Accreditation Resource Services Newsletter
December 2020

CIHQ-ARS Article

Hazardous Vulnerability Analysis

By: Don Roush
As you sit at home watching the news, it suddenly dawns on you that the majority of what is being reported is related to emergencies and disasters that have occurred just that day. You begin thinking, what if any one of these events had impacted the hospital in which you work? Is the hospital prepared to deal with such events? It is not uncommon for hospital personnel to be part of a team of individuals who are accountable for looking into such events and assessing if they could impact the hospital, and determine the probability and severity of how such events would affect the daily operations of the hospital. This process is commonly referred to as a hazardous vulnerability analysis.
A hospital’s hazard vulnerability analysis (HVA) is a systematic approach to identifying hazards or risks that identify the hospital’s highest vulnerabilities to natural and man-made hazards and the direct and indirect effect these hazards may have on the hospital and surrounding community. The HVA provides a straightforward way to complete a risk assessment. The HVA assesses your hospital’s current level of emergency preparedness and the human, property, and business impact of multiple hazards. Also, the HVA can help quantify the level of risk and the severity of impact, so preparedness efforts address the most important potential emergencies. The challenge to your hospital is how do you accomplish this?

Conducting the Hazard Vulnerability Analysis

To properly begin to conduct an HVA you will need to identify a responsible person to coordinate this process. This person traditionally has been a leader of the environment of care or safety team; one who has not only experience leading a group of people, but one who has been exposed to the HVA process. This person in turn will be accountable for assembling a multidisciplinary team of talented individuals from the hospital that can contribute to the development of the HVA for the hospital. As a rule, this team is made up of, but not limited to, representatives from administration, facilities engineering, supply chain or material management, legal, finance and IT. One of the most important tasks of the team leader is to ensure that the representatives work as a cohesive group and that individual silos are not introduced. This is a team effort and members are to be treated equally so that all possible hazardous are identified and discussed. After this stage is completed, the team will need to identify the categories of incidents that could affect the hospital and its surrounding areas.
The HVA is generally broken down into categories of incidents for the hospital to evaluate. The categories that have been traditionally used by hospitals are as follows: Technological (e.g. IT failure, HVAC failure, electrical failure, supply shortage, etc.), Man Made (e.g. active shooter, VIP situation, infant abduction, civil disturbance, etc.) and Naturally Occurring (e.g. tornado, snow storm, pandemic, ice storm, earthquake, etc.), and Hazardous Materials (chemical exposure, external, mass casualty hazmat incident, large internal spill, etc.). As you evaluate the events your team has identified, you will become aware of how they soon begin to fit into these specific categories or another category altogether.
After the team has determined the activities that can affect the hospital and arranged them into categories, you will then start the assessment process of how each of the events will impact your hospital. Here the team will determine not only the probability of the event happing but the severity of such an event as it is related to hospital operations. For instance, how the event will impact patients, staff and visitors if the event were to occur – could it cause death or injury to them? The other areas that are generally assessed related to the event are the effects on the hospital’s property (losses and damage) and the business impact – how it will affect the services the hospital provides? After the team has determined the impact on the hospital, they will then need to determine how well the hospital has mitigated their operations to deal with these events.
During the mitigation review the team will evaluate how prepared the hospital is to deal with each event. In other words, how able is your hospital to deal with the events you have identified? Do you have proper training and personnel to deal with the event? Remember each event is unique and the essential personnel and training can vary dramatically with each event. It is up to the team to effectively evaluate each event to ensure your hospital can effectively deal with such an event. The team will also need to consider both internal and external response to the events. Here it is important to ensure that effective resources are available or maintained not only by your hospital, but your community as well. It is important to understand that the community may be relied upon to assist your hospital in such situations.
Finally, all this information needs to be properly documented through a formal HVA which includes appropriate team meeting minutes approved by the environment of care or safety team. You are required to develop and maintain an emergency preparedness plan that includes all of the required elements under standard 42 CFR §482.15(a) Condition of Participation for Emergency Preparedness. The plan must be reviewed and updated at least every two years. The biennial review must be documented to include the date of the review and any updates made to the emergency plan based on the review. The format of the emergency preparedness plan is at the discretion of your hospital. While there are a number of ways to conduct the HVA, Kaiser Permanente has developed a widely used HVA tool that can help identify and assess the most common hazards. This tool can be used as one form of documenting how your team assessed the HVA related to your hospital.
The key to reducing the impact of emergencies and disasters is taking the necessary steps to ensure preparedness. Determining the areas of vulnerability is critical to any emergency and disaster preparedness plan. While avoiding hazards entirely may be impossible, a proactive approach to disaster management will help reduce the degree of impact and mitigate further damage. It is the responsibility of your hospital to develop a thorough understanding of potential risks and resources required prior to a disaster, resulting in an effective, efficient response.