Evaluation of Effectiveness of Emergency Ops Plan

The Emergency Operations Plan is also subject to regular review and improvement.

1. The hospital activates its EOP twice a year.

   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.

2. For each site the hospital offers emergency services or is a community designated disaster receiving station, at least one of the hospital's two emergency response exercises includes an influx of simulates patients:
   

   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.

3. For each site of the hospital that offers emergency services or is a community designated disaster receiving station, at least one of the hospital's two emergency response exercises includes an escalating event in which the local community is unable to support the hospital:

   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.

4. For each site of the hospital with a defined role in its community's response plan, at least one of the two emergency response exercises includes participation in a community wide exercise.

   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.

5. Emergency response exercises incorporate likely disaster scenarios that allow the organization to evaluate its handling of communications, resources and assets, security, staff, utilities, and patients:

   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.

6. The hospital designates and individual(s) whose sole responsibility during an emergency response exercise is to monitor performance and document opportunities for improvement:

   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.

7. During emergency response exercises, the hospital monitors the effectiveness of communication both within the hospital as well as with response entities outside of the hospital such as local governmental leadership, police, fire, public health, and other healthcare organizations within the community:

   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.

8. During emergency response exercises, the hospital monitors resource mobilization and asset allocation including equipment, supplies, personal protective equipment, and transportation:

   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.

9. During emergency response exercises, the hospital monitors its management of safety and security:

   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

10. During emergency response exercises, the hospital monitors its management of staff roles and responsibilities:

    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.

11. During emergency response exercises, the hospital monitors Utility systems:

    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.

12. During emergency response exercises, the hospital monitors its management of patient clinical and support care activities:

    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.

13. Based on all monitoring activities and observations including relevant input from all levels of staff effected, the hospital evaluates all emergency response exercises and all responses to actual emergencies through a multi-disciplinary process (which includes physicians and licensed independent practitioners)

    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.

14. The evaluation of all emergency response exercises and all responses to actual emergencies identify deficiencies and opportunities for improvement:

    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.

15. The deficiencies and opportunities for improvement, identified in the evaluation of all emergency response exercises and all responses to actual emergencies are communicated to the multidisciplinary improvement team responsible for monitoring environment of care issues and to senior hospital leadership:

    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

16. The hospital modifies its EOP plan based on its evaluations of emergency response exercises and response to actual emergencies:

    The strengths and weaknesses identified in exercise critiques are utilized to modify the EOP and supporting plans, policies, and procedures.

17. Subsequent emergency response exercises reflect modifications and interim measures as described in the modified emergency operations plan. An evaluation of the effectiveness of improvements that were made in response to critiques of the previous exercise is also conducted:

During exercises, an evaluation is conducted identifying the effectiveness of improvements and interim measures that were made in response to critiques from previous exercises.