TJC Accreditation for healthcare providersWhat We Do For Healthcare Providers
Your Crisis Team provides healthcare providers with the expertise to gain or maintain accreditation with The Joint Commission’s Emergency Management standards.
Members of Your Crisis Team have responded to events where loss of life and property were clearly the result of a lack of emergency preparedness planning. Your Crisis Team was founded to meet this need and foster resilience.
We know how bad it can be – so you don’t have to find out the hard way. Our team of specialists
TJC Emergency Management Compliance can be intimidating. Your Crisis Team has demystified the process and will help you identify where you are and then walk you through the steps towards compliance.
Healthcare Providers We Support
Ambulatory Health Care
Behavioral Health Care
Critical Access Hospitals
TJC Accreditation Services for Healthcare Providers
Our job is to help you empower you to continue caring for your patients even on a bad day. This preparedness is also essential to meeting the Elements of Performance for Emergency Management, as set down by The Joint Commission.
Your Crisis Team equips healthcare providers with everything you need to gain or maintain accreditation with The Joint Commission’s Emergency Management standards. This can include any or all the following:
- Guiding you through the risk assessment
- Helping you get the local information you need
- Providing assistance in developing your plans
- Assessing your training and exercise records
- Designing, conducting, and evaluating readiness exercises
Understand the role of Risk Assessment in TCJ Elements of Performance
Lead your colleagues in compiling risk assessment data for your facility
Learn to transition from evaluating risks, to determining emergency capabilities
Follow-up review of risk assessment is conducted two weeks after training
Hazard Vulnerability Analysis
The first step in emergency preparedness is to assess the risks that your community and your facility face. This process involves several key people from your facility discussing the specific threats that you face, including natural disasters, technological emergencies, and malicious attacks. You need to know what can happen, but also what problems can it cause: structural damage, power outage, access problems, supply shortages, etc. This, in turn, determines the capabilities you must develop and strengthen as part of your emergency plan: the ability to continue serving patients even without commercial power; the ability to evacuate to a safer location; the ability to shelter in place for an extended period, etc.
Your Crisis Team provides an online tutorial and booklet to guide you through the process. We also connect you with local resources that have may already have identified the risks in your community.
Emergency Operations Plans Review
With the risk assessment complete (and reviewed by our experts) you are ready to begin developing or improving your plan.
If you already have a written emergency plan, no matter how old, we will review it against the TJC Elements of Performance and identify, line by line all the potential gaps. We will provide you with guidance and examples so you can complete your plan to meet the requirements.
Another key part of compliance includes you training your staff on how to carry out the emergency procedures we will help you develop. You must keep good records. New employees must be trained as part of their onboarding, and all employees need training annually. We will review your records and help you document the time you invest in training.
Receive a customized report – your step-by-step guide for TJC compliance
Assist in documenting your training activities
Introduction to local, partner resources
Your facility must participate in two operations-based exercises each year. Depending on your facility, there are additional exercise requirements such as patient surge.
Your Crisis Team will work with you to determine your exercise needs, then design, deliver, and evaluate your exercise.
You will receive, within a few days of the exercise, an “After-Action Report/Improvement Plan” which will summarize the exercise, your actions, and identify strengths as well as areas of improvement. You will receive specific, concrete recommendations for you to improve your plans.
This exercise will be designed and supervised by a Your Crisis Team member certified as a “Master Exercise Practitioner” by the US Department of Homeland Security. This is the highest possible certification for anyone conducting readiness exercises in the U.S.
Real World After-Action Report
If your organization has a real-world emergency, and you use your emergency plan, then that emergency can count as one of your required exercises… if you produce, in a timely manner, an After-Action report that documents the incident, the actions you took, and any plans, policies, or procedures that you reviewed as a result.
Your Crisis Team will work with your staff to document the event and help determine what improvements will leave you even more prepared next time. We will then produce, for your approval, the required documents that will guide your preparedness improvements and please your surveyor.
Training conducted on-site or remotely
Monthly follow-up of improvement plan with your Safety Committee
Focused on improvement, capturing lessons learned and areas for improvement
What does a project engagement with Your Crisis Team look like?
Our proven process and methodologies ensure a smooth and productive project.
Just like any incident, it’s important to first determine the initial facts and objectives. What’s the current situation with your emergency plans, training, and/or exercises? What are your mission objectives?
We will ask you the hard questions that help you draw a clear picture of where you are or need to be, and what obstacles exist between here and there.
We will work with you to develop a step-by-step plan to help you achieve your objective. We will define operational periods – often two-week or monthly periods – which each contain clear steps to be taken. We will update you each period with an Incident Action Plan that reflects what has happened so far, and what is expected of each of us in the coming period. (If this sounds a lot like the NIMS you’re used to, that’s a good thing!)
We will work with your staff and/or independently, as dictated by the Action Plan, to achieve the tangible deliverables promised – plans, training guides, exercise elements – that reflect your organization’s culture and our professionalism.
You will have the opportunity to review and revise each, so the final version exceeds your expectations.
No significant project is complete until you and we have had the chance to weigh in on how well we did, and how this project has improved your preparedness.
We thrive on feedback. We can’t get better unless we get honest feedback from you.
Clients & Testimonials
Thank you for your assessment of our Emergency Preparedness Plan! Working with you has helped us understand how to prepare in an emergency and increase communication between our staff and patients.
Healthcare Leadership Team
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by Rick Christ Currently, almost every provider type is required to participate in two exercises per year. One “should be” a “community full-scale exercise” while the other can be a tabletop. The original version of the current exercise standards was...
by Rick Christ Currently, the typical CMS regulation says this about the training requirement: The training and testing program must be reviewed and updated at least annually. (1) Training program. The hospital must do all of the following:(i) Initial...