Emergency Preparedness 5:
Emergency Management Program Portal
This portal, written as an existing Emergency Management Program, provides a prototype in the form of a focused, ten-step process that covers all events and threats through the use of an All Hazards Response approach. This portal provides readers the ability to duplicate or incorporate all or portions of this Emergency Management Program when revising a current program. Text [indicated by brackets] is not a part of the program but is an explanation or clarification of the step and intended to help the user understand how best to incorporate that section into emergency management planning.
Background
The Homeland
Security Presidential Directive (HSPD-5), issued by President GW Bush
in February 2003, mandated the National Incident Management System
(NIMS). NIMS provides a consistent framework for incident management at
all jurisdictional levels, regardless of the cause, size, or complexity
of the incident. Until NIMS, there was no standard for response across
all government and emergency response agencies. HSPD-5 required the
adoption of NIMS by September 2006 across all levels of federal, state,
and local government as well as local organizations, except hospitals,
which are required to have full implementation complete by August 31,
2008. Compliance is a condition for receiving federal assistance (eg,
grants, contracts).
Ten Steps for
Developing a Comprehensive Emergency Management Program
Scope
[Insert
name] Medical Center’s Emergency Management Program comprehensively
describes [insert name] approach to responding to emergencies within
[insert community name] and the surrounding area, which would suddenly
and significantly affect either the need for [insert name] services or
[insert name] ability to provide those services. The program addresses
four phases of emergency management: mitigation, preparedness,
response, and recovery through a ten-step functional process. The
Emergency Management Program is developed with the involvement of
[insert name] leaders, medical staff, and the [insert county or city
name] Division of Emergency Preparedness, under the coordination of the
Emergency Preparedness Committee.
Step 1. Establishment of an Emergency Preparedness Committee to coordinate and oversee the Emergency Management Program. The Emergency Preparedness Committee is a multidisciplinary group representing key departments whose input is essential to planning and development of policies and procedures related to hospital and community emergency preparedness. The Emergency Preparedness Committee reports to the Environmental Health and Safety Committee. Emergency Preparedness Committee membership includes:
- Chairperson
- Emergency Management Coordinator (Director of Safety and Emergency Preparedness)
- Representatives from key departments including but not limited to:
- Medical Director for Emergency Preparedness
- Nursing
- Emergency Medical Services (if affiliated with hospital)
- Infection Control
- Emergency Department
- Facilities Management
- Security
- Safety and Emergency Preparedness
- Telecommunications
- [insert county/city] Division of Emergency Preparedness
- Departments with critical operational responsibilities
Step 2. The Emergency Preparedness Committee is responsible to establish and maintain an Emergency Operation Plan that addresses the four key phases of emergency management: mitigation, preparedness, response, and recovery.
The [insert hospital name] Emergency Operation Plan (EOP) is compliant with NIMS and built on the template of the National Response Framework (NRF) http://www.fema.gov/emergency/nrf/. The operational and resource coordinating structures within the EOP are designed to support existing hospital policy mechanisms and decision making entities during the response to a specific threat or incident.
The EOP pulls together emergency procedures that have to date existed in various locations across the system. The EOP is compliant with all regulations and applies not only to accredited areas of the organization, but also to the organization as a whole in responding to emergencies. The EOP is a comprehensive plan that improves coordination among all hospital departments as well as an integrated response within the community to all emergencies regardless of their place of origin.
The EOP is a living document and the hospitals Emergency Preparedness Committee will make changes as necessary, communicating significant changes to the Environment of Care Committee, and the Executive Leadership. Annually the EOP will be submitted to the Hospital Board for review and approval.
The EOP contains an All Hazards Response Plan with functional annexes, appendices, and supporting documents. The All Hazards Response Plan is organized using the HICS model for command and control during an event. (See Hospital Incident Command System Organizational Flow Chart.) [Though the Organizational Flow Chart details many job positions and a small hospital may not have this many personnel, the job functions attached to those positions must still be performed in the event of an Emergency Incident-Disaster.]
- The All Hazards Response Plan identifies:
- An [insert HICS] organizational chart with corresponding job action sheets that assigns the roles and responsibilities necessary to manage emergencies and communicate effectively with outside agencies.
- Specific departmental responsibilities during an emergency
event
including:
- Department-specific response plan;
- [Insert HICS] responsibilities as assigned;
- Current staff call-back list;
- Maintenance of an updated department resource list, which includes key roles and contact numbers;
- Department-specific evacuation plan;
- Notification of external authorities when events have the potential to affect the community;
- Alternative means of meeting essential building utility needs: electricity, water, ventilation, fuel sources, and medical gas/vacuum systems;
- Back-up internal and external communication systems; and
- Facilities for radioactive, biological, and chemical isolation and decontamination.
- Maintenance of both the All Hazards Basic Response Plan and the [insert HICS] system occurs through an annual review and revision conducted by the Emergency Preparedness Committee.
