Resources for Developing an Emergency Operations Plan

Last week, I shared a brief checklist for evaluating your hospital emergency operations plan and now, I’m here to share a couple of free resources with you to aid in this process.

U.S. Department of Health & Human Services ASPR TRACIE
This website, which is free to join, is a great national resource for templates and more. They also have a feature section titled “Beyond the Response: Experiences from the Field” which details organizations’ responses to emergencies.

California Emergency Medical Services Authority (EMSA)
This website provides multiple tools and templates to assist you with the emergency preparedness process. You can find editable Word documents that cover topics such as active shooter, infectious disease, missing persons, utility failure, and more.

If you would like more information regarding hospital emergency operations plans, please contact me at carrie.kotecki@complianceonegroup.com.

Teaming with Law Enforcement in Healthcare

Q: What resources can hospitals use to manage workplace violence?

A: The law enforcement department in your community is a significant resource for healthcare in designing a united front in managing workplace violence. A strong and consistent relationship between the law enforcement leaders and the hospital leaders promotes safety for your institution and ensures a final process when violence occurs.

Here are some actions and tactics to consider in your program:

  1. Develop a direct communication plan between the hospital and law enforcement to troubleshoot emergencies. Have the leaders from law enforcement and the hospital meet regularly, including front-line staff. Record meeting notes and send them to the Environment of Care Committee for sharing and consistency.
  2. Consider including law enforcement in your security huddles.
  3. Develop a prior notification process with law enforcement that addresses incarcerated individuals or other persons in a “Not Free to Leave” status. This provides advance notice to the emergency department of a potential high-risk patient.
  4. If you have a hospital security department, consider making the security supervisor the point of contact for any officer coming to the hospital.
  5. A weapons policy that addresses managing a police officer’s weapon if they are injured and brought into the emergency department.

These are just a few of the actions that can be taken with your local law enforcement agency to improve the overall safety of your facility. Enlisting their assistance and creating a relationship is pivotal to a successful workplace violence program.

If you would like a copy of Carrie’s article, “Teaming Up with Law Enforcement in Healthcare,” please email info@complianceonegroup.com with “Carrie’s Article” in the subject line.

Workplace Violence

Q: How do I decrease workplace violence incidents in the hospital where I work?

A: In my experience working within a healthcare setting, the best way to decrease workplace violence incidents is to have a workplace violence plan that is specific to your facility. This document must also be re-evaluated on a regular basis and be updated accordingly.

Developing a workplace violence plan can be daunting, but it’s critical to the health and safety of your employees. The key components to include in your plan are:

  1. You should perform a risk assessment of the facility you work in. Ask yourself, “What are the significant safety hazards that exist?”
  2. Utilize data collection tools to collect specific information on each incident to determine which solutions are necessary.
  3. Consider implementing safety and/or security teams that can manage the information and report to the administration on a regular frequency (monthly).
  4. Develop a user-friendly safety reporting process that all employees are required to fill out.
  5. Implement and stick to a zero-tolerance policy that supports all employees and empowers them to press charges on any acts of violence.
  6. Provide customer service training for all employees, as well as de-escalation training for those in high-impact areas. It’s also best to consider situational awareness training for employees too.
  7. Develop a controlled access plan for your facility and minimize the number of entrances for visitors and employees. This will allow you to better control who enters and exits your facility.
  8. Provide regular, hands-on, scenario-based training for your employees to teach them how to best manage workplace violence.

If you have additional questions about how to implement a workplace violence plan, please feel free to email Carrie at carrie.kotecki@complianceonegroup.com.

Delayed Egress Locks

Q: Our hospital is not fully sprinklered and is not fully smoke detected, but we want to install an infant security locking system in our Mother/Baby unit. I discussed this with our vendor who wants to sell us the infant security locking system, and he says we qualify for delayed egress locks because being 100% fully sprinklered is not the only criterion for compliance. He says we comply because we demonstrate the existence of an approved, supervised automatic fire detection system by having an automatic fire detection system in our hospital, so that should allow the installation of the infant security locking system. The vendor also said as long as the local AHJ approves the installation, that’s all we need, because the local AHJ has the final word. What do you say?

A: NFPA 101 Life Safety Code, 2012, section 7.2.1.6.1 is rather clear: Among other requirements, in order to have delayed egress locks, you need one of the following:

  • The building needs to be fully protected throughout by an automatic sprinkler system, or;
  • The building needs to be fully protected throughout by an automatic fire detection system.

