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Health centers must have risk management
policies and procedures in place that
proactively and continually identify and
plan for potential and actual risks to
the health center in terms of its facilities,
staff, clients/patients, financial, clinical,
and organizational well-being. Plans and
procedures for emergency management must
be integrated into a health center’s
risk management approach to assure that
suitable guidelines are established and
followed so that it can respond effectively
and appropriately to an emergency. Health
centers should also be aware that other
entities (i.e., accrediting organizations,
State and/or local health departments)
may also have requirements related to
emergency management activities.
Health centers are diverse organizations.
Therefore, each health center will require
an emergency management approach that
considers the center’s size, location,
resources, as well as current State, local,
or community/regional plans. Location
and size of the facility, the number of
staff, and the type of operations are
key factors to consider in developing
an appropriate emergency management strategy.
Small health centers might have relatively
basic emergency management strategies
whereas centers with multiple sites, greater
variability in operations, or large numbers
of staff may develop more complex approaches.
The emergency management expectations
for health centers addressed in this guidance
are as follows:
A. Emergency management planning—health
centers should be engaged in an ongoing,
continuous process to ensure that emergency
management plans (EMP) are appropriate.
B. Linkages and collaborations—health
centers should maximize their linkages
and collaborations.
C. Communications and information sharing—health
centers should have policies and procedures
for communicating and sharing information
with internal and external stakeholders.
D. Maintaining financial and operational
stability—health centers’
business plans should address financial
viability in the event of an emergency.
A. Emergency Management Planning
Emergencies can disrupt care provided
to health center patients by significantly
increasing demand for services or severely
impacting current operations. An emergency
management plan or EMP (also known as
an emergency operations plan or disaster
plan) is essential to minimize the disruption
of services for patients, assure the health
center’s ongoing financial and organizational
well-being, and link the health center
to the local community response.
The purpose of the EMP is to ensure predictable
staff behavior during a crisis, provide
specific guidelines and procedures to
follow, and define specific roles and
responsibilities. The EMP should address
the four phases of emergency management—mitigation,
preparedness, response, and recovery:
- Mitigation activities lessen the
severity and impact a potential disaster
or emergency might have on a health
center’s operation;
- Preparedness activities build capacity
and identify resources that may be used
should a disaster or emergency occur;
- Response refers to the actual emergency
and controls the negative effects of
emergency situations; and
- Recovery actions begin almost concurrently
with response activities and are directed
at restoring essential services and
resuming normal operations. Recovery
planning is a critical aspect to sustaining
the long-term viability of the health
center.
It is essential that the EMP be developed
with an interdisciplinary approach involving
all departments within the organization
as the entire organization will be affected
and play a role in an emergency. The Governing
Board, senior management, and the clinical
staff should have a lead role in the development
of the EMP, and the Governing Board should
approve the final EMP and any revisions
to it.
Health centers should initiate emergency
management planning by conducting a risk
assessment such as a Hazard Vulnerability
Analysis. The risk assessment should identify
potential emergencies and the direct and
indirect effects these emergencies may
have on the health center’s operations
and the demand for services. The risks
identified in the risk assessment should
be prioritized based on the likelihood
of occurrence and severity and addressed
in the EMP. There are many risk assessment
tools available and health centers are
encouraged to use the tools that best
meets their specific needs.
Health centers are encouraged to participate
in community level risk assessments and
integrate their own risk assessment with
the local community. Many States and communities
may have already completed a risk assessment
for their area, and health centers are
encouraged to use these assessments as
a starting point for their own assessment.
In developing the EMP, health centers
should describe their approach to responding
to emergencies that would suddenly and
significantly affect the demand for the
organization’s services or its ability
to provide those services. The EMP should
take an all-hazards approach—meaning
that the health center has considered
and has developed an EMP that is simple
and flexible enough to respond to all
of the identified emergencies. These could
include a sudden and abrupt event such
as an explosion or a sustained event over
a longer period of time such as pandemic
influenza.
Many State and/or local EMPs are already
in place and, to the extent possible,
a health center’s EMP should be
aligned and integrated with these emergency
plans. The role of the health center in
these plans should be clearly established
and reflected in both the health center’s
internal EMP as well as in the State and/or
local EMPs. To maximize integration, health
centers are encouraged to connect with
any ongoing efforts in these areas before
developing and implementing their EMP.
