Hospital Emergency Operations Plan Workshop Updating the Hospital and Rural Medical Center EOP for the Use of Volunteer

1. Hospital Emergency Operations Plan WorkshopUpdating the Hospital and Rural Medical Center EOP for the Use of Volunteers in Medical Surge Purpose of the Workshop is to begin the process of refining the Hospital EOP in light of: New building New organizational changes/responsibilities (basically MORE) New collaboration/coordination effortsPurpose of the Workshop is to begin the process of refining the Hospital EOP in light of: New building New organizational changes/responsibilities (basically MORE) New collaboration/coordination efforts

2. Acknowledgements: This workshop was developed by the Mesa County Health Department as part of the National Association of City and County Health Officials (NACCHO) Advanced Practice Centers (APC) Program (Blueprint Project.) It takes into account new information in light of: Emergency Support Function 8 (ESF8) Planning; Homeland Security Exercise and Evaluation Program (HSEEP); Hospital Incident Command System (HICS); and National Health Security Strategy (NHSS). California Emergency Medical Services Authority�s Clinic Emergency Preparedness Project is acknowledged for providing a framework from which a Hospital Emergency Operations Plan template could be created. Contributions of Family Health West Hospital, Fruita, Colorado in the review and revision of this information. Blueprint project- focus is reaching standardized and easily implemented Volunteer management plan for rural hospitals Coordinated efforts with ESF8 have identified gaps in community planning and part of this project will help address those. Community Clinic and Health Center Emergency Operations Plan Template and tools were useful in addressing preparation and planning for similar �level of care� issues that CAH�s and rural hospitals would address. <Agency Name> for participation in this project which will benefit <Agency Name> operations, planning, and also MRC integration into healthcare response.Blueprint project- focus is reaching standardized and easily implemented Volunteer management plan for rural hospitals Coordinated efforts with ESF8 have identified gaps in community planning and part of this project will help address those. Community Clinic and Health Center Emergency Operations Plan Template and tools were useful in addressing preparation and planning for similar �level of care� issues that CAH�s and rural hospitals would address. <Agency Name> for participation in this project which will benefit <Agency Name> operations, planning, and also MRC integration into healthcare response.

3. Objectives Participants will understand the importance and process needed for All Hazard emergency operations planning in Hospitals. Participants will understand the phases of Emergency Management. Participants will understand how an incident command leadership structure is an integrated component of the Hospital emergency operations planning . Participants will understand the major components needed to write an effective hospital emergency operations plan. Participants will understand why volunteer use in medical surge is critical to writing an effective plan for rural hospitals.

4. Why is this an issue today? Terrorism Disasters Other What keeps you awake at night? What often happens? What are you unprepared for? What can be done to plan for these situations? Application of regs should be straightforward for first receivers due to their increased risk�or is it? These ground zero firefighters are being exposed to a broad range of toxins even though they are in an open air environment, but the limitations of SCBA generally mean that outside a confined space, they are not used, despite continued smoke and particulate exposure. Few fire companies carry dust/mist masks or PAPRs which could be used for longer durations. Joint Commission, Centers for Medicare and Medicaid Services, (CMS), and Public Health Emergency Preparedness requirements are all similar in an effort to reduce redundancy, increase uniformity in compliance, and increase efficiency in management of resources and facilities. Public perceptions that healthcare organizations are �prepared� as a result of Homeland Security funding, multi-agency partnerships, and increased levels of expectations due to increased public awareness have resulted in a sense of �entitlement� on the part of the public. Individuals feel that they are entitled to an immediate response and a higher level of care in extreme situations simply because it is an emergency. One only has to look at the frustration with the timeliness of vaccine delivery during H1N1 to see this.Application of regs should be straightforward for first receivers due to their increased risk�or is it? These ground zero firefighters are being exposed to a broad range of toxins even though they are in an open air environment, but the limitations of SCBA generally mean that outside a confined space, they are not used, despite continued smoke and particulate exposure. Few fire companies carry dust/mist masks or PAPRs which could be used for longer durations. Joint Commission, Centers for Medicare and Medicaid Services, (CMS), and Public Health Emergency Preparedness requirements are all similar in an effort to reduce redundancy, increase uniformity in compliance, and increase efficiency in management of resources and facilities. Public perceptions that healthcare organizations are �prepared� as a result of Homeland Security funding, multi-agency partnerships, and increased levels of expectations due to increased public awareness have resulted in a sense of �entitlement� on the part of the public. Individuals feel that they are entitled to an immediate response and a higher level of care in extreme situations simply because it is an emergency. One only has to look at the frustration with the timeliness of vaccine delivery during H1N1 to see this.

