It is the policy of Mahaska Health Partnership to provide excellent healthcare services, a healing environment and community service to the people of its service area. Consistent with this mission, the Board of Directors, medical staff and administration provide ongoing support for the emergency management program described in this plan.
The purpose of the Emergency Management Plan is to provide resources for the continuation of patient care during a variety of emergencies that may disrupt operations at MHP. The plan includes processes designed to provide for the medical needs of patients as a result of a hospital or community-based incident and includes processes to respond effectively to events that pose an immediate danger to the health and safety of patients, staff and visitors.
The emergency management program is designed to assure appropriate staff response to a wide variety of emergency situations. The plan consists of a number of procedures designated to respond to those situations most likely to disrupt the normal operations of the hospital. Each response is designed to assure availability of resources for the continuation of patient care during an emergency. The program is designed to address the emergency response needs of all patient care and business operations of MHP. The Emergency Management Plan applies to MHP and itís affiliated off-campus services.
1.A disaster is defined as a natural or man-made event that significantly disrupts patient care. Effective planning will reduce the impact of emergencies on the quality of patient care and increase the hospitalís ability to continue to provide necessary patient services. This plan ensures effective response to disasters of emergencies affecting the hospitalís environment of care.
A.Internal disaster: A significant event, natural or man-made; occurring within the hospital or on facility grounds significantly disrupting the safety or security of the normal operations of service for patients, staff and visitors.
B.External disaster: A significant event, natural or man-made; occurring within the community or service area that results in an influx of patients into the hospital that disrupts normal operation of services.
2.The MHP Safety Committee has designed and outlined an effective Plan, through identification and evaluation of past organizational and community experiences which prepares MHP for multiple consequences, including but not limited to plans that functionally address like situations and high-risk emergencies. The Plan defines MHP's role in community emergency preparedness efforts, including notification of proper outside emergency agencies and the allocation of resources.
3.The Plan considers hospital facilities, space, personnel, supplies, communications and other resources needed to provide essential services under less than ideal conditions. It considers both on and off-duty staff in determining what staff is needed to maintain essential services.
4.The Plan considers conditions that may require modifications of normal patient care routines including treatment. The conditions may require discontinuation of services, patient transfer, facility evacuation or discharge of patients.
1.GOALS AND OBJECTIVES
A.The Safety Committee will conduct two drills annually for the purpose of maintaining staff awareness of emergency procedures and for evaluating the effectiveness of the Plan. The drills are observed, documented and critiqued to identify opportunities for improvement. Actions are taken to address deficiencies and are documented and tested during subsequent drills. Summaries of the activities are presented to the Safety Committee.
B.Conduct an annual evaluation of the objectives, scope, performance and effectiveness of the Emergency Management Plan and report the results to the Safety Committee.
C.A Hazard Vulnerability Assessment (HVA) is completed to assess the impact of likely emergencies. The HVA is used to guide the development of the Emergency Management program. The HVA is reviewed periodically to determine if the likely emergencies have changed.
D.The Plan clearly states the process for initiation and implementation of emergency events. The description includes the command structure for the plan, the conditions requiring activation of the plan, and the individual(s) responsible for implementation of the plan.
E.The Plan includes a current description and organization chart illustrating how the hospitalís disaster command staff will be organized, and will work interactively with the community Emergency Operations Center.
F.The Plan includes a current list of governmental and commercial organizations that must be notified to effectively implement the plan. The list includes the agency or organization name and the telephone or other contact numbers, as available.
G.The Plan includes a list of key staff essential for full implementation of the plan and procedures for contacting the staff. The contact procedure includes on site and remote contact.
H.The Plan includes a description of the methods of identification of care givers, other facility staff, and community responders. Community responders may include law enforcement, fire department, media, volunteer organizations and contractors.
I.The Plan includes a list of the most critical response requirements. A list of on-duty staff that will be assigned (i.e., Job Action Sheets) to the critical response positions is also included in the plan.
J.The Plan includes processes that address support of staff and staff family members. In addition, they include processes for identifying critical supplies and monitoring consumption, a process for metering supplies to maximize response effectiveness, and a process for re-supplying.
