Joint Commission Emergency Management Standards — What Accredited Healthcare Organizations Must Do to Maintain Accreditation

The Joint Commission’s Emergency Management standards establish what accredited healthcare organizations must do to prepare for, respond to, and recover from emergencies and disasters. Accreditation is voluntary, but for many organizations it is also how they qualify for Medicare and Medicaid participation through CMS deemed status. The current EM chapter — standards EM.09.01.01 through EM.17.01.01 — was rolled out in stages: hospitals and critical access hospitals on July 1, 2022; home care on July 1, 2023; and ambulatory care and office-based surgery practices on July 1, 2024. Some Joint Commission programs continue to use the older EM chapter (EM.01.01.01 through EM.04.01.01) until further notice.

Last revised: April 2026  |  Source: The Joint Commission, Comprehensive Accreditation Manuals — EM Chapter (HAP, CAH, AHC, OBS, OME, NCC, LAB)  |  Owner: Adams Operations Group

The Joint Commission’s Emergency Management chapter is built around nine standards. Each standard contains multiple elements of performance (EPs) that surveyors evaluate during accreditation visits.

# EM Standard What It Requires
1 EM.09.01.01 — Comprehensive Emergency Management Program The organization establishes a comprehensive, all-hazards emergency management program.
2 EM.10.01.01 — Leadership and Committee Senior leadership oversees the program. The organization establishes an emergency management committee with defined membership and responsibilities.
3 EM.11.01.01 — Hazard Vulnerability Analysis The organization conducts a facility-based, all-hazards hazard vulnerability analysis (HVA) and uses the prioritized findings to drive mitigation and preparedness.
4 EM.12.01.01 — Emergency Operations Plan The organization develops and maintains an Emergency Operations Plan (EOP) that addresses response procedures across all critical operational areas.
5 EM.13.01.01 — Continuity of Operations Plan The organization develops a continuity of operations (COOP) plan based on prioritized hazards from the HVA.
6 EM.14.01.01 — Disaster Recovery Plan The organization develops a disaster recovery plan based on prioritized hazards from the HVA.
7 EM.15.01.01 — Education and Training The organization provides ongoing emergency management education and training to all staff, volunteers, physicians, and other licensed practitioners consistent with their roles.
8 EM.16.01.01 — Testing the Emergency Operations Plan The organization conducts annual exercises to test the EOP.
9 EM.17.01.01 — Annual Evaluation The organization annually evaluates the emergency management program. Senior leadership reviews the evaluation and approves updates.

Applicability — Who Must Comply

The Joint Commission’s Emergency Management standards apply to organizations that are accredited or seeking accreditation by The Joint Commission. Joint Commission accreditation is voluntary — no federal or state law requires a healthcare organization to be accredited by The Joint Commission specifically. However, accreditation carries significant operational consequences:

  • CMS deemed status. Joint Commission accreditation provides deemed status for Medicare and Medicaid participation in many provider categories. Organizations that hold deemed status are surveyed by The Joint Commission rather than directly by CMS, but they remain subject to CMS Conditions of Participation, including the CMS Emergency Preparedness Rule.
  • Commercial payer requirements. Many commercial insurance contracts require accreditation by The Joint Commission or another approved accrediting body.
  • Reputational and operational standing. Loss of accreditation is a public event with material consequences for referrals, contracts, and recruitment.

The current EM chapter (EM.09.01.01 through EM.17.01.01) was rolled out by program in stages. The applicable standards and effective dates depend on which Joint Commission accreditation program the organization holds:

Joint Commission Program EM Chapter Effective Date
Hospital Accreditation Program (HAP) EM.09.01.01–EM.17.01.01 July 1, 2022
Critical Access Hospital (CAH) EM.09.01.01–EM.17.01.01 July 1, 2022
Home Care (OME) EM.09.01.01–EM.17.01.01 July 1, 2023
Ambulatory Care (AHC) EM.09.01.01–EM.17.01.01 July 1, 2024
Office-Based Surgery (OBS) EM.09.01.01–EM.17.01.01 July 1, 2024
Nursing Care Centers (NCC) EM.09.01.01–EM.17.01.01 Phased rollout
Laboratory (LAB) EM.09.01.01–EM.17.01.01 Phased rollout
Behavioral Health Care and Human Services EM.01.01.01–EM.04.01.01 (older chapter) Older chapter remains in effect until further notice
All other programs not yet transitioned EM.01.01.01–EM.04.01.01 (older chapter) Older chapter remains in effect until further notice

