Conduct a Hazard Vulnerability Analysis CMS requires it BY ROBERT KURTZ


ou cannot control when your ASC might encounter a natural or man-made hazard. You can, how- ever, control your readiness to tackle those hazards.

That is the objective of conduct- ing a hazard vulnerability analy- sis (HVA), says Toya Brown, RN, director of perioperative services for Metro Health OAM Surgery Center in Grand Rapids, Michigan. “You are working to identify the risks that could negatively impact your ASC and would require a plan of action. The HVA is intended as a guide to assist in priority setting within the construct of

your comprehensive

emergency management program.” Conducting an HVA, says Debra Stinchcomb, RN, CASC, senior con- sultant with Progressive Surgical Solutions in Incline Village, Nevada, is a requirement in the Centers for Medicare & Medicaid Services’ Emergency Preparedness Rule and an expectation of accreditation bod- ies. “Essentially, you assess all of the potential risks facing your facility. This includes natural events, such as hurricanes, earthquakes and floods; technical and utility events, such as sewage or natural gas system fail- ures; and human events, such as bio- logical terrorism, bomb threats and mass casualty.”

ASCs often task their quality assurance and process improvement (QAPI) committee with conducting the HVA, Stinchcomb says. To do so, she says, facilities typically use a spreadsheet they create themselves or find HVA tool templates from rep- utable companies, such as Kaiser Permanente, online.

The document used by Metro Health OAM Surgery Center includes an ini-

Stinchcomb adds, “On a funda-

The HVA is intended as a guide to assist in priority setting within the construct of your comprehensive emergency management program.”

—Toya Brown, RN Metro Health OAM Surgery Center

tial column to identify those hazards the ASC is likely to experience, Brown says. “We consider our geographical area, historical data and industry sta- tistics to help ensure we cover a wide variety of applicable disasters.” Following this is a series of col- umns tasking the ASC with “scoring” the probability of the risk occurring and its probable effects on the facil- ity, Brown says. “’Zero’ is unlikely to occur and then it goes up to ‘three,’ which is highly likely to occur within the next year. We then assess how the hazard would affect the ability of our ASC to deliver an appropriate level of service in three areas: human, prop- erty and business impact.”


mental level, you are looking at how probable is it that the event is going to happen, what is the risk to the ASC and whether you are prepared or not. Events that are of a high prob- ability and/or high risk require plans of action.” As an example, Stinchcomb points to fire alarm failure—a risk facing all ASCs. “When evaluating this risk, there is probably a low probability of it occurring if an ASC is keeping up with preventative maintenance and routine checks. If the alarm were to fail, you are looking at a high-risk situation that would threaten lives and could lead to significant harm to the business.”

A compliant facility would be well-prepared for such an incident because they would have policies and practices in place that would mandate stopping cases and rem- edying the situation were the alarm system to malfunction, she says. “If your ASC is lacking in such adequate preparation, conducting an HVA should bring this need and oppor- tunity for improvement to the fore- front. You would develop new poli- cies and procedures and train your staff on them.”

Upon Metro Health OAM Sur- gery Center’s completion of its HVA, which is performed annually, Brown says, the scoring is discussed at the ASC’s QAPI, clinical operations and board of managers meetings. “We use the information to guide deci- sions concerning our disaster drills. It is imperative that we work to be as prepared as possible for the dangers our ASC is most likely to face.”

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