Public Health Emergency Preparedness
This resource was part of AHRQ's Public Health Emergency Preparedness program, which was discontinued on June 30, 2011, in a realignment of Federal efforts.
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Chapter 2. Accreditation Requirements
This section provides an overview of hospital preparedness exercise requirements in the following sections:
- Overview: Accreditation Requirements.
- The Joint Commission.
- American Osteopathic Association (AOA).
- Det Norske Veritas (DNV) Healthcare, Inc.
- Other Accreditation Organizations.
- Centers for Medicare & Medicaid Services (CMS) (as related to accreditation).
- National Fire Protection Association (NFPA) (related to CMS).
- Useful Resources and Tools.
Overview: Accreditation Requirements
Accreditation Organizations serve as independent authorities for evaluating a hospital's patient care delivery. This evaluation is based on a set of standards developed by the accrediting organization.
If a hospital is accredited,3,4 in most cases the hospital preparedness coordinator will begin planning an exercise by examining accreditation standards of the respective accreditation organizations. This is because the preparedness exercise standards of accreditation organizations generally have more specific requirements compared to those of other exercise-related entities. Furthermore, meeting accreditation requirements typically allows hospitals to achieve "deemed"
status by the Centers for Medicare & Medicaid Services (CMS), which is a requirement for Federal hospital reimbursement. (Select for more detail.)
Joint Commission
The Joint Commission is one organization that accredits health care organizations in the United States. According to the Joint Commission, receiving accreditation from the organization helps to assure quality care and safety for health care recipients.
The Joint Commission has a specific chapter on Emergency Management in its accreditation manual that covers standards related to managing consequences of emergencies (2009).5 The standards include requirements for developing, maintaining, and implementing a comprehensive Emergency Operations Plan that covers the following critical areas in emergency management:
- Communication.
- Resources and Assets.
- Safety and Security.
- Staff Responsibilities.
- Utilities Management.
- Patient and Clinical Support Activities.
- Regular Testing and Evaluation of the Plan.
Emergency Management Standards That Contain Exercise Requirements
The Emergency Management Standards related to exercise requirements are found specifically in Emergency Management Standard EM.03.01.03 and require that a hospital undertake exercises as a means of evaluating a its Emergency Operation Plan.
American Osteopathic Association
The American Osteopathic Association (AOA) provides hospital accreditation through its Healthcare Facilities Accreditation Program (HFAP).6 The HFAP initially began as a program to ensure that osteopathic medical students were educated in facilities attuned to their training. However, it is now recognized by the Federal Government, State governments, insurance carriers, and managed care organizations as a comprehensive hospital accreditation program.
AOA's HFAP emergency preparedness-related standards are located in the Physical Environment chapter. AOA's HFAP emergency preparedness-related standards focus on developing "Disaster Plans," which are listed under the sub-categories "Weapons of Mass Destruction Plans" and "Disaster Response Plans." HFAP also uses the term "Disaster Drills" instead of exercises.
Disaster Drills Standards that Contain Exercise Requirements
The Disaster Drills Standards that contain exercise requirements are found specifically in Standard 11.07.03 and 11.07.09.7
Det Norske Veritas Healthcare Inc.
Det Norske Veritas (DNV) Healthcare Inc. provides hospital accreditation through its National Integrated Accreditation for Healthcare Organizations (NIAHO) Accreditation Program.8 DNV uses the International Organization for Standards (ISO) 9001 to guide its accreditation process, which, according to DNV, aims at identifying best practices and translating them into standard operating procedures.
The emergency preparedness-related standards are located in the Physical Environment chapter. All the emergency preparedness standards for DNV's accreditation program center on having a functional emergency management program. This involves developing and maintaining an emergency management system, conducting exercises to evaluate the system, and improving the system.
Emergency Management System Standards that Contain Exercise Requirements
The Emergency Management System Standards related to exercise requirements are found specifically in SR.49 and are further clarified in DNV's Interpretative Guidelines and Surveyor Guidance.
Other Organizations
Hospitals may also follow standards of other organizations, depending on the services provided. Some examples of these organizations are:
- American College of Surgeons for verified trauma centers.
