Disaster Preparedness
The goal of disaster planning is to protect patients, visitors, staff, physical property and financial assets in the event of an emergency situation. Effective disaster planning can help outpatient healthcare facilities maintain order, prevent major service disruption, reduce losses and restore vital facility functions with minimal delay. It may also affect the success of future business continuity for the facility.
Although it may be tempting to postpone analyzing future risks and focus on more immediate concerns, the key to successful disaster management is to plan ahead. Proactive planning by healthcare facilities may help mitigate the following risk exposures, among others:
- Negligence for failing to maintain an up-to-date emergency response plan and/or prepare for emergencies through staff training and simulation exercises.
- Professional liability, when healthcare providers are physically and emotionally exhausted, creating vulnerability to clinical errors.
- Unauthorized scope of practice, when providers transcend legally prescribed practice parameters under the stress of delivering emergency care.
- Breach of privacy and confidentiality for failing to protect patient/resident privacy and confidentiality during emergencies.
- Inappropriate emergency use authorization, when healthcare facilities and providers disregard important conditions related to these temporary issuances.
- Discriminatory allocation of resources, when healthcare settings lack a legitimate process for determining appropriate and reasonable use of limited resources.
- Regulatory violations for failing to comply with federal and state emergency preparedness mandates; accommodate patients/ residents with disabilities, as prescribed by the Americans with Disabilities Act; or permit access to treatment pursuant to the Emergency Medical Treatment and Active Labor Act, among other sources of noncompliance.
- Premises liability, when patients and staff are left to shelter in place despite structural indications for facility evacuation.
Mitigation of risks associated with disaster preparedness extends beyond policy development, requiring a continuous process of review, testing and improvement. This section serves as a tool to help outpatient healthcare facilities and providers develop a range of emergency management initiatives in response to regulatory expectations, industry guidelines and professional risk management recommendations. Because no two facilities or outpatient practice settings are identical, the information included here should be adjusted to the type, size and complexity of a setting or practice. By tailoring risk initiatives to the nature and scope of operations, healthcare settings and providers may respond to a crisis with practical, realistic and efficient measures. For additional information regarding emergency planning and disaster preparedness, please see the CNA Special Resource –
Emergency Planning: A Risk Management Guide for Healthcare Facilities and Providers.
Federal and state statutes provide a degree of immunity to facilities and providers during emergency conditions. However, failure to prepare for crisis situations can nullify those protections. The Centers for Medicare & Medicaid Services (CMS) Emergency Preparedness Rule requires
17 types of healthcare providers, suppliers and facilities to have a written
emergency management plan to guide their response to natural and man-made disasters.
The four basic components of emergency readiness outlined in the CMS regulations will be discussed in this section:
- an annual risk assessment utilizing an “all hazards” approach;
- response-related policies and procedures;
- communication plans; and
- a training program.
This information applies to all types of outpatient healthcare settings, irrespective of whether or not the setting is governed by the CMS regulatory requirements.
Identifying Risks
The first step in preparing for disaster-related risks is to identify and prioritize potential foreseeable events, both man-made (e.g., active shooter, violent crime, sabotage, arson, riots, terrorism and contamination) and weather-related (e .g ., hurricanes, tornadoes, wildfires, floods and blizzards). A team-based, systematic approach to conducting a gap analysis will broaden the scope of the assessment and provide a comprehensive risk analysis.
Quantifying Risks
After identifying potential sources of loss, the next step is to quantify the hazard posed by specific events. This process involves ascertaining the likelihood (frequency) of an occurrence against its potential impact (severity). It may be determined that it is no longer safe to shelter in place, and an evacuation is required. Use of a risk matrix, such as the widely recognized
Kaiser Permanente HVA tool, enables the crisis management team to identify exposures and prioritize resources.
Gauging the probability and potential impact of an event requires a clear understanding of the vulnerabilities of the facility, as well the environment in which it operates. This evaluation involves reviewing the loss history, as well as consulting with local emergency management agencies and first responders, government and private agencies, and other external authorities.
It also involves knowing the available backup processes, systems and equipment in the event of an emergency, including power sources and other utilities.
Creating a Response Plan
After immediate risks have been identified and evaluated, the next step is to develop a response plan. An emergency response plan should be based upon the results of the risk assessment and incorporate disaster response and recovery protocols. The plan should be specific and include the titles of the individuals assigned to tasks. When designing the response plan, request input and active involvement of local authorities and first responders, as partnerships formed during the planning and drafting phases can become useful during an actual emergency.
The following tasks, among others, should be addressed in the emergency response plan:
- Emergency notification
- Incident command
- Media relations
- Crisis staffing
- Phone contact procedures
- Resource procurement
- Healthcare information record maintenance
- Care site establishment
- Bed utilization
- Surge capacity/diversion
- Shelter availability
- Evacuation and patient tracking
- Transfer arrangements
- Child care for staff
- Mortuary services
- Supply chain management
- Utility outages
The plan should include detailed instructions for managing outages involving critical systems, such as electricity, IT, natural gas, water, sewage and ventilation/heating/air conditioning. The
National Fire Prevention Association (NFPA) Standard 110 outlines performance requirements for emergency and standby power systems in healthcare settings, including weekly and monthly inspections of emergency generator systems.
