Welcome to ZZ Cape Fear Valley Health System

Cape Fear Valley Emergency Operations Plan

The Base Plan is an overview of the Health System's emergency response organization.  It states the legal and regulatory authority for emergency operations, summarizes the situations addressed in the EOP, explains the general concept of operations, and assigns responsibilities for emergency planning and operations.

Purpose
The purpose of the Cape Fear Valley Health System (CFVHS) Emergency Operations Plan (EOP) is to provide general guidance to all staff in the conduct of operations during incidents, either man-made or naturally occurring, which directly impact the health system's ability to deliver care and services.

Situation and Assumptions
Situation.  Unexpected events will occur in both the health system and the region we support.  CFVHS has the responsibility to provide quality health services during both normal conditions and in those out of the ordinary.  Planning, before something occurs, will mitigate the incident's impact on the Health System, improve the response provided, and recover the system more quickly to normal operations.

Hazard Vulnerability Analysis.  CFVHS, with numerous community partners, conducts an annual Hazard Vulnerability Analysis (HVA) to identify emergency planning priorities.  The HVA process identifies specific threats to the health system and the community that are then prioritized and addressed in the Hazard Specific Appendices in this plan. The HVA assists in developing target capabilities that might be required in any incident response.    These include managing resources and utilities, communications, safety and security, organizational and staff responsibilities, and the management of clinical and support activities.  The EOP Functional Annexes cover these target capabilities and selected others on how an incident might affect their delivery.

Assumptions.  No plan can anticipate every eventuality or every situation that might confront the Health System.  In order to provide some guidelines in planning, it is necessary to develop assumptions to keep the process moving forward and to place a limit on the scope and the number of situations addressed in the plan.

Planning included the following assumptions:

At least 50% of municipal boundaries, authority, and essential services remain

Employees, providers, and patients are able to reach CFVHS facilities

At least 50% of staff remain on or report for duty

Damage to facilities, if any, would have minimal impact on operations

Back-up power is in place and operational

Concept of Operations
The CFVHS utilizes the National Incident Management System (NIMS) and has adopted the Hospital Incident Command System (HICS) as the foundation for this EOP and for the System's response in times of crisis.  These proven systems provide a flexible, scalable model for the Health System's participation in the four phases of emergency management:  mitigation, preparedness, response, and recovery.

With few exceptions, the staff members authorized to activate the EOP are the VPs, the Administrator-On-Call, the House Supervisor, or the senior person in charge of the Emergency Department.  Calling a “Code Triage” or a “Code Triage: Standby”, activates the EOP.

Once the EOP is activated that individual becomes the Incident Commander (IC) until properly relieved under the principles of the Incident Command System (ICS).  The IC assembles an Incident Management Team (IMT) from on duty personnel activating the HICS positions required for the circumstances.  The IC, along with the IMT, assesses the severity and complexity of the situation, determines how best to effectively respond with available resources, and begins the foundation of an Incident Action Plan (IAP).

Incident management shall take place in the Hospital Command Center (HCC).    As required by the Incident Commander, labor pools and/or staging areas shall also be established to deploy personnel as needed throughout the healthcare system.

The Health System mandates that leaders maintain individual department, section, and facility-level Emergency Operations Plans specific to the responsible area.  These plans contain the detailed activities conducted during an activation of the Health System EOP and can be more restrictive, but not less.  Any contradiction found between a department-level plan and the CFVHS EOP will defer to the system-wide plan.

In keeping with the “All Hazard” approach in emergency management, certain initial actions are common to all EOP activations.  They include, but are not limited to:

Responsible authority calls a Code Triage or Code Triage: Standby;

Switchboard announces the code and begins notification procedures;

Managers notify all on-duty staff that a Code Triage/Triage Standby is in effect;

Fill out the Incident Manning Report from the Incident Response Packet;

Assess patient, staff, equipment and supply levels;

Assess the incident's impact on your respective department or service; advise HCC accordingly

Determine if additional staff is required;

Follow the department's “Incident” Plan.

Maintain normal functioning of the unit as much as possible.

Provide and receive periodic updates to and from the HCC;

Fill out updated Incident Manning Report no less than every shift change.

As operations return to normal, Incident Command will be demobilized in a phased manner to ensure that pertinent information is recorded and to ensure that management of the incident is indeed complete.

Initiation and Termination of Response Activities
As a general rule, any VP-level employee, the Administrator-On-Call, the house supervisor, or the senior person in the Emergency Department can activate the EOP.  The Incident Commander, with counsel from the General Staff will determine the phased timeline of the Health Systems activities.  Likewise, the Incident Commander establishes the Recovery phase initiation and termination.

Demobilization
The ICT will monitor the event and begin demobilization at the first opportunity.  This will include communication to the staff with plans for resumption of normal operations.  The General Staff sections consider reversing all conducted response activities for demobilization (i.e. closing staff shelters, returning borrowed equipment, etc.)

In keeping with the cycle of emergency management, staff members keep a list of “things to improve” and “things to maintain” to serve later as “Lessons Learned”.  Staff training and EOP development depend on the input from those involved in the incident.  Leadership will hold debriefings at every level of the response to accurately capture the information necessary to review potential modifications to the plan based on the most recent event.

Organizational Responsibilities
The Incident Management Team (IMT) is responsible for operations management during an incident.  The IMT consists of key senior leadership, medical staff, and technical/medical experts that have received specialized training on emergency management and the Hospital Incident Command System.  More detailed information on specific roles and responsibilities of staff can be found in the HICS Job Action Sheets available online or in the HCC.

Staff Training
Department managers and supervisory staff are asked to complete training to be familiar with the Incident Command System.  Suggested courses include the FEMA IS100, IS200 and IS700 online courses.  Those directly involved with Emergency Management or those included in Incident Command roles should complete IS800 online and ICS 300 in the classroom.

Staff receive periodic department-level training on disaster preparedness including the location of the Incident Response Packet in their work area and immediate steps in the process that occurs when incident response is activated.

US Patent Numbers 7,720,998 B2, 7,836,207