Hospital leaders provide oversight and support of the emergency management program.

(1)

The hospital’s senior leaders provide oversight and support for the following emergency management program activities: - Allocation of resources for the emergency management program - Review of emergency management program documents - Review of the emergency operations plan, policies and procedures, and training and education that support the emergency management program - Review of after-action reports (AARs) and improvement plans Note 1: The hospital defines who the members of the senior leadership group are as well as their roles and responsibilities for emergency management–related activities. Note 2: An AAR provides a detailed critical summary or analysis of a planned exercise or actual emergency or disaster incident. The report summarizes what took place during the event, analyzes the actions taken by participants, and identifies areas needing improvement.

(2)

The hospital’s senior leaders identify a qualified individual to lead the emergency management program who has defined responsibilities that include, but are not limited to, the following: - Developing and maintaining the emergency operations plan and policies and procedures - Implementing the four phases of emergency management (mitigation, preparedness, response, and recovery) - Implementing emergency management activities across the six critical areas (communications, staffing, patient clinical and support services, safety and security, resources and assets, and utilities) - Coordinating the emergency management exercises and developing after-action reports - Collaborating across clinical and operational areas to implement organizationwide emergency management - Identifying and collaborating with community response partners Note: Education, training, and experience in emergency management should be taken into account when considering the qualifications of the individual(s) who leads the program.

(3)

The hospital has a multidisciplinary committee that oversees the emergency management program. The committee includes the emergency program lead and other participants identified by the hospital; meeting frequency, goals, and responsibilities are defined by the committee. Note 1: Other multidisciplinary committee participants may include representatives from senior leadership, nursing services, medical staff, pharmacy services, infection prevention and control, facilities engineering, security, and information technology. Note 2: The multidisciplinary committee that oversees the emergency management program may be incorporated into an existing committee.

(4)

The multidisciplinary committee provides input and assists in the coordination of the preparation, development, implementation, evaluation, and maintenance of the hospital’s emergency management program. The activities include, but are not limited to, the following: - Hazard vulnerability analysis - Emergency operations plan, policies, and procedures - Continuity of operations plan - Training and education - Planning and coordinating incident response exercises (for example, seminars; workshops; tabletop exercises; functional exercises; full-scale, community-based exercises) - After-action reports (AARs) and improvement plans Note: An AAR provides a detailed critical summary or analysis of a planned exercise or actual emergency or disaster incident. The report summarizes what took place during the event, analyzes the actions taken by participants, and specifies areas needing improvement.