Section 3

Emergency Management Program

Development Process

Table of Contents

3.1. Introduction to the Nine-Step Process 3 - 1

3.2. New Areas of Importance 3 - 1

3.2.1. Federal Preparedness Circular #65 (FPC-65), Continuity of
Operations Plan (COOP) 3 - 1

3.2.2. National Fire Protection Association (NFPA) Standard 1600:

Standard for Disaster/Emergency Management and Business Continuity 3 - 1

3.2.3. National Incident Management System (NIMS) 3 - 2

3.3. Roles and Responsibilities 3 - 2

3.4. Nine Steps to a Successful Emergency Management Program 3 - 4

Figure 3.1: Nine Steps to Establish a Successful Emergency Management
Program 3 - 4

3.4.1. ***Step 1*** - Designate the Emergency Management Committee
(EMC), Identify

Operating Unit Roles and Assign Responsibilities 3 - 4

3.4.2. ***Step 2*** - Develop the Emergency Operations Plan (EOP) 3 - 6

3.4.3. ***Step 3*** - Conduct a Hazard Vulnerability Analysis (HVA) and

Identify Priority Hazards, Threats and Events 3 - 9

3.4.4. ***Step 4*** - Develop Incident-Specific Guidance for Priority
Hazards, Threats and Events 3 - 10

3.4.5. ***Step 5*** - Review/Revise Operating Unit Templates, and

Implement Mitigation Strategies 3 - 11

3.4.6. ***Step 6*** - Coordinate with External Entities 3 - 11

3.4.7. ***Step 7*** - Provide Education and Training to Staff on
Emergency Operations 3 - 12

3.4.8. ***Step 8*** - Implement the EOP and Incident-Specific Guidance

in Response to an Exercise or Actual Event 3 - 13

3.4.9. ***Step 9*** - Conduct On-Going Reviews and Corrective Actions
for the

Emergency Management Program (EMP) 3 - 14

3.5. Emergency Management Program Tools 3 - 15

3.5.1. Emergency Management Program Guidebook Overview 3 - 15

3.5.2. Key Personnel Resource Matrix 3 - 15

3.5.3. Timeline for Development of Emergency Management Program 3 - 15

3.5.4. Hazard Vulnerability Analysis (HVA) 3 - 15

3.5.5. Sample Standard Operating Procedures (SOP) 3 - 16

3.5.6. Sample Operating Unit Template 3 - 16

3.5.7. Reporting Forms 3 - 16

3.5.8. Emergency Management Program Assessment Tool 3 - 16

*Enclosures*

> 1\. Emergency Management Program Guidebook Overview (PowerPoint
> Presentation) 3 - 19
>
> 2\. Key Personnel Resource Matrix (Sample Completed Form) 3 - 27
>
> 3\. Timeline for Development of Emergency Management Program (Sample
> Completed Form) 3 - 29
>
> 4\. Hazard Vulnerability Analysis (Sample Completed Forms)
>
> A. Naturally Occurring Event 3 - 31
>
> B. Human Related Event 3 - 32
>
> C. Hazardous Materials Event 3 - 33
>
> 5\. Sample Standard Operating Procedure Template with Attachments 3 -
> 35
>
> 6\. Operating Unit Assignment Matrix (Sample Completed Form) 3 - 37
>
> 7\. Incident Report (Sample Completed Form) 3 - 39
>
> 8\. Operating Status Checklist and Report (OSCAR) (Sample Completed
> Form) 3 - 41
>
> 9\. Situation Report (SITREP) (Sample Completed Form) 3 - 43
>
> 10\. After Action Report (AAR) (Template) 3 - 45

*The following documents are on the CD-ROM that accompanies this
Guidebook*

*and at the CEOSH web site (vaww.ceosh.med.va.gov):*

> 10A. Sample After Action Report - Florida Hurricanes of 2004 CD

11\. Emergency Management Program Assessment Tool CD

*Section 3*

*Emergency Management Program*

Development Process

3.1. ***Introduction to the Nine-Step Process***. The following
information provides a roadmap for the development, maintenance and
evaluation of an Emergency Management Program (EMP). It is focused on:

-   Ensuring compliance with the Joint Commission on the Accreditation
    of Healthcare Organizations (JCAHO), Environment of Care, Emergency
    Management standards; the Department of Homeland Security \[Federal
    Preparedness Circular #65, Federal Executive Branch Continuity of
    Operations Planning (COOP)
    (<http://www.fas.org/irp/offdocs/pdd/fpc-65.htm>) and the National
    Incident Management System (NIMS)\]; and, the National Fire
    Protection Association (NFPA) Standard 1600, Disaster/Emergency
    Management and Business Continuity Programs.

