The following table shows how our HICS System™ kit (Blue Text) can help address JACHO 2009 Emergency Management Standards. The HICS System™ kit is scalable and All-Hazard in approach. Using HICS IV formats, HICS System™ incorporates NIMS elements such as Incident Command Structure.

Cat

Standard

and

EPs

EMERGENCY OPERATIONS PLAN

2009 Emergency Management Standards

HICS SystemTM

EM.1.01.01

The [organization] engages in planning activities prior to developing its written Emergency Operations Plan.

Use components of the HICS System to develop the EOP and as a strategy for implementing the EOP.

A

1.

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

HICS System: Use the INCIDENT RESPONSE GUIDE and Hazard-Specific Reminders as planning tools.

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 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)

Note: 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.

Footnote: If the hospital identifies a surge in infectious patients as a potential emergency, this issue is addressed in the “Infection Prevention and Control” chapter. (See also IC.01.06.01, EP 4)

HICS System: Use the Hazard-Specific Reminders table, a cross-index of possible internal and external emergency scenarios for hospitals, for HVA.

A

3. D

The hospital, together with its community partners, prioritizes the potential emergencies identified in its hazard vulnerability analysis and documents these priorities

Note: The hospital determines which community partners are critical to helping define priorities in its hazard vulnerability analysis. 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.

HICS System: Use the Hazard-Specific Reminders table, a cross-index of possible internal and external emergency scenarios for hospitals, for prioritizing potential emergencies.

A

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 Plan and whenever its needs or vulnerabilities change. (See also EM.03.01.01, EP 1)

HICS System: Use the Hazard-Specific Reminders table to list needs and vulnerabilities for community emergency response agencies.

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 and potential damage from an emergency).

Note: Mitigation, preparedness, response, and recovery are the four phases of emergency management. They occur over time; mitigation and preparedness generally occurring before an emergency and response and recovery occurring during and after the emergency.

HICS System: Use the Hazard-Specific Reminders table to define mitigation activities.

A

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)

HICS System: Use the Hazard-Specific Reminders table, together with the Activation Guides to activate appropriate HICS Jobs.

A

7,

The hospital’s incident command structure is integrated 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.

Footnote: The National Incident Management System (NIMS) is one of many models for an incident command structure available to health care organizations. NIMS provides guidelines for common functions and terminology to support clear communications and effective collaboration in an emergency situation. NIMS is required of hospitals receiving certain federal funds for emergency preparedness.

HICS System uses HICS IV terminology which is identical to NIMS Incident Command and General Staff terminology used by most city and county emergency managers.

A

8. D

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)

HICS System: HICS Form 257 – RESOURCE ACCOUNTING RECORD is a place to start the inventory.

EM.02.01.01

The hospital has an Emergency Operations Plan.

Note: The [organization]‘s Emergency Operations Plan 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 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

HICS System provides many implementing components for an All-Hazard hospital EOP. A key strategy and decision point for any hospital would be to activate a Hospital Command Center to synchronize hospital efforts during an emergency. The hospital EOP can reference EOP responsibilities and response procedures in the EOC System staff binders.

A

1.

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

Hospital leaders must develop the EOP policies that result in the activation of a Hospital Command Center. The EOC System staff binders provide a starting point for focusing the hospital leaders on essential response procedures.

A

2. D

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)

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: – Maintaining or expanding services. – Conserving resources. – Curtailing services. – Supplementing resources from outside the local community. – Closing the hospital to new patients. – Staged evacuation. – Total evacuation

The hospital must provide its own over-arching EOP. The activation of the EOC System Kit provides key response procedures that address many JACHO 2009 Emergency Management Standards

A

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.

Note: Hospitals are not required to stockpile supplies to last for 96 hours of operation.

