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Elements of Performance for EC.4.12, B-6
Do you actually need 96 hours of fuel on
site, or will a tightly drawn contract
with a fuel supplier suffice? How will
EC.4.12, B-6 it be interpreted by
surveyors when it takes affect on Jan 1,
2008?
EC.4.12, B-6 states the following:
The EOP identifies the organization’s
capabilities and establishes response
efforts when the organization cannot be
supported by the local community for at
least 96 hours in the six critical
areas.
Note:
An acceptable response effort would be
to temporarily close or evacuate the
facility, consistent with their
designated role in their community
response plan
When we asked the Joint this question we
received the following reply:
“The Joint Commission does not require
any organization to purchase additional
storage tanks for their emergency
generators, provided the systems are
currently compliant with local and state
requirements. What the Joint Commission
does expect is that the organization
conduct an assessment to determine the
“organization’s capabilities and
establishes response efforts when the
organization cannot be supported by the
local community for at least 96 hours in
the six critical areas.” This is
clearly stating that the organization
understand their system capability to
function for 96 hours without outside
assistance. To accomplish this, the
organization may pre-identify load that
can be shed to more efficiently operate
the EPSS, with the goal of achieving a
96 hour run. This may include
pre-determining that certain services
are curtailed to reduce energy
consumption, to support other areas in
the facility.
If an organization only had enough fuel
on site for 48 hours, but found through
load shedding it could extend to 60
hours, then that organization would know
that at 48 hours they had 12 hours in
which to plan and implement evacuation
(see the note: An acceptable response
effort would be to temporarily close or
evacuate the facility, consistent with
their designated role in their community
response plan.”
To summarize again, the Emergency
Management standards do not require 96
hour capacity, but does require the
organization understand their systems to
the point of forecasting the reliability
of various systems. I would not be
surprised if, once an assessment was
completed, the organization found that
it had the capability to operate the
EPSS for at least 96 hours, but found
that other utility systems were not able
to meet the 96 hour self-sufficiency and
resulted in evacuation. Remember, this
EP is not specific to EPSS.”
Our response:
The reaction we are getting from
healthcare facilities to EC.4.12, B-6 is
one of confusion coupled with serious
concerns about how the standard’s vague
wording will impact them once 2008
surveys begin, and unfortunately the
explanation above does little to clarify
the issue.
If we may state our concerns:
The ‘96
hours’ reference in the standard causes
confusion about the standard’s intent.
EC.4.12, B-6 represents a departure from
previous standards in that it makes
mention of a specific time frame, 96
hours, that a facility might have to
operate without support from outside
sources. As written, the reference does
not appear to require that
facilities be able to function
independently for four days; indeed it
states only that the facility must
identify its capabilities and have a
plan of response to being cut off for 96
or more hours that may culminate in
closing or evacuating the facility.
While it is not stated as a requirement,
the time period ’96 hours’ does appear
in the standard’s wording and leaves
open the possibility for some to
interpret that 96 hours represents in
some way a concrete requirement. Your
own interpretation suggests that the
facility should pursue ‘the goal of
achieving a 96 hour run’ [emphasis
added]. What does this phrase mean? And
will surveyors have to attempt to
quantify or grade a facility’s intent
to achieve a 96 hour run?
The standard’s wording is imprecise and
is easily interpreted in multiple ways.
To quote the standard: “The EOP
identifies the organization’s
capabilities…when the organization
cannot be supported by the local
community for at least 96 hours…”
Many would say this simply means that
the facility must know what it will be
able to do during extended disaster or
emergency periods. Your interpretation
differed somewhat––you wrote “This is
clearly stating that the organization
understand their system capability to
function for 96 hours without outside
assistance.” While you are not stating
the facility must be capable of
functioning for 96 hours, some would say
you are again implying the goal
of 96 hours. ‘Understanding
system capability’ is not the same as ‘having
system capability,’ but already in
discussion, the two are becoming
blurred, and we fear that the standard
will be misunderstood and
misinterpreted.
Your statement suggests that ‘load
shedding’ and other belt-tightening
measures during an emergency will have a
significant positive effect on the
length of self-sufficiency. Experience
and logic argues against this.
By definition, the EPSS powers the
“Essential Distribution System”––all
loads necessary for patient care as per
NFPA 99, Chapter 4. If they weren’t
necessary for patient care those loads
would be on the “Non-Essential
Distribution System.” While load shed
sequences are in place in most
hospitals, they are for short term
periods, and not for long term emergency
situations and long term power outages.
During hurricanes – and other periods of
power outage, my experience has been the
load on the generators actually
increases rather than decreases. This
has become even more likely with the
release of the Joint Commission’s
Sentinel Event Alert #37. This document
makes it clear that additional elevators
and air conditioning loads should be
considered as essential––even though
these loads are not yet code required.
Whether or not the hospital’s mission is
to stay open for 24 hours or
indefinitely, additional fuel is going
to be required to support the additional
loads.
Given these circumstances, the idea you
suggest that a facility that is in
compliance with a 24 or 36 hour fuel
capacity could, through creative
management, operate the EPSS for 96
hours is too great a stretch. If the
intent of the standard is to require
facilities to be operational for 96
hours by whatever means necessary, we
need to know how to be in compliance.
Our position:
After satisfying compliance with local
AHJ’s requirement for time duration
specified for class, we believe that
each facility should be allowed to make
the decision concerning additional
on-site fuel or having a contracted
offsite fuel source, but facilities will
be looking to the Joint Commission for
concrete answers and guidance. Yes, we
all must have an evacuation plan in
place, but we all know the goal of any
hospital is to remain open, defending in
place without abandonment.
With legal actions now pending in the
aftermath of Hurricane Katrina, most of
which are based on non-existent,
conflicting or confusing codes, we think
a more detailed set of consensus-based
standards should be implemented in the
hope that such standards will at least
slow down the waste of time and money.
We would appreciate your taking a few
minutes to give us your opinion by
completing this survey.
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