TJC - Emergency Management Chapter

• Conducted on

  Date

• Prepared by

• Location
  Address

EM.01.01.01 - The hospital engages in planning activities prior to developing its written Emergency Operations Plan.

• EP1 - The hospital’s leaders, including leaders of the medical staff, participate in planning activities prior to developing an Emergency Operations Plan.

  Yes

  No

  N/A

• EP2 - The hospital conducts a hazard vulnerability analysis (HVA) to identify potential emergencies within the organization and the community 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.

  Yes

  No

  N/A

• EP3 - 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.

  Yes

  No

  N/A

• EP4 - 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.

  Yes

  No

  N/A

• EP5 - 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).

  Yes

  No

  N/A

• EP6 - The hospital uses its hazard vulnerability analysis as a basis for defining the preparedness activities that will organize and mobilize essential resources.

  Yes

  No

  N/A

• EP7 - The hospital's incident command structure is integrated into and consistent with its community’s command structure.

  Yes

  No

  N/A

• EP8 - 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.

  Yes

  No

  N/A

EM.02.01.01 - The hospital has an Emergency Operations Plan.

• EP1 - The hospital’s leaders, including leaders of the medical staff, participate in the development of the Emergency Operations Plan.

  Yes

  No

  N/A

• EP2 - The hospital develops and maintains a written Emergency Operations Plan that describes the response procedures to follow when emergencies occur.

  Yes

  No

  N/A

• EP3 - 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.

  Yes

  No

  N/A

• EP4 - 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.

  Yes

  No

  N/A

• EP5 - 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.

  Yes

  No

  N/A

• EP6 - The Emergency Operations Plan identifies the individual(s) who has the authority to activate the response and recovery phases of the emergency response.

  Yes

  No

  N/A

• EP7 - The Emergency Operations Plan identifies alternative sites for care, treatment, and services that meet the needs of the hospital's patients during emergencies.

  Yes

  No

  N/A

• EP13 - If a hospital has one or more transplant centers (see Glossary), the following must occur:<br>- A representative from each transplant center must be included in the development and maintenance of the hospital's emergency preparedness program<br>- The hospital must develop and maintain mutually agreed upon protocols that address the duties and responsibilities of the hospital, each transplant center, and the organ procurement organization (OPO) for the donation service area where the hospital is situated, unless the hospital has been granted a waiver to work with another OPO, during an emergency

  Yes

  No

  N/A

• EP8 - If the hospital experiences an actual emergency, the hospital implements its response procedures related to care, treatment, and services for its patients.

  Yes

  No

  N/A

• EP12 - For hospitals that use Joint Commission accreditation for deemed status purposes: The Emergency Operations Plan includes a continuity of operations strategy that covers the following:<br>- A succession plan that lists who replaces key leaders during an emergency if a leader is not available to carry out his or her duties<br>- A delegation of authority plan that describes the decisions and policies that can be implemented by authorized successors during an emergency and criteria or triggers that initiate this delegation

  Yes

  No

  N/A

• EP14 - For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital has a procedure for requesting an 1135 waiver for care and treatment at an alternative care site.

  Yes

  No

  N/A

• EP15 - The Emergency Operations Plan describes a means to shelter patients, staff, and volunteers on site who remain in the facility.

  Yes

  No

  N/A

• EP16 - The hospital has one or more emergency management policies based on the emergency plan, risk assessment, and communication plan. Procedures guiding implementation are defined in the emergency management plan, continuity of operations plan, and other preparedness and response protocols. Policy and procedure documents are reviewed and updated on an annual basis; the format of these documents is at the discretion of the hospital.

  Yes

  No

  N/A

EM.02.02.01 - As part of its Emergency Operations Plan, the hospital prepares for how it will communicate during emergencies.

• EP1 - The Emergency Operations Plan describes the following: How staff will be notified that emergency response procedures have been initiated.

  Yes

  No

  N/A

• EP2 - 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.

  Yes

  No

  N/A

• EP3 - The Emergency Operations Plan describes the following: How the hospital will notify external authorities that emergency response measures have been initiated.

  Yes

  No

  N/A

• EP4 - The Emergency Operations Plan describes the following: How the hospital will communicate with external authorities during an emergency.

  Yes

  No

  N/A

• EP5 - 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.

  Yes

  No

  N/A

• EP6 - The Emergency Operations Plan describes the following: How the hospital will communicate with the community or the media during an emergency.

  Yes

  No

  N/A

• EP7 - The Emergency Operations Plan describes the following: How the hospital will communicate with suppliers of essential services, equipment, and supplies during an emergency.