5. How does terrorism/disasters affect the healthcare system? Produces mass casualties Murrah Building in Oklahoma City Suicide bombers in Middle East Olympic Park Bombing in Atlanta Twin Towers in New York Hurricane Katrina Virginia Tech School Shooting Mexican Hat, Utah Bus rollover

6. How does terrorism/disasters affect the healthcare system? Produces a redirection of resources and change in preparedness activities Smallpox planning for hospitals and health departments H1N1 Strategic National Stockpile (SNS) � vaccines and drug caches, mass dispensing plans Surge capacity planning Agro-chemical/oil and gas chemical regulatory compliance issues

7. Haven�t we done this before? Pre-1950�s �Civil Defense� Era. �Fire Protection� Era (1960�s-1970�s) �Disaster� Planning Era (1970�s) Emergency response for hospitals used to mean a disaster plan, fire plan, utility failure plan. Current (post- 9-11) all-hazards expectations (public/partners): community integration, address all aspects of patient care issues, records and data tracking/security, supply status tracking, surge resource tracking. Result: more complex planning due to a more complex response.

8. Hospital planning & preparedness County Mass Casualty Plan Surge capacity planning (H1N1) Aligns with EOP plans at city/county level NIMS/ICS compliance Homeland Security compliance funding HPP deliverables LPHA grants and deliverables What factors seem to be affecting (dictating?) planning and preparedness activities? Mass Casualty Plan! Do the plans reflect the facilities and individuals in the community? Has a EMS transportation plan been exercised since a new facility was built. Have physicians been �scrambled� to figure out where they�d go in an emergency? And who would scramble Whom? Surge capacity during H1N1� staffing was already in short supply. How can we plan NOW for Volunteer deployment? Respiratory Therapists and those that were contracted were in great demand! ALL Plans are being structured at the city/county level to encourage ESF8 alignment and integration- Family Health West needs to integrate ESF8 Plan activation as well. NIMS/ICS incorporated planning and response has become a REQUIREMENT for all agencies receiving federal funding and reimbursement. Department of Homeland Security has required all grantees to comply with federal NRF guidelines and HSEEP guidance. The Federal HHS Assistant Secretary of Preparedness and Response (ASPR), Hospital Preparedness Program (HPP) requires NIMS/ICS, HSEEP, and EOP planning to incorporate recent changes and concepts. Local Public Health Agency (LPHA) deliverables and special grants (H1N1) require community benefit, integration, and partnerships. What factors seem to be affecting (dictating?) planning and preparedness activities? Mass Casualty Plan! Do the plans reflect the facilities and individuals in the community? Has a EMS transportation plan been exercised since a new facility was built. Have physicians been �scrambled� to figure out where they�d go in an emergency? And who would scramble Whom? Surge capacity during H1N1� staffing was already in short supply. How can we plan NOW for Volunteer deployment? Respiratory Therapists and those that were contracted were in great demand! ALL Plans are being structured at the city/county level to encourage ESF8 alignment and integration- Family Health West needs to integrate ESF8 Plan activation as well. NIMS/ICS incorporated planning and response has become a REQUIREMENT for all agencies receiving federal funding and reimbursement. Department of Homeland Security has required all grantees to comply with federal NRF guidelines and HSEEP guidance. The Federal HHS Assistant Secretary of Preparedness and Response (ASPR), Hospital Preparedness Program (HPP) requires NIMS/ICS, HSEEP, and EOP planning to incorporate recent changes and concepts. Local Public Health Agency (LPHA) deliverables and special grants (H1N1) require community benefit, integration, and partnerships.