-   Providing a mechanism for standardization of the structure of
    Emergency Management Programs across the Veterans Health
    Administration (VHA) while at the same time encouraging flexibility
    in content by individual facilities.

-   Promoting application of continuous quality improvement principles.

3.2. ***New Areas of Importance***.

3.2.1. *Continuity of Operations (COOP)*. The Federal Preparedness
Circular (FPC) #65, Federal Executive Branch Continuity of Operations
(COOP), provides mandatory guidance to federal executive departments and
agencies in developing COOP plans and procedures. COOP plans are a
subset of the organization's Emergency Operations Plan (EOP) and are
incorporated within this Guidebook. The sample provided in Section 5,
Part 7, provides a framework that VA Medical Centers (VAMCs) can use to
develop COOP plans. FPC #65 can be downloaded at the web site listed in
paragraph 3.1 above.

3.2.2. *Standard for Disaster/Emergency Management and Business
Continuity*. The National Fire Protection Association (NFPA) Standard
1600 (<http://www.nfpa.org/assets/files/PDF/NFPA1600.pdf>) establishes a
common set of criteria for disaster/emergency management and business
continuity programs. Standard 1600 was endorsed as the national
preparedness standard by the 9-11 Commission, also known as the National
Commission on Terrorist Attacks Upon the United States. NFPA 1600 is a
voluntary standard and included in this Guidebook as an additional
reference for those involved in emergency management program
development. As VA Medical Centers engage in cooperative planning with
other healthcare organizations, local and state public health and
emergency management agencies' knowledge of NFPA 1600 will enhance
coordination efforts.

3.2.3. *National Incident Management System (NIMS)*. NIMS, created by
Homeland Security Presidential Directive 5 (HSPD-5), Management of
Domestic Incidents
(<http://www.whitehouse.gov/news/releases/2003/02/20030228-9.html>),
establishes a uniform approach to incident management for federal, state
and local governments, and mandates its adoption beginning in fiscal
year 2005. NIMS consists of several components, one of which is the
Incident Command System (ICS). A Crosswalk for Compliance with the
various elements of NIMS is provided in Figure 1.5. (NIMS can be
downloaded at <http://www.fema.gov/nims>.)

Another requirement under HSPD 5 was the creation of a single integrated
National Response Plan (NRP). The NRP builds upon the previous Federal
Response Plan and incorporates elements from the Federal Radiological
Emergency Response Plan, National Contingency Plan and an interagency
terrorism concept of operations plan. VA was given additional
responsibilities in the NRP (see Section 8 for more information on
these). The Emergency Operations Plan (EOP) format described in Section
4 is consistent with the NRP. The NRP can be downloaded at
<http://www.dhs.gov/interweb/assetlibrary/NRPbaseplan.pdf>.

3.3. ***Roles and Responsibilities***. Before describing the nine steps
to establish a successful Emergency Management Program (EMP), a
clarification of roles and responsibilities may be useful.

*Veterans Integrated Service Network (VISN) Director* - The Network
Director shall be responsible for the development, coordination,
implementation and evaluation of a Network-wide EMP. This program
includes:

-   Response to all hazards, threats and events that adversely affect
    VHA facilities within the Network, including Outpatient Clinics and
    Consolidated Mail Outpatient Pharmacies (CMOPs).

-   External response plans \[i.e., VA-DoD Contingency Plans, National
    Disaster Medical System (NDMS) and the National Response Plan
    (NRP)\].

*Area Emergency Manager* - The Area Emergency Manager (AEM) serves as a
consultant to both Network Directors and Medical Center Directors for
the purpose of developing EMPs. The AEM should also assist with
education, exercises and external coordination.

*VISN Safety Manager/Industrial Hygienist* - The VISN Safety
Manager/Industrial Hygienist reviews and evaluates the EMP at all
facilities within the Network.

*Medical Center Director* - The Medical Center Director is responsible
for the development and implementation of an EMP that addresses all
facilities under the control of the Medical Center. The Director must:

-   Establish an Emergency Management Committee (EMC).

-   Define and approve the role of the Medical Center in the community
    during emergencies.

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-   Ensure that the EMP addresses internal and external hazards, threats
    and events.

*Associate Director or Equivalent* - The Associate Director or other top
management operation official shall serve as Chairperson of the EMC.

*Chief of Staff* - The VA Medical Center (VAMC) Chief of Staff (COS) is
responsible for the development, endorsement, training and
implementation of clinical guideline protocols for the EMP. The Chief of
Staff must:

-   Establish a workgroup of healthcare providers to review and edit, as
    appropriate, medical treatment and triage procedures contained in
    this guidance to meet the needs of the VAMC.

-   Endorse all clinical treatment protocols distributed to VAMC
    healthcare providers addressing the delivery of patient care during
    an emergency.

