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Hospital Accreditation

Hospital Accreditation: Emergency Preparedness - Staff Training
Posted by
on 7/10/2018 10:00:00 AM
I surveyed a hospital several years ago and asked various staff about their role in the event of a disaster. The answer was always the same: “I report to my unit and await instructions from my supervisor”. I asked the hospital’s emergency preparedness coordinator if he felt that the staff truly understood their respective roles in an emergency. It just seemed there should be more to it than simply knowing where to go and who to report to. He hesitantly agreed, but was quick to point out that standards at the time had no prescriptiveness around the content of staff training. Technically, the standard was met he argued.
Whether he was correct or not – at this point – is irrelevant. Today, the expectations for staff training are extensive and well-prescribed. So what does CMS look for when evaluating staff training in emergency preparedness? The interpretive guidance under §482.15(d)(1) forms the basis for this discussion.
Initial Training
All new staff, including contract staff and volunteers should be trained in their respective role(s) in emergency preparedness. This includes individuals who provide services on a per diem basis such as agency nursing staff and any other individuals who provide services on an intermittent basis and would be expected to assist during an emergency.
Initial training should be provided during orientation (or shortly thereafter). CMS expects that initial training be completed by the time staff has completed your hospital’s new hire orientation program. Also, if your hospital has multiple locations, CMS expects that staff also receive training at their specific location and when they are assigned to a new location.
Content of Training
Specificity is the key! While staff should obviously be trained to the core elements of your hospital’s emergency preparedness plan, it is of equal importance that training addresses job specific responsibilities. For example, if facilities staff are required to install portable showers as part of a hazmat decontamination response, there should be evidence that they have been provided the training on how to do so.
Likewise, if security personnel are responsible for crowd control and establishing access points into the hospital, they should be trained specifically on how to do so. It is highly recommended that your hospital review each department or service, establish what their specific role(s) will be in an emergency, and then provide training accordingly.
Certain clinical staff may require additional topics. For example, dietary staff who prepare meals may not need to complete training that is focused on patient evacuation procedures. Instead, it would be more beneficial to provide training that focuses on the proper preparation and storage of food in an emergency. Training does not necessarily need to be provided internally. It may be beneficial or necessary for selected staff to obtain training from external entities. For example, staff who work with radiopharmaceuticals may attend external training that teach staff how to handle radiopharmaceutical emergencies. It is up to you to decide if external training meets your requirements.
Annual Training
Hospitals have the flexibility to determine the focus of annual training, as long as it aligns with its emergency plan and risk assessment. Ideally, annual training should be modified each year, incorporating any lessons learned from the most recent testing of the hospital’s emergency preparedness plan, real-life emergencies, and the annual review of your program. For example, training could include new evacuation procedures identified as being needed when the last testing of the plan was evaluated.
It’s up to your hospital to decide what level of training each staff member will be required to complete each year based on an individual's involvement or expected role during an emergency.
Your hospital must maintain documentation of training for all staff. The documentation must include the specific training completed as well as the methods used for demonstrating knowledge of the training program. Hospitals have flexibility in ways to demonstrate staff knowledge of emergency procedures. The method chosen should be appropriate to the knowledge required. For example: computer-based or printed self-learning packets may contain a test to demonstrate knowledge. Setting up a decontamination area could be assessed by observed performance. Regardless of the method your hospital must maintain documentation that training was completed and that staff are knowledgeable of emergency procedures.
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About the Author

Richard Curtis RN, MS, HACP

Richard (Rick) Curtis is the Chief Executive Officer for CIHQ. Rick is nationally recognized as an expert on the Medicare Conditions of Participation and the CMS Certification & Survey Process. As CEO, he successfully guided CIHQ in becoming the nation's 4th CMS approved deeming authority for acute care hospitals.
Rick's clinical background is in critical care nursing with a focus in cardiovascular and trauma service lines. He has held both clinical and executive management level positions in Quality, Risk, Education, Infection Control, and Regulatory Compliance.
Rick is a regular speaker at numerous state and national conferences on the federal regulations and accreditation standards, and is host of CIHQ's popular monthly webinars addressing key compliance challenges in today's environment.
Rick is nationally certified in healthcare accreditation, and serves as Chair of the Board of Examiners for the Healthcare Accreditation Certification Program (HACP). Rick has a degree in Nursing with a Master's Degree in Health Services Administration.
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