Surgery Center Guidance: How to Comply With the Conditions for Coverage on Emergency Preparedness

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The following article is written by W. Jan Allison, RN, CHSP, manager of accreditation and survey readiness, clinical services department, for Surgical Care Affiliates.


It is imperative for ambulatory surgery centers to ensure appropriate preparation in managing unexpected events or circumstances that are likely to threaten the health or safety of those in the facility. An ASC's team of staff and physicians need to be knowledgeable about their facility's disaster preparedness plan and ability to provide safe, quality care for patients, family members and staff members, because disasters and other emergency events can strike with an unexpected and devastating force.


Historically, it has not been a common practice to include ASCs in responding to disasters or when conducting community drills and training to prepare for disaster response. Hospitals are typically the primary responder in a community disaster but when the hospital which would serve as a primary responder has been incapacitated or the scale of the disaster is at a major or catastrophic level, experience is teaching us that ASCs can indeed play an important role beyond the scope of traditional thinking that they don't have the capacity to contribute during a disaster.


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Effective May 18, 2009, CMS established disaster preparedness regulations that ASCs are required to meet. The federal regulations require that ASCs maintain a written disaster preparedness plan that addresses five different phases of disaster management:


1. Hazard identification — This is putting attention on identifying and prioritizing emergencies the ASC is most likely to experience and this should be done in collaboration with the local authorities. A common tool used for this purpose is the hazard vulnerability analysis. It is intended that a HVA be seen as an evolving document and be reviewed at least annually and updated as needed. It is documentation that provides evidence the center has identified all hazards and the direct and indirect effect these hazards may have on the center.


2. Hazard mitigation — These are strategies put into place to reduce the severity of impacts from hazards that cannot be prevented.


3. Preparedness — These are activities that will organize and mobilize essential resources for managing prioritized emergencies.


4. Response — These are established policies and procedures and an organizational structure for the management of effects of an emergency, including the emergency care of patients, staff and others in the ASC.


5. Recovery — Involves having activities intended to return the ASC to its normal state


The disaster preparedness plan must be coordinated, as appropriate, with state and local authorities. ASCs should send a letter by certified mail to their local or state authority, notifying them of the ASC's interest in coordinating disaster planning and providing a list of the ASC's resources and assets that may be tapped into during a community disaster response. A copy should be kept to demonstrate to regulatory authorities they have made this notification to the local or state agency.


Additionally, facilities are required to participate in at least one emergency drill per year, preferably one that is community wide and based on an emergency that the facility and community is vulnerable to experience, as identified on the HVA. A written evaluation of each drill must be completed and any identified corrections to the plan documented and promptly implemented. An ASC's disaster preparedness plan can be sharpened through regular drills and systematic evaluation. The training gives staff a well-rehearsed action plan and an increased sense of confidence when faced with the possibility of a disaster or other emergency occurring.

Learn more about Surgical Care Affiliates.

More Articles Featuring Surgical Care Affiliates:

Future of Physician-Owned Facilities: Q&A With Dr. Jeff Hessing of Treasure Valley Hospital and SCA

5 Surgery Center Specialties Predicted to Grow in 2011

ACOs: What to Expect and How to Prepare

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