Title: Policy on Emergency Management Exercises
Effective Date: / Reviewed : / Revised: /Function: Environment of Care
POLICY
The Facility Nameshall test its emergency plans during exercises and/or actual event, and critique the responses to determine deficiencies and opportunities for improvement.
PROCEDURE
The Facility Namewill test its Emergency Operations Plan (EOP) at least twice a year, either in response to an actual emergency or in a planned exercise. At least one drill or actual event requiring activation of an emergency response plan will be documented and critiqued in each freestanding primary care clinic. Tabletop sessions, though useful, are not acceptable substitutes for exercises.
At least one of the exercisesper year will include participating in at least one communitywide exercise. This exercise can be conducted concurrently with an exercise involving an influx of patients.
At least one of the exercisesper year will include an influx of actual or simulated patients.
The following is a method for conducting an exercise:
The Facility Namewill test its emergency management plan involving the influx of patients that will “stress” the emergency capacity of the organization
This exercise can be in response to an actual emergency or in a planned exercise.
Tabletop sessions are acceptable in testing the response to an influx of patients, but will not satisfy the requirement for the two exercises per year.
The exercise scenarios will be realistic and related to the priority emergencies identified in the hospital’s Hazard Vulnerability Analysis (HVA) involving an influx of patients.
The Facility Namewill test its emergency plansto “stress” the assets and resources that are currently available to facility. Tabletop sessions are acceptable in testing the community response requirement.
- This exercise can be a planned exercise or tabletop session.
- This exercise could also be immediately after an exercise as a tabletop session before the after action debriefing.
- The assets and resources that have been evaluated through the Inventory of Assets should be used in evaluation on their sustainability over a period of 72-96 hours. The exercise or tabletop does not need to continue for those hours or the command center expected to continue operations for 3 to 4 days. The process of discussion should extend to using those assets and resources as hypothetical for those hours.
- This exercise should not account for local, state, or federal emergency management assistance, or response from other healthcare organizations.
- This exercise should account for in-stock assets, warehoused stock under the facilities control and/or corporate assets warehoused for Facility Name.
- The hospital’s ability to adapt to an escalation of events during a single disaster scenario will be tested and evaluated.
During the planned exercises, the Safety Officer, Emergency Preparedness Coordinator, etc> or designee will appoint an individual, whose sole responsibility will be to monitor the performance of the exercise. This individual will be knowledgeable in the goals and expectations of the exercise and will critique the exercise to document the opportunities for improvement. The monitors will evaluate the exercise to identify deficiencies and opportunities for improvement based upon monitoring the activities and observations during the exercise.
The following performance items will be evaluated:
Communication, including the effectiveness of communication both within the hospital as well as with emergency groups outside of the hospital, such as local governmental leadership, police, fire, public health, and other healthcare organizations within the community.
Resource mobilization and allocation, including responders, equipment, supplies, personal protective equipment, transportation, and security personnel.
Safety and Security, including patients, staff, visitors, perimeter, and access entry control.
Staff Roles and Responsibilities, including adaptation to disaster role and responsibility and wearing of identification.
Patient management, including provision of both clinical and support care activities, processes related to triage activities, and patient identification and tracking processes.
Utilities,including the interruption of services and supplies.
All exercises are critiqued to identify deficiencies and opportunities for improvement based upon monitoring the activities and observations during the exercise. Completed exercises will be critiqued through a multi-disciplinary process that includes administration, clinical (including physicians), and support staff.
The hospital will modify the Emergency Operations and Response Plans, based on the critiques of exercises and implement improvements to the appropriate plans, if applicable. If the improvements require resources that are not currently available for the planned exercise, interim improvements will be put in place until final the resources do become available and changes are included in the Plans.
Improvements/revisions made to the plan will be retested and critiqued for effectiveness at the next scheduled drill.
The strengths and weaknesses identified during exercises will be communicated to the Emergency Management Team and Environment of Care Committee for review.
EM.03.01.03 EP 1-17a Policy on Emergency Mgt Exercises.doc