Information
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Document No.
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Audit Title
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
EM.01.01.01: The hospital engages in planning activities prior to developing its written Emergency Operations Plan.
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1 The hospital’s leaders, including leaders of the medical staff, participate in planning activities prior to developing an Emergency Operations Plan.
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2 The hospital conducts a hazard vulnerability analysis (HVA) to identify potential emergencies that could affect demand for the hospital’s services or its ability to provide those services, the likelihood of those events occurring, and the consequences of those events. The findings of this analysis are documented. (See also EM.03.01.01, EP 1; IC.01.06.01, EP 4) <br>Note 1: Hospitals have flexibility in creating either a single HVA that accurately reflects all sites of the hospital, or multiple HVAs. Some remote sites may be significantly different from the main site (for example, in terms of hazards, location, and population served); in such situations a separate HVA is appropriate.<br>Note 2: If the hospital identifies a surge in infectious patients as a potential emergency, this issue is addressed in the "Infection Prevention and Control" (IC) chapter.
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3 The hospital, together with its community partners, prioritizes the potential emergencies identified in its hazard vulnerability analysis (HVA) and documents these priorities. <br>Note: The hospital determines which community partners are critical to helping define priorities in its HVA. Community partners may include other health care organizations, the public health department, vendors, community organizations, public safety and public works officials, representatives of local municipalities, and other government agencies.
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4 The hospital communicates its needs and vulnerabilities to community emergency response agencies and identifies the community’s capability to meet its needs. This communication and identification occur at the time of the hospital's annual review of its Emergency Operations Plan and whenever its needs or vulnerabilities change. (See also EM.03.01.01, EP 1)
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5 The hospital uses its hazard vulnerability analysis as a basis for defining mitigation activities (that is, activities designed to reduce the risk of and potential damage from an emergency). <br>Note: Mitigation, preparedness, response, and recovery are the four phases of emergency management. They occur over time: Mitigation and preparedness generally occur before an emergency, and response and recovery occur during and after an emergency.
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6 The hospital uses its hazard vulnerability analysis as a basis for defining the preparedness activities that will organize and mobilize essential resources. (See also IM.01.01.03, EPs 1-4)
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7 The hospital's incident command structure is integrated into and consistent with its community’s command structure. * <br>Note: The incident command structure used by the hospital should provide for a scalable response to different types of emergencies.
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8 The hospital keeps a documented inventory of the resources and assets it has on site that may be needed during an emergency, including, but not limited to, personal protective equipment, water, fuel, and medical, surgical, and medication-related resources and assets. (See also EM.02.02.03, EP 6)
EM.02.01.01: The hospital has an Emergency Operations Plan.
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EM.02.01.01: The hospital has an Emergency Operations Plan. <br>Note: The hospital’s Emergency Operations Plan (EOP) is designed to coordinate its communications, resources and assets, safety and security, staff responsibilities, utilities, and patient clinical and support activities during an emergency (refer to Standards EM.02.02.01, EM.02.02.03, EM.02.02.05, EM.02.02.07, EM.02.02.09, and EM.02.02.11). Although emergencies have many causes, the effects on these areas of the organization and the required response effort may be similar. This "all hazards" approach supports a general response capability that is sufficiently nimble to address a range of emergencies of different duration, scale, and cause. For this reason, the Plan’s response procedures address the prioritized emergencies but are also adaptable to other emergencies that the organization may experience.
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1 The hospital’s leaders, including leaders of the medical staff, participate in the development of the Emergency Operations Plan.
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2 The hospital develops and maintains a written Emergency Operations Plan that describes the response procedures to follow when emergencies occur. (See also EM.03.01.03, EP 5) <br>Note: The response procedures address the prioritized emergencies but can also be adapted to other emergencies that the hospital may experience. Response procedures could include the following: <br>- Maintaining or expanding services<br>- Conserving resources<br>- Curtailing services<br>- Supplementing resources from outside the local community<br>- Closing the hospital to new patients<br>- Staged evacuation<br>- Total evacuation
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3 The Emergency Operations Plan identifies the hospital’s capabilities and establishes response procedures for when the hospital cannot be supported by the local community in the hospital's efforts to provide communications, resources and assets, security and safety, staff, utilities, or patient care for at least 96 hours. <br>Note: Hospitals are not required to stockpile supplies to last for 96 hours of operation.
