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Written Emergency Operations/Management Plan

  1. The hospital’s leaders including leaders of the medical staff, participate in the development of the EOP:

    The EOP is developed in pre-planning meetings by the EOC, Patient Safety, and Emergency Management Committee members. Medical staff leadership has also provided review and input to the development of the EOP. All Directors at St. Mary Medical Center receive the annual EMP and Appendices to comment, review and add information to. This is accomplished through committee attendance by leadership and medical staff, as well as participation in developing and review of After Action Reports (AAR’s) post exercise to seek opportunities for improving the EOP and supporting plans.

    To facilitate the orderly initiation of the response to an emergency, the following steps of the EOP are initiated:

    • Information received by St. Mary Medical Center concerning an external emergency facing the community or an internal emergency involving the function of the Hospital will be communicated directly to House Supervisor, Administrator on Duty, or designee.
    • When notified of a potential emergency situation, Administrator on Duty will:

      1. Identify the nature of the incident such as location (internal, external)
      2. Discuss the operations pertaining to the conversion of the hospital to disaster status (internal or external Code Triage)
      3. Plan care of casualty and non-casualty patients arriving in the Emergency Department during a disaster
      4. Evaluate incident information to determine if initiation of the EOP is warranted.
      5. Once the EOP has been activated, the Incident Commander (IC) will notify the leadership team as soon as possible.

        Levels or Response

        Response options may include minimizing operations or closure of operations. The HCC may initiate collaboration with countywide emergency operations as needed when planning involves a loss or diminishing supplies, or when patients need shelter in place or evacuation.



        Normal operations.


        No system response is needed but the potential for a response exists. The EOP has not been activated. Pre HICS activation meeting.

        Level 1

        Minor incident affecting the hospital, the situation can be handled with HCWs on duty at the time.  The hospital command center may or may not be open at the discretion of the hospital leadership. HCWs should remain on duty and review their department specific procedures to be prepared to respond to the next level if situation requires an upgrade.  The Nursing (House)Supervisor will complete a bed count and expected discharges ready to report as well as updating Reddinett and HAVBED Data for Los Angeles County.

        Level 2

        Major incident in the community surrounding the hospital or within the hospital itself.  Additional HCWs may be needed in specific areas of the hospital.  The hospital requires limited support from division resources (e.g., supply chain, staffing, patient transfer center).

        This level also includes significant event warnings for the community

        The HCC is activated at a level determined by hospital leadership.

        Level 3

        Event of such a significant impact to the hospital that additional resources are required from corporate or community partners.

        The HCC is fully activated.  This major event will require mobilization of most aspects of the HICS and EOP, including department callback procedures and planning for HCW relief over an extended period of time. 

        All Clear

        The disaster situation is contained. Recovery phase.

  2. The hospital develops and maintains a written EOP that describes the response procedures to follow when emergencies occur:

The response procedures address hospital vulnerabilities and may be adapted to other emergencies that the hospital may experience. The response procedures include but are not limited to the following: 

  • Determination for maintaining and or expanding services during a disaster
  • Conservation of resources
  • Curtailment of services
  • Supplementing resources from outside the community

3. The EOP identifies the hospital’s capabilities and establishes response procedures for when the hospital cannot be supported by the local community in the hospital efforts to provide communications, resources and assets, security and safety, staff, utilities or patient care for at least 96 hours:

As a leading healthcare provider in the community, St. Mary Medical Center is committed to shelter in place and self sustain effective operations for a minimum period of 96 hours.

Based upon the amount and location of supplies St. Mary Medical Center strives to maintain the ability to sustain operations without the support of the community for 96 hours before requiring replenishment of key assets and resources. 

St. Mary Medical Center maintains an inventory of assets and resources that is available on site for use in an emergency. DRC trailers store additional disaster equipment as well as the bottom of the Parking Garage DRC Storage Area.

Identification and calculation of these assets and resources includes supplies located on site and the ability of stretching these assets and resources during an emergency. Considerations taken include conservation of resources, curtailment of services, resource sharing among local hospitals, and supplementing resources from outside the community.

4. The hospital develops and maintains a written EOP that describes recovery strategies and actions to help restore the systems that are critical to providing care, treatment, and services after an emergency:

St. Mary Medical Center has determined what processes are critical to operations and has a resource list readily available. These processes are continually updated as changes take place.  Examples of these would include sources of portable A/C units, portable lighting units stored in DRC Storage Area, portable generators, back up paper system in place in the event of a computer failure, and vendors for supplemental water supplies in the event of a water failure.  In addition, many contingency plans include specific recovery issues (such as capture of patient records and billing, return of supplies and equipment to their normal locations) that are defined in the plans as part of the overall process of response and recovery.

5. & 6. The process for initiating and terminating the hospital’s response and recovery phases of the emergency, including under what circumstances these phases are activated:

The individual who assumes the Incident Commander role has the authority to initiate and terminate the hospital’s response phase of the emergency.  The EOP is activated when a planned or unexpected event disrupts the facility’s ability to provide care, reduces operational capacity, or results in a sudden and increased demand for services.

The Incident Commander also has the authority to initiate aspects of the recovery phase; however, recovery operations may be extended due to the nature of the incident.

7. Identification of alternate care sites for care, treatment, and services that meet the needs of the hospital’s patients during emergencies:

In the unlikely event the facility is deemed unsuitable for continued occupancy or cannot support adequate patient care, communication will be coordinated through a collaborative effort between the HCC, Operations, Planning, and Logistics sections.  The management of necessary patient materials, the transfer of medications, medical records, medical equipment, as well as transportation arrangements and tracking patients to and from the alternative care site(s) is also a collaborative effort.  Communication to the City/County and other healthcare facilities to find potential adequate outside facilities may be obtained through Reddinettt, HAVBED and Hear Radio located in the Emergency Department.

Determination of  an alternative care site to be used will be made at the time by the Incident Commanders of the hospital and local jurisdictional authorities.  Consideration will be given to clinical services required by the patients along with the nature of the emergency.  Every effort will be made to provide the same quality of care at the alternate site chosen.

8. If the hospital experiences an actual emergency, the hospital implements its response procedures related to the care, treatment, and services for its patients:

It is the policy of St. Mary Medical Center to implement without delay all response policies and procedures for all conditions that are deemed as an actual emergency by the Incident Commander or their designee. This includes coordination with the community and response agencies.

Response implementation also includes advanced preparations required to support communications, assets and resources, security and safety, staff management, utilities, and patient management during an emergency.