Each hospital must identify its own capabilities. The HICS SystemHICS System staff binders organize and store procedures until needed. contains response procedures to help hospital leaders assess the emergency situation and coordinate resources. The

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

HICS System: Each HICS IV Job Action Sheet and INCIDENT RESPONSE GUIDE lists Demobilization/ System Recovery tasks for restoring the hospital to pre-emergency status.

A

5.

The Emergency Operations Plan describes the processes for initiating and terminating the hospital’s response and recovery phases of the emergency, including under what circumstances these phases are activated.

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 the emergency.

The hospital must decide what emergencies will trigger the activation of the Hospital Command Center. Once activated, the HICS System binder for Incident Commander guides the expansion or contraction of the hospital emergency response organization.

A

6.

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

The HICS System identifies the Incident Commander as the authority for activating phases.

A

7.

The Emergency Operations Plan identifies alternative sites for care, treatment and services that meet the needs of its patients during emergencies.

Each hospital must identify its own alternative sites. A list of sites can be stored in the binder for Incident Commander.



A 3

8.

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

HICS System: Staff binders and HICS IV Job Action Sheets contain response procedures.

EM.02.02.01

As part of its Emergency Operations Plan, the [organization] prepares for how it will communicate during emergencies – the EOP describes the following:


A

1

How staff will be notified that emergency response procedures have been initiated

Each hospital has its own Codes for alerting staff. The staff binders and Job Action Sheets remind Hospital Command Center staff to telephone additional staff.

A

2

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

The Hospital Command Center will distribute HICS System staff binders which contain Job Action Sheets and relevant HICS IV Forms.

A

3

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

HICS System: The staff binders and Job Action Sheets remind Hospital Command Center staff to telephone external authorities.

A

4

How the hospital will communicate with external authorities during an emergency

HICS System: The staff binder for Liaison Officer has instructions for contacting and reporting Hospital status to the local gov’t EOC.

A

5

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

HICS System: The staff binders and Job Action Sheets such as Med Care Branch Director binder and Inpatient Unit Leader contain appropriate procedures.

A

6

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

HICS System: The staff binders and Job Action Sheets such as Public Information Officer binder contain appropriate procedures.

A

7

How the hospital will communicate with purveyors of essential supplies, services, and equipment during an emergency.

HICS System: The staff binders and Job Action Sheets such as MATERIEL TRACKING MANAGER contain appropriate procedures.

A

8

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.

HICS System: The staff binder for Liaison Officer has instructions for contacting and regularly updating other Hospital Command Centers.

A

9

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.

HICS System: The staff binder for Liaison Officer has instructions for contacting and regularly updating other Hospital Command Centers.

A

10

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.

HICS System: The staff binder for Liaison Officer has reminders for establishing consistent communications with other health care organizations.

A

11

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.

HICS System: Job Action Sheets direct PATIENT TRACKING MANAGER and the PATIENT REGISTRATION UNIT LEADER to use relevant HICS IV Forms within HIPAA and local guidelines

A

12

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 FBI).

HICS System: The staff binders and Job Action Sheets such as MEDICAL CARE BRANCH DIRECTOR, Unit Leaders and the Liaison Officer contain appropriate procedures.

A

13

How the hospital will communicate with identified alternative care sites.

HICS System: Hazard-Specific Reminders and the Incident Action Plan (IAP) document include HICS Form 206 for listing alternate sites and telephone contacts.

A

14

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

The HICS System is portable to an alternate Hospital Command Center, if the primary site is unavailable.



A

17

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

HICS System: The Communications Unit Leader Job Action Sheet refers to preparations for loss of internal and external telephone communications

EM.02.02.03

As part of its Emergency Operations Plan, the [organization] prepares for how it will manage resources and assets during emergencies. The EOP describes the following.

The hospital EOP can refer to management procedures in the EOC System.

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 stockpiled by the hospital, its affiliates, or local, state, or federal sources

HICS System: The staff binders and Job Action Sheets such as MEDICATION STAGING TEAM LEADER of Staging contain appropriate procedures.

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 personal protective equipment where required.