Being fully protected throughout with automatic sprinklers is obvious – you need full sprinkler coverage everywhere in the building. But it appears the term ‘being fully protected throughout by an automatic fire detection system’ is not so obvious. If you are not fully protected with sprinklers, then section 7.2.1.6.1 requires a smoke detector in all occupiable areas. This is explained in section 9.6.2.9 of the 2012 LSC. This means a smoke detector must be inside every room, every sleeping room, every procedure room, every corridor, every office, every conference room, every utility room, every lounge, every classroom, every work-room, every mechanical room, etc. In my 40-years of doing this work, I’ve yet to see a hospital qualify for this in regards to installing smoke detectors in all occupiable areas. If you believe your hospital meets the requirements for being fully protected with smoke detectors, then I would like to schedule a visit and take a look, because I’ve never seen that before.

Please understand the way your vendor described it “demonstrate the existence of an approved, supervised automatic fire detection system”, does not meet the description of being fully protected throughout by an automatic fire detection system. All hospitals have an approved, supervised automatic fire detection system, because the LSC requires that. But no hospital (so far that I have seen) has a smoke detector in all occupiable areas. It’s not required and it is too costly to install. Sprinklers are far cheaper.

Your vendor is correct, though: Sprinklers are not the sole criterion for the installation of delayed egress locks. But, it is one of two criteria, and so far, no hospital is choosing to go with the other choice (smoke detectors). Even if you could afford to install smoke detectors in every occupiable areas, the hospital would likely not be able to afford the maintenance (testing & inspection) and all of the false alarms that go with it.

By the way… the phrase “the local AHJ has the final word” is not accurate. I appreciate the respect that the vendor is trying to say, but all AHJs have the final word, not just the local AHJ. The typical hospital has many (between 5 and 8) AHJs that they have to comply with regarding the Life Safety Code:

  • CMS (Federal)
  • Accreditation organization
  • State licensing agency
  • State agency in charge of hospital construction
  • State fire marshal
  • Local fire authority
  • Local building code authority
  • Insurance company

All AHJs are equal. No one AHJ can override the decision of another AHJ. Any AHJ can decide to interpret the LSC in the way they deem necessary and if it disagrees with another AHJ, then so be it. The hospital must comply with the most restrictive interpretation. So, saying the local AHJ has the final word is not accurate; all AHJs have the final word. For example: If the local AHJ said it is okay to install delayed egress locks for infant security (because nobody wants to see infants stolen), even though the building is not fully sprinklered and not fully smoke detected, that’s not okay with other AHJS like CMS, your accreditation agency and your state agency on hospital construction. So, the hospital cannot do that, because they have to follow the most restrictive interpretation.

I see other hospitals that are not fully sprinklered or fully smoke detected use infant security systems but they do not install the door locking hardware. So, it operates like a warning system. If the hospital does not want to invest in being fully protected with sprinklers (or smoke detectors), then that is their only option. It is an incentive to become fully protected with sprinklers.

Security Cameras in Stairwells

Q: What is the Life Safety Code ruling on cameras and speakers in stairwells? Joint Commission was in and cited us on having cameras in the stairwells. We were told by the surveyor that they don’t pertain to the stairwells.

A: The Life Safety Code does not specifically address cameras in the stairwells, but section 7.1.3.2.1(10) of the 2012 LSC does limit what penetrations are permitted into an exit enclosure. Conduit is permitted as long as the conduit serves the stairway. This seems to be an interpretation issue, and apparently, the surveyor decided the use of cameras does not fit the description in 7.1.3.2.1(10). To me, a camera focused on people using the stairway seems to fit the description of “serving the stairway”, but it really doesn’t matter what I think.

If you can prove the camera installation qualifies as ‘existing’ conditions, then it should be accepted by the accreditor. The definition of ‘exiting’ conditions is any design, construction, or governmental approval that was in existence prior to July 5, 2016 (the date the 2012 LSC was adopted). However, since the 2000 LSC also prohibited new penetrations in stairwells for cameras, it is likely that a surveyor will hold you accountable to what the 2000 LSC required when you were supposed to comply with that edition, and that edition was adopted March 11, 2003. So, if the camera was installed in the stairwell since March 11, 2003, I can see that the surveyor would have a legitimate finding.