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Annual Evaluation of the 2014 Emergency Management Program

Determined effective.

Hospital:  Saint Mary Medical Center, Long Beach, California 

Purpose: Annual Evaluation of the St. Mary Medical Center Emergency Management Program

Author: Kathy Dollarhide RN, BSN, CEN, CEM® Director of Disaster Resource Center

Annual evaluation examines the objectives, scope, performance, and effectiveness of the overarching Emergency Management Program to include the Emergency Operations Plan (EOP).  The annual evaluation uses a variety of information sources including the reports from internal policy and procedure review, incident report summaries, Emergency Management Committee (EC) meeting minutes, EC Committee reports, and summaries of other activities.  In addition, findings by outside agencies, such as accrediting or licensing bodies or qualified consultants, are used.  The findings of the annual evaluation are presented within the context of this document supported by relevant data.  This report provides a balanced summary of the Emergency Management Program’s performance over the preceding 12 months.  Strengths are noted and deficiencies are evaluated to set goals for the next year or longer-term future.

The authority for effective design, implementation and evaluation of the Emergency Management Program has been delegated to the EC Committee in collaboration with the administrative and physician leaders/medical staff. Actions and recommendations of the EC Committee are documented in meeting minutes.  The annual evaluation is distributed to hospital senior leadership for review and appropriate action. Senior leadership is responsible for overall strategic planning and budgetary planning and will be provided with the following:

  • A review of all evaluations of emergency response exercises and actual emergencies using a multidisciplinary process.
  • This document once completed for leadership consideration and prioritization of recommendations.

Once the review is finalized, the Emergency Management Coordinator is responsible for implementing the recommendations in the report as part of the Performance Improvement (PI) process.


In accordance with The Joint Commission's (TJC’s) 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.  This authorization of responsibility includes management of the hospital’s comprehensive Emergency Management Program (mitigation, preparedness, response, recovery). Refer to the Emergency Management Authority Responsibility -Authority Statement for the current year.


The Emergency Management Program applies to all organizational activities, departments, and staff and is applicable throughout all organizational buildings and grounds, including any organizational on or off-site medical office buildings at SMMC.  The Plan provides for a systematic approach to emergency management.  It identifies the methods of notification, alert and process for activation of key personnel to manage internal and external disasters.  Key personnel utilize an incident command structure. St. Mary Medical Center adopts the Hospital Incident Command System (HICS) as designated under the National Incident Management Systems (NIMS) to mange internal and external disasters.  Facility management, leadership team and personnel coordinate internal efforts in conjunction and liaison with external emergency response agencies.  St. Mary Medical Center Emergency Management Plan is developed and activated within the contexts of Long Beach and/or Los Angeles County community wide disaster plan.  Disaster drills and activities including those focusing on high risks identified in the annual Hazard and Vulnerability Analysis. Issues drilled and trained on include, active shooter, mass casualty triage, HAZMAT, surge capacity, infectious diseases and emergency readiness as structured and documented via the Homeland Security Exercise and Evaluation Program (HSEEP). Exercises of the Emergency Management Program are based on foundation, exercise design and development, conduct, evaluation (including After Action Reports and outside auditors/evaluators) and Improvement Planning. The Emergency Management exercises are activated twice a year (EM. 03.01.03) either during an actual emergency, tabletop exercise or during a disaster exercise. Modifications to the Emergency Operations Plan are made annually. In 2015 new appendices are being added to the Emergency Management Plan to meet the Joint Commission standards and reflect the Hazard Vulnerability Analysis of 2015.


The table below outlines the objectives established for this plan during the evaluation period, and whether or not objectives by the organization were met:


Met in 2014

Not Met

Increase Health Care Worker (HCW) knowledge of hospital emergency codes. Train and educate Physicians on CBRNE. In-service Hospital staff on emergency management procedures ie. Evacuation and active shooter



Provide HAZMAT awareness and operations training. Continue with quarterly decontamination First Receiver hospital worker HAZMAT training and annual decontamination drill – October, November and December hundreds of SMMC HCW were trained on Ebola and PPE from the DRC stockpile



Continue testing mass notification systems- Everbridge/X matters blast emails etc. for disaster communications testing system wide



Continue alliance building and coalition building with external agencies to network, train, and drill with outside disaster responders. Strengthen coalitions between St. Mary Medical Center and external agencies.



Have all management team and leadership complete the ICS 100, 200 and 700 courses on line



50% of management have not completed NIMS ICS Online courses

Performance Standard:

The performance measurements are based on the evaluations of exercises and emergency After Action Reports (AAR’s) and evaluations. The evaluation after each exercise or emergency will be conducted by a team of involved all levels of staff that was affected; the resulting action plans for EOP improvement will be forwarded to the EC Committee and senior leaders for review. The ongoing status of the action items will be reported to the EC Committee as they are implemented and after the corrective actions are evaluated in a subsequent exercise or emergency.  When modifications require substantive resources and cannot be accomplished by the next emergency response exercise, interim measures are put in place until final modifications can be made.

Performance measures, orientation, education and training programs will change based on the results of the action plans as appropriate. The table below outlines the performance standard established for this plan during the evaluation period, and whether or not performance standard was met:

Performance Standard


Not Met

90% - Callbacks to emergency page (within 15 minutes) by members on the disaster callback list via Everbridge system- Need to discontinue disaster phones for leadership who do not answer monthly disaster pages



100% of house staff physicians will be trained in CBRNE Annually including HAZMAT suits



75% of hospital staff will be trained and educated on evacuation sleds, chairs and shelter in place



Leadership, directors and managers will participate in disaster drills



Many directors have never attended a drill

Objectives for the Next 12 Months:

Based on a review of past performance, data analysis, and information from both internal and external sources, the following objectives have been established for the next 12 months:

Objectives 2015

How Performance

Will be Determined

  1. Improve education in responding to an emergency, with a focus on disaster equipment training (decontamination showers, personal protective equipment, etc.)

Continue lecturing on CBRNE and Weapons of Mass Destruction as well as HAZMAT

  1. Increase the number of staff trained in hospital HAZMAT and improve training in the decontamination process. Improve quality of HAZMA T equipment and provide training on upgrades in equipment.

Numbers of staff trained in HAZMAT will be recorded and documentation kept in Disaster Resource Center. Annual decontamination training will continue with staff and include outside responding agencies.

  1. Reassess active shooter training and provide more shelter in place drills for each unit in hospital

EOC Committee will review all after action reports including active shooter trainings.

  1. Organize and inventory all Emergency Preparedness supplies/equipment. Continue to maintain trauma surge/burn surge and ASPER audit medical/surgical disaster caches.Continue to stockpile CHEMPACK via the Center for Disease Control strategic national stockpile program.

Stockpiles will be audited and reviewed annually and PARR levels will be maintained for deployable and sustainability status

  1. Improve communication capability and capacity throughout the hospital. Implement X matters as well as Everbridge for robust redundancy in communications systems.

X matters will be introduced at SMMC to combine with Everbridge as mass notification and call back systems.

  1. Encourage management and leadership to attend drills in 2015 and complete their ICS courses

Bring to leadership active shooter drills, airport drill and information about non compliance on ICS courses for directors

Evaluation of Effectiveness:

Based on the above information, the program has been found to be:

X      Effective


Evaluation Completed by:

Kathy Dollarhide- Director DRC SMMC

Date: January 22, 2015

EC Committee Review/EC Chair Signature:

Stephen Dunn- Safety Officer SMMC



Administrative Leadership Signature:






2014 Hospital Accreditation Standards – EM.03.01.01, EM.03.01.03, LD.04.04.01, LD.04.01.05