During times of crisis, supply chain operations can be adversely affected by inefficient distribution networks, inadequate inventory space, outdated manual processes and data systems that cannot track real-time supply levels, among other deficiencies. As part of the emergency management planning process, measures should be taken to help prevent or mitigate shortages and supply chain breakdowns that may adversely affect patient care and safety.
Policies and Procedures
Policies and procedures should reflect the emergency response plan and include steps for designating a command center, establishing communication procedures, maintaining security, and developing patient evacuation and tracking protocols, as well as drafting measures to safeguard the healthcare information record.
Chain of Command and Communication
If disaster strikes, staff must know who is in charge. Effective emergency preparedness requires a clear chain of command that extends from senior leadership to every level of staff. By creating an incident command center, healthcare facilities and office practices can ensure that necessary tasks – such as information gathering, staff coordination and debriefing – are completed in a prompt and efficient manner.
Whether an emergency requires evacuating a setting, initiating a lockdown, diverting patients or establishing a controlled external perimeter, promptness, clarity and accuracy of communication is critical to maximizing safety and minimizing loss.
The following guidelines can minimize confusion during and immediately following an emergency situation:
- Designate a disaster coordinator, who has responsibility for declaring the disaster, mobilizing the response and keeping everyone informed.
- Clearly define roles and duties of staff members, including contacting government agencies, neighboring healthcare facilities, emergency aid providers and other outside entities.
- Maintain a list of providers and staff, by title, in the chain of command that are to be contacted in case of an emergency, and post the list in strategic locations.
- Develop a system to track all patients, staff and visitors who may have been in the facility at the time of the disaster.
- Arrange an alternative means of communicating information to key internal and external audiences, such as cellular telephone “trees,” electronic mail “blasts,” text messaging, online portals, satellite telephones and two-way radios.
- Develop a listing of preferred vendors and alternative suppliers that details their contact information, including primary and emergency telephone numbers.
- Maintain electronic and hard copy contact information for key stakeholders, including fire and police departments, ambulance services, utility companies, contractors, insurance companies and relevant government agencies.
- Establish an emergency hotline to relay urgent instructions and safety messages to employees, and also to summon appropriate on-call personnel if the incident occurs after business hours.
Sheltering in Place
Certain emergencies – such as a contained hazardous materials release, armed intruder situation or inclement weather – may require patients and staff to shelter in place. Identify areas of lower risk within the premises depending upon the type of emergency at hand and move patients and staff to safer zones. As part of the emergency planning process, supplies needed for sheltering in place should be stored in advance. For example, water, durable food, emergency medications, portable radios, first aid kits, eating utensils, blankets, flashlights, batteries and other basic supplies should be stockpiled. Continually assess the safety of sheltering in place arrangements and be prepared to order an evacuation if it becomes the safer option.
Evacuation Procedures
Depending upon circumstances, it may be determined that it is no longer safe to shelter in place, and an evacuation is required. The decision to evacuate requires consideration of several factors, including the urgency of the threat, the type of damage sustained and the capability of staff and providers to meet the medical needs of patients. Immediate threats to life, such as a fire or explosion, will require emergent evacuation. Other situations may permit a planned and phased evacuation. When selecting an evacuation site, leaders must consider both the short- and long-term needs of patients. In a large scale disaster, patients may be evacuated to multiple, widely dispersed sites. It is essential to know where patients and staff are located, both during the crisis and afterward. Plan ahead for appropriate transportation needs during an evacuation, and select the safest mode based upon the acuity needs of patients. Draft an emergency transfer protocol, emphasizing the need for staff to properly monitor patients enroute, irrespective of the mode of transportation. Prior to transport, print out the patients’ baseline history and medication administration record, if applicable, and provide these documents to the accepting facility/location.
The following measures can help reduce panic and ensure an orderly evacuation:
- Prepare detailed diagrams of the facility and surrounding area, showing all critical access and escape routes.
- Check all patient care areas to ensure that no patients are left behind. Instruct staff to close doors behind them as a sign that the room is empty.
- Implement a voicemail system during the period of evacuation in order to convey ongoing evacuation details to families ofpatients, relay information to staff, and provide daily updates on the status of evacuation.
- Instruct staff members to meet at a designated location following the evacuation.
Plan Testing and Training
Disaster drills should be scheduled on a regular basis. Evacuation techniques and the response plan, in its totality, should be evaluated at least annually and updated to reflect organizational changes, lessons learned from drills and emerging exposures. Training should be mandatory for all staff and providers, temporary/contracted employees and volunteers upon hire, and as required by CMS and other regulatory bodies. Training sessions should include a review of emergency-related policies. Document all training events, drills and other exercises, including dates and names of attendees. For those facilities falling within the CMS rule, the first level of testing involves “tabletop” exercises, in which team members review the plan’s effectiveness by analyzing various disaster scenarios. The second level consists of “walk-through” drills, in which responders perform their functions using the methods and communication tools indicated in the plan.
Continue reading Chapter 9: Hazard Risks
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