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4 The hospital develops and maintains a written Emergency Operations Plan that describes the recovery strategies and actions designed to help restore the systems that are critical to providing care, treatment, and services after an emergency.
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5 The Emergency Operations Plan describes the processes for initiating and terminating the hospital's response and recovery phases of an emergency, including under what circumstances these phases are activated.<br>Note: Mitigation, preparedness, response, and recovery are the four phases of emergency management. They occur over time: Mitigation and preparedness generally occur before an emergency, and response and recovery occur during and after an emergency.
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6 The Emergency Operations Plan identifies the individual(s) who has the authority to activate the response and recovery phases of the emergency response.
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7 The Emergency Operations Plan identifies alternative sites for care, treatment, and services that meet the needs of the hospital's patients during emergencies.<br>
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8 If the hospital experiences an actual emergency, the hospital implements its response procedures related to care, treatment, and services for its patients<br>
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7 The hospital's incident command structure is integrated into and consistent with its community’s command structure. * <br>Note: The incident command structure used by the hospital should provide for a scalable response to different types of emergencies.
EM.02.02.01: As part of its Emergency Operations Plan, the hospital prepares for how it will communicate during emergencies.
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1 The Emergency Operations Plan describes the following: How staff will be notified that emergency response procedures have been initiated.
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2 The Emergency Operations Plan describes the following: How the hospital will communicate information and instructions to its staff and licensed independent practitioners during an emergency.
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3 The Emergency Operations Plan describes the following: How the hospital will notify external authorities that emergency response measures have been initiated.
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4 The Emergency Operations Plan describes the following: How the hospital will communicate with external authorities during an emergency.
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5 The Emergency Operations Plan describes the following: How the hospital will communicate with patients and their families, including how it will notify families when patients are relocated to alternative care sites.
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6 The Emergency Operations Plan describes the following: How the hospital will communicate with the community or the media during an emergency.
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7 The Emergency Operations Plan describes the following: How the hospital will communicate with suppliers of essential services, equipment, and supplies during an emergency.
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8 The Emergency Operations Plan describes the following: How the hospital will communicate with other health care organizations in its contiguous geographic area regarding the essential elements of their respective command structures, including the names and roles of individuals in their command structures and their command center telephone numbers.
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9 The Emergency Operations Plan describes the following: How the hospital will communicate with other health care organizations in its contiguous geographic area regarding the essential elements of their respective command centers for emergency response.
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9 The Emergency Operations Plan describes the following: How the hospital will communicate with other health care organizations in its contiguous geographic area regarding the essential elements of their respective command centers for emergency response.
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10 The Emergency Operations Plan describes the following: How the hospital will communicate with other health care organizations in its contiguous geographic area regarding the resources and assets that could be shared in an emergency response.
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11 The Emergency Operations Plan describes the following: How and under what circumstances the hospital will communicate the names of patients and the deceased with other health care organizations in its contiguous geographic area.
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12 The Emergency Operations Plan describes the following: How, and under what circumstances, the hospital will communicate information about patients to third parties (such as other health care organizations, the state health department, police, and the Federal Bureau of Investigation [FBI]).
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13 The Emergency Operations Plan describes the following: How the hospital will communicate with identified alternative care sites.
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14 The hospital establishes backup systems and technologies for the communication activities identified in EM.02.02.01, EPs 1-13.
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17 The hospital implements the components of its Emergency Operations Plan that require advance preparation to support communications during an emergency.<br>
EM.02.02.03: As part of its Emergency Operations Plan, the hospital prepares for how it will manage resources and assets during emergencies.
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1 The Emergency Operations Plan describes the following: How the hospital will obtain and replenish medications and related supplies that will be required throughout the response and recovery phases of an emergency, including access to and distribution of caches that may be stockpiled by the hospital, its affiliates, or local, state, or federal sources.
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2 The Emergency Operations Plan describes the following: How the hospital will obtain and replenish medical supplies that will be required throughout the response and recovery phases of an emergency, including personal protective equipment where required.
