Accreditation Resource Services Newsletter
December 2020


Emergency All-Hazardous Plan

By: Don Roush
When you think about it, the worst time to think about emergency planning is when the risk of an emergency threatens your hospital. When you are called to respond to an emergency, hospital administration will be thankful they already formed an emergency planning team headed up by responsible team members such as yourself.
As a rule, all-hazards plans address the resources and steps your hospital needs to take before and after an emergency happens to minimize injury to people and destruction of property. With the all-hazards approach, your hospital can take emergency preparedness to a level that is more effective and scalable. The all-hazards approach is defined by the Centers for Medicare and Medicaid Services as an “integrated approach to emergency preparedness planning that focuses on capacities and capabilities that are critical to preparedness for a full spectrum of emergencies or disasters”. The emergency all-hazards plan is just one part of a hospital’s emergency preparedness program. A well-developed plan provides the framework for conducting facility-based and community-based risk assessments that will assist the hospital in addressing the needs of their patient populations, along with identifying the continuity of business operations which will provide support during an actual emergency.

All-Hazards Plan Process

Traditionally, members of your environment of care or safety team are designated to initiate the review process of the all-hazards plans. Your hospital should identify hazards that are specific to your location and surrounding areas, and use the information to initiate the planning process. Planning is generally structured based upon the facility and community risk assessment using an “all-hazards” approach. Information gathered should be reviewed first when developing an emergency all-hazards plan to validate if potential hazards related to the hospital are still applicable to your hospital. Examples identified by past and present hazards that are specific to your hospital’s location and surrounding areas may include, but are not limited to, natural disasters prevalent in the hospital’s geographic region such as wildfires, tornados, flooding, natural disasters, and man-made disasters. Additionally, consider facility-based disasters such as care related emergencies; equipment and utility failures, including but not limited to, power, water, and gas; as well as interruptions in communication, including cyber-attacks. And finally, consider loss of all or a portion of a facility and interruptions to the normal supply of essential resources, such as water, food, fuel (heating, cooking, and generators), and in some cases, medications and medical supplies (including medical gases, if applicable).
One common misperception is that all-hazards planning means planning for everything that can go wrong with a healthcare organization. To the contrary, all-hazards planning focuses on developing capacities and capabilities that matter when the going gets tough, assuring the healthcare organization can respond appropriately. In other words, it doesn’t zero in on every single threat, but instead makes sure that healthcare organizations have the training, supplies, and leadership to address a broad range of emergencies. Also, be aware that “community” is not defined in order to afford hospitals the flexibility in deciding which agencies it considers to be part of its community for emergency planning purposes. However, the term could mean entities within a state or multi-state region. The goal of the provision is to ensure that your hospital collaborates with other entities within a given community to promote an integrated response. Conducting integrated planning with state and local entities could identify potential gaps in state and local capabilities that can then be addressed in advance of an emergency.
Take note that if the your hospital relies on a community-based risk assessment developed by other entities (such as public health agencies, emergency management agencies, and regional health care coalitions) in conjunction with conducting its own facility-based assessment, you are expected to have a copy of the community-based risk assessment and to work with the entity that developed it to ensure that the healthcare organization’s emergency all-hazards plan compliments and is in alignment with these risk assessments. Additional resources to assist you when preparing your emergency all-hazards plan include utilizing the concepts outlined in the National Preparedness System, published by the United States Department of Homeland Security’s Federal Emergency Management Agency (FEMA), as well as guidance provided by the Agency for Healthcare Research and Quality (AHRQ).
After the information is collected, then you are required to prioritize this information into the probability of it actually occurring. The probability is based on actual events that have taken place or expose a high degree of actually happening even if no events have occurred. For example, if your hospital is located next to or near an airport, you will need to include the airport in your risk analysis as if they had an actual airport disaster and how it would affect the hospital. It is at this point that the team will construct what is commonly referred to as the hazard vulnerability analysis.
You are required to develop and maintain an emergency preparedness plan that includes all of the required elements under standard §482.15(a). 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 for the emergency preparedness plan is left to the hospital’s discretion.
Remember the all-hazards approach is your approach to emergency preparedness planning that focuses on the hospitals capabilities that are critical to deal with a complete variety of emergencies or disasters. This approach is specific to the location of your hospital and considers the types of hazards most likely to occur in your area. Basically, the all-hazards approach takes what seems like a monumental task and breaks it down into a plan that will ensure your employees have a standard protocol to follow in case of an emergency.
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