As health care providers are preparing for a potentially crippling Nor’easter, it is perhaps the first major disaster to affect a large geography since the effective date of the new CMS Emergency Preparedness Rule. There is a potentially under-noticed clause in a majority of the 17 CoPs:
Analyze the hospital’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the hospital’s emergency plan, as needed.
In years past, many organizations have responded well to emergency events and either not documented them at all or only documented selective events, since accreditation organizations only required 1 or 2 incidents a year to demonstrate compliance. Now, if you organization is one of the 17 affected provider types, you should be documenting every emergency event declared within your facility.
Documenting every event is a mixed blessing. On one hand, completing an After Action Report (AAR) can be tedious and titime-consuming (we can help with that), while on the other if you have a documented real world event it should meet compliance for one of the possibly two required disaster exercises for your facility.
Regardless, if you find yourself even considering activating your incident command, opening your command center, and/or declaring a disaster, begin documenting and collecting documents immediately. The more documentation you have, the easier it will be to develop a practical AAR that drives the right performance improvement for your organization and meets compliance requirements.