Audit

EM 01.01.01

A 1. The hospital's leaders,including leaders of the medical staff,participate in planning activities prior to developing an emergency operations plan

A 2. (D) The hospital conducts a hazard vulnerability analysis (HVA) to identify potential emergencies that could affect demand for the hospital's services or it's ability to provide those services,the likelihood of those events occurring,and the consequences of those events. The findings of this analysis are Documented! (also see EM 03.01.01 EP 1;IC 01.06.01 EP 4)

A 3. (D) The hospital,together with its community partners,prioritize potential emergencies identified in its hazard vulnerability analysis(HVA) and documents these priorities
(note: The hospital determines which community partners are critical to helping define priorities in its HVA)

A 4. The hospital communicates its needs and vulnerabilities to community emergency response agencies and identifies the community's capabilities to meet its needs. This communication and identifcation occur at the time of the hospitals annual review of its emergency operation plan and whenever it's needs or vulnerabilities change. ( also see EM 03.01.01,EP 1)

A 5. The hospital uses its hazard vulnerability analysis as a basis for defining mitigation activities.( that is activities designed to reduce the risk of potential damage from an emergency)

A 6. The hospital uses its hazard vulnerabality analysis as a basis for determining preparedness activities that will organize and mobilize essential resources. ( see also IM 01.01.03,EP's 1-4)

A 7. The hospital's incident command structure is intergrated into and consistent with its community, s command structure.
( Note: the incident command structure used by the hospital should provide for a scalable response to different types of emergencies.)

A 8. (D) the hospital keeps a documented inventory of resources and assets it has on site that may be needed during an emergency, including but not limited to,PPE,water,fuel and medical,surgical and medication related resources and assets.
(also see EM 02.02.03, EP 6)

EM 02.01.01

A 1. The hospitals leaders,including leaders of the medical staff,participate in the development of the emergency operations plan.

A 2. (D). The hospital develops and maintains a written Emergency Operation Plan that describes the response procedure to follow when emergencies occur.
( see also:EM 03.01.03, EP 5)

A 3. The Emergency Operations Plan identifies the hospitals capabilities and establishes response procedures for when the hospital cannot be supported by the local community in the hospitals efforts to provide communications,resources and assets,security and safety,staff,utilities,or patient care for at least 96 hours.
( Note: Hospitals are not required to stockpile supplies to last for 96 hours of operations)

A 4. (D). 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.

A 5. The Emergency Operations Plan describes the process for initiating and terminating the hospitals response and recovery phases of an emergency,including under what circumstances these phases are activated.

A 6. The Emergency Operations Plan identifies the individuals who has the authority to activate the response and recovery phases of the emergency response.

A 7. The Emergency Operations Plan identifies alternative sites for care, treatment, ans services that meet the needs of the hospitals patients during emergencies. <3>

A 8. If the hospital experiences an actual emergency, the hospital implements its response procedures related to care,treatment and services for its patients<3>

EM 02.02.01 ~EOP~

A1. How will the staff be notified that an emergency response procedures have been initiated.

A 2. How will the hospital communicate information and instructions to its staff and licensed independent practitioners during an emergency.

A 3. How the hospital will notify external authorities that emergency response measures have been initiated.

A 4. How the hospital will communicate with external authorities during an emergency.

A 5. How the hospital will communicate with patients and their families, including how it will notify families when patients are relocated to alternate care sites.

A 6. How the hospital will communicate with the community or the media during an emergency.

A 7. How the hospital will communicate with suppliers of essential services,equipment and supplies during an emergency.nicate

A 8. How the hospital will communicate with other health organizations in its geographic area regarding the essential elements of their respective structures,including the names and roles of individuals in their command structure and their command center telephone numbers.

A 9. How the hospital will communicate with other healthcare organizations in its geographic area regarding essential elements of their respective command centers for emergency response.

A 10. How the hospital will communicate with other healthcare organizations in its geographic area regarding the resource and assets that could be shared in an emergency.

A 11. How and under what circumstance the hospital will communicate the names of patients and the deceased with other healthcare organizations in its geographic area.

