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Reference code:

Program Performance Improvement Projects and Indicators


Internal policy and procedure review, incident report summaries, Emergency Management Committee meeting minutes, reports and summaries.

Annual evaluation examines the objectives, scope, performance, and effectiveness of the overarching Emergency Management Program to include the 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 and supported by relevant data and 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:

  • Review of the annual emergency management planning reviews.
  • Review of the evaluation of all emergency response exercises and all responses to actual emergencies.

Senior leadership will make the determination of which emergency management improvements will be prioritized for implementation recognizing that some emergency management improvements might be a lower priority and not taken up in the near term. The Emergency Management Director is responsible for implementing the recommendations in the report as part of the Performance Improvement (PI) process.

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.  Performance measures, orientation, education and training programs will change based on the results of the action plans as appropriate. 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.