For ambulatory surgery centers, urgent care chains operating under ambulatory care accreditation, and office-based surgery practices — common AOG client profiles — the relevant EM chapter is EM.09.01.01 through EM.17.01.01, effective July 1, 2024. For behavioral health organizations and certain other programs, the older EM chapter (EM.01.01.01 through EM.04.01.01) continues to apply until The Joint Commission completes the rollout to those programs. The Joint Commission publishes program-specific reference guides that cross-walk the new and old chapter requirements.

Joint Commission accreditation is voluntary, but the consequences of accreditation are not. If your organization holds Joint Commission accreditation for CMS deemed status, you are subject to both the Joint Commission EM standards and the CMS Emergency Preparedness Rule. Compliance with one does not eliminate the requirement to comply with the other. Surveyors evaluate both.

For healthcare-adjacent organizations — ambulatory surgery centers, urgent care chains, behavioral health facilities, dialysis centers, and medical group practices — every target client exceeds the 10-employee threshold. Written EAPs are mandatory without exception.

The Nine EM Standards

Each of the nine EM standards has substantive requirements specified in the Comprehensive Accreditation Manual through elements of performance (EPs). The standards below summarize what each requires at the organization level. Surveyors evaluate compliance through the EPs, not the standard headings — organizations that satisfy the headline requirement but miss EPs receive findings.

The organization has a comprehensive emergency management program that uses an all-hazards approach. The program addresses the four phases of emergency management — mitigation, preparedness, response, and recovery — and is designed to protect the facility, staff, patient population, and surrounding community before, during, and after an emergency or disaster.

The program includes:

  • Emergency response policies and procedures covering communications, staffing, patient care, safety and security, utilities, and clinical/support activities during an emergency.
  • Coordination with external partners — local emergency management, public health agencies, and healthcare coalitions where applicable.
  • Periodic review and revision based on exercises, real-world events, regulatory changes, and after-action findings.

Senior leadership provides oversight and active support of the emergency management program. The organization establishes a multidisciplinary emergency management committee.

Senior leadership responsibilities include:

  • Identifying a qualified emergency management program coordinator with defined responsibilities across the four phases of emergency management.
  • Reviewing the Emergency Operations Plan, supporting policies, training, and education.
  • Reviewing after-action reports following exercises and actual emergencies, and approving program updates based on findings.

Committee membership must include the emergency management program coordinator and representation from senior leadership, nursing, medical staff, infection prevention and control, facilities engineering, security, and information technology. The committee participates in planning and coordinating exercises, reviewing exercise and real-event after-action reports, and developing, reviewing, and updating the EOP and supporting policies.

The organization conducts a facility-based hazard vulnerability analysis (HVA) using an all-hazards approach. The HVA identifies hazards likely to impact the organization’s geographic region, community, facility, and patient population.

Key requirements:

  • Separate HVAs are required for facilities that significantly differ from the main site in location, hazards, threats, patient population, or services.
  • The organization may incorporate community-based risk assessments developed by public health agencies, local emergency management, or healthcare coalitions, but a facility-based assessment remains required.
  • Findings must be evaluated and prioritized based on likelihood of occurrence and operational impact. Findings must be documented.
  • Prioritized hazards drive mitigation and preparedness actions, EOP development, COOP development, disaster recovery planning, and the design of training and exercises.

The organization develops and maintains an Emergency Operations Plan (EOP) that guides decision making at the onset of an emergency and as an emergency evolves. The EOP must be both responsive to the prioritized hazards identified in the HVA and adaptable to other emergencies.

