Disaster Resource Center
End of Life Option Act
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The Emergency Operations Plan is also subject to regular review and improvement.
St. Mary Medical Center conducts exercises to assess the effectiveness of the EOP at least twice a year, stressing the limits of the plan to support assessment of preparedness and performance. The design of exercises will reflect hospital vulnerabilities, and will test the facility's ability to respond to emergencies, and to provide care, treatment and services under stressed situations. Off site areas classified as business occupancy (as defined by the Life Safety Code) will conduct one drill a year.
Off-campus sites that are business occupancies participate in at least one drill each year, either as part of the system, or in response to events that would cause them to respond at their location. In addition, some events may call for HCWs to be included in hospitals response.
At least one drill a year conducted by the facility will include an influx of simulated patients. This portion of the drill may be conducted separately or in conjunction with a community wide drill, or tabletop exercise. One exercise will be conducted in participation with the County and/or State including the California Statewide Disaster and Medical Health Exercise every November.
At least one of the exercises annually is escalated where the scenario that is set, changes in various stages to include greater severity, greater influx of patients and greater taxation on the hospital's resources and assets.
St. Mary Medical Center participates in at least one communitywide drill each year, relevant to emergency incidents identified in the HVA and community plans appropriate to the hospital role and designation in the community and/or region.
At least one drill a year conducted by St. Mary Medical Center simulates an escalating event in which the surrounding community is unable to support the hospital. This portion of the drill may be conducted separately or in conjunction with a community wide drill, or tabletop exercise. One exercise will be conducted in participation with the County and/or State.
Exercises are designed to test the EOP and preparations for specific events predicted as high potential events by the HVA priorities and are as realistic as possible. The scenarios and objectives are designed to test the plans and to objectively measure performance in key issues and activities against expectations, and to focus improvements where the evidence indicates that are needed. Performance is and will be monitored in terms of timeliness and effectiveness of HCW notification of events, internal and external communications, availability and mobilization of resources, and effective and timely patient management as well as the six critical areas (Communication, Resources and assets, safety and security, HCW responsibilities, utilities management, patient clinical and support activities). Where opportunities for improvement are identified, they will be developed and tested.
An individual who is not a participant in the exercise and whose sole responsibility is to monitor performance during exercises is assigned to each exercise. This individual is knowledgeable in the goals and expectations of the exercises and documents opportunities for improvements objectively.
The hospital monitors the effectiveness of communication within the facility and outside the facility. In addition, effectiveness is also expressed in the exercise critiques and data is aggregated to seek opportunities for improvements.
The hospital monitors the effectiveness of resource mobilization and allocation including responders, equipment, supplies, PPE’s and transportation. Effectiveness is also expressed in the exercise critiques and data is aggregated to seek opportunities for improvements.
The hospital monitors the effectiveness of safety and security. Effectiveness is also expressed in the exercise critiques and data is aggregated to seek opportunities for improvements and involvement of outside agencies
The hospital monitors the effectiveness of HCW roles and responsibilities. Effectiveness is also expressed in the exercise critiques and data is aggregated to seek opportunities for improvements.
The hospital monitors the effectiveness of utility systems. Effectiveness is also expressed in the exercise critiques and data is aggregated to seek opportunities for improvements.
The hospital monitors the effectiveness of patient clinical and support care activities. Effectiveness is also expressed in the exercise critiques and data is aggregated to seek opportunities for improvements.
Critiqued data from the exercises, are also reviewed and critiqued again through the Emergency Management Committee members including representative from administration, clinical services, physicians and support staff. Actual emergencies are also responded to in accordance with the EOP and are documented and critiqued through a multi-disciplinary process.
Each exercise is critiqued and identifies deficiencies and opportunities for improvement that are based on monitoring activities, observations and metrics utilized to gauge strengths and weaknesses and they identify deficiencies observed during exercises as well as define opportunities for improvement. After every exercise an After Action Report is completed to assist with the continuous process improvement in Emergency Management Program.
From aggregated data that precipitates from exercise critiques and metrics utilized to gauge the effectiveness of exercises, strengths and weaknesses that are identified during exercises are communicated to the EOC
The strengths and weaknesses identified in exercise critiques are utilized to modify the EOP and supporting plans, policies, and procedures.
During exercises, an evaluation is conducted identifying the effectiveness of improvements and interim measures that were made in response to critiques from previous exercises.