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-   Ensure that healthcare providers receive the required educational
    training specific to various types of emergency situations; such as,
    blast injuries, crush injuries, human events,
    nuclear/biological/chemical injuries and mass casualty triage.

-   Ensure that the Emergency Operations Plan (EOP) addresses the
    medical chain-of-command to use during the emergency situation.

-   Ensure appropriate safety measures are utilized to protect
    employees, staff and visitors within the VAMC.

-   Review, approve and endorse the mass-distribution of materials
    (e-mail, brochures, etc.) within the VAMC related to medical
    management of an emergency event.

-   Maintain coordination of emergency medical activities with the
    Network Director or Medical Director, other VISN Chiefs of Staff
    (COS), and the VISN Healthcare Advisory Committee.

-   Review and endorse Memoranda of Understanding (MOUs)/sharing
    agreements for medical resources, supplies, medical care and
    alternate treatment sites.

-   Ensure compliance with all medical treatment-related regulatory
    requirements \[e.g., Emergency Medical Treatment for Active Labor
    Act (EMTALA), Consolidated Omnibus Budget Reconciliation Act
    (COBRA)\].

*Key Operations Managers* - Key Operations Managers have
responsibilities that have broad control of systems and operations of
the facility (i.e., Chief of Engineering, Chief of Acquisition and
Materiel Management, Chief of Security, etc.).

*Emergency Program Coordinator* - The Emergency Program Coordinator
(EPC)/Emergency Management Program Coordinator (EMPC) is the individual
responsible for coordinating with the AEM, the staff within the VAMC,
and the community and regulatory agencies. On a day-to-day basis, the
EPC is responsible for ensuring that the EMP complies with all
applicable regulations and standards. This position is typically
assigned to the Facility Safety Officer, the Chief of Safety or the
Chief of Facilities.

*Operating Unit Managers* - The Operating Unit Managers are responsible
for participating in the EMP, including planning, training and
implementation during drills, exercises and actual threats/events.

Figure 3.1: Nine Steps to Establish a Successful

Emergency Management Program

3.4. ***Nine Steps to a Successful Emergency Management Program***.

3.4.1. **STEP 1 - Designate the Emergency Management Committee (EMC),
Identify Operating Unit Roles and Assign Responsibilities**.

Emergency Management Committee (EMC) - The EMC is a multi-disciplinary
committee established to coordinate and oversee the Emergency Management
Program (EMP).

3.4.1.1. EMC Membership - The membership of the EMC should be specified
in the EMP and should include:

-   Chairperson

-   Emergency Program Coordinator (EPC)

-   Representative from:

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-   Physicians

-   Nursing

-   Infection Control

-   Facilities Engineering

-   Safety/Industrial Hygiene

-   Acquisition and Materiel Management

-   Fiscal

-   Police

-   AEM (if available)

-   Critical Operating Unit Managers

3.4.1.2. The EMC should report to, or have a very close liaison with,
the Facility Safety Committee.

3.4.1.3. Functions of the EMC include:

-   Define the role of the VAMC in the community-wide emergency
    management program.

-   Conduct a Hazard Vulnerability Analysis (HVA) that addresses all
    hazards that threaten the facility.

-   Develop Standard Operating Procedures (SOPs) that address hazards
    identified in the HVA.

-   Develop Continuity of Operations (COOP) procedures.

-   Develop the hospital-wide Emergency Operations Plan and coordinate
    it with other healthcare organizations in the community-wide
    emergency management program.

-   Assign roles and responsibilities of Operating Unit Managers and Key
    Operators/Managers included in the EMP.

-   Oversee the development and maintenance of the EMP.

-   Ensure that all employees have received appropriate training as
    required by the EMP.

-   Conduct an annual evaluation of the effectiveness of the EMP.

-   Keep an updated Key Personnel Resource Matrix. The matrix should
    contain the names and telephone numbers of contacts for Operating
    Units/Critical Activities, back-up contacts and location of
    information sources. An example of the Key Personnel Resource Matrix
    is included in this section as Enclosure 2.

-   A timeline can be used to track progress toward completion of EMC
    responsibilities. A sample Timeline for the Development of an
    Emergency Management Program is included as Enclosure 3.

3.4.1.4. Compliance with JCAHO EC.4.

-   At a minimum, an emergency management plan (program) is developed
    with the involvement of the hospital's leaders, including the
    medical staff.

-   Define a common ("all-hazards") command structure in the hospital to
    respond to and recover from emergencies that links with the
    community's command structure.

-   Alternate roles and responsibilities of staff during emergencies,
    including to whom they report in the hospital's command structure
    and, when activated, in the command structure.

3.4.1.5. Compliance with FPC #65.

> Two elements from FPC #65 may be addressed by the EMC at this point:
> Orders of Succession and Delegation of Authority. See Section 5, Part
> 7, for more information.