EM.12.01.01 lists eleven key components that must be addressed in the EOP and its supporting policies and procedures, including:

  • Communications during emergencies — internal and external.
  • Staffing and staff roles during emergencies.
  • Patient care, including identification of at-risk patient populations and persons at risk in the surrounding community.
  • Safety and security operations.
  • Management of utilities — power, water, fuel, medical gas.
  • Management of resources, supplies, and pharmaceutical inventories.
  • Coordination with external partners and the broader community response.
  • Continuity of essential operations during the response phase.

The EOP is a living document. It must be reviewed at least every two years and updated based on exercise findings, after-action reports from real events, regulatory changes, and operational changes within the organization.

The organization develops a continuity of operations (COOP) plan that addresses how essential functions continue during and after an emergency that disrupts normal operations. The COOP plan is informed by the prioritized hazards from the HVA and is integrated with the EOP.

The organization develops a disaster recovery plan that addresses how the organization restores normal operations following an emergency or disaster. The plan is informed by the prioritized hazards from the HVA and is integrated with the EOP and COOP plan.

The organization provides ongoing emergency management education and training to all staff, volunteers, physicians, and other licensed practitioners. Training must be consistent with each individual’s role and responsibilities during an emergency.

Training requirements include:

  • Initial training at the time of hire or appointment, before an individual is assigned independent emergency response responsibilities.
  • Ongoing training at a frequency the organization defines based on role complexity, regulatory requirements, and after-action findings.
  • Documentation of all training, including dates, content, and participants.
  • Training content aligned to the EOP, the four phases of emergency management, and the prioritized hazards from the HVA.

The organization conducts annual exercises to test the EOP. The intent is to identify gaps in the plan, in staff knowledge, and in operational readiness — and to drive improvements.

Exercise requirements include:

  • At least one full-scale or functional exercise annually that tests the organization’s response to a realistic emergency scenario based on a prioritized hazard from the HVA.
  • Additional tabletop exercises and drills as appropriate to the organization’s size, complexity, and prioritized hazards.
  • An after-action report (AAR) for each exercise summarizing what occurred, analyzing participant actions, and identifying areas needing improvement.
  • Documented use of AAR findings to update the EOP, training, and supporting policies.

The organization annually evaluates the entire emergency management program — not just individual exercises or events. The evaluation assesses the program’s effectiveness across all four phases of emergency management.

Requirements include:

  • Senior leadership reviews the annual evaluation.
  • The organization documents the evaluation, including findings and recommended changes.
  • The organization updates the program based on evaluation findings and tracks implementation of changes.

Additional Operational Requirements

In addition to the nine EM standards, the EM chapter includes operational requirements that apply across the standards and are commonly cited during survey. The four subsections below address those requirements and a fourth named subsection covering the operational shift introduced by the restructured chapter.

Integrated Healthcare Systems

Healthcare systems that operate multiple facilities under a single accreditation may develop a unified emergency management program, but each facility must conduct its own facility-based hazard vulnerability analysis. The system-level program must address the specific hazards, operational realities, and patient populations of each individual facility — a single corporate-level plan does not satisfy the standards if it fails to address site-specific differences.

Hazard Vulnerability Analysis as Foundation

Across the entire EM chapter, the HVA functions as the foundation for every other planning and operational activity. The EOP, COOP plan, disaster recovery plan, training program, and exercise program must all be traceable back to the prioritized hazards identified in the HVA. This is one of the most-cited Joint Commission expectations during survey: organizations that produce strong individual documents but cannot demonstrate that those documents flow from the HVA receive findings.

Coordination with External Partners

The EM standards require that the organization coordinate with external emergency management partners — local emergency management agencies, public health departments, and where applicable, regional healthcare coalitions. Coordination must be documented and is verified during survey. Surveyors look for evidence of two-way coordination, not unilateral notification.

