To The Rear, March! – TJC Reversal’s Unintended Consequences || Elements of Performance

by | Sep 7, 2012 | Accreditation, Posts - Manmade Hazards and Issues, Public Health

The June 2007 TJC posting of an alert to the hospital community to be prepared to implement a set of new and revised Elements of Performance (EP) was a shock to many in the industry. The new or revised all-hazards Elements of Performance were not new to existing standards. Nobody thought TJC would ever enforce the additional requirements.

For the first time since 9/11 and the tragic loss of life in Katrina/Rita, new EPs matched the all-hazards challenge.

What followed the requirement for implementation of these All-hazards EPs on 1 January 2008 was also a shock to those who had diligently complied with the intent of the new EPs.  Predicted by some and surprised by others, the scoring of these measures for preparedness and response to natural disasters and manmade events were suspended by TJC. The following Client Issue Brief was our way of dealing with the potential loss of credibility by “doing the right thing at the right time.â€


#Client Issue Brief, Facility Groups 1-3-5, 2nd Qtr 2008

If we have over-prepared you we are not going to apologize. Being ahead of the “Power Curve†is a good place to be!!!

How are you all handling this revision?  In June 2007 TJC made some significant changes to the EC Standards. The changes, by their own statements, bring the EC Standards to a level which made them compatible with COPs and sets the stage for National Incident Management System (NIMS) compliance. The period April- Jan 2009 places the strategy for Homeland Security healthcare at substantial risk.

Res ipsa Loquitur

Without meeting these EPs, the sector cannot meet any of the “six critical areas of emergency management†as earlier defined by the June 2007 TJC Justification statements, including:

1.   Communication

2.   Resources and assets

3.   Safety and Security

4.   Staff responsibilities

5.   Utilities management

6.   Patient clinical and support activities

Failing to hold the organizations accountable for Personal Protective Equipment (PPE), Hazardous Materials, information on which to base “protect in place or evacuate†decisions, tracking vulnerable patients, including behavioral and forensic population etc. is at best incomprehensible and places hospital populations at unacceptable risk.

The changes referenced were posted on the TJC website, and the section reads as follows:

Some new emergency management requirements will not count toward accreditation decision

Hospitals, critical access hospitals and long term care facilities have expressed to The Joint Commission that it is taking a longer time to implement some of the new requirements of the Emergency Management standards that were effective in January 2008. These requirements call for the involvement of the community in organization plans and response efforts during disasters.

In order to allow more time for organizations to implement these standards, The Joint Commission will allow the following through 2008: the new requirements will be surveyed, non-compliance will be cited in an organization’s survey report, and the organization will need to address the non-compliant standards in its Evidence of Standards Compliance. However, non-compliance will not be included in the count of non-compliant standards contributing to either a Preliminary Denial of Accreditation or Conditional Accreditation decision. The following Elements of Performance in the Environment of Care chapter would not count toward the accreditation decision:

  • EC.4.11 EP 9, 10 EC.4.12 EP 6
  • EC.4.13 EP 7 EC 4.14 EP 8, 10
  • EC.4.15 EP 2, 3, 5 EC.4.16 EP 2, 3
  • EC.4.17 EP 4 EC.4.18 EP 4, 5, 6

Meeting on April 17, 2008-

TJC, under pressure from the healthcare industry and segment supporters, changed the scheduled scoring of these elements which they had so eloquently justified.

The following Elements of Performance will not be scored in 2008

EC. 4.11 EP .9 & .10-

  • 9 Documented Inventory of asset and resources it has on site needed for Emergency
  • 10 Established methods for monitoring same

EC. 4. 12 EP .6

  • 6 EOP Identifies capabilities and establishes response efforts when hospital cannot be supported by the local community for 96 hours in the six critical areas.

EC. 4. 13 EP .7

  • 7 The plans for communicating with purveyors of essential supplies, services, and equipment once emergency measures are initiated

EC. 4. 14 EP .8 & .10

  • 8 Plans for: potential sharing of resources and assets with health care organizations outside of the community in the event of a regional or prolonged disaster.
  • 10 Plans for: transporting pertinent information, including their medications and equipment, and an alternative care site when the environment cannot support care, treatment and services.

EC. 4. 15 EP .2 .3 & .5

  • 2 The organization identifies the roles of community security agencies (police, sheriff, national guard, etc.) and defines how the org will coordinate security activities with these agencies.
  • 3 The organization identifies a process that will be required for managing hazardous materials and waste once emergencies are initiated;
  • 5 The organization identifies residents who might be susceptible to wandering once emergency measures are initiated.

EC. 4. 16 EP .2 .3

  • 2 Staff are trained for their assigned roles during emergencies
  • 3 The organization communicates to licensed independent practitioners their roles in emergency response and to whom they report during an emergency.

EC. 4. 17 EP .4

  • 4 Organizations identify an alternative means of providing for the following utilities in the event that their supply is compromised or disrupted: fuel required for building operations or essential transport activities other essential utilities needs (for example, ventilation, medical gas/vacuum systems, etc.)

EC. 4. 18 EP .4 .5 & .6

  • 4 Plans to manage the following during emergencies: Mental Health Services needs of its patients
  • 5 Mortuary Services
  • 6 Plans for documenting and tracking patients clinical info

We have been – on one side or the other – of JCAHO/TJC for forty years. This is the closest to an admission of impotency by TJC and those oversight entities at all levels of government. Jim

James D. Blair, FACHE
Center for HealthCare Emergency Readiness

(770) 558-3704


Post Your Comment


Core Topics

Contact Us

*We will never sell or share your contact information” to “Your email address will not be published.