Health centers may also want to explore
developing mutual aid agreements with
other community health care providers
such as other health centers, hospitals,
and rural health clinics for resources
such as personnel, equipment, and supplies.
To find out if there is an established
community and/or regional EMP, health
centers should contact their local county
government.
The EMP is necessary to ensure the continuity
of patient care in the event of an emergency.
It should describe under what circumstances
and how, when, and by whom the EMP is
activated, procedures for notifying staff
when it has been initiated, and the roles
and responsibilities of all personnel
responding to the emergency. Health centers
should appropriately include components
in their plan that reflect the unique
characteristics of the health center—size,
location, resources, environment, populations
served, and the role it plays within its
community. For many health centers, the
EMP can be a basic plan; for others, the
EMP will need to reflect the complex nature
of its operations and capacities. A health
center’s EMP should address the
following components as appropriate, considering
the role of the health center in the local
and/or State plans and what is most appropriate
and necessary for the health center to
respond to an emergency:
- Continuity of operations;
- Command and control;
- Staffing;
- Surge patients;
- Medical and non-medical supplies;
- Pharmaceuticals;
- Security;
- Evacuation;
- Decontamination;
- Isolation;
- Power supply;
- Transportation;
- Water/Sanitation;
- Communications; and
- Medical records security and access.
Individuals impacted by emergencies often
experience significant emotional stress.
The health center’s EMP should address
the behavioral needs of both patients
and staff and identify additional resources
for providing those services. The plan
should also help staff prepare their families
for emergencies—if staff are prepared
at home, they are more likely to carry
out vital responsibilities and duties
at work in the health center. For additional
information on personal preparedness,
visit the
Department of Homeland Security’s
www.Ready.gov Web site.
The EMP should describe if and how health
centers will continue to provide primary
health care services to current and surge
patients to the extent possible during
an emergency, including consideration
for continuity of services for contracted
services as well as those services that
are directly provided by the health center.
The EMP should evaluate a health center’s
ability to maintain normal operations
and describe the circumstances that must
be met for the health center to discontinue
non-emergency primary care services or
cease operations for a period of time,
especially if staffing levels decrease.
Provision of primary health care services
should be consistent and aligned with
the health center’s role, as determined
in consultation with the local community.
If applicable, the EMP should also address
how the health center will utilize mobile
vans during an emergency and how services
to patients served by the van will be
continued should access be impeded, or
if it were damaged or destroyed.
Health centers should plan for assuring
access for special populations, such as
migrant and seasonal farmworkers, homeless
people, and residents of public housing.
Many times these populations need additional
assistance and communication (such as
culturally and linguistically appropriate
messages and outreach). In developing
the EMP, health centers are encouraged
to also consider other populations such
as non-English speaking individuals, children
including those with special needs and
those served at school-based health centers,
individuals living with HIV disease, and
disabled and elderly individuals.
Health centers should provide ongoing
training on emergency management and the
implementation of the EMP to employees
at all levels of the organization. Health
center employees may be eligible to participate
in State and local trainings on emergency
management and health centers are encouraged
to use these available resources. Appropriate
planning and adequate education and training
are critical to ensure staff are prepared
to deal with an emergency when confronted
with one.
Health centers should continually test
and evaluate the effectiveness of their
EMP and make adjustments as necessary.
Exercises reveal what works, what does
not, and what is needed to enhance the
effectiveness of the EMP. The objectives
of testing EMPs through exercises are
to minimize confusion and mistakes that
may occur during an actual emergency.
The frequency and methods of testing and
evaluation (table top drills, functional
exercises, etc.) should be determined
by the organization, but should be at
least on an annual basis. Health centers
are also encouraged to test their plan
in a community-wide and regional setting
by participating in local, regional, or
national disaster drills or exercises,
if possible and as appropriate. Health
centers’ EMPs should be updated
and revised based on any lessons learned
from participation in drills, exercises,
or actual emergencies.
B. Linkages and Collaborations
Normal operations can become overwhelmed
during an emergency, and health centers
may have to rely on other community organizations
for assistance and, possibly, for assuming
some aspects of patient care. Established
linkages and collaborations are critical
for an effective EMP. Coordinated efforts
are necessary to provide comprehensive
care during this time and integration
into the local community response can
increase the health center’s ability
to obtain needed resources for continuing
care.
In developing their EMP, health centers
should integrate with the emergency management
system at the State, local, and community
levels. Health centers should collaborate
with State and local emergency management
agencies, professional volunteer registries
housed in State Departments of Health,
emergency medical services systems, public
health departments, hospitals, mental
health agencies, national organizations,
PCAs, and Primary Care Organizations (PCO).