  Yes

  No

  N/A

• EP8 - he 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.

  Yes

  No

  N/A

• EP9 - 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.

  Yes

  No

  N/A

• EP10 - 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.

  Yes

  No

  N/A

• EP11 - 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.

  Yes

  No

  N/A

• EP12 - 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]).

  Yes

  No

  N/A

• EP13 - The Emergency Operations Plan describes the following: How the hospital will communicate with identified alternative care sites.

  Yes

  No

  N/A

• EP14 - The hospital establishes backup systems and technologies for the communication activities identified in EM.02.02.01, EPs 1–13.

  Yes

  No

  N/A

• EP17 - The hospital implements the components of its Emergency Operations Plan that require advance preparation to support communications during an emergency.

  Yes

  No

  N/A

• EP20 - As part of its communication plan, the hospital maintains the names and contact information of the following:<br>- Staff<br>- Physicians<br>- Other hospitals and critical access hospitals<br>- Volunteers<br>- Entities providing services under arrangement<br>- Relevant federal, state, tribal, regional, and local emergency preparedness staff<br>- Other sources of assistance

  Yes

  No

  N/A

• EP21 - The Emergency Operations Plan describes the following:<br>- Process for communicating information about the general condition and location of patients under the organization’s care to public and private entities assisting with disaster relief<br>- Process, in the event of an evacuation, to release patient information to family, patient representative, or others responsible for the care of the patient

  Yes

  No

  N/A

• EP22 - The organization maintains documentation of completed and attempted contact with the local, state, tribal, regional, and federal emergency preparedness officials in its service area. This contact is made for the purpose of communication and, where possible, collaboration on coordinated response planning for a disaster or emergency situation.

  Yes

  No

  N/A

EM.02.02.03 - As part of its Emergency Operations Plan, the hospital prepares for how it will manage resources and assets during emergencies.

• EP1 - 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.

  Yes

  No

  N/A

• EP2 - 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.

  Yes

  No

  N/A

• EP3 - The Emergency Operations Plan describes the following: How the hospital will obtain and replenish nonmedical supplies (including food, bedding, and other provisions consistent with the hospital's plan for sheltering on site) that will be required throughout the response and recovery phases of an emergency.

  Yes

  No

  N/A

• EP4 - 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.

  Yes

  No

  N/A

• EP5 - 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.

  Yes

  No

  N/A

• EP6 - The Emergency Operations Plan describes the following: How the hospital will monitor quantities of its resources and assets during an emergency.

  Yes

  No

  N/A

• EP9 - The Emergency Operations Plan describes the following: The hospital's arrangements for transporting some or all patients; their medications, supplies, and equipment; and staff to an alternative care site(s) when the environment cannot support care, treatment, and services.

  Yes

  No

  N/A

• EP10 - 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.

  Yes

  No

  N/A

• EP12 - The hospital implements the components of its Emergency Operations Plan that require advance preparation to provide for resources and assets during an emergency.

  Yes

  No

  N/A

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.

• EP1 - The Emergency Operations Plan describes the following: The hospital's arrangements for internal security and safety.

  Yes

  No

  N/A

• EP2 - 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.

  Yes

  No

  N/A

• EP3 - The Emergency Operations Plan describes the following: How the hospital will coordinate security activities with community security agencies

  Yes

  No

  N/A

• EP4 - The Emergency Operations Plan describes the following: How the hospital will manage hazardous materials and waste.

  Yes

  No

  N/A

• EP5 - The Emergency Operations Plan describes the following: How the hospital will provide for radioactive, biological, and chemical isolation and decontamination.

  Yes

  No

  N/A

• EP7 - The Emergency Operations Plan describes the following: How the hospital will control entrance into and out of the health care facility during an emergency.

  Yes

  No

  N/A

• EP8 - The Emergency Operations Plan describes the following: How the hospital will control the movement of individuals within the health care facility during an emergency.

  Yes

  No

  N/A

• EP9 - The Emergency Operations Plan describes the following: The hospital's arrangements for controlling vehicles that access the health care facility during an emergency.

  Yes

  No

  N/A

• EP10 - The hospital implements the components of its Emergency Operations Plan that require advance preparation to support security and safety during an emergency.

  Yes

  No

  N/A

EM.02.02.07 - As part of its Emergency Operations Plan, the hospital prepares for how it will manage staff during an emergency.

• EP2 - 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 and evacuation during an emergency.

  Yes

  No

  N/A

• EP3 - The Emergency Operations Plan describes the following: The process for assigning staff to all essential staff functions.