9. Hospital planning & preparedness State Hospital Associations: Emergency planning, HSEEP , state-level hospital coordination systems. �9-11� and heightened expectations for increased integration in surge capacity and response. Tendency towards credentialing and accreditation: Credentialing for surge staff/volunteers National trends toward accreditation: schools and health departments. What will be the future relationship between CMS-CoP�s and Joint Commission Standards? State Hospital Associations have been leading (due to grant funding themselves) initiatives aimed at emergency preparedness. We�ve already talked about the �entitlement� that the public feels to have emergency services at their disposal. Increasing our capacity/capability is crucial to a facilities success. Medical Reserve Corps can augment and provide surge staffing, and operations support. Medical supply warehouses/caches are an extension of supply coordination- resource even though they don�t plan. State Hospital Associations have been leading (due to grant funding themselves) initiatives aimed at emergency preparedness. We�ve already talked about the �entitlement� that the public feels to have emergency services at their disposal. Increasing our capacity/capability is crucial to a facilities success. Medical Reserve Corps can augment and provide surge staffing, and operations support. Medical supply warehouses/caches are an extension of supply coordination- resource even though they don�t plan.

10. Chemical incidents � planning considerations What measures must be planned in advance to safely evacuate/ treat patients contaminated with toxic chemicals? Does your hospital have the capability to decontaminate? What antidote medications might be important if a chemical terrorist attack occurred? These types of �scenarios� point out a couple of key terms: Go to next slide!These types of �scenarios� point out a couple of key terms: Go to next slide!

11. Definitions Capacity: amount or availability of resources and ability of staff, training, and depth. Capability: type of services in terms of emergencies, partnerships, and readiness. Vulnerability: susceptibility to failure due to inadequate resources, training, equipment, or planning. The goal is to decrease vulnerability. Readiness/Preparedness: a direct result of the adequacy of planning and the potential of those plans to create results in the area of training and resources.

12. What is an incident? Any event that overwhelms existing resources to deal with that event. Weather � tornadoes, flooding, severe storms Terrorism Infrastructure failures affecting operations for a prolonged period Hazardous materials incident Large volume of patients Pandemic

13. Incident implications Transportation Electrical Telephone Water Fuel Structural Communications

14. Incident implications Incidents restrict and overwhelm resources, communications, transportation and utilities. Individuals and communities are cut off from the outside support. While being cut off from outside support seems unlikey� scenarios do exist which will require a higher level of coordination (evacuation) or a higher level of support (water failure.) The likelihood of increased staff support is slim given rural hospitals relative lack of surge staff with necessary training.While being cut off from outside support seems unlikey� scenarios do exist which will require a higher level of coordination (evacuation) or a higher level of support (water failure.) The likelihood of increased staff support is slim given rural hospitals relative lack of surge staff with necessary training.

15. What is your goal in an incident? RESPONSE � manage victims (treat, triage, transfer, disposition). RECOVERY � operational, financial, and return to �normal� operations. Response and Recovery have their own categories of issues: Federal/state support FEMA support �Disaster� funds Mutual Aid Response and Recovery have their own categories of issues: Federal/state support FEMA support �Disaster� funds Mutual Aid

16. All Hazards approach to planning A conceptual framework for organizing and managing emergency protection efforts. The core idea here is that Hospitals are part of an integrated plan for response involving a variety of Public/private partnerships. The label of ESF8 adequately describes the functional elements but relies heavily on a deeper understanding of what ESF8 is and how it functions in partnership with the member organizations. (Medical Reserve Corps, Red Cross, Hospitals, Emergency Medical Systems, Dispatch, etc�) The core idea here is that Hospitals are part of an integrated plan for response involving a variety of Public/private partnerships. The label of ESF8 adequately describes the functional elements but relies heavily on a deeper understanding of what ESF8 is and how it functions in partnership with the member organizations. (Medical Reserve Corps, Red Cross, Hospitals, Emergency Medical Systems, Dispatch, etc�)

17. Who is involved in All Hazard response efforts? Federal Tribal State Local Emergency Management Public Works Fire/Rescue EMS Hospitals Public Health During many incidents the �lead� for ESF8 is public health. The close partnership between the Local Public Health Agency and the hospitals in their county crucial factor in determining the effectiveness and efficiency of the response and the success of the recovery effort. During many incidents the �lead� for ESF8 is public health. The close partnership between the Local Public Health Agency and the hospitals in their county crucial factor in determining the effectiveness and efficiency of the response and the success of the recovery effort.

