Emergency Operations Plan

Lesson 3: Topic 9 of 9

The Emergency Operations Plan requires signatures from the facility’s Administrator, Medical Director, CEO, and representatives of the Board of Directors. It also must be reviewed at least annually and executed twice a year. Execution may be actual crises or disasters, drills, or tabletop exercises. 

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In the real-life potential shooter scenario where I had been working, described at the outset of this course, the receptionist’s “Code Orange” page was announced over the loudspeaker in the hospital and Emergency Room… but nowhere else. This was one of a few problems that were reviewed after the fact, when I convened a team to gauge how well the Emergency Operations Plan had been executed when the gunman was onsite. 

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When the receptionist realized there was a gunman in the lobby, she used a code on the phone system to announce Code Orange. That was part of her training; however, she used a code that paged only the ER and hospital, rather than the one that covered the entire medical facility. The Long Term Care facility, pharmacy, clinics, labs, and therapy gym did not hear the page (word did spread internally, though). A second problem was that although the staff immediately manually switched off the photoelectric door openers as they had been trained, many kept re-opening the doors to coworkers arriving to work at shift change. Lockdown means lockdown, after all, so people coming to work should not have been allowed entry until the all-clear was sounded. That rule was reviewed with staff as soon as possible at multiple inservice meetings. Finally, it was discovered that the only functional panic button was in the ER. This was corrected with the help of an electrician a few days later. 

Even if your company does not accept Medicare or Medicaid funding, and thus is not bound by CMS’ emergency requirements, it would be prudent to implement them anyway. By formally evaluating how well (or not) emergency protocols functioned, and how well employees adhered to them (or not), leadership can continuously improve them. This in turn makes the workplace safer.