Leadership – Emergency Response

Service: Risk Management
Subject: Leadership

Ongoing emergency preparedness is critical in keeping the patients, visitors, volunteers, staff and physicians in a variety of healthcare settings safe at all times.  Deficiencies that place organizations at risk can include outdated emergency plans, inadequate staff knowledge and training, inadequate supplies, or lack of oversight of planning, preparedness and monitoring activities. This document contains information entered by your peers in the Risk Register application to help you manage this risk.

Ranking / Ratings

  • Likelihood – average score 2.62
  • Impact rating – average score 3.18

The Risk Register allows for risks to be assessed on a five-point likelihood and impact scale, with five being the highest.

Key Controls / Mitigation Strategies

  • 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 Communications and Emergency Management Plan
    • Business Continuity Plan for prioritizing and contacting patients in the event of an emergency
    • Dedicated permanent Emergency Preparedness Manager
    • Dedicated permanent Public Relations Specialist (communication approval process, media releases, advisories, social media posts)
    • Experienced staff with core competencies (e.g. response teams for various emergencies)
    • Ability to deploy staff during emergencies
    • Standard Emergency Colour Codes followed
    • Emergency Operations Centre in place and emergency supplies available at all sites
    • Chemical, Biological, Radiological, Nuclear, Explosives (CBNRE) response equipment in place
    • Regularly scheduled N95 fit testing and compliance reporting 
    • Emergency preparedness patient information pamphlets
    • Hazard identification and risk assessment (HIRA)
    • Business Impact Assessment (BIA)
    • On-call system of administrative staff
    • Fan-out lists updated regularly
    • Retain adequate liability insurance
    • Robust information technology/information management backup system(s)
  • Exercises, evaluation and updating the program/plan
    • Annual staff education/online training modules
    • Annual review of Emergency Colour Codes
    • Quick reference sheets (Emergency Colour Codes) for use by staff
    • Intranet materials with Emergency Colour Code of the month featured
    • Management staff complete Incident Management System training
    • Fire Marshal and Fire Brigade review fire and evacuation plans
    • Mock codes conducted at least annually to test operational readiness
    • County-wide disaster exercises conducted every two to three years
    • Monthly testing of electronic communications system
    • Annual verification of alert and suppression system
    • 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, relationships/partnerships
    • 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)
    • Partner with other organizations and leading experts
    • Compliance with provincial/federal regulations
    • Strong collaborative relationships between organizational programs and services during emergencies

Monitoring / Indicators

  • Monthly fire drill compliance rate
  • Annual fire department inspection
  • Location of Emergency Colour Codes called
  • Maintenance of alert and suppression systems (deficiency repairs)
  • 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
  • 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

Note: Information presented in this document has been taken from the shared repository of risks captured by HIROC subscribers participating in the Integrated Risk Management program.