  Yes

  No

  N/A

• EP4 - The Emergency Operations Plan identifies the individual(s) to whom staff report in the hospital's incident command structure.

  Yes

  No

  N/A

• EP5 - The Emergency Operations Plan describes how the hospital will manage staff support needs.

  Yes

  No

  N/A

• EP6 - The Emergency Operations Plan describes how the hospital will manage the family support needs of staff.

  Yes

  No

  N/A

• EP7 - The hospital trains staff for their assigned emergency response roles.

  Yes

  No

  N/A

• EP8 - 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.

  Yes

  No

  N/A

• EP9 - The Emergency Operations Plan describes how the hospital will identify licensed independent practitioners, staff, and authorized volunteers during emergencies.

  Yes

  No

  N/A

• EP10 - The hospital implements the components of its Emergency Operations Plan that require advance preparation to manage staff during an emergency.

  Yes

  No

  N/A

• EP11 - For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital has a system to track the location of on-duty staff during an emergency.

  Yes

  No

  N/A

• EP13 - Initial and ongoing training relevant to their emergency response roles is provided to staff, volunteers, and individuals providing on-site services under arrangement. This training is documented and then reviewed and updated annually and when these roles change. Staff demonstrate knowledge of emergency procedures through participation in drills and exercises, as well as post-training tests, participation in instructor-led feedback (for example, questions and answers), or other methods determined and documented by the organization.

  Yes

  No

  N/A

• EP14 - The Emergency Operations Plan describes the use of volunteers in an emergency, including emergency staffing strategies, such as the role and process for integration of state or federally designated health care professionals to address surge needs during an emergency.

  Yes

  No

  N/A

EM.02.02.09 - As part of its Emergency Operations Plan, the hospital prepares for how it will manage utilities during an emergency.

• EP2 - As part of its Emergency Operations Plan, the hospital identifies alternative means of providing the following: Electricity and lighting.

  Yes

  No

  N/A

• EP3 - As part of its Emergency Operations Plan, the hospital identifies alternative means of providing the following: Water needed for consumption and essential care activities.

  Yes

  No

  N/A

• EP4 - As part of its Emergency Operations Plan, the hospital identifies alternative means of providing the following: Water needed for equipment and sanitary purposes.

  Yes

  No

  N/A

• EP5 - 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.

  Yes

  No

  N/A

• EP6 - As part of its Emergency Operations Plan, the hospital identifies alternative means of providing the following: Medical gas/vacuum systems.

  Yes

  No

  N/A

• EP7 - As part of its Emergency Operations Plan, the hospital identifies alternative means of providing the following: Utility systems that the hospital defines as essential

  Yes

  No

  N/A

• EP8 - The hospital implements the components of its Emergency Operations Plan that require advance preparation to provide for utilities during an emergency.

  Yes

  No

  N/A

• EP9 - For hospitals that use Joint Commission accreditation for deemed status purposes: The generator must be located in accordance with the location requirements found in the Health Care Facilities Code

  Yes

  No

  N/A

EM.02.02.11 - As part of its Emergency Operations Plan, the hospital prepares for how it will manage patients during emergencies.

• EP2 - 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.

  Yes

  No

  N/A

• EP3 - 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.

  Yes

  No

  N/A

• EP4 - The Emergency Operations Plan describes the following: How the hospital will manage a potential increase in demand for clinical services for vulnerable populations served by the hospital, such as patients who are pediatric, geriatric, disabled, or have serious chronic conditions or addictions.

  Yes

  No

  N/A

• EP5 - The Emergency Operations Plan describes the following: How the hospital will manage the personal hygiene and sanitation needs of its patients.

  Yes

  No

  N/A

• EP6 - The Emergency Operations Plan describes the following: How the hospital will manage its patients' mental health service needs that occur during an emergency.

  Yes

  No

  N/A

• EP7 - The Emergency Operations Plan describes the following: How the hospital will manage mortuary services.

  Yes

  No

  N/A

• EP8 - The Emergency Operations Plan describes the following: How the hospital will document and track patients’ clinical information.

  Yes

  No

  N/A

• EP11 - The hospital implements the components of its Emergency Operations Plan that require advance preparation to manage patients during an emergency.

  Yes

  No

  N/A

• EP12 - The hospital has a system to track the location of patients sheltered on site during an emergency. This system includes documentation of the name and location of the receiving facility or alternate site in the event a patient is relocated during the emergency.

  Yes

  No

  N/A

EM.02.02.13 - During disasters, the hospital may grant disaster privileges to volunteer licensed independent practitioners.