HICS System: The staff binders and Job Action Sheets such as Supply UNIT LEADER of the Logistics Section Support Branch contain appropriate procedures.

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.

HICS System: The staff binders and Job Action Sheets such as Supply UNIT LEADER of the Logistics Section Support Branch contain appropriate procedures.

A

4.

How the hospital will share resources and assets with other health care

organizations within the community, if necessary.

Note: Examples of resources and assets that might be shared include beds, transportation, linens, fuel, personal protective equipment, medical equipment and supplies.

HICS System: The staff binders and Job Action Sheets such as Liaison Officer, and Resources Unit Leader, Planning Section contain appropriate procedures and forms such as HICS Form 258, Hospital Resource Directory.

A

5.

How the hospital will share resources and assets with other health care

organizations outside of the community, if necessary, in the event of a regional or prolonged disaster.

Note: Examples of resources and assets that might be shared include beds, transportation, linens, fuel, personal protective equipment, medical equipment and supplies.

HICS System: The staff binders and Job Action Sheets such as Liaison Officer, and Resources Unit Leader, Planning Section contain appropriate procedures and forms such as HICS Form 258, Hospital Resource Directory.

A

6.

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

HICS System: The staff binders and Job Action Sheets such as Resources Unit Leader, Planning Section, contain appropriate procedures and forms such as HICS Form 258, Hospital Resource Directory.

A

9

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)

HICS System: The staff binders and Job Action Sheets such as Transportation UNIT LEADER contain appropriate procedures.

A

10

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)

HICS System: The staff binders contain appropriate procedures and Job Action Sheets such as Patient Tracking Unit, Casualty Care Unit use HICS 255 – MASTER PATIENT EVACUATION TRACKING FORM



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


As part of its Emergency Operations Plan, the [organization] prepares for how it will manage security and safety during an emergency. The EOP describes the following:



A

1.

The hospital’s arrangements for internal security and safety.

HICS System: The staff binders and Job Action Sheets such as Security Branch Director contain appropriate procedures

A

2.

The roles that community security agencies (for example, police, sheriff, national guard) will have in the event of an emergency.

HICS System: The staff binders and Job Action Sheets such as Liaison Officer, Law Enforcement Interface Unit contain appropriate procedures

A

3.

How the hospital will coordinate security activities with community security agencies (for example, police, sheriff, national guard

HICS System: The staff binders and Job Action Sheets such as Liaison Officer, Law Enforcement Interface Unit contain appropriate procedures

A

4.

How the hospital will manage hazardous materials and waste.

HICS System: The staff binders and Job Action Sheets such as Hazmat Branch contain appropriate procedures

A

5.

How the hospital will provide for radioactive, biological, and chemical isolation and decontamination.

HICS System: The staff binders and Job Action Sheets such as Detection and Monitoring Unit, Spill Response Unit, Victim Decontamination Unit, Facility/Equipment Decontamination Unit, of the Hazmat Branch contain appropriate procedures

C

7.

How the hospital will control entrance into and out of the health care facility during an emergency.

HICS System: The staff binders and Job Action Sheets such as Access Control Unit job action sheet contain appropriate procedures

C

8. D

How the hospital will control the movement of individuals within the health care facility during an emergency.

HICS System: The staff binders and Job Action Sheets such as Access Control Unit, Crowd Control Unit, Command Center Reception contain appropriate procedures

A

9.

The hospital’s arrangements for controlling vehicles that access the health care facility during an emergency

HICS System: The staff binders and Job Action Sheets such as Traffic Control Unit, Law Enforcement Interface Unit contain appropriate procedures



A

10.

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

HICS System: The staff binders and Job Action Sheets such as Security Branch can provide input to the EOP.

EM.02.02.07


As part of its Emergency Operations Plan, the [organization] prepares for how it will manage staff during an emergency.



A

2.