A 12. How and under what circumstances,the hospital will communicate information about patients to third parties ( such as. Healthcare organizations,state health departments,police,and the FBI.

A 13. How the hospital will communicate with identified alternate care sites.

A 14. The hospital establishes systems and technologies for the communication activities identified in EM 02.02.01,EP 1-13

A 17. The hospital implements the components of its Emergency Operations Plan that require advance preparation to support communications during an emergency.

EM 02.02.03 ~resources~

A 1. 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 stock piled by the hospital,it's affiliates, or local,state,or federal sources.

A 2. How the hospital will obtain and replenish medical supplies that will be required throughout the response and recovery phases of an emergency,including PPE where required.

A 3. How the hospital will obtain and replenish non medical supplies that will be required throughout the response and recovery phases of an emergency.

A 4. How the hospital will share resources and assets with other healthcare organizations within the community,if necessary.
(note: examples of resources, beds,fuel,linen,transportation)

A 5. How the hospital will share resources and assets with other healthcare organizations outside the community,if necessary,in the event of a regional or prolonged disaster

A 6. How the hospital will monitor quantities of its resources and assets during an emergency,
( also see EM 01.01.01. EP 8)

A 9. The hospitals arrangements for transporting some or all patients,their medications,supplies,equipment ,and staff than alternate care site when the environment cannot support care,treatment, and service.
(see also EM 02.02.11,EP 3)e

A 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 ~security~

A 1. The hospitals arrangements for internal security and safety.

A 2. The roles that community security agencies(for example,police,sheriff,National Guard) will have in the event of an emergency.

A 3. How the hospital will coordinate security activities with community security agencies ( police,sheriff,National Guard)

A 4. How the hospital will control entrance into and out the healthcare facility during an emergency.

A 5. How the hospital will control movement of individuals within the healthcare facility during an emergency.

A 6. The hospitals arrangements for controlling vehicles that access the healthcare facility during an emergency.

A 7. The hospital implements the the components of its Emergency Operation Plan that require advance preparation to support security and safety during an emergency.

EM 02.02.07 - the EOP discribes the following. ~staff~

A 2. The roles and responsibilities of staff for communications,resources,and assets,safety,and security,utilities and patient management during an emergency.

A 3. The process for assigning staff to all all essential staff functions.

A 4. The EOP identifies the individuals to whom staff report in the hospital incident command structure.

A 5. The EOP describes how the hospital will manage staff support needs ( example, housing,CISM,transportation)

A 6. The EOP describes how the hospital will manage the family support needs of staff( example child care , elder care, pet care)

C 7. The hospital trains staff for their assigned emergency response roles (M)

C 8. (D) The hospital communicates,in writing,with each of its licensed independent practitioners regarding his/her role in emergency response and to whom they report to during an emergency.

A 9. The EOP describes how the hospital will identify licensed independent practitioners,staff,and authorized volunteers during emergencies ( also see EM 02.02.13 EP 13 & EM 02.02.15 EP 3)

A 10. The hospital implements the components of its EOP that require advance preparation to manage staff during an emergency.

EM 02.02.09 ~utilities~

As part of its EOP the hospital identifies alternate means of providing the following

A 2. Electricty

A 3. Water needed for consumption and essential care activites

A 4. Water needed for equipment and sanitary purpose

A 5. Fuel required for building operations,generators and essential transport services that the hospital would typically provide

A 6. Medical gas/vacuum systems

A 7. Utility systems that the hospital defines as essential.( heating,cooling,steam)

A 8. The hospital implements the components of the EOP that require advance preparation to provide for utilities during emergencies.

EM 02.02.11 ~patient management~

A 2. How the hospital will manage the activities required as part of patient scheduling,triage,assessment,treatment,admission,transfer,and discharge.

A 3. 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. (also see EM 02.02.03,, EP 9 & 10)

A 4. How the hospital will manage a potential increase in demand for clinical services for vulnerable hospital populations served by the by the hospital,such as patients who are pediatric,geriatric,disabled,or have serious chronic conditions or addititions,

A 5. How the hospital will manage the personal hygiene and sanitation needs that occur during an emergency.

