By James Kendig
“The next deadly disease that will cause a global pandemic is coming. We’re not ready. An illness like the pandemic 1918 influenza could kill 30 million people within six months,” Bill Gates said during a presentation in 2015. He added that the next disease might not even be a flu, but something we’ve never seen. “The world should prepare as it does for war,” Gates later said in 2017. We now all know that Bill was right!
The Joint Commission is helping our accredited organizations better prepare for the future based on what the COVID-19 pandemic has taught us. Recently, The Joint Commission enterprise worked with C+R Research to conduct an assessment among several Joint Commission accredited health care organizations to measure the perceived impact of COVID-19 on their organizations. Interestingly, the data validates some of the information our surveyors reported from the field.
For example, the impact of COVID-19 on accredited organizations is not necessarily tied to an elevated number of cases in one area (being designated as a “hot spot”). Joint Commission surveyors noted this same issue as the research reported 20% of hospitals were experiencing a significant surge whereas 80% did not see a surge of patients. However, it is worth noting that the census recording lower numbers in non-impacted areas were because of decreased non-emergency surgeries and outpatient visits.
The Joint Commission learned that the decrease of elective procedures coupled with the lower census numbers in many cases, which hovered at approximately 43%, had a dramatic impact on the financial status of many health care organizations.
Our research also illustrated Joint Commission-accredited organizations needed an increase in support and resources in the areas of communications and planning. Common needs included communications on regulatory/guideline changes resulting from COVID-19, including those related to 1135 Waivers from the Centers for Medicare & Medicaid Services (CMS). These waivers have helped ease the burden of timely actions related to inspection, testing and maintenance activities – easing the burden on health care organizations severely impacted by COVID-19.
Updates to Emergency Management Standards
Accredited organizations asked for support around emergency management planning, development and implementation. As a result, a Joint Commission committee and subject matter experts are currently updating standards and elements of performance in the emergency management (EM) chapter for all accreditation programs, including adding a much-needed glossary. These updates tie into the overall issue that most EM plans are designed for a short-term disaster, which has been a shortcoming during the pandemic. In addition, EM plans are not designed to address an influx of patients presenting challenges in the areas of supply, staffing, finances and morale. We believe our revised standards will focus on these longer-term needs.
Updates to Survey Process
Another Joint Commission team is evaluating survey process with the goal to make EM sessions more meaningful for health care organizations, help identify unknown risks and share novel approaches to the pandemic and other EC scenarios.
The Joint Commission’s EM Committee has historically learned from organizations post disaster (e.g., Hurricane Harvey, Super Storm Sandy, the Pulse night-club shooting) and the impact that the standards and elements of performance had on an organization’s ability to “weather” the storm. Many lessons learned from speaking with organizations post-storm have been incorporated into updated standards and elements of performance as well as into survey process tips.
For example, one lesson learned after the Joplin tornado on May 22, 2011 was that according to post-event reports, patients were able to ambulate but could not self-evacuate because of significant amounts of glass and metal debris that had collected. As a result, some organizations acquired slippers (one size fits all) to be taped to patients’ feet to assist in evacuation. Kits compete with emergency slippers are now kept in command centers. Additional learning opportunities will be available by addressing staff psychological support during and after the pandemic. We continue to learn more as we investigate.
COVID-19 Experiences and Challenges
For The Joint Commission to understand health care organizations’ experiences and challenges of the impact of COVID-19, our accredited organizations shared via the research, longer-term challenges for which they felt prepared. These challenges included overall preparedness, personal protective equipment (PPE)/supplies/equipment, revised guidelines/protocols and receiving updated information. Accredited organizations also expressed challenges related to physical space changes and facilitating remote interactions. HHS ASPR Technical Resources, Assistance Center and Information Exchange (TRACIE email@example.com) continues to be a vital partner in sharing information.
Considerations should be given to specific variables while evaluating the impact of the pandemic on health care organizations. These variables include length of the impact (short term to permanent); challenge level of issues addressed (from easy to difficult); and, finally, level of preparation (not prepared for the pandemic to fully prepared).
Impact on Ambulatory Settings
For ambulatory settings, some have closed and some, using the CMS 1135 Waivers, have taken the opportunity to increase hospital capacity under the CMS program, CMS HOSPITALS WITHOUT WALLS.
CMS is allowing health care systems and hospitals to provide services in locations beyond their existing walls to help address the urgent need to expand care capacity and to develop sites dedicated to COVID-19 treatment.
Ambulatory surgery centers can contract with local health care systems to provide hospital services or they can enroll and bill as hospitals during an emergency declaration as long as they are not inconsistent with their state’s Emergency Preparedness or Pandemic Plan. The new flexibilities also leverage these types of sites to decant services typically provided by hospitals such as cancer procedures, trauma surgeries and other essential surgeries.
Ambulatory settings that have been idle will need to develop a plan to address recommissioning their facility with special attention to water systems, power, medical equipment and gases, as well as other aspects of the physical environment that support patient care. A thorough review of these systems is necessary to assure health care organizations continue to operate as designed.
“Overall, the standards have helped our agency prepare for this situation. Our infection control plan, our environment of care processes and our performance improvement program have resulted in systems which were adaptable to the pandemic. The only area in which I wish we had been more prepared was videoconferencing. I wish we had the technology and equipment to implement telehealth services in a much broader spectrum,” one individual said when The Joint Commission’s EM Committee members met with organizations post-disaster. They also noted that Environment of Care (EC) and EM standards and elements of performance afforded them the opportunity to prepare well.
Joint Commission leadership has led the way in a dialogue supporting the value of virtual surveys. When Joint Commission-accredited organizations were asked their survey preferences, interestingly an increase in virtual surveys was noted. Research shows that 38% of respondents preferred a virtual survey during the COVID-19 pandemic; only 18% noted an in-person survey was preferred; and 44% noted a mix of virtual and in-person survey was the more preferred method of surveying. The Joint Commission has a history of virtual surveys that goes back to 2017. Additional virtual surveys are being scheduled for triennial, follow up surveys, and, of course, initial surveys approved to be conducted virtually earlier in the year by CMS. Deemed initial surveys require an in-person survey once counties meet our on-site survey criteria.
Moving ahead, we expect to see many health care organizations updating and addressing the pandemic in their future requirements and guidance, including the National Fire Protection Association (NFPA), the Facility Guidelines Institute (FGI), Centers for Disease Control and Prevention (CDC) and others. COVID-19 is part of our history and is inevitability shaping our future.
James Kendig is the field director for the life safety code surveyors/engineers at The Joint Commission. In this role, he oversees half of the surveyors who specialize in surveying the Joint Commission’s life safety, environment of care and emergency management standards.