• EP1 - 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.

  Yes

  No

  N/A

• EP2 - The medical staff identifies, in its bylaws, those individuals responsible for granting disaster privileges to volunteer licensed independent practitioners.

  Yes

  No

  N/A

• EP3 - The hospital determines how it will distinguish volunteer licensed independent practitioners from other licensed independent practitioners.

  Yes

  No

  N/A

• EP4 - The medical staff describes, in writing, how it will oversee the performance of volunteer licensed independent practitioners who are granted disaster privileges.

  Yes

  No

  N/A

• EP5 - 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

  Yes

  No

  N/A

• EP6 - During a disaster, the medical staff oversees the performance of each volunteer licensed independent practitioner.

  Yes

  No

  N/A

• EP7 - 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.

  Yes

  No

  N/A

• EP8 - 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 first. If primary source verification of a volunteer licensed independent practitioner’s licensure cannot be completed within 72 hours of the practitioner’s arrival due to extraordinary circumstances, the hospital documents all of the following: <br>- Reason(s) it could not be performed within 72 hours of the practitioner’s arrival<br>- Evidence of the licensed independent practitioner’s demonstrated ability to continue to provide adequate care, treatment, and services<br>- Evidence of the hospital’s attempt to perform primary source verification as soon as possible

  Yes

  No

  N/A

• EP9 - 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.

  Yes

  No

  N/A

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.

• EP1 - 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.

  Yes

  No

  N/A

• EP2 - The hospital identifies, in writing, those individuals responsible for assigning disaster responsibilities to volunteer practitioners who are not licensed independent practitioners.

  Yes

  No

  N/A

• EP3 - The hospital determines how it will distinguish volunteer practitioners who are not licensed independent practitioners from its staff.

  Yes

  No

  N/A

• EP4 - 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 responsibilities. Examples of methods for overseeing their performance include direct observation, mentoring, and medical record review.

  Yes

  No

  N/A

• EP5 - 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 (for example, a driver’s license or passport) and one of the following: <br>- A current picture identification card from a health care organization that clearly identifies professional designation<br>- A current license, certification, or registration<br>- Primary source verification of licensure, certification, or registration (if required by law and regulation in order to practice)<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 hospital staff with personal knowledge of the volunteer practitioner’s ability to act as a qualified practitioner during a disaster

  Yes

  No

  N/A

• EP6 - During a disaster, the hospital oversees the performance of each volunteer practitioner who is not a licensed independent practitioner.

  Yes

  No

  N/A

• EP7 - 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.

  Yes

  No

  N/A

• EP8 - 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. If primary source verification of licensure, certification, or registration (if required by law and regulation in order to practice) for a volunteer practitioner who is not a licensed independent practitioner cannot be completed within 72 hours due to extraordinary circumstances, the hospital documents all of the following:<br>- Reason(s) it could not be performed within 72 hours of the practitioner's arrival<br>- Evidence of the volunteer practitioner’s demonstrated ability to continue to provide adequate care, treatment, or services<br>- Evidence of the hospital’s attempt to perform primary source verification as soon as possible

  Yes

  No

  N/A

• EP9 - 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.

  Yes

  No

  N/A

EM.03.01.01 - The hospital evaluates the effectiveness of its emergency management planning activities.

• EP1 - The hospital conducts an annual review of its risks, hazards, and potential emergencies as defined in its hazard vulnerability analysis (HVA). The findings of this review are documented.

  Yes

  No

  N/A

• EP2 - The hospital conducts an annual review of the objectives and scope of its Emergency Operations Plan. The findings of this review are documented.

  Yes

  No

  N/A

• EP3 - The hospital conducts an annual review of its inventory. The findings of this review are documented.

  Yes

  No

  N/A

• EP4 - The annual emergency management planning reviews are forwarded to senior hospital leadership for review.

  Yes

  No

  N/A

EM.03.01.03 - The hospital evaluates the effectiveness of its Emergency Operations Plan.

• EP1 - As an emergency response exercise, the hospital activates its Emergency Operations Plan twice a year at each site included in the plan. <br>Note 1: If the hospital activates its Emergency Operations Plan in response to one or more actual emergencies, these emergencies can serve in place of emergency response exercises. <br>Note 2: Staff in freestanding buildings classified as a business occupancy (as defined by the Life Safety Code * ) that do not offer emergency services nor are community designated as disaster-receiving stations need to conduct only one emergency management exercise annually. <br>Note 3: Tabletop sessions, though useful, are not acceptable substitutes for these exercises. <br>Note 4: In order to satisfy the twice-a-year requirement, the hospital must first evaluate the performance of the previous exercise and make any needed modifications to its Emergency Operations Plan before conducting the subsequent exercise in accordance with EPs 13–17.

