Accreditation Resource Services Newsletter
November 2020


Essential Phases to an Emergency Preparedness Program

By: Don Roush
You have just been promoted to a management position and you have been called into the directors’ office and find out you have been assigned additional responsibilities related to your new job. What surprises you is that you now have the responsibly of the emergency preparedness program, and you are asked to give a five-minute summation of how it is set up at next month’s leadership meeting. So where do you begin? The first thing is to identify how the phases of an emergency preparedness program are currently maintained in the hospital.
Essentially, there are four phases to an emergency preparedness program that hospitals commonly work with; hazard mitigation, preparedness, response and recovery. These phases are important for leadership to have a fundamental understanding of, since they commonly drive the overall emergency preparedness program in preparing the hospital to deal with hazards, disasters and emergencies that can ultimately affect the operations of the hospital.

Hazard Mitigation

Hazard mitigation are the steps taken by your hospital to eliminate or reduce the probability of an event, or reduce its severity or consequences, either prior to or following the disaster or emergency. Your emergency plan should include mitigation processes for both patients and staff. The mitigation details should address care for the patients and how the hospital will educate staff in protecting themselves in the likelihood of an emergency. This can be achieved through risk analysis, which will provide information for a foundation of typical mitigation measures that may include, but are not limited to; building codes, zoning requirements, surrounding business, resources, training, community, and environmental conditions that are associated with the hospital and its surrounding area. These activities precede any imminent or post-impact timeframe and are considered part of the response. Remember that comprehensive hazard mitigation efforts, including staff education, will aid in reducing staffs' vulnerability to potential hazards and better prepare your hospital to deal with prospective emergencies that may arise.


Preparedness includes developing a plan to address how your hospital will meet the needs of patients, employees, and the surrounding population, if essential services breakdown as a result of a disaster. The preparedness plan for your hospital should be the product of a review of the basic facility information, a hazard analysis, and an analysis of your hospital’s ability to continue providing care and services during an emergency. It also includes training staff on their role in the emergency plan, testing the plan, and revising the plan as needed. Preparedness measures can take many forms including the construction of shelters, installation of warning devices, creation of back-up life-line services (e.g. power, water, sewage), and rehearsing evacuation plans.


These are activities immediately before (for an impending threat), during and after a hazard impact to address the immediate and short-term effects of the emergency that your hospital has identified. Your first step when developing the emergency response plan is to conduct a risk assessment to identify potential emergency scenarios. An understanding of what can happen will enable hospital personnel to determine resource requirements and to develop plans and procedures to prepare your hospital. Be sure that your emergency plan is consistent with your performance objectives.
At a minimum, your hospital should develop and implement an emergency plan for protecting employees, visitors, physicians and anyone else in the hospital, and includes building evacuations (“fire drills”), sheltering from severe weather such as tornadoes, “shelter-in-place” from an exterior airborne hazard such as a chemical release, and facility lockdown protection.


What needs to be understood is that recovery differs from the response phase because of its focus. Recovery efforts are concerned with issues and decisions that your hospital must make after immediate needs are addressed. Recovery efforts are primarily concerned with actions that involve rebuilding destroyed property, maintaining hospital services, and the repair of other essential infrastructure. Another way to look at it, is that recovery is the development, coordination, and execution of services and site restoration plans that not only impact the hospital but the community as well. Activities and programs that you implement during and after the response are designed to return the hospital to its usual state or a "new normal."
You should make every effort to include any potential hazards that could directly and indirectly affect your hospital and community. Indirect hazards could affect the community but not the hospital, and as a result, interrupt necessary utilities, supplies or staffing. Be mindful of the fact that the emergency preparedness program is comprised of many different components, each contributing to the overall improvement of your hospital to fully evaluate what is currently being addressed, and what needs to needs be implemented.
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