The compliance landscape is changing once again, but this time it is within the Emergency Management (EM) chapter. The year 2017 has been full of changes. Let us help you understand the upcoming EM changes. A CMS EM update will follow in the coming weeks. (Click here for CMS Part 1 & Part 2) For now, here is a list of Joint Commission EM updates to be aware of from our knowledgeable EM expert, Susan McLaughlin.

  • CMS Emergency Management Conditions of Participation (EM COPs) go into effect November 15, 2017.
  • CMS says, in many cases, if an organization is compliant with TJC, they will be mostly compliant with CMS. But, there are very few findings in EM. Currently, TJC is not looking closely, and CMS is not looking at all. Many hospitals may be only marginally compliant.
  • The Joint Commission has submitted corresponding changes to CMS for publication in July, pending CMS review.
  • The Joint Commission is proposing to CMS that their Hazard Vulnerability Assessment (HVA) requirements are sufficient to meet the COPs. The outcome of this is proposal is unknown at the time of writing.
  • An IT representative is expected to sit on the EM Committee to address cybersecurity.
  • Cybersecurity will be discussed during the EM Interview session.
    • Risk awareness
    • Incident detection
    • Incident response
    • Cybersecurity exercise recommended
  • IT resilience also will be discussed in Leadership Interview.
  • The required CMS communications plan can be included within the EOP. A separate plan is not necessary, but the COP requirements must be met.
  • The Joint Commission EM training (exercise) requirements are more stringent than those of CMS, and will remain.
  • An additional section on Integrated Healthcare Systems will be added to The Joint Commission EM requirements.
  • The requirement for annual review of the EOP will remain the same.
  • Continuity of Operations (COOP) and Leadership Succession Plans will be required.
    • Continuity of Operations: Strategies to continue critical and time sensitive processes, as identified in a business impact analysis.
    • Business Impact Analysis: Analysis that identifies impacts or disruption of an entity’s resources, and may include time-critical functions, recovery priorities, dependences, etc.
    • Additional resources for COOP:
      • ASPR Guidance
      • NFPA Guidance (Section 5.3 and Appendix Material, Business Impact Analysis; Sections 6.9-6.10 and Appendix Material, Continuity)
  • Documentation of collaboration with community partners will be required.
  • Many groups of policies and procedures required by CMS will be included in the Joint Commission EM standards.
  • 1135 Waiver policies and procedures will be expected. Organizations must know how to contact the government if a waiver is required.
    • 1135 Waiver: Under certain declared disasters or public health emergencies, waivers may be granted to ensure specific healthcare items and service are available. Examples include HIPAA, EMTALA, pre-approvals, etc. For further information click here
  • All new and existing staff, contractors, and volunteers must have documented EM training annually.
  • Additional EM resources can be found at:




Following 9/11, the Federal Emergency Management Agency (FEMA) developed high-level objectives for the nation’s healthcare delivery systems, then called NIMS Implementation Elements. These have been updated regularly, and the following are the capabilities (objectives) for the current time period.

Capability 1: Foundation for Health Care and Medical Readiness 

Goal of Capability 1: The community’s health care organizations and other stakeholders—coordinated through a sustainable HCC—have strong relationships, identify hazards and risks, and prioritize and address gaps through planning, training, exercising, and managing resources. 

  • HCC:  Health Care Coalition

Capability 2: Health Care and Medical Response Coordination

Goal of Capability 2: Health care organizations, the HCC, their jurisdiction(s), and the ESF-8 lead agency plan and collaborate to share and analyze information, manage and share resources, and coordinate strategies to deliver medical care to all populations during emergencies and planned events. 

  • ESF 8:  Emergency Support Function 8 (Public Health & Medical Services)

Capability 3: Continuity of Health Care Service Delivery

Goal of Capability 3: Health care organizations, with support from the HCC and the ESF-8 lead agency, provide uninterrupted, optimal medical care to all populations in the face of damaged or disabled health care infrastructure. Health care workers are well-trained, well-educated, and well-equipped to care for patients during emergencies. Simultaneous response and recovery operations result in a return to normal or, ideally, improved operations. 

Capability 4: Medical Surge

Goal of Capability 4: Health care organizations—including hospitals, EMS, and out-of-hospital providers—deliver timely and efficient care to their patients even when the demand for health care services exceeds available supply. The HCC, in collaboration with the ESF-8 lead agency, coordinates information and available resources for its members to maintain conventional surge response. When an emergency overwhelms the HCC’s collective resources, the HCC supports the health care delivery system’s transition to contingency and crisis surge response and promotes a timely return to conventional standards of care as soon as possible. 


Please contact us if you have questions or if you are interested in consulting services including EM program evaluation and organization. We have crafted specialized EM services that will assist you in implementing a comprehensive emergency management program that will make your environment safer when the inevitable happens.