3.4.1.6. Relevant Components of NFPA 1600.

> Additional information on emergency management program leadership and
> direction can be found in the following sections of NFPA 1600: Program
> Administration - 4.1; Program Coordinator - 4.2; Advisory Committee -
> 4.3; and Laws, Authorities and Regulations - 5.2.

3.4.2. **STEP 2 - Develop the Emergency Operations Plan (EOP)**

3.4.2.1. The Emergency Operations Plan (EOP) describes the hospital-wide
strategy for responding to, and recovering from any hazard, threat or
event. It focuses on establishing direction, control and coordination
structures and processes. As such, it organizes the various Operating
Units into six groups based upon their missions and resources:

-   Management and Planning

-   Logistics and Finance

-   Business Continuity Operations

-   Equipment, Plant and Utilities Operations

-   Safety and Security Operations

-   Health and Medical Operations

The benefits to this approach include greater coordination between
Operating Units; the transition to incident response is guided by the
Incident Command System; and, greater consistency with local and state
Emergency Operations Plans and the National Response Plan. Additional
information on EOPs is found in Section 4.

3.4.2.2. The particular EOP format used by a VAMC may vary. For example,
EOPs can be formatted with a basic plan, functional annexes and
incident-specific appendices, or they can be developed using the
Memorandum format (please see Section 4, Enclosures 1-3, for sample
VISN, VAMC and CBOC EOPs).

3.4.2.3. Continuity of Operations (COOP) planning requirements can be
integrated within the EOP (e.g., Business Continuity operational
function) or contained in a separate document that is attached to the
EOP. See Section 5, Part 7, for an explanation of the COOP elements.

3.4.2.4. Compliance with JCAHO EC.4. In the following, the various JCAHO
EC.4 standards have been aligned with their relevant EOP/ICS functional
area:

1\) [Command/Management Functional Area]{.underline} - The command or
management function is responsible for overall management of the
incident.

-   Initiating the response and recovery phases of the plan, including
    how, when and by whom the phases are to be activated.

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-   Notifying staff when emergency response measures are initiated.

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-   Notifying external authorities of emergencies, including possible
    community emergencies identified by the hospital (for example,
    evidence of a possible bioterrorist attack).

-   Identifying and assigning staff to cover all essential staff
    functions under emergency conditions.

-   Managing communication with the news media.

-   Re-establishing usual operations after an emergency.

-   Under emergency conditions, managing activities related to modifying
    or discontinuing services and controlling information about
    patients.

2\) [Planning Functional Area]{.underline} - The planning function is
responsible for the collection, evaluation and dissemination of tactical
information about the incident.

-   Cooperative *(trans-event)* planning among healthcare organizations
    that together provide services to a contiguous geographic area (for
    example, among organizations serving a town or borough) to
    facilitate the timely sharing of information about:

> \- Essential elements of their command structures and control centers
> for emergency response.
>
> \- Names, roles and telephone numbers of individuals in their command
> structure.
>
> \- Resources and assets that could potentially be shared in an
> emergency.
>
> \- Names of patients and deceased individuals brought to their
> hospitals to facilitate identifying and locating victims of the
> emergency.

-   Tracking patients to and from the alternative care site.

-   Identifying care providers and other personnel during emergencies.

3\) [Logistics Functional Area]{.underline} - The logistics function is
responsible for providing all support needs to the incident (personnel,
facilities, transportation, supplies, equipment maintenance and fueling,
feeding and communications).

-   Backup internal and external communication systems in the event of
    failure during emergencies.

-   Managing the following under emergency conditions:

> \- Staff support activities (for example, housing, transportation,
> incident stress debriefing).
>
> \- Staff family support activities.
>
> \- Critical supplies (for example, pharmaceuticals, supplies, food,
> linen, water).

-   Establishing an alternative care site(s) that can meet the needs of
    patients when the environment cannot support adequate care,
    treatment or services, as well as procedures for, as applicable:

> \- Transporting patients, staff and equipment to the alternative care
> site.
>
> \- Transferring necessities of patients (for example, medications,
> medical records) to and from the alternative care site.
>
> \- Interfacility communication between the hospital and the
> alternative care site.

-   Facilities for radioactive or chemical isolation and
    decontamination.

4\) [Finance Functional Area]{.underline} - The finance function is
responsible for accounting for all incident-related personnel time and
attendance, procurement, compensation/claims and costs incurred. (No
JCAHO EC.4 standards apply to this function.)

5\) [Operations Functional Area]{.underline} - The operations function
is responsible for all activities associated with protecting the
organization from an impending or on-going hazard, threat or event
and/or resolving problems created by the emergency.

-   Identifying and assigning staff to cover all essential staff
    functions under emergency conditions.

