A Template for developing the perfect emergency management plan for your surgery center.
Updated: Nov 6, 2019
Criteria for Ambulatory Surgery Centers
Emergency Management Plan
This questionnaire provides you the basic outline for achieving
a comprehensive emergency management plan for your
ambulatory surgery center.
By using this template and outline, you can rest assured that all
your basic bases are covered and that your plan has been
systematically thought through to the point of governing body
readiness and presentation to your board for final approval.
This has been reviewed by many surveyors to include both
Medicare CMS surveyors with Joint Commission and Joint
Commission Surveyors whereby they have approved this
format for other clients to use for their own internal plan
should there be an emergency of the magnitude that would
cause the plan to be executed.
You can reach me, the author of this by calling me at
323.603.8333 or by email at
firstname.lastname@example.org should you have further
questions or concerns. Good Luck and Best Regards.
A.Provide basic information concerning the center to include:1.Name of center, address, phone number, 24-hour emergency contact phone number, pager number (if available), fax number, type of center, and license.2.Owner of center, address, phone (private or corporate ownership).3.Year center was built, type of construction and date of any subsequent construction. 4. Name of Administrator, address, work/home phone number, and work/home phone number of his/her Alternate. 5. Name, address, work and home phone number of designated Safety Liaison serving as the primary contact for emergency operations. 6. Name, address, work and home phone number of person implementing the provisions of this plan, if different from the Administrator. 7. Name, work, and home phone number of person(s) who developed this plan.8.Organizational chart identifying key management positions, with phone numbers. B.Provide an introduction to the Plan that describes its purpose, time of implementation, and the desired outcome that will be achieved through the planning process. Also, provide any other information concerning the center that has bearing on the implementation of this plan.
II. AUTHORITIES AND REFERENCES
A.Identify the legal basis for plan development and implementation to include statutes, rules and local ordinances, etc.B.Identify reference materials used in the development of the plan. C. Identify the hierarchy of authority in place during emergencies. Provide an organizational chart, if different from the previous chart required.
III. HAZARD ANALYSIS
A.Describe the potential hazards that the center is vulnerable to such as hurricanes, tornados, flooding, fires, hazardous materials, transportation accidents, proximity to a nuclear power plant, power outages during severe cold or hot weather, gas leaks, etc. Indicate history and lessons learned.B.Provide site-specific information concerning the center to include:1.Location Map, a street level map noting the location of the facility. 2. Licensed capacity, number of recovery beds, number of operating suites, maximum number of patients on site, and average number of patients on site. 3. Maximum number of staff on site. 4. Identify types of patients served by the center. C. Identify the elevation of the first finished floor of the facility.D.Identify the hurricane surge evacuation zone the facility is located in, as of July 1, 2011. E. Identify the flood zone the facility is located in, as identified on a Flood Insurance Rate Map, as of 8/28/08. F. Number of miles center is located from a railroad or major transportation artery. G. Identify if center is located within 10 mile or 50-mile emergency planning zone of a nuclear power plant.
This section of the plan defines the policies, procedures, responsibilities and actions that the center will take before, during and after any emergency situation. At a minimum, the center plan needs to address direction and control; notification; and evacuation and sheltering.
IV. CONCEPT OF OPERATIONS
A.Direction and Control1.Identify by title who is in charge during an emergency and one alternate, should that person be unable to serve in that capacity.2.Identify the chain of command to ensure continuous leadership and authority in key positions. 3.State the procedures that ensure timely activation and staffing of the center during emergency incidents. 4. State the operational and support roles for all surgical center staff (This will be accomplished through the development of Standard Operating Procedures, which must be attached to this plan). 5. State the procedures to ensure the following needs are supplied:a.Emergency power and, if applicable, natural gas or diesel. If natural gas, identify alternate means should loss of power occur (which would affect the natural gas system).What is the capacity of the fuel tank for the emergency power system? b. water and other essential supplies. 6. Describe the ambulatory surgical center’s role in the community wide comprehensive emergency management plan and/or its role in providing for the treatment of mass casualties during an emergency. 7. Provide information on the management of patients treated at the center during an external and internal emergency.