K.The Plan includes a plan for horizontal and vertical evacuation of the facility.
L.The Plan includes a list of organizations that the facility can use as alternate care sites.
M.A set of current utility failure response plans is within the Plan.
N.Backup systems for internal and external communications systems are in place.
O.Appropriate facilities for managing biological, chemical, and radioactive isolation and decontamination are in place.
A.The Plan is developed, implemented, monitored and revised by the Safety Committee as needed/required.
B.The Safety Committee and Board of Directors provide support and delegate emergency response accountabilities to the safety officer in the absence of administration.
C.Department directors are responsible for the following:
1)Development, implementation, monitoring and revisions of their department specific emergency management plans as well as training of their staff.
2)Orienting new personnel and, as appropriate, to job and task-specific responsibilities for emergency preparedness.
3)Staff to receive, at a minimum, annual training on department specific and hospital emergency management plans.
4)Documentation of all staff training. Individual personnel are responsible for learning and following job and task-specific procedures for emergency response within their departments.
5)Maintaining a current Disaster Call List of their staff, either by notation of a telephone tree or cascade system. Directors are to route current lists to their staff and to the safety officer for distribution to the Incident Command Center, PBX, and Administration. It is critical the lists be kept current should it be necessary to recall staff or to obtain additional staff to assist with an emergency event.
3.PROCESSES OF THE EMERGENCY MANAGEMENT PLAN
A.Hazard Vulnerability Assessment (HVA)
1)The Safety Committee, with the assistance of others including local emergency response personnel, conducts a HVA of the operations and environment of MHP. The HVA is used to determine conditions or events that are likely to have a significant adverse impact on the health and safety of the patients, staff, and visitors of MHP or on the ability of MHP to conduct normal patient care and business activities. The result of the HVA is a list of significant threat situations and the consequences that would affect the ability of the facility to maintain normal operating conditions.
B.Emergency Response Priority Evaluation
1)The Ambulance Director will work with community emergency response agencies to establish priorities for development of emergency response plans. A prioritization process is used to determine which identified emergencies can be addressed by means of a self-contained procedure and which need to be addressed using a flexible response process. MHP has chosen to use the Incident Command System (ICS) as the basis for the emergency plan determined to require a flexible response.
C.Emergency Response Procedures
The Plan includes policies addressing mitigation, preparation, response and recovery.
1)The mitigation section describes equipment and human activity designed to be put in place beforehand to minimize the impact of an emergency.
2)The preparation section describes the training, supplies, and equipment required to initiate full effective response at the time of an emergency. These preparation descriptions include a list of stand-by supplies and equipment and may require maintenance or inspection.
3)The response section describes the command structure required to manage the plan after initiation, during the emergency situation, and sustaining operations during protracted disruptions.
4)The recovery section describes the processes for moving from the emergency operations back to normal operations, and the process for assessing and implementing a full recovery of the structure and all internal components and systems.
D.Community-wide Response Involvement
1)MHP is part of the Mahaska County/Emergency Operations Center. The group works together with county, city and state planning agencies to define the role each provider will play during an emergency. The role of MHP is to function as an acute medical care facility capable of effectively treating many levels of injury. This role might be reduced if environmental circumstances affect the integrity of the campus or the utility systems essential to providing care.
2)MHP actively participates in the County Emergency Planning Committee. The hospital participates in plans for emergencies, including medical emergencies, and for its role in community-wide disasters.
3)Twice a year, MHP conducts emergency drills, generally including a number of ďvictimsĒ which are used to test the hospitalís mass casualty plan, as well as the EMS triage and transport plans and other agency plans related to a community-wide emergency. Other agencies, such as the Red Cross, local ham radio operators are included in the drills. Post-drill critiques include the activity of the hospital, as well as the other agencies that interface with the hospital during the exercise.
1)MHP has chosen to use the Hospital Emergency Incident Command Structure (HEICS) to manage the implementation of emergency responses and to integrate the facility response with the community and other health care providers. The HEICS model plan is developed to manage emergency responses that have unpredictable elements. These are determined as part of the HVA and priority analysis. Plans that stand alone are designed to allow immediately available staff to effect instant activation and to manage the consequences. Most others are designed to use the ICS for emergency management.
