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Emergency Operations Plan


Date of Last Review 3/16/10

Date of Last Review 01/19/2011

Date of Last Review 10/31/11
Safety Compliance Coordinator


UTHCPC has developed the Emergency Operations Plan (EOP) to assist staff to prepare for disaster/emergency events before they occur, to respond to such events, and to support recovery efforts to various disaster/emergency events.

The purpose of the EOP is to provide a documented plan with guidelines for the mitigation and response to natural and manmade events that may endanger the patient, visitors, and staff at the UTHCPC. This plan describes how UTHCPC mitigates, prepares, responds, and recovers from the effects of disaster/emergency event and identifies the role of UTHCPC in a community-wide disaster.

The EOP consists of procedures designed to respond to disaster/emergency events that are likely to disrupt operations of the UTHCPC and return the hospital to a normal status. The EOP is designed to be an "all- hazards" plan and for disaster/emergency events identified in the Hazard Vulnerability Analysis (HVA). The EOP is developed to assure availability of resources for the continuation of patient care during an emergency. It is designed to assure appropriate, effective response to a variety of disaster/emergency events that could have an impact on the safety of our patients, visitors, and staff and that may adversely impact the hospital‘s ability to provide services to the community.


The EOP is designed to provide appropriate, effective response to a variety of emergency events that could affect the safety of our patients, visitors, and staff and/or the environment of UTHCPC, or adversely impact the hospital‘s ability to provide services to the community.


A The Hazard Vulnerability Analysis (HVA) is documented and updated annually to identify potential emergencies before they occur. The HVA is used to assist in planning activities that prepare us in developing strategies for preparedness. (EM.01.01.01)
B Emergency Management Exercises using the National Incident Management System (NIMS) philosophy are conducted twice a year to evaluate the EOP. The exercises are critiqued to identify opportunities for improvement. (EM.02.01.01)
C Communication capabilities are tested at least annually for the purpose of communicating response efforts to staff, patients, and external organizations. (EM.02.02.01)
D Resources and assets availability and consumption are assessed at least annually during planned exercises to ensure UTHCPC can obtain and replenish supplies during actual emergency events. (EM.02.02.03)
E Safety and Security response awareness is managed during emergency events to ensure our facility is safe and secure by means of securing the facility and by providing nuclear, biological, and chemical isolation and decontamination capabilities. (EM.02.02.05)
F Training is provided for all staff required to respond to disaster/emergency events. Training is specific to staff roles and responsibilities. Training may include use of personnel protective equipment or other specialized equipment required to be used or operated.
G Ensure utility capabilities are in place to provide support to patient care activities and services during actual emergency events.
H To ensure patient care treatment and services are delivered in a safe manner during emergency events.
I Record, analyze, and act on problems, failures and user errors observed during implementation of the plan. The findings are forwarded and reviewed with the Safety Committee to assure broad awareness of the ongoing development of the EOP.
J Collect appropriate performance data during implementation of the plan. The data supports the improvement standards established by the Safety Committee. That data is used to identify opportunities to improve Emergency Management performance, planning, response, and exercise activities.
K Conduct an annual evaluation of the objectives, scope, performance, and effectiveness of the EOP.

Organization and Responsibility

A The Governing Body: 1) Receives reports of the activities of the Emergency Management Program from the Safety Committee Chair 2) Reviews the reports and, as appropriate, communicates concerns about identified issues and regulatory compliance and 3) Provides support facilitating ongoing activities of the Emergency Operations Program.
B The Administrator receives reports of the current status of the Emergency Operations Program through the Safety Committee. The Administrator reviews the reports and, as necessary, communicates concerns about key issues and regulatory compliance. The Safety Compliance Coordinator makes recommendations to the Safety Committee for purchase of supplies and equipment necessary to make improvements to the Emergency Operations Program.
C The Safety Compliance Coordinator is responsible for managing the Emergency Management Program. The Safety Compliance Coordinator advises the Safety Committee regarding emergency management issues which may necessitate changes in policies and procedures, orientation, education, and/or purchase of equipment.
D Department heads are responsible for orienting new employees to their department emergency preparedness plan and, as appropriate, their specific roles and responsibilities for disaster/emergency events. Where necessary, the Safety Compliance Coordinator and members of the Safety Committee provide assistance.
E Staff is responsible for knowing their roles and responsibilities during a disaster/emergency event.



