Emergency Management Program  – Joint Commission Standards & Elements of Performance

PDF Version - UTMB compliance with Emergency Management standards and elements of performance.

EM.09.01.01 – The hospital has a comprehensive emergency management program that utilizes an all-hazards approach.

EM.09.01.01 - Emergency Management Program

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  • EP 1 - Comprehensive Emergency Management Program (All-Hazards Approach)

    The hospital has a written comprehensive emergency management program that utilizes an all-hazards approach. The program includes, but is not limited to, the following:

    • Leadership structure and program accountability
    • Hazard vulnerability analysis
    • Mitigation and preparedness activities
    • Emergency operations plan and policies and procedures
    • Education and training
    • Exercises and testing
    • Continuity of operations
    • Disaster recovery
    • Program evaluation

    UTMB’s written comprehensive emergency management program utilizes an all-hazards approach. The program includes the following:

    • Leadership structure and program accountability: The Institutional Safety and Security (ISS) Executive Committee oversees all aspects of UTMB’s emergency management program. The ISS is chaired by the UTMB President and includes the Health System CEO. A senior physician is assigned to be the Institutional Emergency Preparedness Officer (IEPO) for the ISS (The ISS Charter describes the purpose of the ISS fully). 

    • Hazard vulnerability analysis – The ISS oversees the completion of a Hazard Vulnerability Analysis/Risk Analysis for all UTMB campuses and clinics. Each location completes an HVA specific to the risk profile for that location.  A risk assessment is used as the basis for the all-hazards emergency management program. The risk assessment and formal risk prioritization is generally done at the September ISS meeting. The risk assessment presented to the ISS generally addresses: 1) macro-level risks; 2) a Hazard Vulnerability Analysis that includes at a minimum natural, technological, human-caused, hazardous materials, and emerging infection hazards; and 3) facility, utility, and infrastructure analysis. The ISS prioritizes risks for the program year and uses the priority risks as the basis of the preparedness program and risk management including risk mitigation.  

    • Mitigation and preparedness activities – The ISS oversees development of a formal Hazard Mitigation Plan. The plan is submitted to the Texas Division of Emergency Management and FEMA Region 6 for approval. The adoption of the Hazard Mitigation Plan makes UTMB eligible for FEMA mitigation grant funding as well as Stafford Act Public Assistance for disaster recovery assistance. FEMA requires that the plan be updated every 5 years. In addition to this formal Hazard Risk Mitigation plan, UTMB uses priority risks as the basis for mitigation and preparedness activities.

    • Emergency operations plan and policies and procedures– The ISS maintains the UTMB Emergency Operations Plan (EOP). Scope and objectives are reviewed at least annually. The EOP is reviewed as part of the overall Emergency Preparedness annual program review (usually conducted at the December meeting of the ISS). Policies and procedures related to all aspects of emergency preparedness are also overseen by the ISS. UTMB Resilience Policy established coordinated emergency management and business continuity programs. The institutional Command Team may delegate policy development to the Health System Command Team or to specific tasks forces as needed (e.g., Covid response, infection control, vaccination).

    • Education and training – The ISS annual emergency management program establishes education and training topics for the program year. The ISS formally approves the annual education and training plan.

    • Exercises and testing – The ISS annual emergency management program establishes exercise and testing for the program year. Actual emergencies where the command team is activated may be substituted for exercises.

    • Continuity of operations – UTMB continuity planning includes a top-down Continuity Plan that establishes a template and set of general strategies for departments to use. Critical departments (as identified in the Business Impact Analysis) complete a departmental plan which should be updated annually prior to June 1. The overall Health System BCP lists a succession plan and serves to document the delegation of authority for succession. Each departmental plan follows this model.

    • Disaster recovery – Disaster recovery is an annex to the EOP. The disaster recovery plan provides a process for disaster accounting and claims processing, damage assessments, and recovery/continuity. The disaster recovery plan incorporates the UTMB Disaster Debris Management Plan. The Debris Management Plan is submitted to the Texas Division of Emergency Management and FEMA Region 6 for advice and recommendations. 

    • Program evaluation – The ISS completes an annual program evaluation (generally at the December quarterly meeting) The program proposal for the next calendar year is based on analysis of the program evaluation.