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3 The Emergency Operations Plan describes the following: How the hospital will obtain and replenish nonmedical supplies that will be required throughout the response and recovery phases of an emergency.
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4 The Emergency Operations Plan describes the following: How the hospital will share resources and assets with other health care organizations within the community, if necessary. <br>Note: Examples of resources and assets that might be shared include beds, transportation, linens, fuel, personal protective equipment, medical equipment, and supplies.
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5 The Emergency Operations Plan describes the following: How the hospital will share resources and assets with other health care organizations outside the community, if necessary, in the event of a regional or prolonged disaster. <br>Note: Examples of resources and assets that might be shared include beds, transportation, linens, fuel, personal protective equipment, medical equipment, and supplies.
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6 The Emergency Operations Plan describes the following: How the hospital will monitor quantities of its resources and assets during an emergency. (See also EM.01.01.01, EP 8)
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9 The Emergency Operations Plan describes the following: The hospital's arrangements for transporting some or all patients, their medications, supplies, equipment, and staff to an alternative care site(s) when the environment cannot support care, treatment, and services. (See also EM.02.02.11, EP 3)
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10 The Emergency Operations Plan describes the following: The hospital's arrangements for transferring pertinent information, including essential clinical and medication-related information, with patients moving to alternative care sites. (See also EM.02.02.11, EP 3)
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12 The hospital implements the components of its Emergency Operations Plan that require advance preparation to provide for resources and assets during an emergency.
.EM.02.02.05: As part of its Emergency Operations Plan, the hospital prepares for how it will manage security and safety during an emergency.
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1 The Emergency Operations Plan describes the following: The hospital's arrangements for internal security and safety.
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2 The Emergency Operations Plan describes the following: The roles that community security agencies (for example, police, sheriff, National Guard) will have in the event of an emergency.
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3 The Emergency Operations Plan describes the following: How the hospital will coordinate security activities with community security agencies (for example, police, sheriff, National Guard).
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4 The Emergency Operations Plan describes the following: How the hospital will manage hazardous materials and waste.
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5 The Emergency Operations Plan describes the following: How the hospital will provide for radioactive, biological, and chemical isolation and decontamination.
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7 The Emergency Operations Plan describes the following: How the hospital will control entrance into and out of the health care facility during an emergency.
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8 The Emergency Operations Plan describes the following: How the hospital will control the movement of individuals within the health care facility during an emergency.
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9 The Emergency Operations Plan describes the following: The hospital's arrangements for controlling vehicles that access the health care facility during an emergency.
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10 The hospital implements the components of its Emergency Operations Plan that require advance preparation to support security and safety during an emergency.
EM.02.02.07: As part of its Emergency Operations Plan, the hospital prepares for how it will manage staff during an emergency.
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2 The Emergency Operations Plan describes the following: The roles and responsibilities of staff for communications, resources and assets, safety and security, utilities, and patient management during an emergency.
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3 The Emergency Operations Plan describes the following: The process for assigning staff to all essential staff functions.
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4 The Emergency Operations Plan identifies the individual(s) to whom staff report in the hospital's incident command structure.
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5 The Emergency Operations Plan describes how the hospital will manage staff support needs (for example, housing, transportation, incident stress debriefing).
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6 The Emergency Operations Plan describes how the hospital will manage the family support needs of staff (for example, child care, elder care, pet care, communication).
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7 The hospital trains staff for their assigned emergency response roles.
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8 The hospital communicates, in writing, with each of its licensed independent practitioners regarding his or her role(s) in emergency response and to whom he or she reports during an emergency.
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9 The Emergency Operations Plan describes how the hospital will identify licensed independent practitioners, staff, and authorized volunteers during emergencies. (See also EM.02.02.13, EP 3; EM.02.02.15, EP 3)
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10 The hospital implements the components of its Emergency Operations Plan that require advance preparation to manage staff during an emergency.
EM.02.02.09: As part of its Emergency Operations Plan, the hospital prepares for how it will manage utilities during an emergency.
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2 As part of its Emergency Operations Plan, the hospital identifies alternative means of providing the following: Electricity.
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3 As part of its Emergency Operations Plan, the hospital identifies alternative means of providing the following: Water needed for consumption and essential care activities.