-   Evacuation of the entire facility (both horizontally and, when
    applicable, vertically) when the environment cannot support adequate
    patient care and treatment.

-   Managing the following during emergencies (in VHA's guidance, there
    are four functional areas that fall under the operations function):

> \- Business Continuity
>
> \- Equipment, Plant and Utilities
>
> \- Safety and Security
>
> \- Health and Medical

6\) [Business Continuity Functional Area]{.underline} - No JCAHO EC.4
standards apply to this function.

7\) [Equipment, Plant and Utilities Functional Area]{.underline} -

-   When the hospital is designated to provide continuous service during
    an emergency, an alternative means of meeting essential building
    utility needs (for example, electricity, water, ventilation, fuel
    sources, medical gas/vacuum systems).

-   Re-establishing usual operations after an emergency.

8\) [Safety and Security Functional Area]{.underline} -

-   Security (for example, access, crowd control, traffic control).

-   Notifying external authorities of emergencies, including possible
    community emergencies identified by the hospital (for example,
    evidence of a possible bioterrorist attack).

9\) [Health and Medical Functional Area]{.underline} -

-   Activities related to care, treatment or services (of current
    patients as well as any event-generated casualties).

-   An influx of casualties of a number sufficient to stress the
    capabilities of the hospital.

-   Communications with patients.

3.4.2.5. Compliance with FPC #65.

> Four elements from FPC #65 may be addressed during development of the
> EOP: Devolution of Control and Direction and Reconstitution
> (Management functional area); and, Alternate Operating Facilities and
> Inter-operable Communications (Logistics functional area).

3.4.2.6. Relevant Components of NFPA 1600.

> Additional information on EOPs can be found in the following sections
> of NFPA 1600: Planning (emergency operations/response plan) - 5.7;
> Direction, control and coordination - 5.8; Communications and
> warning - 5.9; Logistics and finance - 5.11; Crisis communications and
> public information - 5.14; and, Finance and administration - 5.15.

3.4.3. **STEP 3 - Conduct a Hazard Vulnerability Analysis (HVA) and
Identify Priority Hazards, Threats and Events**.

3.4.3.1. Hazard Vulnerability Analysis (HVA) is a systematic approach to
assessing the probability and consequence of hazards or threats/events
that may affect the continued operation of the VAMC and surrounding
community.

3.4.3.2. Input to the HVA by Operating Unit Managers is very important.
Some threats to individual Operating Units are so severe that they may
interrupt the continuity of critical operations in the VAMC.

3.4.3.3. The Emergency Management Committee (EMC) oversees the HVA
process to ensure that all major threats to the VAMC are accounted for
and assessed. Using the input submitted by Operating Unit Managers, the
EMC should create a prioritized list of hazards, threats and events that
require incident-specific guidance.

(See Enclosure 4 of this Section of the Guidebook for instructions for
an example of a completed HVA.) This sample HVA has been developed to
assist the EMC and Operating Unit Managers in conducting the HVA.

3.4.3.4. Compliance with JCAHO EC.4.

-   Conducting a hazard vulnerability analysis to identify potential
    emergencies that could affect the need for the hospital's services
    or its ability to provide those services.

-   Establishing, in coordination with community emergency management
    planning (where available), priorities among the potential
    emergencies identified in the hazard vulnerability analysis for
    which mitigation, preparation, response, and recovery activities
    will need to be undertaken.

-   Hazard vulnerability analysis: The identification of potential
    emergencies and the direct and indirect effects these emergencies
    may have on the healthcare organization's operations and the demand
    for its services.

3.4.3.5. Relevant Components of NFPA 1600.

> Additional information on the HVA process can be found in the
> following section of NFPA 1600: Hazard Identification, Risk Assessment
> and Impact Analysis - 5.3.

3.4.4. **STEP 4 - Develop Incident-Specific Guidance for Priority
Hazards, Threats and Events**.

3.4.4.1. There are two types of incident-specific guidance contained in
this document: Readiness Plans and Standard Operating Procedures (SOPs).

3.4.4.2. *Readiness Plans*. Readiness Plans augment the facility's
all-hazard Emergency Operations Plan, providing detailed preparedness
and response guidance for priority hazards, threats and events. When a
Readiness Plan is written for a particular hazard, threat or event, it
references the SOP for the same hazard, threat or event. Sample
Readiness Plans are provided in Section 5 of this Guidebook.

3.4.4.3. *Standard Operating Procedures (SOPs)*. Sample SOPs likely to
be needed at most VAMCs are provided in Section 6 of this Guidebook.
These samples must be customized to address conditions at each VAMC. The
SOPs have a description of the threat/event or key activity, and
strategies for mitigation, preparedness, response and recovery with
attachments. A sample SOP template, along with attachments that
illustrate initial response guidance using the Incident Command System,
is included as Enclosure 5 in this Section.