July 2024 Revision — Shift Toward Operational Readiness

The Joint Commission’s restructured EM chapter became effective for ambulatory care organizations and office-based surgery practices on July 1, 2024 — the same chapter that had taken effect for hospitals and critical access hospitals on July 1, 2022, and for home care on July 1, 2023. The restructured chapter reflects a deliberate shift in Joint Commission’s expectations:

  • Reduction in elements of performance. The restructured chapter reduced the total number of EPs by more than 40 percent, eliminating redundant documentation requirements that had accumulated over previous chapter versions.
  • Increased emphasis on the HVA. The HVA now drives every other component of the program. Surveyors look for explicit traceability from the HVA to mitigation activities, planning, training, and exercises.
  • Increased emphasis on leadership oversight. Senior leadership involvement is no longer a formality. EM.10.01.01 requires documented senior leadership oversight of the program, review of after-action reports, and approval of program updates.
  • Increased emphasis on operational readiness over documentation. The chapter is structured to test what the organization can actually do during an emergency, not what the organization has written down. Exercises, training, and the annual evaluation are designed to expose gaps between plan and practice.

For ambulatory surgery centers, urgent care chains, and office-based surgery practices that came under the restructured chapter on July 1, 2024, the practical effect is straightforward: organizations that previously satisfied accreditation through documentation alone are now expected to demonstrate operational capability. Programs built on binders without exercises, training without traceability to the HVA, or plans without leadership engagement will not survive a survey under the restructured chapter.

Review and Update Requirements

The EM chapter establishes specific review and update requirements that organizations must meet on a defined cycle. The table below summarizes the cadence by component.

Component Required Review Frequency Notes
Hazard Vulnerability Analysis At least annually Reviewed and updated based on changes to hazards, operations, or after-action findings
Emergency Operations Plan At least every two years Updated based on exercise AARs, real-event AARs, regulatory changes, operational changes
Continuity of Operations Plan At least every two years Aligned with EOP review cycle
Disaster Recovery Plan At least every two years Aligned with EOP review cycle
Training Program Ongoing Initial at hire/appointment; ongoing at organization-defined frequency
Exercises At least annually Full-scale or functional exercise based on prioritized HVA hazard
Annual Program Evaluation Annually Senior leadership review required
Accreditation Survey Triennial (every three years) Joint Commission survey cycle

In addition to scheduled reviews, organizations are expected to update applicable components after any substantive change to operations, after each exercise, after each real-event activation, after regulatory changes, and after any change in patient population or service mix that affects emergency response.

What the Joint Commission EM Standards Do Not Require

Several common assumptions about Joint Commission EM standards are incorrect. The standards do not require:

  • A specific format for the EOP. The EOP can be formatted in any way that addresses the eleven key components in EM.12.01.01. There is no Joint Commission template, no required page count, and no required section ordering.
  • A standalone written document called “Emergency Action Plan.” The Joint Commission EM standards use the term “Emergency Operations Plan,” which is broader than OSHA’s Emergency Action Plan and includes elements not required under OSHA. Organizations may consolidate documents, but each required element must be addressed.
  • Use of any specific HVA tool or template. The Kaiser Permanente HVA tool, the FEMA THIRA framework, and other tools are commonly used but not required. The organization selects the methodology.
  • Participation in a regional healthcare coalition. Coordination with external partners is required. Healthcare coalition participation is one common way to satisfy this expectation, but it is not the only acceptable approach.
  • Specific exercise types beyond the annual exercise. EM.16.01.01 requires at least one full-scale or functional exercise annually. Tabletop exercises, drills, and other exercise types are encouraged and frequently necessary to support training, but only the annual exercise is explicitly required.
  • Joint Commission accreditation. Accreditation by The Joint Commission is voluntary. Organizations may pursue accreditation by other CMS-approved accrediting bodies (such as DNV, AAAHC, or HFAP) or be surveyed directly by CMS.

Enforcement and Consequences

The Joint Commission enforces EM standards through the survey process. Findings are categorized and addressed through the Requirements for Improvement (RFI) process.