    Note: The comprehensive emergency management program includes the main location of the hospital and its freestanding outpatient care buildings (those that provide patient care, treatment, or services). – The UTMB emergency management program is institutional in scope and applies to all UTMB locations. The UTMB emergency management program is implemented under the authority of the UTMB President. The President delegates authority to all separate locations to implement the program and to respond to incidents when time is of the essence. 

  • EP 2 - Healthcare System Emergency Management Program (EMP) Integration

    If the hospital is part of a health care system that has a unified and integrated emergency management program and it chooses to participate in the program, the following must be demonstrated within the coordinated emergency management program:

    Under UT System Policy 172, the responsibility for all emergency preparedness rests with the UTMB President and the president delegates authority in order to meet this responsibility. UTMB therefore operates as an integrated emergency preparedness program. All hospitals/campuses under the UTMB umbrella participate in planning, preparedness, and response activities.

    • Each separately certified hospital within the system actively participates in the development of the unified and integrated emergency management program – UTMB uses an integrated emergency management program. All campuses and Ambulatory Services are represented on the ISS Emergency Management sub-committee and representatives participate in the development of the UTMB emergency management program.

    • The program is developed and maintained in a manner that takes into account each separately certified hospital’s unique circumstances, patient population, and services offered – A separate risk assessment is developed for each campus so that it reflects any unique hazards, patient populations, or specific services. More details on the Priority Risks webpage.

    • Each separately certified hospital is capable of actively using the unified and integrated emergency management program and is in compliance with the program – Each UTMB campus hospital participates in the overall UTMB integrated emergency management program. The Institutional Command Team includes command teams from each campus. 

    • Documented community-based risk assessment utilizing an all-hazards approach – Each UTMB campus and clinic conducts an annual risk assessment. HVAs are sent to each campus for review and update; and a copy is included in the Environment of Care - Emergency Management SharePoint site. Campus risk assessments are also sent to community officials (e.g., local Emergency Management Office) for feedback. UTMB also provides feedback to those agencies (e.g., local fire department) when they conduct their own risk assessments. 

    • Documented individual, facility-based risk assessment utilizing an all-hazards approach for each separately certified hospital within the health care system – Each UTMB campus and clinic conducts an annual risk assessment (including a hazard vulnerability analysis; EP1 of EM.11.01.01), which is coordinated by the Institutional Preparedness department. These HVAs are location-based, meaning the risk profile of a coastal clinic will be different from a clinic further inland. UTMB facilities-based risk assessments include risk information relevant to the geographic location, but also facilities-related characteristics such as floor elevations and building system elevations for each building so that we have detailed risk information relevant to our highest priority risks (hurricane/flood).  The ISS reviews these facilities-based risk assessments at the March ISS meeting (e.g., Facilities Readiness Report). The ISS reviews risk assessments generally at the September quarterly meeting and prioritizes risks so that an institutional preparedness program will reflect those risks. In general, because of the close geographic proximity of UTMB hospitals, the risk profile is very similar across hospitals with hurricanes as the top priority risk.

    • Unified and integrated emergency plan – UTMB's emergency plan, emergency management program, and emergency operating procedures are all unified and integrated. The ISS reviews and approves these items annually, and Incident Command Teams bring everyone together to activate them. Our approach to unifying our plan is that for all notice incidents (e.g., hurricane) the Incident Command structure we use includes representatives from all campuses and representatives from ambulatory services. For no-notice incidents, an individual campus or location has dedicated authority to address the incident following the NIMS/ICS. If additional support is needed, they can escalate the response to include activation of the health system command team or activation of the institutional command team.

    • Integrated policies and procedures – UTMB has integrated policies and procedures, several of which were developed by the centralized Institutional Command Team (ISS is the administrative component) with its 160+ members across the institution, especially emergency policies during the Covid-19 pandemic. Another example is the FEMA-Approved Mitigation Plan that addresses all campuses. The institutional handbook of operating procedures (IHOP), which contains both policies and procedures, is managed at the institutional level and is applicable to all UTMB operations. University of Texas System policies are applicable to all University of Texas institutions.

    • Coordinated communication plan – UTMB's emergency communications plan (authorized personnel only) has details for all major locations, services, key personnel, community partners, authorities, and et cetera. This plan is reviewed, edited, and approved annually by the ISS.

    • Training and testing program – Most training (including annual compliance training, onboarding, and the emergency classification system) is centrally coordinated at the institutional level. The institutional training program for the upcoming year is presented to the ISS for review and approval; this occurs at the December ISS meeting.
    • EP 3 - Applicable Laws & Regulations

      The hospital complies with all applicable federal, state, and local emergency preparedness laws and regulations.