Step 3. The Emergency Preparedness Committee conducts a Hazard Vulnerability Analysis, which addresses all potential hazards that might affect the [insert name] Medical Center and its ability to provide care.
- Annually, subject matter experts will develop a prioritized list of threats and events from the Hazard Vulnerability Analysis.
- Develop or revise current Standard Operating Procedures
that are
relevant to the prioritized vulnerabilities.
- Involve key stakeholders.
- Review local, state and federal regulatory and accreditation standards to assure compliance.
- Identify resources necessary to implement new/revised Standard Operating Procedures.
- Develop cost estimate.
- Submit request for funding to appropriate source(s).
- Develop activity strategies in order to mitigate, prepare, respond, and recover from the prioritized vulnerabilities. Establish subcommittees and/or task forces as necessary to respond to identified needs.
Step 4. The Emergency Preparedness Committee implements Standard Operating Procedures, which incorporate strategies for:
- Mitigation—actions that eliminate or reduce the impact of adverse events to [insert name] Medical Center
- Preparedness—activities necessary to plan a response to emergency threats or events
- Response—activities necessary to effectively manage all aspects of the emergency threat or event and reduce secondary impact to the organization
- Recovery—actions necessary to restore the
organization’s business operations in the key areas of finance,
staffing, service, and communication
- Purchase supplies and equipment.
- Determine and secure necessary space allocation.
- Identify appropriate education curriculum.
- Provide guidance and resources to support staff education.
Step 5. The chair of the Emergency Preparedness Committee semiannually reports results of mitigation and preparedness activities to the Committee. Reports shall include mitigation and preparedness activities that:
- Effectively reduced or eliminated adverse impacts to [insert name]
- Did not reduce or eliminate adverse impacts to [insert name]
- Include recommendations for additional activities such as:
- Necessary resources and materials;
- Projected timeline for initiative completion; and
- Requested funds.
Step 6. The Emergency Preparedness Committee shall ensure oversight and direction to managers regarding the orientation and ongoing education of all personnel, including licensed individual practitioners and volunteers, as it relates to emergency response.
- Department manager responsibilities related to emergency
preparedness include:
- Development of a department-specific All Hazards Response Plan;
- Staff training;
- Annual assessment of staff knowledge and competency;
- Active participation in emergency management exercises; and
- Commitment by key departments to the assignment of a department representative to serve on the Committee.
- The Emergency Preparedness Committee provides:
- Support for the development or revision of department-specific emergency response templates;
- Resources, including subject matter experts; and
- Guidance related to All Hazards Response Plan revisions and staff education.
Step 7. The Emergency Preparedness Committee shall conduct an evaluation of the effectiveness of the All Hazards Basic Response Plan through the measurement and assessment of response to planned emergency exercises or actual events.
- Joint Commission requires that emergency exercises be conducted at least twice per year.
- Exercises are designed to test areas of vulnerability as determined through the annual review of the Hazard Vulnerability Analysis.
- Following an actual emergency event, the Emergency Preparedness Committee shall determine if that event adequately tested their response plan(s), and therefore meets the Joint Commission’s [or insert Minnesota Department of Health and Centers for Medicare/Medicaid Services] requirement to adequately assess the response plan.
Step 8. The Emergency Preparedness Committee recognizes the need for the development of recovery plans. To increase awareness of the recovery phase of emergency planning, the Emergency Preparedness Committee shall incorporate aspects related to recovery following each planned emergency exercise and actual event.
Four Aspects of Recovery Plans
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Step 9. The Emergency Preparedness Committee is knowledgeable of and helps to shape [insert name] Medical Center’s role in community-wide emergency management. This role includes:
- Responsibility to [insert county/city name] EOP, as described in Annex [insert health annex section]. [This point is applicable to your hospital only if the city or county emergency response plan designates your hospital as being responsible for the health annex of the plan. Check with your local emergency manager.]
- Participation in the State Department of Health Emergency Operation planning. [This point is applicable only if your hospital is actively involved with State Department of Health bioterrorism planning for your region.]
- [Insert any other relevant responsibilities or affiliations that your organization is involved with or participating in; consider how your organization should be integrating emergency preparedness activities with your community.]
Step 10. The Emergency Preparedness Committee shall conduct an annual review of the effectiveness of the Emergency Management Plan and submit the results to the [insert what committees the Emergency Preparedness Committee should submit the results to within your organization], Environmental Health and Safety Committee, and Clinical Council for approval.
The health care organization must determine the most appropriate and effective incident command structure and then incorporate that command structure into their EOP. The most efficient way to complete this work is to utilize a multidisciplinary team process. The team membership requires involvement from key positions within and outside the organization, which will provide for an effective implementation of the Emergency Management Program.
Reference
Hospital Incident Command System HICS web site. http://www.hicscenter.org/pages/aboutus.php