The EOP describes the roles and responsibilities of staff for communications, resources and assets, safety and security, utilities, and patient management during an emergency

The EOP can refer to the HICS System for roles and responsibilities.

A

3.

The EOP describes the following: The process for assigning staff to all essential staff functions

HICS System: “HICS System Binders to Distribute” table is used to assign staff.

A

4.

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

HICS System: Each staff binder contains a HICS Organization Chart.

A

5.

The Emergency Operations Plan describes how the hospital will manage staff support needs (for example, housing, transportation, and incident stress debriefing).

HICS System: The staff binders and Job Action Sheets such as Employee Health & Family Care Unit contain appropriate procedures

A

6.

The Emergency Operations Plan describes how the hospital will manage the family support needs of staff (for example, child care, elder care, and communication).

HICS System: The staff binders and Job Action Sheets such as Employee Health & Family Care Unit contain appropriate procedures

A

7.

The hospital trains staff for their assigned emergency response roles.

HICS System: binders and Job Action Sheets are starting points for training

A

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.

HICS System: The staff binders and Job Action Sheets such as MEDICAL/TECHNICAL SPECIALIST – MEDICAL STAFF contain appropriate procedures

A

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)

Note: This identification could include identification cards, wrist bands, vests, hats, or badges.

HICS System: The staff binders and Job Action Sheets such as Labor Pool & Credentialing Unit contain appropriate procedures



A

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 [organization] prepares for how it will manage utilities during an emergency


 

The hospital identifies an alternative means of providing for the following utilities in the event that their supply is compromised or disrupted (EPs 1-5):As part of its EOP, the hospital identifies alternative means of providing the following:

HICS System: The staff binders and Job Action Sheets such as INFRASTRUCTURE BRANCH DIRECTOR:

Damage Unit Food Services Unit contain appropriate procedures

A

2.

Electricity

HICS System: The staff binders and Job Action Sheets such as Power/Lighting Unit contain appropriate procedures

A

2.

Water needed for consumption and essential care activities

HICS System: The staff binders and Job Action Sheets such as Water/Sewer Unit contain appropriate procedures

A

4.

Water needed for equipment and sanitary purposes

HICS System: The staff binders and Job Action Sheets such as Water/Sewer Unit contain appropriate procedures

A

5.

Fuel required for building operations or essential transport activities that the hospital would typically provide

HICS System: The staff binders and Job Action Sheets such as Power/ Lighting Unit contain appropriate procedures

A

6.

Medical gas/vacuum systems

HICS System: The staff binders and Job Action Sheets such as Medical Gases Unit, Medical Devices Unit contain appropriate procedures

A

7.

Utility systems that the hospital defines as essential (for example, vertical and horizontal transport, heating and cooling systems, and stream for sterilization).

HICS System: The staff binders and Job Action Sheets such as HVAC Unit, Environmental Services Unit contain appropriate procedures



A

8

The hospital implements the components of its EOP that require advance preparation to provide for utilities during and emergency.

HICS System: The staff binders and Job Action Sheets involving utilities have relevant reminders for EOP input.

EC.4.18

As part of its Emergency Operations Plan, the [organization] prepares for how it will manage [patient]s during emergencies.


 

The hospital plans to manage the following during emergencies (EPs 1-5):


A

2.

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

HICS System: The staff binders and Job Action Sheets such as Inpatient Unit, Outpatient Unit, Casualty Care Unit, Mental Health Unit, Clinical Support Services Unit Patient Registration Unit contain appropriate procedures

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. (See also EM.02.02.03, EPs 9 and 10)

HICS System: staff binders and Job Action Sheets such as Patient Tracking Unit, Inpatient Unit, Outpatient Unit, Casualty Care Unit contain appropriate procedures

A

4.

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.

HICS System: The staff binders and Job Action Sheets such as Mental Health Unit contain appropriate procedures.

A

5.

