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Performance Improvement Plan


Review below the performance measurements for the Emergency Management Program 2014 and 2015.

Performance Measurements for Emergency Management Program 2014

Performance

Indicators

Goal/Ql

1st Qtr.

2nd Qtr.

3rd Qtr.

4th Qtr.

YTD

Analysis

Incorporate four decontamination drills per year into the Emergtency Management Program

 

 

4/yr

 

(1/Qtr)

Yes

Yes

Yes

Yes

100%

From October till November 2014 over 1000 staff members were trained in wearing Level C Suits and Purified Air Powered Respirators during the drills for Ebola.

 

The Security team drills and trains annually with the DRC in HAZMAT

 

The Emergency Department performed annual HAZMAT and Mark 1 kit competencies as part of their annual education in May 2014

 

Goal/Ql

1st Qtr.

2nd Qtr.

3rd Qtr.

4th Qtr.

YTD

Analysis

Physicians will be trained in CBRNE and hospital decontamination via the House Staff Noon Conferences

 

 

100%

Yes

Yes

Yes

Yes

100%

Physician noon conference held every month on Chemical, Biological/Pandemic, Explosive and Radiation events, blast trauma, START triage as well as Doctor Decon classes throughout the year.

Leadership Team Directors and Managers will complete the NIMS ICS trainings on line FEMA courses for HICS

ICS 100HC, 200HC, 700,800

 

 

100%

No

No

No

No

50%

Only 50% of hospital directors have completed NIMS ICS courses- bring to leadership meeting and put on line on Health Stream

Performance Improvement Plan for the Emergency Management Program 2015

Performance

Indicators

Goal/Ql

1st Qtr.

2nd Qtr.

3rd Qtr.

4th Qtr.

YTD

Analysis-plan for 2015

Incorporate Active Shooter Drills into every fire/evacuation training done in hospital in 2015

 

 

4/yr

 

(1/Qtr)

100%

 

 

 

 

 

Start with OR training and education. Coordinate a Fire/OR/Active shooter and evacuation drill in February 2015

 

Train all NICU staff on high risk infant evacuation with WEE VAC sleds and pouches. Train NICU nurses on Active Shooter as well as evacuation with head lamps for vertical and horizontal evacuation.

 

Goal/Ql

1st Qtr.

2nd Qtr.

3rd Qtr.

4th Qtr.

YTD

Analysis

 

 

100%

 

 

 

 

 

Plans to replace the SAT RAD phones in the hospital as well as upgrade Everbridge to X matters. Plans to host HAM radio bimonthly meetings at SMMC

 

Leadership Team Directors and Managers will complete the NIMS ICS trainings on line FEMA courses for HICS

ICS 100HC, 200HC, 700,800

 

 

 

100%

 

 

 

 

 

 

Email all leaders list each month of compliance with NIMS training. Also bring to leadership meeting and put all course on line on Health Stream. Re email the link to FEMA classes to all managers and directors and Senior Leadership.