A 6. How the hospital will manage its patients mental health service needs that occur during an emergency.

A 7. How the hospital will manage mortuary services.

A 8. How the hospital will document and track patients clinical information.

A 11. The hospital implements the components of its EOP that require advance preparation to manage patients during an emergency.

EM 02.02.13. ~volunteers~

A 1. The hospital grants disaster privileges to volunteer licensed independent practitioners only when the EOP has been activated in response to a disaster and the hospital is unable to meet the immediate patient needs.

A 2. (D) the medical staff identifies,in it's bylaws, those individuals responsible for granting disaster privileges to volunteer licensed independent practioners

A 3. The hospital determines how it will distinguish volunteer licensed independent practioners from other licensed practioners.
( see also EM 02.02.07 EP 9)

A 4. (D) the medical staff describes,in writing,how it will oversee the performance of volunteer licensed practioners who are granted disaster privileges.( for example by direct supervision,mentoring,medical record review.)

A 5. Before a volunteer practitioner is considered eligible to function as a volunteer licensed independent practitioner,the hospital obtains his/her valid government issued photo ID. ( for example drivers license,or passport) and at least one of the following; ~3~

A current picture ID card from the healthcare organization that clearly identifies professional designation

A current license to practice

Primary source of licensure

ID indicating that the individual is a member of a DMORT,DMAT,MRC,ESAR-VHP,SERVGA,or another recognized state or federal response organization or group.

ID indicating they the individual has been granted authority by a government entity to provide patient care,treatment,or services in a disaster circumstance.

Conformation by a licensed independent practitioner currently privileged by the hospital or staff member with personal knowledge of the volunteers practitioners ability to act as a licensed independent practitioner during a disaster.

A 6. During a disaster,the medical staff oversees the performance of each volunteer licensed independent practitioner.

C 7. Based on its oversight of each volunteer licensed practitioner the hospital determines within 72 hours of the practitioners arrival if granted privileges should continue.

C 8. (D) Primary source verification of licensure occurs as soon as the disaster is under control within 72 hours from the time the volunteer licensed practitioner presents to the hospital,whichever comes first. If primary source verification of a volunteers license can not be verified with in 72 hours of the practitioners arrival due to extraordinary circumstances the hospital documents all of the following:

Reasons it could not be preformed within 72 hours of the practitioners arrival

Evidence of the licensed practitioners demonstrated ability to continue to provide adequate care , treatment and services

Evidence of the hospitals. Attempt to preform primary source verification as soon as possible

C 9. If,due to extraordinary circumstances,primary source verification of licensure of volunteer cannot be completed within 72 hours of the practitioners arrival it is preformed as soon as possible.
EM 02.02.15

A 1. The hospital assigned disaster responsibilities to volunteer practitioners who are not licensed practitioners only when the EOP has been activated in response to a disaster and the hospital is unable to meet immediate patient needs.

A 2. (D) The hospital identifies in writing,those individuals responsible for assigning disaster responsibilities to practitioners who are not licensed practitioners

A 3. The hospital determines how it will distinguish volunteer practitioners who are not licensed practitioners from its staff

A 4. (D) The hospital describes in writing,how it will oversee the performance of volunteer practitioners who are not licensed who have been assigned disaster responsibilities. Examples of methods for overseeing theirrecord review. performance include direct observation,mentoring,and medical

A 5. Before volunteer practitioners who are not a licensed practitioner are considered eligible to function as a practitioner,the hospital obtains their valid government issued photo ID and one of the following ~3~

A current photo ID card from a healthcare organization that clearly identifies professional designation

A current license,certification or registration.

Primary source verification of licensure ,certification ,or registration.(if required by law and regulation in order to practice)

ID indicating membership on DMORT,DMAT,ESAR-VHP,MRC or other state or federal recognized orginazation or group.

ID indicating that the individual has been granted authority by a government entity to provide patient care,treatment or services in a disaster

Conformation by hospital staff with personal knowledge of the volunteers practitioners ability to act as a qualified practitioner durning a disaster

A 6. During a disaster,the hospital oversees the performance of each volunteer practitioner who is not a licensed practitioner.