2)A number of minor modifications may be made during the implementation of plans. Changes in the normal use of space and facilities may change. Treatment locations may change. The Incident Command Center location may change. Modifications are tested as part of the normal drill exercises and their use evaluated during the critique of drill or actual event.
G.MHP participates in the County Emergency Planning Committee. The discussions of the group are used to guide the development of the MHP Emergency Management Plan.
1)The emergency management plans clearly state the process for implementation of the plan. The description includes the command structure for the plan, the conditions or criteria requiring activation of the plan, and the individuals responsible for implementation of the plan. The simplest implementation procedure is immediate activation of the response using an equipment-activated alarm for the fire plan or audible announcements for other potential emergency events. More complex response procedures involving setting up a command center and ICS response team are required for most emergencies, including major utility failures and community-based emergencies.
2)The Incident Commander or if an influx of patients is anticipated, the shift supervisor in conjunction with the emergency department physician, will make the determination to implement the emergency management plan. Staff members are notified when emergency plans are activated by the Incident Command Center staff. Internal staff members are notified by PBX operators via a series of coded announcements stated over the audible paging system. If it has been determined staff are to be recalled, activation of the disaster call lists will be given by notification through a coded announcement by either the shift supervisor or the Incident Commander.
I.Notification of Civil Authority
1)Several local agencies may play a role in managing an emergency. MHP maintains a current list of these agencies and key contacts for various kinds of emergency situations. Contacts on the list include police, fire, emergency medical transport, local emergency management offices, and the Red Cross. The Incident Commander or designee notifies agencies as appropriate as soon as possible after an emergency response is initiated.
1)Staff members are notified when emergency plans are activated by the Incident Command Center staff. Internal staff members are notified by PBX operators via a series of coded announcements stated over the audible paging system. If it has been determined staff are to be recalled, activation of the disaster call lists will be given by notification through a coded announcement be either the shift supervisor or the Incident Commander.
2)Staff is notified of plan implementation in several ways. Audible page, telephone or runner notifies staff in the hospital. Telephone trees and pagers are used to notify staff away from the hospital.
1)MHP uses the regular staff identification badge to identify care givers, including physicians, and other employees during mass casualty or major environmental disasters. Everyone coming into the facility needs to have a visible MHP ID badge in order to enter. Staff without IDís must go through Security, be positively identified, and receive a temporary badge or other approved alternate.
L.Staff Coverage of Critical Positions
1)The plan includes processes for the incident commander and departments to communicate to determine staffing needs and to assign available staff to critical responder positions. Some response procedures assign departments or individuals specific roles automatically to assure timely and effective implementation.
2)Where sufficient staff are not available for all roles during an implementation of the plan, the Incident Command Center staff will assure that the most critical jobs are filled with available staff and less critical jobs are filled by staff returning to the facility.
3)Designated staff members are used to extend the security roles during a number of emergency events, primarily to limit access to the hospital buildings and to assist in traffic control as necessary.
4)As appropriate to the time and shift, additional staff members are designated to assist in provision of supplies and materials as requested by Incident Command Center staff and patient care areas.
M.Management of Patient Care Activity
1)The Plan addresses management of patient care activities. It includes procedures for discontinuation of elective treatment, for evaluation of patients for movement to other units, release to home or transfer to other facilities as space is needed, management of information about incoming patients and about current patients for planning, patient management and informing relatives and other; and for transport of patients.
2)Arrangements are made with vendors and other services to assure availability of supplies and materials in a timely fashion. In addition, the local emergency operations center plans provide for provision of some types of mission critical supplies.
3)Release of information to the news media will follow the procedures of the Public Affairs department, who will act as spokes persons for the organization. The incident commander will release information as appropriate to the situation.
4)Security activity is designed to assure coordination with local public safety staff.
1)MHP evacuation plan is in place and can be implemented in phases. Relocation of staff away from the area of emergency may be undertaken by staff on the spot, moving to areas in adjacent zones. A full evacuation would be implemented if the impact of an emergency renders the hospital inoperable or unsafe for occupancy, and would be implemented with the involvement of the Incident Commander or senior leadership available.
