JCIA 5th Edition

FMS.2 and FMS.6 Disaster Preparedness PLAN – OUTLINE √ If

Presen
t

 Purpose
o To ensure a hospitalwide plan to respond to and manage emergencies, epidemics,
and disasters that may affect the hospital.
o To determine the type, likelihood and consequences of hazards, threats, and
events;
o To determine organization’s role in such events;
o To establish communication strategies for such events;
o To establish processes for managing resources during events, including
alternative sources;
o To establish processes for managing clinical activities during an events,
including alternative care sites; and
o To identify and assign staff roles and responsibilities during an event.

 Goals (measurable for what is to be accomplished or maintained (annually updated)

 Responsible individual designated with scope of authority defined

 Risk assessment
o HVA - Risk assessment using a structured format
 Describe process and how used to set priorities for policies and
procedures
 Identify who conducts HVA and where report results
 Conduct the HVA and include the conclusions in the plan

 Identification of major internal and external disasters and major

epidemic events which pose significant risks of occurring based upon
HVA

 Identify any country law or regulations regarding community emergency plan and
describe hospital role in a community disaster

 Program response strategies

o Describe responses to each likely disasters including:
 Determining the organization’s role in such events
 Communication strategies for events
 Managing of resources during events, including alternative sources
 Management of clinical activities during an event, including alternative
care sties
 Role of Outpatient Clinics operations and staff in disasters and
emergencies
 Describe the HICS process and reference any policies
 Identification and assignment of staff roles and responsibilities during
such events
 Describe process for working with community resources

JCI Disaster Plan – Outline 10/2014

P. 1
 JCIA 5th Edition

FMS.2 and FMS.6 Disaster Preparedness PLAN – OUTLINE √ If

Presen
t
o Police – directing traffic, allowing hospital personnel to
pass
o Special ID for staff identification (police, security know)
o Fire Department
o Communication – backup systems between hospital and
municipality, etc.
o Security – limiting access to property, guards at doors,
etc
o Civil defense or central governmental coordinating
group
o News – determining news ‘room’ or location, hospital
spokesman
o Ambulance services
o Coordination with hospital security force
 Responses to Internal or External event including:
o Triage (entry) points in hospital
o Triage methodology and supplies
o Designated space according to triage type
o Method of identifying incoming patients
o Identification of teams, membership of teams and
numbers of teams
o Identify decontamination area and process
o Identification of location of teams within hospital
o Supplies:
 What is pre-stocked and where
 Availability of medications, food, supplies, and
sterile supplies
o Off-site clinical alternative sites selected, if necessary
o Communication with staff
o HICS - command center
o Special phones or other communication equipment for
staff
o Notification of inpatients
 Who is responsible
 What should be told
 How is information conveyed
o Management of bed space utilization
o Process for triaging hospitalized patients for discharge to
create bed space
 Movement of or discharge of inpatients? Who
decides? New locations?
o Management of clinical processes such as elective
surgeries, outpatient clinics
 Reference policies and procedures to support Emergency Management Plan

JCI Disaster Plan – Outline 10/2014

P. 2
 JCIA 5th Edition

FMS.2 and FMS.6 Disaster Preparedness PLAN – OUTLINE √ If

Presen
t

 Testing of management plan through drill or exercise

o An annual test of the full program internally or as part of a community-wide test
(new for 5th Edition) or
o Describe process for testing emergency management plan in whole or at least the
critical elements c) through g) in the intent statement.
o Describe any external notification process and requirements
o Describe process for debriefing and evaluation of test/drill to identify strengths
and process opportunities
o If applicable, describe participation in communitywide emergency drill
o State where drill evaluation analysis is reported such as to the Emergency
Disaster Committee to the Safety committee with recommendations for
improving the procedures and staff training

 Training / education program

o Describe process for training all staff at least once per year and how their
knowledge is tested
o Include any education provided to patients, such as information about
evacuation in the patient handbook

 Monitoring data (measures) for improvements in the Disaster Preparedness

program
o Define monitoring measures
o Define collection, aggregation, report structure, reporting process and frequency
to organizational leadership on QUARTERLY BASIS (new for 5th Edition)
o Flow or integration of data and analysis to Safety Committee

 Annual program plan evaluation

o Statement describing the process for the annual evaluation including use of
drill data and evaluation of drill response, staff training findings, monitoring
data of the plan, annual risk re-assessment, review of program goals, and
recommendations for program or policy and training changes.

JCI Disaster Plan – Outline 10/2014

P. 3