Health centers should also be prepared
to work with organizations that may not
be part of their usual primary health
care delivery network. These may include
local businesses, law enforcement, fire
services, local military installations,
schools, and faith-based organizations.
Health centers should define their role
within their local community prior to
an emergency and be proactive in engaging
community leaders, identifying key organizations,
and developing ongoing relationships.
Well in advance of an emergency, health
centers should establish relationships
with key decision makers to assist in
effectively navigating State and local
systems to obtain needed resources before,
during and after an emergency. Participating
in State, local, and community emergency/disaster
exercises will aid in initiating and developing
linkages with these individuals and organizations.
C. Communications and Information
Sharing
During an emergency, standard communication
systems are often overwhelmed or destroyed
and health centers will likely have difficulty
accessing critical information. A well-defined
communications plan is an important component
of an effective EMP. The EMP should identify
the health center’s policies and
procedures for communicating with internal
(staff, patients, special populations,
Governing Board) and external (appropriate
Federal, State, local, and Tribal agencies)
stakeholders as well as with the public
during emergencies.
Health centers should also develop policies
and procedures that describe who will
be responsible for communicating important
information and which agencies or groups
should receive communication, the process
for how the communication will take place,
and what general information should be
communicated.
As part of the EMP, the health center
should develop strategies for communicating
with patients during an emergency including
procedures to make patients aware of any
alternative primary care service arrangements
that may be available in the event the
health center is closed. Health centers
are encouraged to work with their State
and/or local public health department
in developing appropriate communication
messages for patients. Local radio and
television may be useful for communicating
such messages. All educational materials
and other emergency information should
be culturally and linguistically appropriate
and developed at reading levels appropriate
for the population being served.
The health center’s EMP should
identify backup (also referred to as redundant)
communication systems in the event that
standard communication systems are unavailable
and include these in its EMP. Example
of redundant communication systems include:
two-way radios, mobile/cell phones, and
wireless messaging. The health center’s
communication policies, procedures, command
structure, and backup communication systems
should be tested in conjunction with the
EMP at least on an annual basis or more
frequently, as appropriate. Health centers’
communications systems should be integrated
into the local health care and community
systems and be tested in conjunction with
these systems.
Health centers should have an all-hazards
command structure within the organization,
such as a standard ICS, that links with
the community’s command structure
for emergencies. As a component of the
NIMS, many communities have established
an ICS for use during an emergency—the
ICS provides a unified, organized, and
structured method for cooperation and
coordination as well as to facilitate
decision making and response. The health
center’s ICS should also include
procedures for communicating with staff
and other key stakeholders during an emergency.
These policies and procedures should be
integrated with the health center’s
EMP.
The quality of key decisions made during
emergencies is critically dependent on
the availability of current, accessible,
accurate, and relevant information. Data
reporting assists decision makers in assessing
the current situation and identifies critical
needs, such as supplies and staffing,
that are essential to continuing the provision
of care prior to, during and after an
emergency. Data reporting can assist local
communities in positioning resources and
facilitate access to these resources for
health centers.
To maximize access to resources, health
centers are encouraged to have systems
in place which accurately collect and
organize data for anticipated requested/required
reporting. Health centers should collaborate
with State and local agencies, such as
PCAs, PCOs, and local public health departments
to develop standard reporting protocols.
The reporting protocols should be integrated
into the communication section of the
health center’s EMP.
In the event of an emergency, health
centers (both Health Center Program grantees
and FQHC Look-Alikes) will be required
to submit data to their HRSA Project Officer
(PO). Depending on the circumstances,
HRSA may initiate procedures before, during
and after emergency events that include
asking for information from each affected
health center such as the status of health
center operations, patient capacity and/or
staffing/resource/infrastructure needs.
D. Maintaining Financial and
Operational Stability
Health centers can face significant obstacles
in regaining financial stability after
an emergency and may spend several months
or even years in the recovery phase. Physical
or property losses sustained from emergencies
can cause interruption or discontinuation
of services for patients and disrupt the
community health care infrastructure.
Adequate planning for recovery in the
assessment, planning, and response process
will shorten the time it takes a health
center to become fully operational.