C 7. Based on its oversight of each volunteer practitioner who is not a licensed practitioner,the hospital determines within 72 hours after the practitioners arrival whether assigned disaster responsibilities should continue.
Document as in EM 02.02.13 why verification cannot be met.

C 8. (D) primary source verification of licensure, certification or registration( if required by law or regulation to practice) of volunteer practitioners who are not licensed practitioners occurs as soon as the disaster is under control or within 72 hours from the time time the practitioner arrives whichever comes first

C 9. If, due to extraordinary circumstances,primary source verification of licensure of the volunteer practitioner cannot be completed within 72 hours of the practitioners arrival, it is preformed as Soon as possible .

EM 03.01.01 ~ emergency management planning~

A 1. (D) th hospital conducts an annual review of its risk,hazards,and potential emergencies as defined in the HVA. The findings of this review are documented ( see EM 01.01.01 EP 2-4)

A 2. (D) the hospital conducts an annual review of the objectives and scope of its EOP. The findings of this review are documented.

A 3. (D) the hospital conducts an annual review of its inventory. The findings are documented.

EM 03.01.03 ~ EOP~

As an emergency response exercise, the hospital activates it's EOP twice a year at each site included in the plan
note 1- if the hospital activates it's EOP in response to one or more actual emergencies,these can serve in the place of emergency preparedness exercises.
Note 2- Staff in free standing buildings classified as a business occupancy that do not offer emergency services nor are a community designated as a disaster receiving station need to conduct only one emergency management exercise annually.
Note 3- Tabletop sessions,though useful,are not acceptable as a substitute for these exercises.

A 2. For each site of the hospital that offers emergency services,or is a community designed
disaster receiving station,at least one of the hospitals two emergency response exercises includes an influx of patients.
Note 1. Tabletops cannot be used as a portion of this requirement.
Note -2 this portion of the emergency response exercise can be conducted alone or in conjunction with EM 03.01.03 EP 3 &4.

A 3. For each site of the hospital that offers emergency services or is a designated community disaster receiving station,at least one of the hospitals two emergency response exercises include an escalating event in which the local community is unable to support the hospital.
Note -1 this portion of the exercise can be conducted separately or in conjunction with EM 03.01.03 EP2 & 4
note -2 tabletop sessions ARE acceptable in meeting the community portion of this exercise.

A 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.
Note 1- this portion of the emergency response exercise can be conducted separately or in conjunction with EM 03.01.03 EP 2 & 3
Note -2 tabletop sessions ARE acceptable in meeting the community portion of this exercise

A 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. ( also see EM 02.01.01 EP 2)

A 6. The hospital designates a individual whose sole responsibility during emergency response exercises is to monitor performance and document opportunities for improvement.
Note -1 This person is knowledgeable in the goals and expectations of the exercise and may be a staff member of the hospital.
Note-2 If the response to an actual emergency is used as one of the required exercises,it is understood that it may not be possible to have an individual whose sole role is to monitor performance. Hospitals may use observations of those who were involved in the command structure as well as the input of those providing service during the emergency.

A 7. During emergency response exercises,the hospital monitors the effectiveness of internal communications and the effectiveness of communications with outside entities such. Local government leadership,police,fire,public health and other healthcare agencies.

A 8. During emergency response exercise,the hospital monitors resource mobilzations and assets allocation,including equiptment,supplies,PPE,and transportation.
During emergency response exercises,the hospital monitors it's management of the following.

A 9. Safety and security

A 10. Staff roles and. Responsibilities

A 11. Utility systems

A 12. Patients clinical and support care activities.

A 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).

A 14. (D). The evacuation of all emergency response exercises and all responses to actual emergencies include the identification of deficiencies and opportunities for improvement. This evaluation will be documented!

A 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 enviorment of care issues.( see also EC 04.01.05,EP 3)

A 16. The hospital modifies its EOP based on its evacuation of emergency response to exercises and actual emergencies.

Note- when modifications requiring substance resources cannot be accomplished by the next emergency response exercise,interm measures are put in place until final modifications can be made.

A 17. Subsequent emergency response exercises reflect modifications and interim measures described in the modified EOP.

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.