How the hospital will manage the personal hygiene and sanitation needs of its patients

HICS System: The staff binders and Job Action Sheets such as Infrastructure Branch Dir binder contain appropriate procedures

A

6.

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

HICS System: The staff binders and Job Action Sheets such as Mental Health Unit Job Action Sheet, Med Care Dir binder contain appropriate procedures

A

7.

How the hospital will manage mortuary services.

HICS System: The staff binders and Job Action Sheets such as Support Branch Dir binder contain appropriate procedures

A

8.

How the hospital will document and track patients’ clinical information.

HICS System: The staff binders and Job Action Sheets such as MEDICAL CARE BRANCH DIRECTOR binder contain appropriate procedures



A

11.

The hospital implements the components of its Emergency Operations Plan that require advance preparation to manage patients during an Emergency

HICS System: The staff binders and Job Action Sheets such as MEDICAL CARE BRANCH DIRECTOR binder contain appropriate procedures

EM.02.02.13

During disasters, the [organization] may grant disaster privileges to volunteer licensed independent practitioners.  Note: A disaster is an emergency that, due to its complexity, scope, or duration, threatens the organization’s capabilities and requires outside assistance to sustain [patient] care, safety, or security functions.

HICS System: The staff binders and Job Action Sheets such as LOGISTICS SECTION CHIEF contain appropriate procedures

A

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

HICS System: The staff binders and Job Action Sheets such as Labor Pool & Credentialing UNIT LEADER contain appropriate procedures

A

2.  D

The medical staff identifies, in its bylaws, those individuals responsible for granting disaster privileges to volunteer licensed independent Practitioners

HICS System: The staff binders and Job Action Sheets such as Labor Pool & Credentialing Unit contain appropriate procedures

A

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)

HICS System: The staff binders and Job Action Sheets such as Labor Pool & Credentialing UNIT LEADER job, Support Branch Dir binder, Access Control UNIT LEADER job, Security Branch Dir binder contain appropriate procedures

B

4.  D

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, or medical record review).

HICS System: The staff binders and Job Action Sheets such as PERSONNEL TRACKING MANAGER job, resources unit leader binder contain appropriate procedures

A 3

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:

-        a current picture identification card from a health care organization that clearly identifies professional designation.

-        A current license to practice.

-        Primary source verification of licensure.

-        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 hospital or group.

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

-        disaster circumstances.

-        Confirmation by a licensed independent practitioner currently privileged by the hospital or a staff member with personal knowledge of the volunteer practitioner’s ability to act as a licensed independent practitioner during a disaster.

Insert hospital’s volunteer screening policy statement into HICS System staff binders and Job Action Sheets such as Security Branch Director and Labor Pool & Credentialing Unit.

A

6.

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

HICS System: Most checklists in binders and Job Action Sheets instruct hospital staff to “observe all staff and volunteers for signs of stress and inappropriate behavior.”

C

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.

HICS System: Insert into Extended (Operational Period Beyond 12 Hours) for Labor Pool & Credentialing UNIT LEADER job, SUPPORT BRANCH DIRECTOR binder

C

8. D

Primary source verification of licensure occurs as soon as the immediate emergency situation 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:

-        Reason(s) why it could not be performed within 72 hours of the practitioner’s arrival.

-        Evidence of the licensed independent practitioner’s demonstrated ability to continue to provide adequate care, treatment, and services.

-        Evidence of the hospital’s attempt to perform primary source verification as soon as possible.

HICS System: Insert into Extended (Operational Period Beyond 12 Hours) for Labor Pool & Credentialing UNIT LEADER job, SUPPORT BRANCH DIRECTOR binder

C

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.

Note: Primary source verification of licensure is not required if the volunteer licensed independent practitioner has not provided care, treatment, or services under the disaster privileges.

HICS System: Insert into Extended (Operational Period Beyond 12 Hours) for Labor Pool & Credentialing UNIT LEADER job, SUPPORT BRANCH DIRECTOR binder

EM.02.02.15

During disasters, the [organization] 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.

