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Emergency Management Program



In accordance with The Joint Commission's (TJC) Emergency Management and Leadership Standard LD.04.01.05 St. Mary Medical Center appoints the Director of the Disaster Resource Center to serve as the Emergency Coordinator for the hospital and its affiliated sites as described in the scope of the Emergency Operations Plan.




Table of Contents

Glossary of Acronyms & Terms

1.0 Program Objectives

2.0 Scope

3.0 Introduction

4.0 Program Organization and Responsibilities

5.0 Program Implementation and Process

-Plans for Managing the Consequences of Emergencies (EM.01.01.01, NIMS Elements 1, 5)

-A Written Emergency Operations Plan (EOP) (EM.02.01.01, NIMS Elements 2, 10, 11)

-Emergency Communication Strategies (EM.02.02.01, NIMS Elements 3, 4, 17)

-Strategies for Maintaining Resources and Assets During Emergencies (EM.02.02.03, NIMS Elements 6, 8, 15, 16)

-Strategies for Maintaining Safety and Security During Emergencies (EM.02.02.05, NIMS Element 13)

-Definition and Management of Staff Roles and Responsibilities (EM.02.02.07, NIMS Elements 8, 10, 11, 12)

-Strategies for Maintaining Utilities During Emergencies (EM.02.02.09, NIMS element 8)

-Strategies for Managing Patient Clinical and Support Service Activities During Emergencies (EM.02.02.11, NIMS Element 8)

-Granting Disaster Privileges to Licensed Independent Practitioners (EM.02.02.13)

-Granting Disaster Responsibilities to Volunteers and Non-Licensed Independent Practitioners (EM.02.02.15)

-Evaluation of the Effectiveness of Emergency Management Planning Activities (EM.03.01.01)

-Evaluation of Effectiveness of the Emergency Operations Plan (EOP) (EM.03.01.03)

6.0 Orientation and Education

7.0 Annual Evaluation

8.0 Program Performance Improvement Projects and Indicators

APPENDIX A – 2015 Hazard Vulnerability Analysis

APPENDIX B – Four Phase Planning Activities

APPENDIX C – 2015 Hospital Incident Command System (HICS)

APPENDIX D – Evacuation Plan

APPENDIX E – Mass Fatality Plan

APPENDIX F- Shelter in Place

APPENDIX G- Surge Plans

APPENDIX H- Bioterrorism/Infectious Disease Plan

APPENDIX I- Active Shooter Plan

APPENDIX J- Disaster Credentialing Plan

APPENDIX K- Decontamination Plan

APPENDIX L-Annual Evaluation of the 2014 Emergency Management Program

APPENDIX M- Program Performance Improvement