3.4.4.4. Compliance with JCAHO EC.4.

> Identifying specific procedures to mitigate, prepare for, respond to
> and recover from the priority emergencies.

3.4.4.5. Compliance with FPC #65.

> Four elements of FPC #65 can be addressed within this Step:
> Identification of Essential Functions; Identification of Vital Records
> and Databases; Human Capital planning; and, Developing Plans and
> Procedures. See Section 5, Part 7, for more information.

3.4.4.6. Relevant Components of NFPA 1600.

> Additional information on developing incident-specific guidance can be
> found in the following sections of NFPA 1600: Planning (continuity of
> operations) - 5.7; and, Operations and Procedures - 5.10.

3.4.5. **STEP 5 - Review/Revise Operating Unit Templates and Implement
Mitigation Strategies**.

3.4.5.1. Operating Unit Templates. After reviewing and/or conducting
HVAs for their areas of responsibility, Operating Unit Managers must
develop Operating Unit templates to address disruptions of services and
operations in their areas. Please see Section 7 for sample Operating
Unit templates. The Operating Unit Managers submit HVA input to the EMC
for consideration and incorporation into the overall facility HVA.

3.4.5.2. Mitigation. Mitigation activities are designed to eliminate or
reduce the impact of hazards, threats and events to the ability to
provide continuity of patient care operations. Standards such as JCAHO
Environment of Care, the National Electrical Code, National Building
Code and so on guide mitigation activities within the facility. The
focus of mitigation efforts in the emergency management program includes
promoting mitigation through education efforts to employees and linking
key operating unit managers with responsibility for business continuity;
equipment, plant and utilities; and safety and security with community
land use or zoning officials; subject matter experts and technical
information for hazards not addressed by these standards (e.g. Chemical
Biological, Radiological, Blast and Explosives).

3.4.5.3. Relevant Components of NFPA 1600.

> Additional information on mitigation programs can be found in the
> following section of NFPA 1600: Hazard Mitigation - 5.4.

3.4.6. **STEP 6 -- Coordinate with External Entities**

3.4.6.1. Creating linkages between the facility's Emergency Management
Program and area hospitals, community agencies and state and federal
government agencies improve response and recovery effectiveness. Many
opportunities exist for VAMCs to get involved with community-wide
planning, training and exercises \[e.g. National Disaster Medical
System, Health Resources and Services Administration (HRSA) Bioterrorism
Program, Metropolitan Medical Response System, and the Cities Readiness
Initiative/Strategic National Stockpile\].

3.4.6.2. Area Emergency Managers (AEMs) can be instrumental in assisting
VAMC staff involvement in these and other emergency preparedness
programs.

3.4.6.3. Resource Management. In the development of incident-specific
guidance, certain types of human, informational or physical resources
are identified. Resource management strategies include pre-event and
trans-event purchase, rental and/or mutual-assistance. Cooperative
planning with other VA facilities and community entities is a key part
of preparedness. (See Section 8 for additional information on External
Coordination and Mutual Support.)

3.4.6.4. Compliance with JCAHO EC.4.

-   Defining and, where appropriate, integrating the hospital's role in
    relation to community-wide emergency response agencies, including
    identifying the community's command structure.

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-   Cooperative *(pre-event)* planning among healthcare organizations
    that together provide services to a contiguous geographic area (for
    example, among organizations serving a town or borough) to
    facilitate the timely sharing about:

> a\. Essential elements of their command structures and control centers
> for emergency response;
>
> b\. Names, roles and telephone numbers of individuals in their command
> structures; and,
>
> c\. Resources and assets that could potentially be shared in an
> emergency.
>
> (See guidance on Sharing Agreements in Section 8.)

3.4.6.5. Relevant Components of NFPA 1600.

> Additional information on aspects important in inter-agency
> coordination can be found in the following sections of NFPA 1600:
> Resource Management - 5.5; Mutual Aid - 5.6; and, Planning \[strategic
> administrative (preparedness) plan; mitigation plan; and, recovery
> plan\] - 5.7.

3.4.7. **STEP 7 - Provide Education and Training to Staff on Emergency
Operations.**

3.4.7.1. All employees must receive education and training consistent
with their roles and responsibilities in emergencies. (See Section 9 for
additional information on education and training activities for
leadership and key operating unit managers, clinicians, emergency
management staff and all employees.)

3.4.7.2. Compliance with JCAHO HR.2.20. Staff members, licensed
independent practitioners, students and volunteers, as appropriate, can
describe or demonstrate the following:

-   Risks within the hospital's environment.

-   Actions to eliminate, minimize or report risks.

-   Procedures to follow in the event of an incident.

