• Principal Consultant

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

troy@consultants4accreditation.com should you have further

questions or concerns. Good Luck and Best Regards.

T. Lair


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.


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.


A.Describe the potential hazards that the center is vulnerable to such as hurricanes, tornados, flooding, fire