The ability to adequately respond to
an emergency can help preserve the financial
viability of the health center. Health
centers’ business plans should address
the financial response to an emergency
including goals for maintaining cash reserves
and plans related to managing and insuring
against business interruptions, equipment,
facilities, and property loss. The purpose
of incorporating emergency management
considerations in the business plan is
to reduce and/or minimize potential adverse
impacts brought about by an emergency.
As part of these plans, health centers
should annually review their insurance
coverage to ensure that it is current
and that the coverage is adequate.
Preserving vital operational records
and documents is critical to a quick resumption
of operations. Health centers should have
backup information technology systems
to ensure that electronic financial and
medical records [2] are
available during and after an emergency.
Consideration should be given to the feasibility
of obtaining off-site storage for these
electronic records with emphasis on electronic
access and retrieval during or after an
emergency. In advance of an anticipated
event, health centers are encouraged to
secure facilities to the extent possible,
and may want to consider off-site or safe
storage for their equipment and data.
Business plans should address strategies
for resuming key functions that would
enable health centers to fully conduct
operations, such as ensuring that billing
systems are in place for obtaining payment
and reimbursement as soon as possible.
Health centers are encouraged to have
a backup billing system in place to track
charges and sustain the flow of reimbursement
needed to maintain the financial viability
of the health center during any response
and recovery. They should have a system
to track patients being treated as a result
of an emergency (i.e., surge patients)
that is independent of normal operations
which can be used in obtaining any supplemental
funding should it become available.
In the event of an emergency, Health
Center Program grantees can use grant
funds to provide services consistent with
their approved scope of project and the
terms of their grant award. Generally,
all costs charged to Federal grant awards
must be consistent with Federal cost policy
guidelines, program regulations, and the
terms of the award. Health centers should
contact their Grants Management Specialist
if they have grants administration questions
related to emergencies. Both Health Center
Program grantees and FQHC Look-Alikes
should make every attempt to collect reimbursement
for services from appropriate public and
private coverage.
Health centers have demonstrated exceptional
expertise in delivering comprehensive,
culturally competent, quality primary
health care services to vulnerable and
underserved populations. This may prove
even more crucial in the event of an emergency.
A successful emergency response may largely
depend on the ability of health centers
to communicate with appropriate stakeholders,
whether staff, patients, or other entities.
Health centers are encouraged to be proactive
in engaging community leaders, identifying
key partner organizations, and developing
ongoing relationships. The ability to
adequately respond to an emergency can
help safeguard the operational and financial
viability of the health center.
The expectations outlined in this guidance
are intended to be broad to ensure applicability
to the diverse range of health centers
and ease in integrating them into what
health centers are already doing related
to emergency and risk management. In addition
to developing, implementing, and maintaining
an EMP, health centers should continually
look for opportunities to enhance awareness,
educate and train boards and staff, evaluate
and test procedures, and integrate emergency
management into what the health center
does on a daily basis. A well-developed
and appropriate emergency management strategy
which reflects the unique characteristics,
circumstances, and environment for the
health center, will assure that it will
be able to recover quickly and continue
to provide essential services in their
community.
Emergency Management:
The process of planning, developing, implementing,
and executing a comprehensive system of
principles, policies, procedures, methods,
and activities designed to ensure an organization’s
effective response to natural and manmade
disasters affecting its environment and
business operations. Emergency management
is a comprehensive system, which includes
planning, mitigation, preparedness, response,
and recovery activities. Health center
emergency management entails developing
a plan based on the hazard vulnerabilities
likely to affect the health center, conducting
exercises and drills to assure sound response
and recovery activities, and includes
annual reassessments and updates to recognize
any new threats or vulnerabilities to
improve on emergency management procedures
and activities.
Emergency Management Plan (EMP):
A document describing the comprehensive
system of principles, policies, procedures,
methods, and activities to be applied
in response to natural and manmade disasters
to ensure patient and employee safety,
to mobilize resources, to maintain health
center business operations, and to assist
in providing mutual aid in a community-wide
response requiring medical services.
Homeland Security Presidential
Directives: Homeland Security
Presidential Directives (HSPDs) are issued
by the President of the United States
on matters pertaining to Homeland Security.
Two key HSPDs were created to establish
national initiatives that develop a common
approach to domestic incident management
and include the National Response Plan
(NRP), the National Preparedness Goal,
the National Incident Management System
(NIMS), the Universal Task List (UTL),
and the Targeted Capability List (TCL).
These are HPSD-5: Management of Domestic
Incidents and HSDP-8: National Preparedness.