-   Reporting processes for common problems, failures and user errors.

3.4.7.3. Compliance with FPC #65.

> One element from FPC #65 is addressed within this Step: Training.

3.4.7.4. Relevant Components of NFPA 1600.

> Additional information on education and training can be found in the
> following section of NFPA 1600: Training - 5.7.

3.4.8. **STEP 8 - Implement the EOP and Incident-Specific Guidance in
Response to an Exercise or Actual Event**.

3.4.8.1. Exercises should be based on existing plans and procedures and
designed to reflect actual events that could likely occur in the
community or at the VAMC. Consideration should be given to conducting
more than the minimum number of required exercises involving various
Operating Units throughout the VAMC to ensure proper response readiness
(including tabletop exercises).

3.4.8.2. The use of the various incident report forms (Enclosures 7-10)
will help ensure the other VAMCs, the VISN and VACO can track the status
of the facility during the emergency.

3.4.8.3. Compliance with JCAHO EC.4.1.

-   The hospital conducts drills regularly to test emergency management.

-   The hospital tests the response phase of its emergency management
    plan twice a year, either in response to an actual emergency or in
    planned drills.

> Note: Staff in each freestanding building classified as a business
> occupancy (as defined by the Life Safety Code^®^) that do not offer
> emergency services nor are designated as disaster-receiving stations
> need to participate in only one emergency preparedness drill annually.
> Staff in areas of the building that the hospital occupies must
> participate in such drills.

-   Drills are conducted at least four months apart and no more than
    eight months apart.

-   Hospitals that offer emergency services or are designated as
    disaster-receiving stations must conduct at least one drill a year
    that includes an influx of volunteer or simulated patients.

> Note: Drills that involve packages of information that simulate
> patients, their families and visitors are acceptable.

-   The hospital participates in at least one community-wide practice
    drill a year (where applicable) relevant to the priority emergencies
    identified in its hazard vulnerability analysis. The drill assesses
    the communication, coordination and effectiveness of the hospital's
    and community's command structures.

> *Note: 1. Community-wide may range from a contiguous geographic area
> served by the same health care providers, to a large borough, to a
> town, city or region.*
>
> *2. Tests of 4 and 5 may be separate, simultaneous or combined.*
>
> *3. Tabletop exercises, though useful in planning or training, are
> acceptable substitutes [only]{.underline} for community disaster
> drills.*

3.4.8.4. Compliance with FPC #65.

One element from FPC #65 is addressed within this Step: Tests and
Exercises.

3.4.8.5. Relevant Components of NFPA 1600.

> Additional information on exercises can be found in the following
> section of NFPA 1600: Exercises and Evaluations - 5.13.

3.4.9. **STEP 9 - Conduct On-Going Reviews and Corrective Actions for
the Emergency Management Program (EMP)**

3.4.9.1. Operating Unit Managers and the Emergency Program Coordinator
(EPC) should regularly report results of mitigation and preparedness
activities to the EMC. Reports should include:

-   Mitigation activities taken that effectively reduced or eliminated
    adverse impacts to the VAMC.

-   Mitigation activities that did not reduce or eliminate adverse
    impacts to the VAMC operation.

-   Recommendations for mitigation and preparedness activities, budget
    and timelines.

-   Overall status report on the EMP, including corrective actions.

3.4.9.2. A critical review/critique of all drills or real events must be
conducted and the results reported to the Emergency Management Committee
(EMC). (See Section 9 for additional guidance on exercise design,
management and evaluation.)

3.4.9.3. A comprehensive Annual Review must be conducted by the EMC and
approved by the Medical Center Director. See Section 1, Figure 1.3,
JCAHO EC.4 Crosswalk; and Enclosure 11 to this Section (on CD-ROM only)
for an EMP Assessment Tool.

3.4.9.4. The goal of the emergency management program development
process is an organizational learning of the lessons identified in
response and recovery to actual events or exercises. The quality
management processes include conducting an incident/exercise critique;
completing an After-Action Report (AAR); and, conducting a corrective
action process for issues or lessons identified in the AARs. (See
Enclosure 10 for the After-Action Report template. A sample completed
After Action Report for the Florida Hurricanes of 2004 is included on
the CD-ROM as Enclosure 10A.)

3.4.9.5. Compliance with JCAHO EC.4.10 and EC.4.20.

3.4.9.6. Relevant Components of NFPA 1600.

> Additional information on program review and evaluation can be found
> in the following section of NFPA 1600: Program Evaluation - 4.4.

3.5. ***Emergency Management Program Tools***. The following tools are
provided to guide facilities through the emergency management program
development process and help to ensure that all the necessary elements
have been addressed:

3.5.1. *Emergency Management Program Guidebook Overview*. This
PowerPoint presentation explains the purpose, scope and major sections
of this Guidebook, including identifying key updates. (Enclosure 1)

3.5.2. *Key Personnel Resource Matrix*. This Resource Matrix lists
contact information for key internal and external individuals or
entities. (Sample form at Enclosure 2.)