O.Alternate Care Sites
1)Alternate care sites are available through MHP transfer/reciprocal agreements with both local and facilities within the state.
2)The Incident Commander and each evacuation coordinator assign appropriate staff to assure required equipment, medication, staffing, communication, and transportation are mobilized to support relocation and management of patients at remote sites.
3)As practical, patients being moved to alternate care facilities will be moved with their patient records and available medications.
1)MHP has recovery plans to return operations to normal functions after most emergencies. The recovery plan is implemented near the completion of the plan activations. The incident commander will determine the degree of activity required. Present activity that is activated by the ďall clearĒ includes action by medical records to capture the records of emergency services, capture of costs by patient billing, and return of facilities to their original and normal use. The plans also call for resetting and recovering emergency equipment and supplies, and documentation of the findings of the after the event debriefing. If substantial damage has been done to the facilities, plans for reconstruction and renovation will be developed at that point.
Q.Alternate Sources of Utility Systems
1)Alternate plans for supply of utilities for patient care are maintained for these contingencies. Plans include use of the emergency power, backup systems for water, fuel for heating and power, HVAC and ventilation systems with alternate power sources.
2)Departments affected by the plans are trained as part of organization wide and department specific education. The plans are tested from time to time as part of the regularly scheduled drills of the emergency management plans and actual outages of utility systems. Plans include the process for obtaining and connecting backup sources for systems or alternatives to those systems.
1)Several alternate communication systems area available for use during emergency responses. The systems include the regular phone system, an emergency phone system, public telephones, two-way radios, and
cellular phones. The implementation of the emergency plan focuses on maintaining vital patient care communications.
2)Once the initial level of the plan is in place, the Information Systems department will work with representatives of the telephone company to determine the scope and likely duration of the outage and to identify alternatives.
3)In the event both the telephone switch and cellular phone availability is down, communications will be provided internally by runners from the reserve labor pool. External communications will be provided by satellite phones and runners.
S.Education and Training
1)Each new staff member of MHP participates in a general orientation program that includes information related the Emergency Management Plan. The Education Department conducts the general orientation program. Records of attendance for staff members who complete the general orientation program are held by the Education Department. New staff members also receive a department specific orientation. Department directors provide new staff members with a department-specific orientation to their role in the Emergency Management program.
2)All staff members of MHP participate at least once each year in a continuing education program (mandatory module). Information specific to Emergency Management is included in the program.
1)The Safety Committee is responsible for coordinating the annual evaluation of the seven functions associated with Management of the Environment of Care. The Ambulance Director is responsible for performing the annual evaluation of the Emergency Management Plan.
2)The annual evaluation examines the objectives, scope, performance, and effectiveness of the Emergency Management program. The annual evaluation uses a variety of information sources including the reports from internal policy and procedure review, incident report summaries, and summaries of other activities. The findings of the annual evaluation are presented in a report supported by relevant data. The report provides a balanced summary of the Emergency Management programís performance over the preceding 12 months. Strengths are noted and deficiencies are evaluated to set goals for the next year or longer term future.
3)The annual evaluation is presented to the Safety Committee who reviews and approves the report.
U.Performance Improvement Management
1)The Safety Committee is responsible for coordinating the performance measurement process for each of the seven EC functions. The Ambulance Director is responsible for the Emergency Management program performance measurement process.
2)The Ambulance Director maintains performance indicators to objectively measure the effectiveness of the Emergency Management Program. The directors responsible for the other six plans, determine appropriate data sources, data collection methods, data collection intervals, analysis techniques and report formats for the performance improvement standards. Personnel, equipment and management performance are evaluated to identify opportunities to improve the Emergency Management program.
3)The Safety Committee report summarizes performance compared to the performance improvement standard. If deficiencies are identified, a plan of action is developed to address the deficiency. The Safety Committee is responsible for evaluating the relevance of performance improvement standards.
4)The performance measurement process is one part of the evaluation of the effectiveness of the Emergency Management program.
|Mahaska Health Partnership, 1229 C Avenue East, Oskaloosa, IA 52577, (641) 673-3431|
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