Hazard Vulnerability Analysis

A Hazard Vulnerability Analysis (HVA) is conducted annually to identify potential emergencies and the direct and indirect effects these emergencies may have on the hospital’s operations. The HVA is used to guide the development of the EOP. It is reviewed at lease annually to determine if the probable emergencies have changed.

UTHCPC, together with its community partners, prioritizes the potential emergencies identified in its HVA and documents the priorities.

Community Emergency Planning

On a monthly basis, UTHCPC Safety meets, under the support of the Regional Emergency Hospital Council (REHC) with other healthcare agencies to share information and to take advantage of opportunities to collaborate with relevant parties in the community.

Inventory of Resources

UTHCPC keeps an updated inventory listing of all emergency supplies it has on site that may be needed during an emergency. This includes, but is not limited to, personal protective equipment, medical supplies, water, fuel, and medication related resources and assets. The emergency supplies are located in rooms 1A82 and 1A83. A hard copy of inventory of emergency supplies on hand is available in the incident command center and an electronic copy is available online. Fans and emergency water is stored in various rooms in the facility. Please refer to inventory listing for exact location/s. The emergency supplies are inventoried on an annual basis. The result of the inventory is provided to the Safety Office by November 1 of each calendar year.


Plan Development and Annual Review

The EOP is developed and maintained for each of the emergencies that UTHCPC identified as priorities in the HVA. These plans are compared to the community-wide plans of the local emergency management agency to assure consistency with their plans, and coordination of the hospital‘s role in those plans at least annually. UTHCPC has developed an “All Hazards” EOP based on the Incident Command System, used by county, state, and national emergency agencies. This system is used for responding to the management of internal and external disaster/emergency events.

Leadership, the medical staff, and the Safety Committee participate in both the development and annual reviews of the EOP. The plan shall be evaluated on an ongoing basis to assure it meets UTHCPC’s needs.

The EOP shall be reviewed at least annually. The review will identify components of the program that need to be instituted, revised or deleted. The annual report will be presented to the Governing Body through the Performance Improvement Council.

Processes for Mitigation, Preparedness, Response and Recovery

UTHCPC EOP includes activities designed to mitigate the impact of the emergency, such as building elements and specialized equipment. Preparation for disaster/emergency events include staff training activities, planned exercises, adequate supplies and equipment for responding to such events, and plans to handle the space and facilities during emergency situations.

The EOP includes specifics of the response, including job assignments, staffing plans, and the management of patients, visitors, and staff during disaster/emergency events.

The plans for recovery include the immediate termination of Emergency Response Plans and return to normal operations, critique and evaluation of the response to the plans, and make updates to the plans to improve them. Recovery plans for incidents that directly affect the hospital facility are done as quickly as practical after the event, and include the interim measures to provide for ongoing patient care.

Relocation - Alternate Care Sites

Nearby hospitals would be the primary alternate care sites. If they are unable to accept patients during an emergency, the Incident Commander or designee will work with local emergency management agencies at the City of Houston Catastrophic Medical Operations Center (CMOC) to determine where patients can be relocated.

Patients would be transported to the alternate sites by a combination of the local EMS system and hospital vans suitable for patient transport. Additionally, hospital vans would be used to move staff to those alternate sites as needed. If additional transportation is needed, and if the CMOC is operational, the Logistics Officer will contact and coordinate additional transportation needs.

The ICS patient tracking (EMTrack) would be used to assure the organization is able to identify the location of all patients and provide them with necessary support.

Processes for Implementing, Terminating, and Recovery Processes (EM.02.01.01)

The EOP states the criteria for, and the processes to initiate the plan and how the plan will be implemented. The criteria include example of the conditions that indicate the plan should be activated, the individual/s responsible for initiation of the plan, and the use of the incident command structure to manage the disaster/emergency event. The plan also includes the response elements for staff, and facility use. The plan defines when the plan should be terminated, and the transition back to normal, including recovery elements such as capture of medical record information, financial information, and restoration of areas modified for the emergency use, and return to normal management processes.

Incident Command Center Activation:

Immediate following an emergency alert, the first of the following to arrive at the hospital activates the hospital Incident Command Center:
Executive Director
Medical Director
Safety Compliance Coordinator

The Incident Command Center will be located in 3D09 unless it is unsafe then it will be relocated to 3A22. The Command Center phone extension is X3857.