Procedures must be in place for the center to receive timely information on impending threats and the alerting of the center’s decision makers, staff, and patients of potential emergency conditions. B.Notification1.Describe how the center will receive warnings of emergencies.2.Describe how staff will be alerted.3.Describe the procedures and policy for staff reporting to work for key workers, when the center remains operational.4.Describe how patients will be alerted, and the precautionary measures that will be taken, including but not limited to voluntary cessation of center operations.5.Identify alternative means of notification should the primary system fail.6.Identify procedures for notifying those hospitals or subacute care (for which mutual aid agreements are in place) to which patients will be evacuated. C. Evacuation-Ambulatory surgical centers must plan for both internal and external disasters. The following criteria should be addressed to allow the ambulatory surgical center to respond to both types of evacuation. 1.Describe the policies, roles, responsibilities, and procedures for the discharge or transfer of patients from the surgical center.2.Identify the staff position responsible for implementing the surgical center discharge and evacuation procedures.3.Identify transportation arrangements made through mutual aid agreements, memorandums of agreement or understandings that will be used to transfer patients (copies of the agreements must be updated annually and attached in the appendix). If this is arranged through a centralized agency, please explain. In addition, if there is a “transportation shortfall” in the area, please explain how the problem is addressed under current limitations.4.Describe transportation arrangements for logistical support to ensure essential records and other necessities. If this is arranged through a centralized agency, please explain.5.Identify the pre-determined locations to which patients will be evacuated. If relocation is coordinated through a centralized agency, please explain.6.Provide a copy of the mutual aid agreement that has been entered into with a facility to receive patients.7.Specify at what point the mutual aid agreements for transportation and the notification of alternate facilities (hospitals or sub-acute care) will begin.8.Identify evacuation routes that will be used and secondary routes that would be used should the primary route be impassable.9.Specify the amount of time it will take to successfully discharge or transfer patients to the receiving hospital or subacute care facility. Keep in mind that in hurricane evacuations, all movement should be completed before the arrival of tropical storm winds (45 mph). 10. Describe the procedures to ensure that the surgical center’s staff will accompany transferring patients. If surgical center staff will not be accompanying patients, what measures will be used to ensure their safe arrival (i.e. who will render care during transport).11.Establish procedures for ensuring that all patients are accounted for and are out of the center. If patients will be considered discharged at the time of relocation, please explain.12. Establish procedures for responding to family inquiries about patients who have been transferred.
Once a surgical center has been evacuated, procedures need to be in place for allowing patients to re-enter the center. D. Re-Entry . 1.Identify who is the responsible person(s) for authorizing re-entry to occur. 2. Identify procedures for inspection of the surgical center to ensure it is structurally sound.
This section identifies the procedures for increasing employee and patient awareness of possible emergencies and providing training on their emergency roles before, during, and after a disaster.
V. INFORMATION, TRAINING
A.Identify how and when staff will be trained in their emergency roles during non-emergency times.B.Identify a training schedule for all employees and identify the provider of the training.
C.Identify the provisions for training new employees regarding their disaster related role(s). D. Identify a schedule for exercising all or portions of the disaster plan on a semi-annual basis.E.Establish procedures for correcting deficiencies noted during training exercises.
The following information is required, yet placement in an APPENDIX is optional, if the material is included in the body of the plan.
A.Roster of employees and companies with key disaster related roles.1.List the names, addresses, and phone numbers of all staff with disaster related roles.2.List the name of the company, agency, organization, contact person, phone number and address of emergency service providers such as transportation, emergency power, fuel, water, police, fire, rescue, Red Cross, emergency management, etc. B. Agreements and Understandings 1. Provide copies of any mutual aid agreements, memorandums of agreement or any other understandings entered into pursuant to the fulfillment of this plan. This is to include reciprocal host center agreements, transportation agreements, current vendor agreements or any other agreement needed to ensure the operational integrity of this plan.C.Evacuation Route Map1.A map of the primary and secondary evacuation routes and description of how to travel to receiving facility(ies). D. Support Material1.Any additional material needed to support the information provided in the plan. 2. Copy of the facility’s fire safety plan that is approved annually by the local fire department, with an annual letter of approval from the fire department. (Fire Inspection Certificate will not be accepted, it must be a letter of approval.) . E.
Standard Operating Procedures