Emergency Management Chapter for Ambulatory Care Re-write

The Joint Commission has rewritten the Emergency Management (EM) Chapter for Ambulatory Care as part of its burden reduction and streamlining standards initiative. This new chapter will go into effect July 1, 2024. This revision resulted in reorganizing requirements,  renumbering standards, deleting repetitious requirements for office-based surgical practices, and a greater than 40% overall reduction of Elements of Performance.  These revisions aim to support the development of more effective EM plans for the organization and the community they serve.

Emphasis on the Hazard Vulnerability Assessment 

Although using the Hazard Vulnerability Assessment (HVA) in developing an organization’s EM Plan is not new, the new standards place a much greater focus on the HVA as the basis of all initiatives and plans to address EM-related events. This includes more of an all-hazards approach in assessing for and addressing vulnerabilities to include, but not limited to:

  • Natural hazards (such as flooding, wildfires)
  • Human-caused hazards (such as bomb threats or cyber/information technology crimes)
  • Technological hazards (such as utility or information technology outages)
  • Hazardous materials (such as radiological, nuclear, chemical)
  • Emerging infectious diseases (such as the Ebola, Zika, or SARS-CoV-2 viruses)

Additionally, the standards require prioritizing the HVA results based on their likelihood of occurrence and the subsequent impact on the organization's ability to provide services.

With the greater emphasis on the HVA as the backbone of the EM plan, organizations may be challenged to expand their current assessment practice to ensure they utilize a more comprehensive approach to identifying, prioritizing, and evaluating hazards' impacts.  This is especially true for smaller facilities or those with limited EM expertise and resources.  Organizations are encouraged to contact local and state emergency preparedness authorities as first-line resources when conducting an HVA.  This can provide readily accessible sources of information on hazards in their community and support their integration in the regional response efforts for major disasters.  There are excellent resources on HVA procedures available from the Office of the Assistant Secretary for Preparedness and Response, Technical Resources, Assistance Center, and Information Exchange, U.S. Department of Health and Human Services (ASPR TRACIE).

Expectations of Leadership Involvement and Oversight of the EM Program

The Joint Commission has additionally increased its expectations of an organization’s leadership with its involvement and oversight in all aspects of the EM program.  This can include allocating resources, planning, and reviewing policies and procedures.  Furthermore, organizational leaders are expected to not only be part of the process of EM program development but also in evaluating the program, including the identification of revisions for improvement.  The organization’s leaders are charged with identifying an individual or team to develop and manage the emergency operations plan, coordinate EM-related education and training, and conduct drills to test the emergency operations plan.

Organizations should ensure that EM program development and evaluation activities are periodically communicated to their leadership team. These discussions should also be documented in committee and/or Board minutes, including directives from the leaders on improvement guidance. Surveyors may request meeting minutes to confirm the leadership team's oversight activities.  Additionally, identified issues from drills, exercises, and program evaluation should be addressed, and any follow-up information on mitigation efforts should be reported to your leadership team.

More Specific Guidance for Initial and Ongoing EM Program Training

The new standards also include more specific guidance on staff education and training of EM program elements.  Specifically, the leader(s) of the EM program is responsible for developing and maintaining a written education and training program based on the prioritized risks identified by the HVA, the emergency operations plan, the communications plan, and organizational policies and procedures.  This would also require changing the program as new vulnerabilities are identified or changes are made.  Training in the EM program would be required upon hire for new staff and periodically after that for all existing staff, individuals providing contracted services, and volunteers as currently required.

Additionally, new requirements for EM program education indicate that the training should be based on staff roles and responsibilities during an emergency.  Training content would include, but not limited to, the following topics:

  • Activation and deactivation of the emergency operations plan
  • Communications plan
  • Emergency response policies and procedures
  • Evacuation, shelter-in-place, lock down procedures
  • Where and how to obtain resources and supplies for emergencies (such as procedures manuals or equipment)

Organizations will need to identify the need to update role-based education and training topics with each new HVA and program change.  This should be part of the update report to leadership as there could be a significant need for resources with major updates and changes.  This could include the need for time away from staff members’ primary duties to attend training.  As with conducting HVAs, organizations should consider contacting local and State authorities for training resources, as there may be existing references and resources applicable to the organization’s education and training needs.  Organizations are also encouraged to engage with their staff education and training departments to assist with developing role-based EM training, as they should be familiar with the process of training requirement development.


The new EM chapter for Ambulatory Programs, which will come into effect in July 2024, streamlines the requirements for organizations to ensure they are prepared to address disasters and events that can impact their ability to maintain operations.  Organizations should review The Joint Commission’s R3 report (Issue 39, December 20, 2023) for applicable program changes and compare their policies and procedures to ensure alignment.

For questions or to learn more contact the C&A team at 704-573-4535 or email us at info@courtemanche-assocs.com.

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