of other regulatory entities (Occupational Safety and Health Administration, Environmental Protection Agency, Food and Drug Administration, Department of Homeland Security, Nuclear Regulatory Commission, etc.). Regulatory enforcement from these entities is fragmented and represents a dazzling highly complex array of “some federal, some state and some local regulatory authority”.
Federally contracted external evaluation mechanisms have long had their critics. Many scholars have observed the harmful effects of the“industry to government regulator”swinging door. This, as we have seen often leads to egregious conflicts of interest and other actions harmful to the trusting public. There are also concerns over the private sector bodies and the reality of their ability to balance the needs of the industry and the best interests of those receiving their services. These concerns were alive and well long before IOM's landmark “To err is human,” and establishment of the Department of Homeland Security (DHS), probably best articulated by long-time critics and observers of the extant mechanisms for healthcare oversight. The following two quotes are taken from the Presidential Advisory Commission on Consumer Protection’s final meeting, March 1998.
“Conflicts of interest can arise from multiple sources. For example, private sector accrediting bodies have, as one of their customers, the entities that the organization accredits. The organizations to be accredited sometimes are the same organizations that created or fostered the creation of the accrediting entity, and often are necessarily involved in identifying the standards to which they will be held accountable.”
“Quality oversight organizations also have a second set of customers – healthcare consumers – who depend on the work of these organizations to make comparative judgments about the quality of certain types of healthcare organizations. This is particularly true when public regulators use accreditation as a means of meeting public standards (e.g., when JCAHO accredited hospitals are deemed to have met Medicare Conditions of Participation). Consumer advocacy organizations become concerned when the accrediting organization seems overly solicitous of the views of the industry, or when very few organizations have their accreditation denied.”
The above referenced JCAHO is the re-branded TJC, or Joint Commission. This organization has enjoyed a near monopoly in the hospital external evaluation arena and is used extensively as the mechanism of choice to assess healthcare quality, safety and security in the nation’s worldwide military, veterans, Native American, and public/private facilities.
The effectiveness of the accreditation and deeming mechanisms on the quality of care measured by hospital acquired infections, treatment errors, and violence in the workplace speak for themselves.
A year before the 9/11 attacks, key elements of the private/public and governmental healthcare sectors met to consider how best to prepare for and respond to looming threats which would call for a “mass casualty” response from the industry. The broad consensus was to follow the JCAHO 1998 Environment of Care Standards and expand involvement with the local community.
The JCAHO's initial response to the 9/11 terrorist attacks may be characterized as a flurry of activity producing reams of comprehensive guidance to its clients and other healthcare stakeholders. Two Public Policy publications (Health Care at the Crossroads and Standing Together) provided ample evidence that the organization had a unique understanding of the scope of the threats and the need for the industry to coordinate with the local community.
The Joint Commission (JCAHO) revised its Environment of Care (E.C.) standards and on January 1, 2003 and formalized the concept of community involvement in the healthcare emergency management process. The new guidance held hospitals accountable for the important new concept of community planning among healthcare organizations that provide services to contiguous geographic areas.
Explicit guidance did not find their way into the evolving JCAHO emergency management standards. It would be another five years before such explicit guidance would find its way into the standards.
The healthcare industry's initial response reflected JCAHO's enthusiasm significantly waned when it became clear that federal funding was not going to meet expenses associated with needed preparedness.
The chaotic response to Katrina (2005), in general, and New Orleans in particular, shocked the nation and bears witness to a collective weakness at all levels in effective disaster planning and response. The reality that a group of Healthcare community decision-makers charged with the grave responsibility to protect the city's most vulnerable population, institutionalized (Hospitalized) frail, sick and injured, failed to take timely action to either "evacuate" or "protect in place" was difficult to reconcile. The lack of timely action was further complicated by the existence of a multi-day storm warning and forecasts of time, direction and landfall. A quick look at the destructive pattern of this type of storm over the past 150 years (Category 3 Hurricane landfall within 100 miles of the City.) would suggest that healthcare authorities would err on the side of patient protection.
Earlier high profile “lessons learned” from “Tropical Storm Allison (2001)” if you are in a hurricane zone, you don't locate your emergency generators in the basement or any vital service center on the lower floors. Lack of action based on these lessons caused tragic loss of life during Katrina. The 9/11 NYC attacks “lessons learned” were seen as a sign that the public health and health sectors were able to successfully cope with mass casualty events. In reality, the event became a mortuary event and not a significant test for hospital and healthcare mass casualty readiness. Indeed, had there been a Chemical, Biological, Radiological or Nuclear (BRN) component in tandem with the explosive event all major healthcare capabilities would have been rendered useless. Poor crowd control at treatment sites and porous hospital security exposed treatment sites to deadly contamination.
The Healthcare Industry was notified on May 26, 2006, that they were expected to become full partners in the nation's strategy for Homeland Security. The National Response Plan (NRP) later The National Response Framework (NRF) called for a seamless bulwark to prepare for and respond to future all-hazards threat to the American land mass. The Incident Management System (NIMS) initiative was and is a vital response component and its adoption key to the success of the larger plan.
The non-federal hospital and healthcare system has been slow to respond to their expected roles and responsibilities in both of these charges and has been characterized by many as "the weakest link in the Homeland Security chain".
The June 2007, Joint Commission publication announced revised standards for January, 2008 which strengthened and clarified guidance for hospital Emergency Management. Emphasis on the six critical areas of emergency management moved the standards closer to expectations identified in the Center for Medicare and Medicaid Services (CMS) Conditions of Participation (COP) and fundamental principles embedded in the national strategy for all-hazards protection, NIMS and NRF.
The revised Elements of Performance (EP) were fundamental to and essential for hospital authorities for rational determinations of the most difficult of decisions to face healthcare executives in times of crisis, “protect –in-place or evacuate” and had been identified as critical “lessons Learned” in post-Katrina guidance.
Toward the end of the first quarter of 2008, the Joint Commission Accreditation Committee responding to near panic concerns from client hospitals and industry trade organizations that enforcement of new EC requirements would place hospitals up for accreditation surveys at substantial risk of losing their deeming status. 
In the interim, the EPs would not be scored. Many of our clients insisted that the new revisions would not be enforced (see Client Memo). Needless to say the reversal (To the rear march) was a shock to us, we had seen changes in standard emasculated in the past but never so sweeping.
Our next article will take a look at 2009 and 2010 and see if the 2008 retrograde movement in oversight was a blip or a trend. Contributor Dr. James Blair, DPA, MHA, FACHE, FABCHS, CAS, is president and CEO of the Center for HealthCare Emergency Readiness. He is the author of the book, Unready: To Err is Human: The Other Neglected Side of Hospital Safety and Security, which was published in June. He is also a career-retired army colonel with 28 years of active service. Among his private sector experiences, he served as VP of Hospital Corporation of America, Middle East Limited and as an independent consultant to Joint Commission International.

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