Incident Command System (ICS):
A system for managing resources
from other organizations during an emergency.
The ICS is a standardized on-the-scene
emergency management system that is used
nationwide. It is specifically designed
for an integrated multi-organizational
structure and is scalable to handle the
complexity and demands of a single or
multiple incidents without being hindered
by jurisdictional boundaries. The ICS
manages and coordinates facilities, equipment,
supplies, procedures, and communications
within a common and defined organizational
structure, to effectively accomplish stated
objectives pertinent to an incident.
Jurisdiction: A range
or sphere of authority. Public agencies
have jurisdiction at an incident related
to their legal responsibilities and authority.
Jurisdictional authority at an incident
can be political or geographical (e.g.,
city, county, tribal, State, or Federal
boundary lines) or functional (e.g., law
enforcement, public health).
National Incident Management
System (NIMS): A system mandated
by HSPD-5 that provides a consistent nationwide
approach for Federal, State, local, and
tribal governments; the private-sector,
and nongovernmental organizations to work
effectively and efficiently together to
prepare for, respond to, and recover from
domestic incidents, regardless of cause,
size, or complexity. To provide for interoperability
and compatibility among Federal, State,
local, and tribal capabilities, the NIMS
includes a core set of concepts, principles,
and terminology. HSPD-5 identifies these
as the ICS; multiagency coordination systems;
training; identification and management
of resources (including systems for classifying
types of resources); qualification and
certification; and the collection, tracking,
and reporting of incident information
and incident resources.
National Preparedness Goal (NPG):
The NPG will guide Federal departments
and agencies, State, territorial, local
and tribal officials, the private sector,
non-government organizations and the public
in determining how to most effectively
and efficiently strengthen preparedness
for terrorist attacks, major disasters,
and other emergencies. The NPG also includes
seven national priorities. The national
priorities are: Implement the National
Incident Management System (NIMS) and
the National Response Plan (NRP), Expanded
Regional Collaboration, Implement the
Interim National Infrastructure Protection
Plan, Strengthen Information Sharing and
Collaboration Capabilities, Strengthen
Interoperable Communications Capabilities,
Strengthen Chemical/Biological/Radiological/
Nuclear/Explosives Detection, Response
and Decontamination Capabilities, and
Strengthen Medical Surge and Mass Prophylaxis
Capabilities. Focusing on these priorities
will ensure adequate infrastructure that
is prepared—at the Federal, State,
local, and regional levels—through
shared priorities, goals, and objectives.
National Response Plan (NRP):
A plan mandated by HSPD-5 that integrates
Federal domestic prevention, preparedness,
response, and recovery plans into one
all-discipline, all-hazards plan.
Targeted Capability List (TCL):
The identification of target
levels of capabilities that Federal, State,
local, and tribal entities must achieve
to perform critical tasks for homeland
security missions. Capabilities are combinations
of resources that provide the means to
achieve a measurable outcome resulting
from performance of one or more critical
tasks, under specified conditions and
performance standards. The TCL identifies
37 capabilities integral to nationwide
all-hazards preparedness, including terrorism.
The full documentation for the TCL can
be viewed at www.llis.gov.
Universal Task List (UTL):
The UTL was developed in close consultation
with Federal, State, local, and Tribal
entities and national associations to
help the homeland security community implement
the capabilities-based planning process
established under HSPD-8. The UTL is a
"living" document that will
continue to be refined and expanded as
it is put into practice.
There are a wide range of resources
available to assist health centers in
support of emergency management activities.
Technical assistance related to emergency
management also may be available from
PCAs that have been engaged in emergency
management planning activities in their
State and health centers that have already
developed EMPs. Listed below are a number
of Federal references health centers may
find helpful.
Department
of Health and Human Services
Health
Resources and Services Administration
Centers
for Medicare and Medicaid Services
Centers
for Disease Control and Prevention—Emergency
Preparedness & Response
Food
and Drug Administration—Bioterrorism/Counterterrorism
Substance
Abuse and Mental Health Services Administration—Disaster
Readiness and Response
National
Institute for Occupational Safety and
Health—Business Emergency Management
Planning
Department
of Labor, Occupational Safety and Health
Administration—Emergency Preparedness
and Response
State
Offices and Agencies of Emergency Management—Contact
Information
Department
of Homeland Security
Footnotes
[2] For information on HIPAA privacy
and disclosures in the event of an emergency,
please visit the HHS
Web site. |