- American Burn Association for verified burn centers.
- Commission for Accreditation of Rehabilitation Facilities for rehabilitation, behavioral health, and other services.
These organizations typically have additional requirements for emergency management and exercises, and it may be useful to refer to their standards in developing an exercise plan.
Relationship of CMS to Hospital Accreditation: "Deemed Status"
In order for hospitals to participate in the U.S. Federal Government's Medicare and Medicaid programs, the Centers for Medicare & Medicaid Services (CMS) has established regulations known as Conditions of Participation (CoPs) that may be found in 42 CFR 482. (See page 25 for more information on CMS.)
Three accreditation organizations—the Joint Commission, AOA, and DNV have received CMS "deemed status." This means that CMS granted these organizations authority to deem their accredited hospitals to meet all Medicare requirements for hospitals because their standards either meet or exceed CMS requirements. Such hospitals also do not have to be subjected to the CMS routine survey and certification (CMS, 2009). Because of this, accredited hospitals will most likely not refer directly to CMS CoPs. Hospitals that are not accredited by any of these three accreditation organizations, but receive CMS reimbursement are subject to CMS' routine survey and certification process and do need to make sure they are compliant with the CMS CoPs.
NFPA Related to CMS
The National Fire Protection Association (NFPA) provides standards and codes on fire safety-related issues for hospitals in the NFPA 99 (Standard for Health Care Facilities), NFPA 101 (Life Safety Code), and NFPA 1600 (Standard on Disaster/Emergency Management and Business Continuity Programs). NFPA codes and standards are incorporated by reference into CMS' CoPs.
CMS and NFPA Relationship to Accreditation Standards
All three accreditation organizations with deemed status (Joint Commission, AOA, and DNV) require compliance with NFPA standards and codes because they are incorporated into the CMS CoPs.
Summary
- Hospital accreditation organizations such as the Joint Commission, AOA, or DNV have specific requirements related to hospital preparedness exercises.
- If your hospital is accredited, it is important to consult the most recent standards from the relevant accreditation organizations in planning preparedness exercises.
- Because the Joint Commission, AOA, and DNV may confer "deemed status" according to CMS, hospitals accredited by these organizations are considered to be compliant with CMS Conditions of Participation for the Medicare and Medicaid programs.
- Hospitals that are accredited by organizations with "deemed status" are also compliant with NFPA standards that relate to hospitals because those standards are incorporated into the CMS CoPs.
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Useful Resources and Tools
Below is a list of useful resources and tools for meeting accreditation requirements. Consult these Web sites for the most recent standards and guidance. ($ = Available for a fee; check with your hospital for existing subscriptions.)
Joint Commission
AOA
- Healthcare Facilities Accreditation Program
These are the standards and requirements that AOA uses for accreditation for healthcare facilities, ambulatory surgical centers, critical access hospitals, mental health centers, clinical laboratories and primary stroke centers. These include the most recent standards related to hospital preparedness exercises.
http://www.hfap.org/pdf/acc_hforderfm.pdf 
[PDF Help] ($)
http://www.hfap.org/manualupdates.aspx (Document updates)
DNV Healthcare, Inc.
National Fire Protection Association (NFPA)
3 For this chapter, planners should focus only on the organization(s) by which their hospital(s) are accredited. Some hospitals may be accredited by more than one organization.
4 Not all hospitals are accredited and accreditation is voluntary. Non-accredited hospitals can begin in Chapter 3. Federal and State/Local Jurisdiction Requirements. However, it may be informative for planners working at non-accredited hospitals to review accreditation standards for emergency preparedness.
5 Joint Commission standards are continuously updated. It is important to use the most recent guidance.
6 HFAP standards are continuously updated. It is important to use the most recent guidance.
7 Reviewing the entire Physical Environment chapter is essential because many of AOA's other emergency preparedness standards are related to the exercise-specific standards.
8 NIAHO standards are continuously updated. It is important to use the most recent guidance.
9 Reviewing the entire Physical Environment chapter is essential because many of the other emergency preparedness standards tie into the exercise-specific standards.
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