Other established centers will be simultaneously established unless otherwise notified:
Center Location Supervisor
Family Center Main Lobby Dir Social Services or designee
Media Center 1A02 Dir of Public Information and Education director or designee
Personnel Pool Cafeteria Dir Social Services or designee

Department Managers should:
Report to the Incident Command Center for briefing when an alert is called.
Notify the Incident Command Center about his/her department’s ability to support emergency operations as soon as possible.

Department managers reporting to Incident Command Center::
Medical Director
UT Police Supervisor
Facilities Management Director
Performance Improvement Director
Safety Compliance Coordinator
Infection Control Nurse
Director of Nursing Services
Social Services Director
Management Information System Director
Health Information Management Director
Public Information and Education Director
Personnel Systems Management Director
Financial Operations Director
Pharmacy Director

Employees not involved in patient care or do not have an assignment from their supervisor or the Incident Command Center should report to the Personnel Pool (cafeteria) after hearing an emergency alert or after being summoned through the hospital recall system.

Employee must remain in the Personnel Pool on alert in the designated area until they receive assignments, are dismissed, or when the alert is cancelled.


Processes to Notify Staff of Emergency Implementations

When emergency plans are implemented, a number of methods are used to notify affected staff. The primary notification with staff onsite would be the audible paging system which is used to announce codes to alert the staff to the emergency type. In addition, communications tools such as telephones, hand radios, email, overhead pager, cellular phones, and pagers are used to assure key staff are aware of the situation. For calling staff back to UTHCPC the cascade recall system will be utilized. Additionally, the plan identifies the process for communications with family members and how family members would be notified if patients are relocated.

Notifying External Authorities

When emergency plans are implemented, dependent on the emergency type, various methods are used to notify external authorities. If the disaster/emergency event is city-wide, the City of Houston Emergency Operations Center is notified by WebEOC. If WebEOC is down then authorities will be notified by phone. Ongoing communications will be established primarily by WebEOC and EMResource.

If the disaster/emergency event is internal, the appropriate authorities including UT Environmental Health and Safety will be notified by phone or email. Ongoing communications will be established via phone and/or email.

Communicate with Community/Media

Release of information to the news media would follow the procedures developed by the Public Information. The Public Information Officer or designee will act as spokespersons for UTHCPC. The Incident Commander will release information as appropriate to the situation. For large scale events, the COH Emergency Operation Center may act as spokesperson for the overall emergency and hospital information.


Resources and Assets

During disaster/emergency events, all emergency supplies that are dissemination and/or consumption are monitored by the Logistics Chief or designee. A log is placed in the emergency supply room (1A81) for tracking impromptu emergency supply distribution and/or consumption. This log should be used when removing supplies and/or returning supplies to inventory. The Logistics Chief or designee is additionally responsible for metering supplies to maximize response effectiveness and is responsible for re-supplying. If additional resources and assets are needed, or if a neighboring facility may be in need of resources and assets, sharing of such with neighboring hospitals may be done by using EMResource or WebEOC to communicate facility needs. EMResource allows our facility to communicate with local and regional areas during disaster/emergency events. Additionally, arrangements have been made with various vendors and other services to replenish supplies including pharmaceutical, medical, fuel, food, water, and protective equipment in the event of an emergency. Ongoing maintenance of PPE is conducted by Support Services on a semi-annual basis.


Security during Emergencies

The EOP is designed to provide security in an emergency/disaster event to ensure the safety of our patients, visitors, and staff and to ensure an orderly flow of traffic in and out of the facility. Security will secure all outside entrances to the facility and provide lobby control to ensure unauthorized entrance. Security will ensure that order is maintained in these areas. Movement within the facility during disaster/emergency events is controlled by card entry access and key. Vehicular access through side entrance and circular drive is controlled and monitored by UT Security. Communications to UT Police would be by phone and/or hand radios. UT Police would coordinate with all necessary community security agencies as necessary.

Nuclear, Biological, Chemical Contamination and Decontamination

The management of situations involving nuclear, biological, or chemical contamination is a joint effort between national, state, and local officials, and the healthcare community. UTHCPC is prepared to manage a limited number of patients, visitors, and staff with hazardous materials. Additionally, UTHCPC has established an Emergency Response Team that has had training for managing decontamination of affected individuals, depending on the severity of the event. Once capability is exhausted, contaminated victims will be isolated and managed by local agencies with specific appropriate expertise.