Note: While this standard allows for a method to streamline the process for verifying identification and licensure, certification, or registration, the elements of performance are intended to safeguard against inadequate care in an emergency situation.

HICS System: Insert into Extended (Operational Period Beyond 12 Hours) for Labor Pool & Credentialing UNIT LEADER job, SUPPORT BRANCH DIRECTOR binder

A

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.

These are key decisions made in the Hospital Command Center.

A

2.  D

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

Insert list of responsible individuals into HICS System staff binders and Job Action Sheets such as Security Branch Director and Labor Pool & Credentialing Unit.

A

3.

The hospital determines how it will distinguish volunteer practitioners who are not licensed independent practitioners from its staff. (See also EM.02.02.07, EP 9)

Insert hospital’s security policy for staff identification into HICS System staff binders and Job Action Sheets such as Security Branch Director and Labor Pool & Credentialing Unit.

A

4.  D

The hospital describes, in writing, how it will oversee the performance of volunteer practitioners who are not licensed independent practitioners who are assigned disaster responsibilities (for example, by direct observation, mentoring, or medical record review).

HICS System: Most checklists in binders and Job Action Sheets instruct hospital staff to “observe all staff and volunteers for signs of stress and inappropriate behavior.”

A  3

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 (for example, a driver’s license or passport) and one of the following:

-        A current picture identification card from a hospital 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).

-        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 hospital or group.

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

-        disaster circumstances.

-        Confirmation by hospital staff with personal knowledge of the volunteer practitioner’s ability to act as a qualified practitioner during a disaster.

Insert hospital’s volunteer screening policy statement into HICS System staff binders and Job Action Sheets such as Security Branch Director and Labor Pool & Credentialing Unit.

A

6.

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

HICS System: Most checklists in binders and Job Action Sheets instruct hospital staff to “observe all staff and volunteers for signs of stress and inappropriate behavior.”

C

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.

Insert hospital’s volunteer expiration policy statement into HICS System staff binders and Job Action Sheets such as Security Branch Director and Labor Pool & Credentialing Unit.

C

8.  D

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 immediate emergency situation 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:

-        Reason(s) why it could not be performed within 72 hours of the practitioner’s arrival.

-        Evidence of the volunteer practitioner’s demonstrated ability to continue to provide adequate care, treatment, or services.

-        Evidence of the hospital’s attempt to perform primary source verification as soon as possible.

Insert hospital’s 72-hour volunteer expiration policy statement into HICS System staff binders and Job Action Sheets such as Security Branch Director and Labor Pool & Credentialing Unit.

C

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.

Note: Primary source verification of licensure, certification, or registration is not required if the volunteer practitioner has not provided care, treatment, or services under his or her assigned disaster responsibilities.

Insert hospital’s 72-hour volunteer expiration policy statement into HICS System staff binders and Job Action Sheets such as Security Branch Director and Labor Pool & Credentialing Unit.

EM.03.01.01

The [organization] evaluates the effectiveness of its emergency management planning activities.


A

1.  D

The hospital conducts an annual review of its risks, hazards, and potential emergencies as defined in its hazard vulnerability analysis. The findings of this review are documented. (See also EM.01.01.01, EPs 2 and 4)

HICS System: Use the INCIDENT RESPONSE GUIDE and Hazard-Specific Reminders as planning tools.

A

2.  D

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

HICS System: Use the INCIDENT RESPONSE GUIDE and Hazard-Specific Reminders as planning tools. Insert the findings into the HICS System binder for Incident Commander.

A

3.  D

The hospital conducts an annual review of its inventory process. The findings of this review are documented.


EM.03.01.01


The [organization] evaluates the effectiveness of its Emergency Operations Plan.



A

1.

As an emergency response exercise, the hospital activates its Emergency Operations Plan twice a year at each site included in the Plan.

