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October 26, 2016
In slightly less than a year (by November 15, 2017), healthcare entities that participate in Medicare and Medicaid will be required to meet the provisions of the Centers for Medicare & Medicaid Services’ emergency preparedness final rule.
In a recent webinar hosted by Hospitals & Health Networks, Regina Phelps, founder of Emergency Management & Safety Solutions, Inc., and an expert in the field of crisis and continuity management, outlined the essentials of an effective hospital disaster preparedness plan. This article summarizes the key takeaways from Phelps’s presentation.
Three Kinds of Emergencies
Emergencies can be divided into three types: routine, crisis and emergent crisis. A routine emergency is predictable; for example, an earthquake in San Francisco. This doesn’t mean that the emergency is easy to deal with, but affected hospitals have usually been able to take advantage of lessons learned from prior experience. They are likely to have thought about what to plan for and to have done emergency exercises to prepare for it.
A crisis emergency, by contrast, is distinguished by novelty—threats never before encountered (for example, the September 11 attack), a familiar event occurring at unprecedented speed (Hurricane Katrina and the simultaneous breaking of the levies) or a confluence of forces that pose new challenges (Hurricane Sandy, which led to widespread power outages, gasoline shortages and the failure of many emergency plans). In a crisis emergency, the routine plan doesn’t work, and attempting to use it might even be counter-productive.
Coping with a crisis emergency involves 1) diagnosing the elements of the novelty; and 2) improvising response measures to cope with the unpredicted elements of the emergency. The response must be creative and extremely adaptable in order to successfully execute the improvised solutions.
The third type of emergency, an emergent crisis, poses special challenges because it looks much like a routine emergency in its early stages. Only later does it reveal its unusual character. The problem that often occurs with this kind of emergency is that leaders may be slow to see the new features of the incident and to understand that it requires a different response. The organization has become “wedded” to its original solution and may be slow to change its plans to adapt to the situation. One example of this is a cyber event that at first appears routine and suddenly worsens and expands. Another is the Toronto SARS outbreak, in which 44 people in Canada died, 400 became ill and 25,000 Toronto residents were quarantined.
Leaders often say “I plan for the worst-case scenario.” The truth is that no one does this. There isn’t enough time, money or willpower to engage in that level of deep experiential planning. The most important thing for a hospital emergency response team to focus on is having the flexibility to adapt in an emergent crisis. A routine emergency could become emergent, so planners also should be aware of and plan for this.
Healthcare organizations must have three essential skills to be prepared for a crisis or disaster:
- Your emergency preparedness team members must know their roles and responsibilities in a disaster. Don’t assume that everyone does. Also, consider what happens if a team member isn’t present and you need to have someone else back them up. What happens? Who is responsible in their absence?
- You must have a clear incident assessment process and escalation strategies that include a team assigned specifically to this task.
- You must know how to develop an incident action plan (IAP). This is your incident response strategy’s guiding light.
The Incident Command System (ICS) is a highly effective model used widely in the public and private sectors. The Hospital Incident Command System (HICS), sponsored by the California Emergency Medical Services Authority, serves as the model for hospital emergency management worldwide. HICS offers a highly effective methodology that provides tremendous support if people know how to use it correctly. The model revolves around the six Cs of crisis management:
- Control: It provides a clear definition of who is in charge.
- Collaboration: It allows you to work effectively within your organization and with other organizations, for example, the Department of Public Health. Everyone uses the same language, which creates a more effective process.
- Coordination between departments
Regardless of what methodology you use, it’s critical that your facility’s team clearly understands its roles in an activation. Checklists should be prepared to drive behavior. Make sure that everything in the checklist is covered by what you have in your plan. If you’re not using HICS, it’s important to decide what methodology will work best to enable you to work optimally with all of the other departments that are part of the recovery scenario.
Practice is essential. In order to be effective, teams should practice at least annually, but preferably twice yearly.
Incident Assessment Team
Many organizations activate an incident response plan without any assessment of the incident or discussion of criteria for deciding whether the plan should be activated. Every hospital should have an incident assessment team (IAT) to perform this task.
The first thing to decide is who is on the team. In most incidents, security, facilities or technology are involved, so the team should always include representatives from these three departments, as well as the incident commander (the individual designated to be in charge of the overall incident), and, depending on the nature of the emergency, a patient care representative.
When an incident occurs, information and decision-making will go up the normal chain of command; however, when the incident begins to impact your mission critical activities, anyone on the incident assessment team should be authorized to initiate a standing communication bridge to assess the situation as a group, review the criteria and escalation strategies for plan activation, and determine whether to activate the plan.
It’s important for all members of the incident assessment team to have the authority to activate the plan so that the team is not hampered by anyone’s absence. This method is far better than waiting and allowing the situation to get worse.
If you’re using an emergency notification system, anyone on the incident assessment team also should be able to activate the system. The team should pre-designate a location where it can meet physically to cover instances in which sending out an emergency notification is impossible.
The first thing the team should do when it meets is to discuss “situational awareness”:
- People: Are lives in danger? Is there an impact on patients, visitors, vendors or employees?
- Facilities/critical infrastructure: Is a facility or critical infrastructure at risk?
- Technology: Is there a disruption in technology services? Is there an information security issue?
- Business: Are you able to perform your mission critical activities? Does the situation have a significant financial impact on the facility?
- Reputation: Does the event have an impact on the organization’s or facility’s reputation?
The next step is to evaluate the incident’s severity level and determine whether the incident meets the criteria for plan activation. If the answer is yes, then the next steps are to activate the crisis management plan, activate the emergency operations center, which can be physical or virtual, and inform the executive crisis management team.
If the answer is no, then you need to decide whether the situation should be monitored and, if so, who should monitor it, how often they should report back to the incident assessment team and when the next meeting will be held.
Incident Action Plan
The IAP is one of the hallmarks of HICS. Roles and responsibilities may be defined, but many organizations do not have a plan. The IAP is essential to avoid confusion. It should be written, and it can be written preemptively, such as when a hurricane is brewing.
The basic IAP contains four elements:
- A summary of the overall incident and situational awareness. Discuss in advance how information about the incident will be validated and managed. Google alerts and social media provide excellent tools for updating situational awareness in real time.
- Strategic objectives to guide the team’s response. If you’re on the facilities team, objectives might be: Conduct an initial damage assessment. Contact emergency vendors. Work with emergency response teams. High-level objectives should be short, clear and action-oriented.
- Assignment of each objective to an individual and/or team for accountability. Everyone on the team should be accountable for something.
- Determination of the operational period. When should the team meet again?
Successful crisis management can be achieved by having:
- Clearly defined team processes.
- Clear team roles and responsibilities.
- A defined initial assessment team and process.
- Written IAPs for all plan activations.
- Regular training and exercises to increase familiarity and competency.
The Centers for Disease Control and Prevention offers resources to help healthcare organizations plan for public health emergencies.
The Joint Commission website provides a variety of emergency management resources for specific types of incidents, including air disasters, cyber-attacks and industrial accidents.