  Yes

  No

  N/A

• EP2 - 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. <br>Note 1: Tabletop sessions, though useful, cannot serve for this portion of the exercise. <br>Note 2: This portion of the emergency response exercise can be conducted separately or in conjunction with EM.03.01.03, EPs 3 and 4.

  Yes

  No

  N/A

• EP3 - 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. <br>Note 1: This portion of the emergency response exercise can be conducted separately or in conjunction with EM.03.01.03, EPs 2 and 4. <br>Note 2: Tabletop sessions are acceptable in meeting the community portion of this exercise.

  Yes

  No

  N/A

• EP4 - 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. <br>Note 1: This portion of the emergency response exercise can be conducted separately or in conjunction with EM.03.01.03, EPs 2 and 3. <br>Note 2: Tabletop sessions are acceptable in meeting the community portion of this exercise.

  Yes

  No

  N/A

• EP5 - 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.

  Yes

  No

  N/A

• EP6 - The hospital designates an individual(s) whose sole responsibility during emergency response exercises is to monitor performance and document opportunities for improvement. <br>Note 1: This person is knowledgeable in the goals and expectations of the exercise and may be a staff member of the hospital.<br>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 responsibility 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 services during the emergency.

  Yes

  No

  N/A

• EP7 - 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.

  Yes

  No

  N/A

• EP8 - During emergency response exercises, the hospital monitors resource mobilization and asset allocation, including equipment, supplies, personal protective equipment, and transportation.

  Yes

  No

  N/A

• EP9 - During emergency response exercises, the hospital monitors its management of the following: Safety and security.

  Yes

  No

  N/A

• EP10 - During emergency response exercises, the hospital monitors its management of the following: Staff roles and responsibilities.

  Yes

  No

  N/A

• EP11 - During emergency response exercises, the hospital monitors its management of the following: Utility systems.

  Yes

  No

  N/A

• EP12 - During emergency response exercises, the hospital monitors its management of the following: Patient clinical and support care activities.

  Yes

  No

  N/A

• EP13 - Based on all monitoring activities and observations, including relevant input from all levels of staff affected, the hospital evaluates all emergency response exercises and all responses to actual emergencies using a multidisciplinary process.

  Yes

  No

  N/A

• EP14 - 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.

  Yes

  No

  N/A

• EP15 - 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 and to senior hospital leadership.

  Yes

  No

  N/A

• EP16 - 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.

  Yes

  No

  N/A

• EP17 - Subsequent emergency response exercises reflect modifications and interim measures as described in the modified Emergency Operations Plan.

  Yes

  No

  N/A

EM.04.01.01 0 For hospitals that use Joint Commission accreditation for deemed status purposes: If the hospital is part of a health care system that has an integrated emergency preparedness program, and it chooses to participate in the integrated emergency preparedness program, the hospital participates in planning, preparedness, and response activities with the system.

• EP1 - For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital demonstrates its participation in the development of its system’s integrated emergency preparedness program through the following:<br>- Designation of a staff member(s) who will collaborate with the system in developing the program<br>- Documentation that the hospital has reviewed the community-based risk assessment developed by the system’s integrated all-hazards emergency management program<br>- Documentation that the hospital’s individual risk assessment is incorporated into the system’s integrated program<br>- Documentation that the hospital’s patient population, services offered, and any unique circumstances of the hospital are reflected in the system’s integrated program<br>- Documentation of an integrated communication plan, including information on key contacts in the system’s integrated program<br>- Documentation that the hospital participates in the annual review of the system’s integrated program

  Yes

  No

  N/A

• EP2 - For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital has implemented communication procedures for emergency planning and response activities in coordination with the system’s integrated emergency preparedness program.

  Yes

  No

  N/A

• EP3 - For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital’s integrated emergency management policies, procedures, or plans address the following:<br>- Identification of the hospital’s emergency preparedness, response, and recovery activities that can be coordinated with the system’s integrated program (for example, acquiring or storing clinical supplies, assigning staff to the local health care coalition to create joint training protocols, and so forth)<br>- The hospital’s communication and/or collaboration with local, tribal, regional, state, or federal emergency preparedness officials through the system’s integrated program<br>- Coordination of continuity of operations planning with the system’s integrated program<br>- Plans and procedures for integrated training and exercise activities with the system’s integrated program

  Yes

  No

  N/A