18. All Hazard steps Planning Training Exercising Policies & procedures Resource requirements Resource upgrade Emergency Operations Plan development through each of these aspects, and the manner in which other response agencies and the level of preparation of the volunteers will affect the success of the implementation of the Plan. Emergency Operations Plan development through each of these aspects, and the manner in which other response agencies and the level of preparation of the volunteers will affect the success of the implementation of the Plan.

19. Major Incident Operations Disruption of normal process of health care delivery Displacement of day-to-day patient management of casualties Distraction of health care providers from usual workflow Addition of mental health burden Disruption of supply chain Disruption of communication systems Fiscal disruption Goal is to adequately plan, train, and prepare for a volunteer workforce to mitigate the effects of each of these. Pre-identify trained and credentialed volunteers. Identify areas of patient management/patient management support. Maintain workflow AND additional duties through Just-in-time training (JITT.) Decrease mental stress that comes with multi-tasking. Identify duties that can be delegated. Create a routine. Facilitate supply processes during surge and support those with volunteer support. Add volunteers to support communication between integrated response agencies. Minimize the fiscal effects of increase staff by utilizing volunteers. Goal is to adequately plan, train, and prepare for a volunteer workforce to mitigate the effects of each of these. Pre-identify trained and credentialed volunteers. Identify areas of patient management/patient management support. Maintain workflow AND additional duties through Just-in-time training (JITT.) Decrease mental stress that comes with multi-tasking. Identify duties that can be delegated. Create a routine. Facilitate supply processes during surge and support those with volunteer support. Add volunteers to support communication between integrated response agencies. Minimize the fiscal effects of increase staff by utilizing volunteers.

20. Emergency Operations Plan Introduction Procedures & Operations HICS Job Action Sheets Specific Departmental Tools Forms/Resources General Discussion of past/previous plans and what led up to these revisions.General Discussion of past/previous plans and what led up to these revisions.

21. Emergency Operations Plan-Part 1 Introduction General overview of <Hospital Name> and facilities/support. Purpose/Policy Provide continuous quality improvement. Provide coordination and integration. Scope Addresses Joint Commission and CMS Conditions of Participation (CoPs.) These are simply general information and declarative statements regarding the compliance aspects of the plan and the objectives regarding what the plan is meant to explain/do.These are simply general information and declarative statements regarding the compliance aspects of the plan and the objectives regarding what the plan is meant to explain/do.

22. All Hazards Emergency Operations Mitigation: Removing/lessening the conditions that lead to incidents. Preparedness Readiness for the unavoidable. Response Decreasing the severity/intensity of an incident. Recovery Getting back to normal.

23. Mitigation Hospital Hazard Vulnerability Analysis (HVA) Multiple Tools Available

26. Mitigation Hazard identification Hazard Assessment (HVA) Structural code compliance Equipment and maintenance Hospital Vulnerability Analysis (HVA) � Appendix D.1 Risk Assessment � Appendix D.2 Hazard Mitigation- D.3 Roles/Responsibilities (Appendix E) Hospital Vulnerability Analysis (HVA) � Appendix D.1 Risk Assessment � Appendix D.2 Hazard Mitigation- D.3 Roles/Responsibilities (Appendix E)

27. Preparedness Plan development Training courses Exercises Employee education and competencies Public education An EOP that �hits all the marks� Aligned with HICS/NIMS HSEEP documented ESF8 Plan Integrated with ESF8 and exercised with ESF8 organizations Joint Exercises/Training Based on Training and Exercise Plan Workshop (TEPW)- See HSEEP materials for more information. Based on HVA- annually updated Involves a higher level of awareness in communityAn EOP that �hits all the marks� Aligned with HICS/NIMS HSEEP documented ESF8 Plan Integrated with ESF8 and exercised with ESF8 organizations Joint Exercises/Training Based on Training and Exercise Plan Workshop (TEPW)- See HSEEP materials for more information. Based on HVA- annually updated Involves a higher level of awareness in community