In the event that a shelter in place is advised for the area including our facility, all persons in the building will be notified that UTHCPC is preparing to shelter-in-place and that all doors will be locked within (3) minutes. All employees and visitors should shelter-in-place at UTHCPC until the "all clear" is announced or whether they will leave the premises within 3 minutes. When the shelter-in-place announcement is made, Facilites Management will immediately power down the HVAC and all related equipment. Employees should ensure that all windows and doors remain closed and locked. All fresh air vents in patient sleeping rooms should be sealed. After that time, no one will be allowed to break the seal on the building until the "all clear" is announced.

Mass Fatality

In the event of a catastrophic mass fatality UTHCPC's ultimate purpose would be to recover, identify and effect final disposition in a timely, safe, and respectful manner. HCPC staff will face a variety of health hazards when handling, or working near human remains. All staff directly involved with recovery efforts that require handling of human remains is susceptible to bloodborne viruses. UTHCPC staff will take precautionary measures while handling human remains by using proper Personal Protective Equipment such as hand protection, foot protection, and eye protection. Proper hygiene will also be measured by maintaining proper hand hygiene to prevent transmission of disease. UTHCPC would establish additional morgue space in the Hospital Wide Education building.


Alternate Roles for Staff during Emergencies

During emergencies, the hospital implements the EOP, which defines the Incident Command Staff that supersedes normal hospital management. Senior staff, as available, is assigned responsibilities using the Incident Command System. They assure that key tasks are staffed. Most staff performs their usual tasks as they are trained, however in the differing circumstance of the emergency. The Incident Commander, Incident Command Staff, and Section Chiefs are compliant with NIMS. Other staff, who will be asked to perform alternate tasks are trained and/or receive an impromptu briefing at the time of the activity.

Staffing in Emergencies

The ICS is used to assure that adequate staffing is available to effectively activate the EOP. The ICS is based on the emergency organization chart and staff availability to complete those tasks.

The emergency organization chart assists the Incident Commander in allocating the available staff to fill the critical positions. Individuals may be asked to accomplish several tasks. This system is designed for both small scale and large scale operations. The ICS process allows for planning staff to look ahead, and determine when more staff should be called in, and when staff on duty should be relieved to provide rest and breaks.

National Incident Management System (NIMS)

ICS-100.HC is an Introduction to ICS online course that is required to be completed by the hospital personnel that would have a direct role in emergency preparedness, incident management, and/or emergency response during an incident.  Personnel designated to fulfill ICS roles (i.e. hospital emergency manager, hospital administration, department heads). Staff members should take course and forward a copy of their NIMS certificate to the Safety Compliance Coordinator. The course can be accessed by clicking on the link below:

Job Assignments

The EOP includes a list of job assignments (Job Action Sheets) to the critical response positions. Job Action Sheets can be found online. A hard copy is provided to the Incident Command Center. Job Action Sheets will be supplied to appropriate staff during activation of the incident command and in changing shifts and/or command staff position/s.

Emergency Plan Organization Chart

The emergency organization chart identifies the incident commander, command staff positions, section chiefs, and general staff positions. It is designed to assist the incident commander in assigning required staff to fill critical positions in the ICS.

Transportation and Overnight Accommodations

The EOP address transportation needs of staff that may not be able to get to and/or from the facility during an emergency event and/or who may need accommodations for overnight stay.

Staff Identification

UTHCPC uses the employee identification badge to identify employees during disaster events. Individuals entering the facility will be required to have a visible employee identification badge in order to enter the facility. Staff or civil authorities without employee identification badges must go through UT Security, be positively identified, and receive a visitors badge or approved alternate.

Key members of the incident command are issued a colored vest which signifies them as a member of the Command team. These vests are moved as incident command roles change, and during longer incidents, as incident command change.


Alternate Sources of Utility Systems

Alternate plans for supply of utilities for patient care are maintained for failure contingencies. Plans include use of the emergency power system; fuel stored for power, water consumption and sanitary purposes, and fuel consumption reduction strategies. Managers and staff in Facilities Management that are affected by the plan are trained as part of department specific education. The plans are tested from time to time as part of the regularly scheduled exercises of the EOP and actual outages of utility systems.

