EMERGENCY MANAGEMENT PLAN 2002

The following is a text version of our Emergency Management Plan for 2002. 

See policies and procedures 

I.                  PURPOSE

The purpose of the Emergency Management Plan is to provide a programmatic framework to reduce the risk to New York State Psychiatric Institute.  The plan includes processes that are designed to evaluate risks that may adversely affect the life or health of patients, staff, and visitors.

Mission:  New York State Psychiatric Institute is committed to providing a safe, secure, and therapeutic environment at its main facility and off-facility program sites for all patients, staff and visitors.  The Emergency Management Plan is designed to support safe, effective patient care by providing reliable information that allows facility management and staff to make better emergency management decisions and to evaluate key issues and opportunities for improvement of emergency management performance.

Consistent with this mission New York State Psychiatric Institute has established and provides ongoing support for the emergency management plan described in this plan.

II.               SCOPE

The facility has an Environment of Care Committee (EOCC) consisting of a cross representation of the facility’s staff.  The EOCC monitors training and competence of staff and assesses conditions of physical plant, grounds, and equipment through building inspections, environmental rounds, safety inspections, and various performance improvement initiatives.  Through review or reliable information, management is able to make the best decisions regarding safety concerns and to evaluate emergency management performance related to key issues with opportunities for improvement.  The EOCC monitors and evaluates all emergency management areas.  It takes action and makes recommendations to the facility leadership, including the Executive Director, who is a member of the Governing Body.  The EOCC may issue assignments to committee members and non-committee staff for follow-up actions/improvements and completion of reports.

III.           FUNDAMENTALS

A.   Effective planning reduces the impact of emergencies on the quality of patient care and increases the facility’s ability to continue to provide necessary patient services.

B.    Many types of emergencies can be identified from past organizational or community experiences.  Evaluating the past experiences provides a baseline of likely threats in future emergencies.  Planning should include responses to these likely situations.

C.   Planning considers facilities, space, personnel, supplies, communications, and other resources needed to provide essential services under less than ideal conditions.

D.   Planning considers on-duty and off-duty staff and other resources when determining what staff is needed to maintain essential services.

E.    Planning considers conditions that may require modifications of normal patient care routines including treatment.  The conditions may require discontinuation of services, patient transfer, facility evacuation, or discharge of patients.

F.    Periodic drills are essential for maintaining staff awareness of emergency procedures and for evaluating the effectiveness of plans.

G.   Scheduled drills and actual implementations of the emergency preparedness program are observed, documented, and critiqued to identify opportunities for improvement.  Actions taken to address deficiencies are documented and tested during subsequent drills.  Summaries of the emergency management program activities are presented to the EOCC for review and recommendations.

IV.            GOALS

A.   Comply with accepted standards for emergency management.

B.    Provide a safe, secure, and therapeutic environment for patients, staff, and visitors.

C.   Integrate emergency management practices into daily operations.

D.   Identify opportunities to improve performance.

V.               ORGANIZATION &                         RESPONSIBILITY

A.   The Executive Director receives regular reports on activities of the Emergency Management Plan from the EOCC.  The Executive Director reviews reports and, as appropriate, communicates safety related concerns about identified issues and regulatory compliance.

B.    The Executive Director reviews reports and, as necessary, communicates concerns about key issues and regulatory compliance to appropriate departments, services and staff.  The administration collaborates with appropriate departments, services, and staff to establish operating and capital budgets for the emergency management program.

C.   The Environment of Care Committee Chairperson has responsibility for identification of safety deficiencies, development of Plans for Improvement; accident and injury prevention and investigation; the Information, Collection, and Evaluation System (ICES); and emergency response.  Training of staff and volunteers is facilitated by the Education and Training Department.

D.   The EOCC coordinates processes within the Environment of Care Standards.  Membership on the EOCC is by appointment from the Executive Director and includes representatives from administration, clinical services, and support services.  The EOCC meets as often as is necessary on a regular basis to receive reports and to conduct reviews of safety issues.  Additional meetings may be scheduled at the request of the EOCC Chairperson.

E.    The Executive Director authorizes key staff to take immediate and appropriate action in the event of an emergency.  An emergency is a situation that poses a threat to life, personal injury, or damage to property.

F.    Department, program and site managers are responsible for orienting new staff members to the department/programs and to job specific emergency management procedures.  Specific training needs and expertise can be requested by the department/program/site managers in concert with the Education and Training Department.

G.   Individual staff members are responsible for learning and following job and task specific procedures for safe operations.  Individual staff members are also responsible for learning and using reporting procedures.

VI.            PROCESSES OF THE EMERGENCY MANAGEMENT PLAN

A.   Identification of Specific Procedures

The hazard vulnerability of analysis is performed by staff of the EOCC.  Based on the analysis specific procedures are developed by EOCC to respond to a variety of disasters.  These specific procedures are found in the Emergency Management Manual or in department program, and site specific procedures.

B.    Initiating the Plan

The plan is initiated by the Director or Deputies or Chief Safety and Security or Chairman of EOCC or Doctor on call or Charge of shift according to the Emergency Preparedness Manual.

C.   Community Planning

The Executive Director plans with the local governments to make decisions and defines New York State Psychiatric Institute role and it’s participation in the community wide emergency management plans.

D.   Notification of External Authorities

The incident command structure will utilize designated staff to notify local, state, and federal agencies when an emergency has occurred that is serious enough to warrant their involvement or notification.

E.    Staff Notification

Department, program, and site managers are responsible for assuring their staff notification plan is current and will notify their staff of an emergency when directed by incident command.

F.    Identification

A list of identified and available staff is provided to the incident command structure.  Physical identification is provided as necessary.