28. Response Alerting Assessment Mobilizing- Healthcare partners and ESF8 Implementing plan Activate systems (HICS, EOC) Control, Set priorities-Infection etc. Communication and situational awareness Section 3- Response, H.1 Emergency Procedures ICS structure? Who/Where? EOC? Backup EOC? Medical Care/Medical Information Communication can mean MANY MANY things- public, media, patients, family, staff�.. These sections really need their own training. Section 3- Response, H.1 Emergency Procedures ICS structure? Who/Where? EOC? Backup EOC? Medical Care/Medical Information Communication can mean MANY MANY things- public, media, patients, family, staff�.. These sections really need their own training.

29. Recovery Those activities undertaken by a hospital after an emergency or disaster occurs to restore minimum services and move towards long-term restoration. Work done during the response that HAS NOT been effectively structured or organized will be less likely to recover successfully and less likely to be able to be tracked for cost recovery and reimbursement. Work done during the response that HAS NOT been effectively structured or organized will be less likely to recover successfully and less likely to be able to be tracked for cost recovery and reimbursement.

30. Recovery Return to �normal� Detailed damage assessment Care and shelter continues Funding assistance Remove debris

31. Part 2- Specific procedures & operations Patient Flow Triage Treatment Areas Security Activities Entry & Egress Visitors Access

32. Procedures & operations Communications Telephone Back-up systems Radio (VHF/800) Satellite phone Walkie � Talkies HAM radio Fax

33. Procedures & operations Patient admissions, triage, disaster tags, registration process Elective procedures Discharge of patients

34. Procedures & operations News Media Public Information Officer (PIO) Strategic location Joint Information Center (JIC)

35. Procedures & operations Hotline Family of victims, visitors, outpatients

36. Procedures & operations Supplies & equipment Essential supplies Pharmaceuticals Medical supplies Equipment Food Water Linen Utilities

37. Procedures & operations Morgue DOAs Others that expire

38. Procedures & operations Evacuation Authority Transportation Location Evacuation routes Practice/Test

39. Procedures & operations Continuing and/or reestablishing operations Off � site care (Alternate Care Sites, or ACS)

40. Procedures & operations Essential utility alternatives Electrical Water Medical gas Waste disposal Fuel

41. Procedures & operations Isolation & decontamination Plan & procedure Equipment Training

42. Procedures & operations Orientation & education Annual plan evaluation

43. Emergency Operations PlanPart 3- HICS Job Action Sheets

44. HICS Job Action sheets Incident Command Operations Logistics Finance and Administration Planning Others

45. HICS Job Action sheets One for each position. Embodies title, mission/function and duties. Adjusted to meet hospital needs.

46. Emergency Operations PlanPart 4 Specific department tools

47. Specific departmental plans Emergency Department Security Maintenance Nursing floors Admission policy & registration Emergency triage Evacuation Communications Emergency Operations Center What is needed? What are Critical Response Tools that ALREADY exsist but have not been incorporated? What is the review/revision schedule and who is involved?What is needed? What are Critical Response Tools that ALREADY exsist but have not been incorporated? What is the review/revision schedule and who is involved?

48. Emergency Operations PlanPart 5-forms/resources

49. Forms/Resources Help drive positions Documentation aid Financial recovery Decreases liability Enhances & tracks communication

50. Emergency Management A successful interface needs: Planning Training Exercising

51. According to Joint Commission1: Emergency Management is now its own accreditation manual chapter. All Standards and Elements of Performance from 2009 are incorporated into the 2010 Emergency Management chapter. This new chapter contains some standards that were in HR, EC and MS sections. Critical Access Hospital requirements are similar to other types of hospitals in most counties.

52. Emergency Operations Plan Emergency Operations Plan (EOP) describes response procedures: Written plan Capabilities to self-sustain for up to 96 hours [EM.02.01.01] As well as Recovery strategies and surge capabilities. Initiation and termination of response and recovery phases. Defines authorities and community relationships Alternative care sites, alternate EOC. Actual implementation is documented.

