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Joint Commission Requirements for 96-Hour Disaster Drill

Since the Joint Commission updated its requirements for hospitals in 2008, there has been some confusion about what hospitals need to do to comply. Many think that the updated requirement requires their organization to remain operable without outside assistance for 96 hours. But according to the Joint Commission, the requirement stipulates that the hospital must determine whether the organization can sustain itself in six critical areas for 96 hours with or without assistance from the local community. If not, an evaluation is necessary. Failure to comply with Joint Commission requirements results in loss of accreditation.

  1. Communication

    • The hospital must document its strategies, terminology and backup capabilities for communicating response information to its staff, patients and their families and external organizations.

    Resources and Assets

    • The plan and drill should determine resource and asset management capabilities in regards to patient care and emergency response, including provisions for critical supplies.

    Safety and Security

    • The plan and drill must provide for the safety and security of patients, staff and visitors with regard to hazardous material management and decontamination. In conjunction with external partners, the hospital must develop, coordinate and test entry and egress controls.

    Staff Training

    • The emergency response plan must enumerate the hospital staff's duties in an emergency response based upon the hazard vulnerability analyses conducted in the early stages of plan development. Staff members must receive training in their emergency duties. The commission suggests use of job action sheets and checklists, as well as cross training personnel.

    Utilities and Water Resources

    • The hospital must provide alternative means of providing sanitation, electricity and fuel and potable and non-potable water. Documentation of these means includes memorandums of understanding vendors and community emergency managers.

    Patient and Clinic Support

    • The Joint Commission requires hospitals to provide a scalable emergency response including efficient triage of patients well enough for discharge, strategies to address special needs patients, meeting personal hygiene and sanitation needs and reassignment of space originally designated for elective procedures and non-critical operations to emergency response.

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