When healthcare facilities approach CMS emergency preparedness compliance, it’s natural to focus on the contents of the emergency operations plan or continuity of operations plan. Careful documentation of policies, procedures and roles is necessary to help ensure that all staff will complete the appropriate tasks in the event of a disaster.

However, an effective emergency preparedness program is more than a written plan. Having a strong EOP and/or COOP is necessary but not sufficient. The other critical component of an emergency preparedness program is an ongoing set of activities for learning, practicing, testing and improving the plan.  Testing, training and continuous improvement are also requirements put forth in the CMS emergency preparedness rule—no facility can be compliant without them.

The nine-step development process for a comprehensive emergency program used by the Veterans Health Administration (VHA) illustrates the substantial role that ongoing preparedness activities play. I will highlight just a few important examples of how the written plan and emergency preparedness activities work together.

  • The Committee:  The team formed to lead the ongoing emergency preparedness program.  The committee, comprised of stakeholders throughout the organization, should take a lead role not only in developing a written plan, but in ensuring that preparedness activities occur regularly. It’s worth noting that the committee identified in step one of the program remains at the center throughout.  

Creating a well-organized written emergency preparedness plan

A carefully prepared plan is essential to both emergency preparedness and CMS compliance. Documentation is a central focus of the CMS survey process, so the written plan should be detailed and organized. The next three steps of the development process focus on the written plan:

  • All-Hazards Planning: The foundation of your plan.  It is a comprehensive assessment of all hazards and is a requirement of the CMS emergency preparedness rule.  The all-hazards plan must be accompanied by an adaptable incident command model.
  • Hazard Vulnerability Analysis: Used to identify and prioritize the hazards, threats and events that could occur, their likelihood and impact they could have on your ability to care for patients. The identified hazards will require incident-specific guidance. This process should include business risk analysis as well, to assess the impact of specific events on essential business activities.
  • Incident-Specific Planning: Hazards determined to be high risk should have an incident-specific annex in the EOP or COOP. For example, depending on the region, a hurricane or wildfire would have an incident-specific annex describing the actions and resources relevant to that event.

The outcome of these steps could be organized as follows:

  • A basic plan
  • Functional annexes describing the role of different groups (such as Command, Logistics, Health and Medical and others) in the plan
  • Incident annex for plan related to specific hazards
  • Appendices including important background information such terms and definition or pre-planning analysis

The plan should be readily accessible in multiple formats and locations, including hard copy and digital. Without the next several steps, however, a written plan will not be fully effective when a genuine emergency occurs.

Developing emergency preparedness through ongoing action

An emergency program is active in several ways. Preventative actions could include upgrading the physical plant or implementing more robust communication technology. Responsive actions occur after an event, to avoid or minimize the impact of a future occurrence of a similar emergency, applying lessons learned. Most of an organization’s preparedness actions, however, will focus on preparing for hazards that cannot be prevented, as reflected in the remaining five steps of the nine-step program development process:

  • Mitigation and Operating Unit Planning: Identifies activities that eliminate or reduce the impact of hazards on patient/resident care, such as installing and maintaining a power generator. Creating communication plans for emergency notifications, crisis communication with the public, and resident and family updates falls under this step.
  • External Coordination and Support: Building and maintaining coalitions and partnerships with other healthcare providers and government agencies
  • Education and Training: Confirming that all staff have been trained in both the knowledge and the application of the emergency plan.
  • Exercises and Operations: Coordinating, executing and documenting drills and full-scale exercises to validate emergency preparedness.
  • Evaluation and Improvement: Identifying gaps in preparedness after drills and exercises – procedures, activities, training, documentation, etc. – with action plans to improve, resulting in updates to the EOP and/or COOP. Annual reviews and updates are required by CMS.

When long-term care facilities are already working full-tilt to provide care for residents, this list of steps may appear overwhelming. It doesn’t have to be! One of the most helpful ways to support staff emergency preparedness is to align everyday practices with those followed in an emergency.

For example, many security protocols used on a daily basis—rounding in particular pattern, checking for locked doors at specific times—can be incorporated into the security function in the emergency plan.

So much of emergency management involves communication, from mass notifications to contact with emergency partners to maintaining situational awareness. Coordinating ordinary resident care also depends on well-organized communication. Issues such as bed availability, staff location and availability, and inventory status become more urgent during an emergency, but they are issues that must also be managed on a day-to-day basis.  A communication system adaptable for both everyday and emergency management needs will minimize the amount of training required for use.

These similarities will help build both muscle memory for activities and fluency with tools. The more seamless the transition to emergency actions can be, the faster your facility can restore continuity of operations and care to residents.

Terry Zysk is the CEO of LiveProcess. For a more detailed discussion of the nine steps and their implementation in nursing homes and other long term care facilities, view the long-term care webinar Building a Compliant Program or visit our blog.