Leadership – Emergency Response

Service: Risk Management
Subject: Leadership
Type: Risk Profiles

Ongoing emergency preparedness is critical in promoting safety awareness and is part of the organization’s commitment for safety of patients, visitors, volunteers, staff, and physicians. Deficiencies that place organizations at risk can include outdated emergency response plans, inadequate staff knowledge and training, inadequate supplies, or lack of oversight of planning, overall preparedness, and monitoring activities. This document contains information entered by HIROC subscriber healthcare organizations (acute and non-acute) in the Risk Register application to help you in your assessment of this risk.

Key Controls/Mitigation Strategies

Operations/Planning:

  • Emergency management program/plan
  • Incident Management System framework for actual and emerging/escalating issues
  • Established culture of emergency preparedness
  • Emergency preparedness committee reviews all emergency plans (including pandemic plan) on a scheduled basis
  • Emergency/Crisis Communications and Emergency Management Plan
  • Evacuation plan and emergency shelter for critical/complex patients
  • Emergency Preparedness patient information pamphlets 
  • Policies and procedures in place and updated on a regular basis including outbreak management policy
  • Drug and supply chain contingency plans in place 
  • Business Continuity Plan in place for:
    • Prioritizing and contacting patients in the event of an emergency
    • Ensuring management of technology disruptions such as key clinical information systems
    • Ensuring strategies in place for loss of utilities
  • Surge protocols in place and plans to maintain care capacity
  • Emergency Operations Centre in place and emergency supplies available at all sites
  • Chemical, Biological, Radiological, Nuclear, Explosives (CBNRE) response equipment in place and in good working order/repair
  • Hazard identification and risk assessment (HIRA)
  • Business Impact Assessment (BIA)
  • Retain adequate liability insurance
  • Five-year working capital plan in place
  • Financial tracking process to monitor financial impacts incurred during code response events

Systems:

  • Identify strategies and processes for:
    • Identification of legacy clinical systems at high risk of failure
    • Access to key service agreements such as union, vendors
    • Downtime processes for all systems
  • Robust information technology/information management backup system(s)

Human Resources:

  • Dedicated permanent Emergency Preparedness Manager 
  • Dedicated permanent Public Relations specialist (communication approval process, media releases, advisories, social media posts)
  • On-call administration staff provided with appropriate orientation and resources
  • Experienced staff with core competencies (e.g., response teams for various emergencies)
  • Ability to deploy staff during emergencies 
  • On-call system of administrative staff
  • Fan-out lists updated regularly
  • Regularly scheduled N95 fit testing and compliance reporting

Exercises, Evaluation and Updating the Program/Plan

  • Orientation and annual staff education/online training modules, training videos
  • Tabletop exercises internal/external annual review of Emergency Codes
  • Quick reference sheets (Emergency Codes) for use by staff
  • Intranet materials with Emergency Code of the month featured
  • Management staff complete Incident Management System training
  • Fire Warden Training
  • Fire Marshal and Fire Brigade review fire and evacuation plans 
  • Inventory of Hospital plans and dates last updated
  • Mock codes conducted at least annually to test operational readiness
  • Workplace Safety Committee commitment to support fire response
  • County-wide disaster exercises conducted every two to three years
  • Monthly testing of electronic communications system
  • Monthly testing of fire alarms
  • Quarterly safety inspections to include fire extinguisher availability, clear exits, illuminated exit signs
  • Annual verification of alert and suppression system
  • Standard Emergency Codes followed 
  • Post emergency code reviews to identify opportunities for improvement and implement required changes
  • Evacuation exercises annually (Pre-identified external location(s) for evacuation purposes)
  • Sustainability program with “train the trainer” model 
  • Debriefs following all actual or mock emergency codes with recommendations to Emergency Management Committee

Resources and Relationships/Partnerships

  • Regional Incident Command implemented as needed to manage threats to business continuity and to aid in business recovery activities
  • Engagement of senior leadership at the regional and provincial levels of decision-making
  • Regional capacity plan to address surges in volumes related to sudden loss of capacity (e.g., pandemic)
  • Maintain good working relationship with community partners (e.g., Emergency Medical Services, Long-Term Care, Public Health) and with Fire Chiefs and Police department
  • User of Canadian Network for Public Health Intelligence
  • Public Health Unit and Public Health Agency of Canada
  • Pandemic Plan and Infection Control strategies reviewed with partner agencies 
  • Established relationships and/or partnerships with municipal and provincial governments (e.g., municipal emergency control group)
  • Ministry of Health (MoH) for funding allocations
  • Partner with other organizations and leading experts
  • Compliance with provincial/federal regulations
  • Strong collaborative relationships between organizational programs and services during emergencies

Monitoring/Indicators

  • Compliance with Accreditation Canada standards
  • Emergency preparedness workplan
  • Number of committee meetings
  • Monthly fire drill compliance rate
  • Number of emergency procedure/process drills conducted
  • Organization training rates
  • E-Learning summary reports by department/program
  • Number of staff completing training modules
  • Annual fire department inspection
  • Monthly health and safety inspections
  • Location of Emergency Codes called
  • Maintenance of alert and suppression systems (deficiency repairs)
  • Inventory of critical supplies monitored and maintained
  • Organization-wide training monitored by dedicated Emergency Preparedness Manager
  • Immunization and disease surveillance data 
  • Media inquiries
  • Public/client feedback 
  • Number of codes (actual/mock); number of recommendations arising from codes
  • Number of staff completing post mock code survey
  • Annual review/revision of emergency code procedures/emergency plan 
  • Immunization and disease surveillance data
  • Municipal/provincial alerts
  • Efficacy rating of Incident Management System (IMS) utilization
  • After Action Report tracking (lessons learned and corrective action)
  • Evacuation statistics for similar organizations
  • Success in relocating staff/patients due to site disruptions
  • Percentage of information technology downtime
  • Power or system failure rate
  • Code statistics for Code Blue Responses
Date last reviewed:
This is a resource for quality assurance and risk management purposes only, and is not intended to provide or replace legal or medical advice or reflect standards of care and/or standards of practice of a regulatory body. The information contained in this resource was deemed accurate at the time of publication, however, practices may change without notice.