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4 As part of its Emergency Operations Plan, the hospital identifies alternative means of providing the following: Water needed for equipment and sanitary purposes.
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5 As part of its Emergency Operations Plan, the hospital identifies alternative means of providing the following: Fuel required for building operations, generators, and essential transport services that the hospital would typically provide.
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6 As part of its Emergency Operations Plan, the hospital identifies alternative means of providing the following: Medical gas/vacuum systems.
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7 As part of its Emergency Operations Plan, the hospital identifies alternative means of providing the following: Utility systems that the hospital defines as essential (for example, vertical and horizontal transport, heating and cooling systems, and steam for sterilization).
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8 The hospital implements the components of its Emergency Operations Plan that require advance preparation to provide for utilities during an emergency.
EM.02.02.11: As part of its Emergency Operations Plan, the hospital prepares for how it will manage patients during emergencies.
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2 The Emergency Operations Plan describes the following: How the hospital will manage the activities required as part of patient scheduling, triage, assessment, treatment, admission, transfer, and discharge.
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3 The Emergency Operations Plan describes the following: How the hospital will evacuate (from one section or floor to another within the building, or, completely outside the building) when the environment cannot support care, treatment, and services. (See also EM.02.02.03, EPs 9 and 10)
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5 The Emergency Operations Plan describes the following: How the hospital will manage the personal hygiene and sanitation needs of its patients.
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6 The Emergency Operations Plan describes the following: How the hospital will manage its patients' mental health service needs that occur during an emergency.
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7 The Emergency Operations Plan describes the following: How the hospital will manage mortuary services.
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8 The Emergency Operations Plan describes the following: How the hospital will document and track patients’ clinical information.
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11 The hospital implements the components of its Emergency Operations Plan that require advance preparation to manage patients during an emergency
EM.02.02.13: During disasters, the hospital may grant disaster privileges to volunteer licensed independent practitioners.
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1 The hospital grants disaster privileges to volunteer licensed independent practitioners only when the Emergency Operations Plan has been activated in response to a disaster and the hospital is unable to meet immediate patient needs.
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2 The medical staff identifies, in its bylaws, those individuals responsible for granting disaster privileges to volunteer licensed independent practitioners. (See also MS.01.01.01, EP 14)
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3 The hospital determines how it will distinguish volunteer licensed independent practitioners from other licensed independent practitioners. (See also EM.02.02.07, EP 9)
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4 The medical staff describes, in writing, how it will oversee the performance of volunteer licensed independent practitioners who are granted disaster privileges (for example, by direct observation, mentoring, medical record review).
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5 Before a volunteer practitioner is considered eligible to function as a volunteer licensed independent practitioner, the hospital obtains his or her valid government-issued photo identification (for example, a driver’s license or passport) and at least one of the following: <br>- A current picture identification card from a health care organization that clearly identifies professional designation<br>- A current license to practice<br>- Primary source verification of licensure<br>- Identification indicating that the individual is a member of a Disaster Medical Assistance Team (DMAT), the Medical Reserve Corps (MRC), the Emergency System for Advance Registration of Volunteer Health Professionals (ESAR-VHP), or other recognized state or federal response organization or group<br>- Identification indicating that the individual has been granted authority by a government entity to provide patient care, treatment, or services in disaster circumstances<br>- Confirmation by a licensed independent practitioner currently privileged by the hospital or by a staff member with personal knowledge of the volunteer practitioner’s ability to act as a licensed independent practitioner during a disaster
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6 During a disaster, the medical staff oversees the performance of each volunteer licensed independent practitioner.
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7 Based on its oversight of each volunteer licensed independent practitioner, the hospital determines within 72 hours of the practitioner’s arrival if granted disaster privileges should continue.
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8 Primary source verification of licensure occurs as soon as the disaster is under control or within 72 hours from the time the volunteer licensed independent practitioner presents him- or herself to the hospital, whichever comes firs
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9 If, due to extraordinary circumstances, primary source verification of licensure of the volunteer licensed independent practitioner cannot be completed within 72 hours of the practitioner’s arrival, it is performed as soon as possible.