3.5.3. *Timeline for Development of Emergency Management Program*. This
tool helps organize the nine program development steps. (Sample at
Enclosure 3.)

3.5.4. *Hazard Vulnerability Analysis*.

3.5.4.1. **Instructions**. The Hazard Vulnerability Analysis (HVA) is a
way to focus attention on those hazards that are most likely to have an
impact on the VA Medical Center (VAMC) and the surrounding community.
The list of hazards includes possible events or threats that may occur
within the community or VA property. Events that impact the community
many times are brought into the facility. It is intended that a HVA be
seen as an evolving document, and be reviewed at least annually within
the JCAHO Environment of Care Emergency Management annual report.

3.5.4.2. **Doing the Analysis**. There are four (4) categories that are
used to help place each hazard into perspective. These categories are
Probability, Human, Property and Operational Impact on the facility.
Each of these categories is based on a point system, ranging from 0 to
3. For each hazard, a point estimate of 0 (N/A) to 3 (high) is given for
each of the four (4) categories.

-   ***Probability** that any event may occur in the future*. VAMC staff
    can gain insight on this by setting up a meeting with the local
    emergency management agency.

-   ***Human Impact** estimates the severity of impact on patients,
    visitors and staff during an adverse event*. For example, total
    electrical failure may result in a total evacuation of the VAMC.
    Potential injuries or death of patients, staff and visitors is
    estimated here. All events whether internal or external to our
    VAMCs, will most likely impact patients in some manner, whether it
    be an inconvenience, or result in injury or worse.

-   ***Property Impact** estimates the potential physical damage and
    losses to the infrastructure of the VAMC*. Such damages and losses
    can result in costly repairs and delay in services, thereby
    impacting patient care and operations. Mitigation activities that
    target utilities, communications, and other building service systems
    will lessen impact of emergency events.

-   ***Operational Impact** estimates the impact of services that are
    required and expected by our patients, employees, and visitors*.
    Understanding how services inter-relate before an emergency event
    occurs is needed to conduct a meaningful analysis. Examples of
    services include: in-patient care, availability of medicines,
    treatment schedules, fiscal accounting, etc. Operational activities
    can be preserved by well-planned mitigation strategies.

3.5.4.3. **Event Scoring Guidelines**. Event scores of 2 or greater in
any category will require that a Standard Operating Procedure (SOP) be
developed.

3.5.4.4. **Sample Forms**. Sample HVA forms are included as Enclosures
4A through 4C to assist you in being prepared to face any of these
hazards, should they occur in your area.

3.5.5. *Sample Standard Operating Procedure (SOP)* (Enclosure 5). The
sample SOPs contained in this Guidebook provide basic guidance for a
variety of hazards, threats and events. This basic guidance is adapted
to meet the needs of each facility. JCAHO's requirement that emergency
management programs address the four phases of Comprehensive Emergency
Management (mitigation, preparedness, response and recovery) is
accomplished in the SOP format.

3.5.6. *Sample Operating Unit Template*. The Operating Unit Templates
are service-level contingency plans for the loss of mission critical
systems. These templates are useful staff education tools. (Sample
Operating Unit Templates are contained in Section 6.)

3.5.7. *Reporting Forms*. Four types of standardized report forms have
been provided:

-   Incident Report (Enclosure 7)

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-   Operating Status Checklist Report (Enclosure 8)

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-   Situation Report (Enclosure 9)

-   After Action Report (Enclosure 10)

3.5.8. *Emergency Management Program Assessment Tool*. VISNs and
facilities can adapt this tool to assess and track key emergency
management activities (Enclosure 11).

Enclosures

1\. Emergency Management Program Guidebook Overview, PowerPoint
Presentation

2\. Key Personnel Resource Matrix (Sample Completed Form)

3\. Timeline for Development of Emergency Management Program (Sample
Completed Form)

4\. Hazard Vulnerability Analysis - Sample Completed Forms

A. Naturally Occurring Event

B. Human Related Event

C. Hazardous Materials Event

5\. Sample Standard Operating Procedure Template with Attachments:

A. Sample Key Activity Management Tool

B. Sample Key Activity Management Structure

6\. Sample Operating Unit Assigned Matrix (Sample Completed Form)

7\. Incident Report (Sample Completed Form)

8\. Operating Status Checklist Report (Sample Completed Form)

9\. Situation Report (Sample Completed Form)

10\. After Action Report (Template)

10A. After Action Report - Florida Hurricanes of 2004

11\. Emergency Management Program Assessment Tool (Sample Form)