How Findings Are Categorized

  • Requirement for Improvement (RFI). When a surveyor identifies non-compliance with an EP, an RFI is issued. The organization must submit evidence of correction within a defined timeframe — typically 60 days for most findings.
  • Direct Impact RFI. Findings that directly affect patient safety carry shorter correction timeframes and may trigger follow-up survey activity.
  • Condition-level finding. Sustained or systemic non-compliance with an EM standard may rise to a condition-level finding, which has accreditation implications.
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Consequences of Non-Compliance

  • Conditional accreditation. Sustained or serious non-compliance can result in conditional accreditation status, which is publicly reported.
  • Preliminary denial of accreditation. Organizations that fail to correct serious findings or that demonstrate immediate threat to patient or public safety may receive preliminary denial of accreditation.
  • Loss of accreditation. Loss of Joint Commission accreditation is publicly reported. For organizations relying on Joint Commission accreditation for CMS deemed status, loss of accreditation also ends deemed status — the organization must either obtain accreditation from another CMS-approved body or be surveyed directly by CMS.
  • Loss of CMS deemed status. Without deemed status, the organization is surveyed by CMS or its state survey agency. Findings under direct CMS survey can result in termination of the Medicare and Medicaid provider agreement, which is a condition-level outcome with material financial consequences.
  • Commercial contract consequences. Commercial payer contracts that require Joint Commission accreditation may be voided or non-renewed if accreditation is lost.
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In practice, EM-related findings are among the most common categories of survey findings. Joint Commission’s published top-cited standards lists frequently include EM standards, with HVA-related EPs (EM.11.01.01) and EOP-related EPs (EM.12.01.01) appearing among the most-cited.

Source

Primary source: The Joint Commission, Comprehensive Accreditation Manuals — Emergency Management chapter (EM.09.01.01 through EM.17.01.01), as published in the Comprehensive Accreditation Manual for Hospitals (CAMH), Critical Access Hospitals (CAMCAH), Home Care (CAMHC), Ambulatory Care (CAMAC), Office-Based Surgery Practices (CAMOBS), Nursing Care Centers (CAMNCC), and Laboratory (CAMLAB).

Effective dates by program: Hospitals and Critical Access Hospitals — July 1, 2022. Home Care — July 1, 2023. Ambulatory Care and Office-Based Surgery — July 1, 2024.

Interpretive guidance: The Joint Commission, R3 Report Issue 34 — “New and Revised Standards in Emergency Management,” with subsequent program-specific R3 Reports for home care, ambulatory care, and office-based surgery. Available on The Joint Commission’s website.

Cross-references: Program-specific Reference Guides published by The Joint Commission cross-walk the new EM chapter (EM.09 through EM.17) to the older EM chapter (EM.01 through EM.04) for organizations transitioning between chapter versions or operating under multiple program accreditations.

Related federal authority: CMS Emergency Preparedness Final Rule (42 CFR §482.15 for hospitals, §485.625 for critical access hospitals, §416.54 for ASCs, and other provider-specific sections); CMS State Operations Manual, Appendix Z.

Related Regulatory References

  • CMS Emergency Preparedness Rule — Federal requirements for Medicare and Medicaid participating providers and suppliers. Joint Commission accreditation provides deemed status for participating provider categories. See AOG Academy: CMS Emergency Preparedness Rule Reference page.
  • OSHA 29 CFR 1910.38 — Federal Emergency Action Plan requirements for all employers with 10 or more employees. Applies to Joint Commission accredited organizations as employers, in addition to the EM chapter standards. See AOG Academy: OSHA 1910.38 Reference page.
  • Texas Health and Safety Code Chapter 331 — Texas-specific workplace violence prevention requirements applicable to many Joint Commission accredited healthcare organizations operating in Texas. (Forthcoming AOG Academy Reference page.)
  • NFPA 99 (Healthcare Facilities Code) — Industry standard referenced by both Joint Commission EM standards and CMS Emergency Preparedness guidance.
  • NFPA 1600 (Standard on Continuity, Emergency, and Crisis Management) — Industry standard referenced in Joint Commission EM rationale and supporting materials.

Document Control

Last revised: April 2026  |  Last reviewed: April 2026  |  Page owner: Adams Operations Group