G.   Staff Assignments

The incident command structure assigns roles to available personnel and provides physical identification as necessary.

H.   Space, Supplies, and Security

The incident command staff will direct department, program, and site managers to modify or discontinue services, patient information, and patients/staff transportation.

The incident command staff is responsible for managing the space that may be needed or reorganized during an emergency.

The incident command staff has the authority to assign employees to alternative roles and responsibilities during an emergency, as necessary.  The incident command staff will be responsible to provide support for employees and their families, for example housing, transportation, and stress debriefing.

Incident command staff with the assistance of department, program, and site managers will manage supplies needed to meet the needs of patients, visitors, and staff.

The Safety and Security Staff in consultation with incident command staff will control the security for the facility and all sites affected by the emergency or disaster.  The incident command staff will notify and request assistance from external law enforcement/security agencies as necessary.

Interaction with the news media will be handled exclusively by the incident command staff.

I.       Evacuation

The Emergency Preparedness Manual describes the evacuation procedures.  At the direction of the incident command staff the evacuation will be implemented when a facility or site cannot sustain or support patient care and treatment.

J.      Alternate Care Sites

The facility and OMH Central Office have identified alternative care sites within OMH and other appropriate care sites throughout the state of New York.  At the request of the incident command staff and with the approval of OMH, patients, staff, and equipment will be moved to specified facilities described in the plan.  The relocation will be carried out according to the procedures within the Emergency Preparedness Manual which include provision for medications, communications, medical records, supplies, patient tracking and transportation.

K.   Continuing and Re-Establishing Operations

The facilities incident command staff in conjunction with Central Office Incident Command Staff, will provide for continuing services and the re-establishment of operations following an emergency and/or disaster.

L.    Alternative Utilities

The incident command system and the Emergency Preparedness Manual documents alternative sources of utilities during an emergency or disaster affecting the facility.

M.  Communications

The Emergency Preparedness Manual documents backup communication systems that will sustain emergency communications.

N.   Facility Designation

The facility is not designated by the local government’s incident command structure as a radioactive or chemical isolation and decontamination sites.

O.   Alternative Staff Roles

The OMH Incident Command System is consistent with the Incident Command System use consistently throughout the State of New York and has the authority to assign staff to alternative roles and responsibilities during an emergency, as necessary.

P.    Orientation and Educations

The facility Education and Training Department has overall responsibility for organizing the orientation and education program for each of the seven functions associated with Management of the Environment of Care.  Department, program, and site managers are responsible for assuring the Emergency Management Plan orientation and education is implemented.

Every new staff member participates in a general orientation program that includes information related to the Emergency Management Plan.

The facility Education and Training Department is responsible for conducting the general orientation program with current information on general safety processes to new staff members as soon as possible but within 30 days of employment.  The Education and Training Department records attendance for each new staff member who completes the general orientation program.  Attendance records are maintained in the Education and Training Department.

Staff members also received department-specific orientation to the department to which they are assigned.  Each department, program, and site manager is responsible for providing their new staff members with department-specific orientation to the Emergency Management Plan.  The goal of the department orientation program is to provide new staff members with current safety information including area or job specific safety issues and hazards specific to the department.

All staff members of the facility must participate in mandatory continuing education at least once each year, which includes information specific to the Emergency Management Plan.  This requirement may be satisfied through completion of a self-learning packet or attendance at a regularly scheduled facility-wide continuing education program.  The Education and Training Department maintains records of all completed training.

Various Departments collaborate with the Education and Training Department and individual department managers, as appropriate, for developing content and supporting material for general and department, program, site specific orientation and for continuing education programs.  The content and supporting materials utilized in general and department, program, site-specific orientation and continuing education programs are reviewed and revised as necessary.

The Education and Training Department reports information on orientation and continuing education data during the reporting period to the EOCC.

Q.   Performance Improvement Monitoring

The EOCC Chairperson through the EOCC has overall responsibility for coordinating the ongoing performance monitoring and the performance improvement monitoring for each of the seven functions associated with Management of the Environment of Care.  The EOCC Chairperson is responsible for all monitoring associated with the Emergency Management Plan.

The intent of establishing performance monitoring is to improve the Emergency Preparedness Plan through objective measures of demonstrated performance.  Performance improvement is an important aspect of the Emergency Preparedness Plan.  Ongoing performance monitoring serves as an indicator of continued effectiveness of the Emergency Management Plan and is a mechanism to identify performance improvement opportunities.

R.   Annual Evaluation

The EOCC Chairperson has overall responsibility for coordinating the annual evaluation of each of the seven functions associated with Management of the Environment of Care.  The EOCC Chairperson, Chief of Safety and Security is responsible for completing the annual evaluation of the emergency management program.  An evaluation of Emergency Management Plan objectives, scope, performance and effectiveness is included in each annual evaluation.

In the completion of the annual evaluation, the EOCC Chairperson, Chief of Safety and Security utilizes a variety of source documents such as policy review and evaluation, incident report summaries, risk assessment activities, meeting minutes, and statistical information summaries.  In addition, other relevant sources of information are used for the annual evaluation, such as results of monitoring studies, reports from accrediting and certification agencies, and goals and objectives.  The annual evaluation of the Emergency Management Plan is used to further develop educational programs, policies, and performance monitoring and performance improvement.  An evaluation of Emergency Management Plan objectives, scope, performance and effectiveness is included in each annual evaluation.

The annual evaluation is reviewed and approved by the EOCC.  The annual evaluation is then presented to the Executive Committee, Executive Cabinet, the Executive Director, and the Governing Body.  Approved minutes or other means of communications are received and reviewed from the Governing Body by the EOCC and recommendations are acted upon.