EM.02.02.15: During disasters, the hospital may assign disaster responsibilities to volunteer practitioners who are not licensed independent practitioners, but who are required by law and regulation to have a license, certification, or registration.
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1 The hospital assigns disaster responsibilities to volunteer practitioners who are not licensed independent practitioners only when the Emergency Operations Plan has been activated in response to a disaster and the hospital is unable to meet immediate patient needs.
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2 The hospital identifies, in writing, those individuals responsible for assigning disaster responsibilities to volunteer practitioners who are not licensed independent practitioners.
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3 The hospital determines how it will distinguish volunteer practitioners who are not licensed independent practitioners from its staff
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4 The hospital describes, in writing, how it will oversee the performance of volunteer practitioners who are not licensed independent practitioners who have been assigned disaster responsibilitie
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5 Before a volunteer practitioner who is not a licensed independent practitioner is considered eligible to function as a practitioner, the hospital obtains his or her valid government-issued photo identification
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6 During a disaster, the hospital oversees the performance of each volunteer practitioner who is not a licensed independent practitioner.
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6 During a disaster, the hospital oversees the performance of each volunteer practitioner who is not a licensed independent practitioner.
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7 Based on its oversight of each volunteer practitioner who is not a licensed independent practitioner, the hospital determines within 72 hours after the practitioner’s arrival whether assigned disaster responsibilities should continue.
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8 Primary source verification of licensure, certification, or registration (if required by law and regulation in order to practice) of volunteer practitioners who are not licensed independent practitioners occurs as soon as the disaster is under control or within 72 hours from the time the volunteer practitioner presents him- or herself to the hospital, whichever comes first.
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9 If, due to extraordinary circumstances, primary source verification of licensure of the volunteer practitioner cannot be completed within 72 hours of the practitioner's arrival, it is performed as soon as possible.
EM.03.01.03: The hospital evaluates the effectiveness of its Emergency Operations Plan.
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1 As an emergency response exercise, the hospital activates its Emergency Operations Plan twice a year at each site included in the plan.
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2 For each site of the hospital that offers emergency services or is a community-designated disaster receiving station, at least one of the hospital’s two emergency response exercises includes an influx of simulated patients
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3 For each site of the hospital that offers emergency services or is a community-designated disaster receiving station, at least one of the hospital’s two emergency response exercises includes an escalating event in which the local community is unable to support the hospital.
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4 For each site of the hospital with a defined role in its community’s response plan, at least one of the two emergency response exercises includes participation in a community-wide exercise
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5 Emergency response exercises incorporate likely disaster scenarios that allow the hospital to evaluate its handling of communications, resources and assets, security, staff, utilities, and patients
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6 The hospital designates an individual(s) whose sole responsibility during emergency response exercises is to monitor performance and document opportunities for improvement.
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7 During emergency response exercises, the hospital monitors the effectiveness of internal communication and the effectiveness of communication with outside entities such as local government leadership, police, fire, public health officials, and other health care organizations.
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8 During emergency response exercises, the hospital monitors resource mobilization and asset allocation, including equipment, supplies, personal protective equipment, and transportation.
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9 During emergency response exercises, the hospital monitors its management of the following: Safety and security.
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10 During emergency response exercises, the hospital monitors its management of the following: Staff roles and responsibilities
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12 During emergency response exercises, the hospital monitors its management of the following: Patient clinical and support care activities.
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13 Based on all monitoring activities and observations, the hospital evaluates all emergency response exercises and all responses to actual emergencies using a multidisciplinary process (which includes licensed independent practitioners).
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14 The evaluation of all emergency response exercises and all responses to actual emergencies includes the identification of deficiencies and opportunities for improvement. This evaluation is documented.
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15 The deficiencies and opportunities for improvement, identified in the evaluation of all emergency response exercises and all responses to actual emergencies, are communicated to the improvement team responsible for monitoring environment of care issues
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16 The hospital modifies its Emergency Operations Plan based on its evaluation of emergency response exercises and responses to actual emergencies. <br>Note: When modifications requiring substantive resources cannot be accomplished by the next emergency response exercise, interim measures are put in place until final modifications can be made.
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17 Subsequent emergency response exercises reflect modifications and interim measures as described in the modified Emergency Operations Plan.<br>