Note 1: If the hospital activates its Plan in response to one or more actual emergencies, these emergencies can serve in place of emergency response exercises.

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.

Note 3: Tabletop sessions, though useful, are not acceptable substitutes for these exercises.

Footnote: The Life Safety Code is published by the National Fire Protection Association. Refer to NFPA 101-2000 for occupancy Classifications

Activate the Hospital Command Center using the HICS System Kit.

A

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.

Note 1: Tabletop sessions, though useful, cannot serve for this portion of the exercise.

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.

The hospital must conduct its own patient surge drills.

A

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.

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.

Note 2: Tabletop sessions are acceptable in meeting the community portion of this exercise.

Although not included with the HICS System, our HICS-X Chemical exercise product involves a mass casualty scenario with escalating “worried well” patients presenting at the hospital.

A

4.

For each site of the hospital with a defined role in its community’s response plan, at least one of the two 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, EPs 2 and 3.

Note 2: Tabletop sessions are acceptable in meeting the community portion of this exercise.

Hospital to participate in the local government’s Emergency Operations Center (EOC) functional 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. (See also EM.02.01.01, EP 2)

Although not included with the HICS System, our HICS-X Chemical exercise product involves a mass casualty scenario with emphasis on staff ability to display the situation and to prepare reports and instructions.

A

6.

The hospital designates an individual(s) 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 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.

Although not included with the HICS System, our HICS-X Chemical exercise product provides instructions and a Master Scenario Events List (MSEL) for evaluators.

A

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.

HICS System: Wall Displays organize hospital resource status for all Hospital Command Center staff.

A

8.

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

HICS System: Wall Displays organize hospital resource status for all Hospital Command Center staff.

A

9.

During emergency response exercises, the hospital monitors its management of safety and security.

HICS System: Wall Displays organize hospital resource status for all Hospital Command Center staff.

A

10.

During emergency response exercises, the hospital monitors its management of staff roles and responsibilities.

HICS System: Wall Displays organize hospital resource status for all Hospital Command Center staff.

A

11.

During emergency response exercises, the hospital monitors its management of utility systems.

HICS System: Wall Displays organize hospital resource status for all Hospital Command Center staff; Job Action Sheets for Power/Lighting Unit, Water/Sewer Unit, HVAC Unit, Damage Unit, Medical Gases Unit and Environmental Services Unit binder for INFRASTRUCTURE BRANCH DIRECTOR include checklists for monitoring utilities.

A

12.

During emergency response exercises, the hospital monitors its management of patient clinical and support care activities.

HICS System: Wall Displays organize hospital resource status for all Hospital Command Center staff; Job Action Sheets for Inpatient Unit, Outpatient Unit, Casualty Care Unit Mental Health Unit, Clinical Support Services Unit and Patient Registration Unit in the binder for MEDICAL CARE BRANCH DIRECTOR includes checklists for monitoring patient management.

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).

This is part of each hospital’s policy for exercise after-action evaluation reports and for improvement.

A

14.  D

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

This is part of each hospital’s policy for exercise after-action evaluation reports and for improvement.

The HICS System binders provide a logical place to store lessons learned for future use.

A

15.

The deficiencies and opportunities for improvement, identified in the evaluation of all emergency response exercises and all responses to actual emergencies, is communicated to the improvement team responsible for monitoring environment of care issues. (See also EC.04.01.05, EP 3)

This is part of each hospital’s policy for exercise after-action evaluation reports and for improvement.

The HICS System binders provide a logical place to store lessons learned for future use.

A

16.

The hospital modifies its Emergency Operations Plan based on its evaluations of emergency response exercises and responses to actual emergencies.

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

This is part of each hospital’s policy for exercise after-action evaluation reports and for improvement.

The HICS System binders provide a logical place to store lessons learned for future use.

A

17.

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

This is part of each hospital’s policy for exercise after-action evaluation reports and for improvement.

The HICS System binders provide a logical place to store lessons learned for future use.