53. Emergency Operations Plan Plan Structure Has the basic structure of most �planning� documents with a Basic Plan, Plan Appendices, Annexes, and Attachments.Has the basic structure of most �planning� documents with a Basic Plan, Plan Appendices, Annexes, and Attachments.

54. Emergency Operations Plan Addresses Twelve Critical Access Hospital Joint Commission Components: Planning [EM.01.01.01] The EOP [EM.02.01.01] Communication [EM.02.02.01] Resources & Assets [EM.02.02.03] Safety & Security [EM.02.02.05] Staff responsibilities [EM.02.02.07] Utilities Management [EM.02.02.09] Patient, clinical & support activities [EM.02.02.11] Volunteer Management [EM.02.02.13] Volunteer Credentialing [EM.02.02.15] HVA and Evaluation [EM.03.01.01] Plan Evaluation [EM.03.01.03]

55. Emergency Operations Plan EM.01.01.01 Planning (8 measures) The critical access hospital engages in planning activities prior to developing its written Emergency Operations Plan. EM.02.01.01 The Plan (8 measures) The critical access hospital has an Emergency Operations Plan. EM.02.02.01 Communication (15 measures) As part of its Emergency Operations Plan, the critical access hospital prepares for how it will communicate during emergencies. EM.02.02.03 Resources & Assets (9 measures) As part of its Emergency Operations Plan, the critical access hospital prepares for how it will manage resources and assets during emergencies.

56. Emergency Operations Plan EM.02.02.05 Safety and Security (9 measures) As part of its Emergency Operations Plan, the critical access hospital prepares for how it will manage security and safety during an emergency. EM.02.02.07 Staff Responsibilities (9 measures) As part of its Emergency Operations Plan, the critical access hospital prepares for how it will manage staff during an emergency. EM.02.02.09 Utilities Management (7 measures) As part of its Emergency Operations Plan, the critical access hospital prepares for how it will manage utilities during an emergency. EM.02.02.11 Patient, clinical & support activities (8 measures) As part of its Emergency Operations Plan, the critical access hospital prepares for how it will manage patients during emergencies.

57. Emergency Operations Plan EM.02.02.13 Volunteer Management (9 measures) During disasters, the critical access hospital may grant disaster privileges to volunteer licensed independent practitioners. EM.02.02.15 Volunteer Credentialing (9 measures) During disasters, the critical access 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. EM.03.01.01 Vulnerability Assessment and Evaluation (3 measures) The critical access hospital evaluates the effectiveness of its emergency management planning activities. EM.03.01.03 Evaluating the Plan (17 measures) The critical access hospital evaluates the effectiveness of its Emergency Operations Plan.

58. Use of volunteers in medical surge 18 Elements of Performance (EP�s) of Joint Commission Standards address use of volunteers. Medical Surge exercises that are HSEEP-compliant must address the use of volunteers in surge activities. How deep is your hospital in each staff skill area? By department? Supervisor? Facility? Occupation? Specialty?

59. For Volunteer Licensed Independent Practitioners and Volunteer Practitioners Section 1: Disaster Privileges Section 2: Credentials Verification Section 3: Volunteer Oversight Section 4: Cessation of Volunteers

60. Use of volunteers What can they do? What can�t they do, unless supervised? What shouldn�t they do? Who can they be? Can spontaneous unassigned volunteers (�SUVs�) be used? What are the most likely scenarios? Who can and cannot supervise volunteers?

61. Review: The Emergency Operations Plan Covers all of the All Hazards phases of Emergency Management Mitigation Planning Response Recovery As well as communications with ESF8 partners

62. Where do I start? <Hospital Name> has: Emergency Operations Plan (a base plan to start with). Departmental Plans (ED, Triage, Admissions, Evacuation, Security. Email <hospital point of contact> to receive the plans electronically.

64. Center for HICS Education & Training- www.hicscenter.org Guidebook Training Resources Job Action Sheets Forms Internal (13) & External (14) Scenarios