Backup Systems for Communications In The Event of Failure

Several alternate communication systems are available for use during emergency responses. The systems include the regular phone system, two-way radios, cellular phones, text pagers, fax machines, WebEOC, EMTrack, EMResource, satellite phone, and 800 MHz radios. The implementation of the emergency plan focuses on maintaining essential patient care communications. Once the initial level of the plan is in place, MIS will work with representatives of the telephone company to determine the scope and likely duration of the outage and to identify alternatives.


Management of Patient Care Activity

The EOP addresses the management of patient care activities during disaster/emergency events. The plans include procedures for discharging acute release to home or transfer to other facilities as space is needed.

The plan also includes procedures for the management of information about incoming patients and about current patients for planning, patient management, and communicating with families; and for transport of patients.

Evacuation of the Facility

The Emergency Evacuation Plan can be implemented in phases. Relocation of staff away from the area of emergency may be undertaken by moving all individuals involved to areas in adjacent fire zones.

Both vertical and horizontal evacuation is covered. A full evacuation would be implemented if the impact of an emergency renders the hospital is not able to operate safely and would be implemented at the direction of the Administrator or designee.

Patient Safety

The Safety Compliance Coordinator is responsible for working with the Director of Nursing, Director of Performance Improvement, and Clinical Leadership for integrating EC monitoring and response activities into the Patient Safety program. The integration includes conducting environmental risk assessments to identify environmental threats to patient safety, conducting weekly environmental rounds, and by conducting semi-annual environmental hazard safety inspections monthly to evaluate patient safety concerns, participating in the analysis of patient safety incidents, participating in the development of material for general and job-related orientation and on-going education, and conducting bi-monthly Safety meetings.


Medical Staff
During disaster/emergency events, UTHCPC may grant disaster privileges to volunteer licensed independent practitioners.

DISASTER – Volunteer not licensed

During disaster/emergency events, UTHCPC may assign disaster responsibilities to volunteer practitioners who are not licensed independent practitioners.


Annual Program Evaluation

The Safety Compliance Coordinator is responsible for performing the annual evaluation of the Emergency Operations Plan. Annual evaluations examine the scope, objectives, performance, and effectiveness of the EOP. Leadership and medical staff are involved in the annual plan evaluation.

The annual evaluation uses a variety of information sources including: internal policy and procedure review, incident reporting, Safety Committee meeting minutes and reports, and summaries actual disaster/emergency events. In addition, findings by outside agencies such as accrediting or licensing bodies are used. The findings of the annual evaluation are presented to the Performance Improvement Council for review and approval as part of the performance improvement process.


Conducts Exercises to test Emergency Management

UTHCPC tests the response phase of its EOP at least twice a year, either in response to an actual disaster/emergency event or in planned exercises. Actual events are documented in the same manner as planned exercises. Exercises are planned to test various elements of the EOP and to test the various Emergency Response Plans for specific emergencies identified in the HVA. Where practical, exercises are planned in conjunction with other hospitals and local Emergency Management agencies.

UTHCPC participates in at least one communitywide exercise each year relevant to high priority emergencies identified in our hazard vulnerability analysis. During each exercise we assess the communication, logistics, and function of the organization‘s and community‘s command structures, and identity area to improve.

All drills and implementations are documented, observed as practical, and critiqued to identify deficiencies and opportunities for improvement. After-Action reviews are documented and shared with appropriate departments and/or committees and copies are forwarded to the Southeast Texas Trauma Regional Council (SETRAC)..

Performance Monitoring

The Safety Compliance Coordinator manages the Emergency Management Program and the performance measurement process.

The Safety Compliance Coordinator is responsible for preparing quarterly reports of performance and experience for the Safety Committee. The reports include ongoing measurement of performance, a summary of identified problems, and potential improvements to the EOP identified during drills and implementations and other activity. The performance monitoring reports are provided to the Governing Body.

The Safety Compliance Coordinator establishes performance indicators to objectively measure the effectiveness of the EOP and determines appropriate data sources, data collection methods, data collection intervals, analysis techniques and report formats for the performance improvement standards. Human, equipment, and management performance are evaluated to identify opportunities to improve the Emergency Management Program.

Related Standards

The Joint Commission: Emergency Management

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Harris County Psychiatric Center University of Texas Health Science Center