Standards and Regulations
Federal Emergency Management Agency (FEMA)
On February 28, 2003, the President issued Homeland Security Presidential Directive 5 (HSPD–5), “Management of Domestic Incidents,” which directed the Secretary of Homeland Security to develop and administer a National Incident Management System (NIMS). HSPD–5 requires all Federal departments and agencies to adopt NIMS and to use it in their individual incident management programs and activities, as well as in support of all actions taken to assist State, tribal, and local governments. In 2006, FEMA released the original NIMS implementation activities guidance, this was updated in 2008. More information on NIMS implementation can be found at FEMA. If you or your facility need training on NIMS, courses are offered free online at our NIMS training page.
NIMS Implementation activities for hospitals and healthcare systems (2006)
NIMS Implementation activities for hospitals update (2008)
Occupational Safety and Health Administration (OSHA)
OSHA Standard 1910.120, Hazardous Waste Operations and Emergency Response (HAZWOPER), provides guidance and direction for emergency first responders at the site of a release. For hospitals, OSHA developed the OSHA Best Practices for Hospital Based First Recievers of Victims. This document provides practical information on the development, training, and operation of a hospital-based mass decontamination team.
OSHA Best Practices for Hospital Based First Receivers of Victims
For more information on Decon training, click here.
Accreditation Organizations
(from the Agency for Healthcare Research and Quality)
Joint Commission
The Joint Commission lists 11 standards focused on Emergency Management. In addition to standards on the Emergency Operations Plan and general requirements, standards are focused on the areas of communications, resources and assets, security and safety, staff, utilities, patients, and disaster volunteers.
Joint Commission Website
Det Norske Veritas
Det Norske Veritas (DNV) Healthcare Inc. provides hospital accreditation through its National Integrated Accreditation for Healthcare Organizations (NIAHO) Accreditation Program. DNV uses the International Organization for Standards (ISO) 9001 to guide its accreditation process, which, according to DNV, aims at identifying best practices and translating them into standard operating procedures.
The emergency preparedness-related standards are located in the Physical Environment chapter. All the emergency preparedness standards for DNV's accreditation program center on having a functional emergency management program. This involves developing and maintaining an emergency management system, conducting exercises to evaluate the system, and improving the system.
The Emergency Management System Standards related to exercise requirements are found specifically in SR.4 and are further clarified in DNV's Interpretative Guidelines and Surveyor Guidance.
NIAHOSMAccreditation Requirements, Emergency Management System - Revision 8.0
American Osteopathic Association
The American Osteopathic Association (AOA) provides hospital accreditation through its Healthcare Facilities Accreditation Program (HFAP). The HFAP initially began as a program to ensure that osteopathic medical students were educated in facilities attuned to their training. However, it is now recognized by the Federal Government, State governments, insurance carriers, and managed care organizations as a comprehensive hospital accreditation program.
AOA's HFAP emergency preparedness-related standards are located in the Physical Environment chapter. AOA's HFAP emergency preparedness-related standards focus on developing "Disaster Plans," which are listed under the sub-categories "Weapons of Mass Destruction Plans" and "Disaster Response Plans." HFAP also uses the term "Disaster Drills" instead of exercises.
Healthcare Facilities Accreditation Program
Other Organizations
Hospitals may also follow standards of other organizations, depending on the services provided. Some examples of these organizations are:
- American College of Surgeons for verified trauma centers.
- American Burn Association for verified burn centers.
- Commission for Accreditation of Rehabilitation Facilities for rehabilitation, behavioral health, and other services.
These organizations typically have additional requirements for emergency management and exercises, and it may be useful to refer to their standards in developing an exercise plan.