      UTMB complies with emergency preparedness requirements of the US Department of Education, US Department of Agriculture, CMS, Texas Education Code, Texas Health and Safety Code, and Governor’s Executive Orders.

    • EP 4 - Transplant Programs

      For hospitals that use Joint Commission accreditation for deemed status purposes: If a hospital has one or more transplant programs the following must occur:

      • A representative from each transplant program must be included in the development and maintenance of the hospital's emergency preparedness program. 
      • The hospital must develop and maintain mutually agreed upon protocols that address the duties and responsibilities of the hospital, each transplant program, and the organ procurement organization (OPO) for the donation service area where the hospital is situated, unless the hospital has been granted a waiver to work with another OPO, during an emergency.

      UTMB's director of transplant services is part of the Institutional Safety & Security (ISS) Emergency Management Subcommittee, as well as a member of the Institutional Command Team. The director therefore assists in the development and maintenance of the emergency management program and emergency operations plan.

      UTMB develops and maintains mutually agreed upon protocols that address the emergency responsibilities of itself, each transplant program, and the OPO. More information on these protocols can be found in the Transplant Services business continuity plan.

    EM.10.01.01 – Hospital leadership provides oversight and support of the emergency management program.

    EM.10.01.01 - Organization Leadership & EM Committee

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    • EP 1 - Senior Leadership Involvement

      The hospital’s senior leaders provides oversight and support for the following emergency management program activities: The ISS executive committee includes the Heath System CEO, CMO and other senior members. A physician is assigned as the Institutional Emergency Preparedness Officer (IEPO; usually the Chief Medical Officer). 

      • Allocation of resources for the emergency management program – The ISS allocates resources for the UTMB emergency management program.

      • Review of the emergency management program documents – The ISS reviews and approves all emergency management program documents.

      • Review of the emergency operations plan, policies, training, and education that supports the emergency management program – The ISS conducts an annual program review of the EOP, policies, training, and education that supports the emergency management program.

      • Review of after-action reports and improvement plans – The ISS reviews after-action reviews and manages and tracks improvement plans.

      Note 1: The hospital defines who the member(s) of the senior leadership group are as well as their roles and responsibilities for EM-related activities. CEO Health System and EVP; CMO (IEPO), CNO, VP Ambulatory Services, Galveston County Public Health Authority, COO, Emergency Department Representative.

      Note 2: An after-action report (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 provides areas needing improvement. (See also LD.01.03.01 EP 5)

      University of Texas System Policy 172 designates the institution President as being responsible to assure that an adequate emergency preparedness program is in place. The President designates the Institutional Emergency Preparedness Officer (IEPO). The IEPO together with the Department of Institutional Preparedness are responsible for the development, annual review, distribution, and control of the Institutional Emergency Preparedness Program and Emergency Operations Plan. The President also delegates authority to other institutional officials to assure that emergency response is effective (e.g. to leadership of the specific campus experiencing the incident). 
    • EP 2 - Emergency Management Coordination

      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:

      The UTMB Associate Vice President for the Institutional Preparedness department serves in this role.

      • Developing and maintaining the emergency operations plan and policies and procedures – UTMB's Institutional Preparedness department fulfills this role, pulling in the Incident Command Teams and the Institutional Safety & Security (ISS) Executive Committee when necessary.

      • Implementing the four phases of emergency management (mitigation, preparedness, response, and recovery) – UTMB Institutional Preparedness addresses the four phases of emergency management; additionally, UTMB follows the National Preparedness Goal that describes five mission areas — prevention, protection, mitigation, response and recovery ( https://www.fema.gov/emergency-managers/national-preparedness/goal ). Prevention can include for example, vaccination efforts to protect staff and patients; as well as actions by the University of Texas Police to prevent e.g. workplace violence or active shooter incidents; and to protect life and property.

      • Implementing emergency management activities across the six critical areas (communications, resources and assets, safety and security, staff responsibilities, utilities, and patient clinical and support activities) – All planning addresses the six critical functions. All after-action reviews address the six critical functions as well as the effectiveness of training.

      • Coordinating the emergency management exercises and developing after-action reports – UTMB's Institutional Preparedness department fulfills this role, conducting over a dozen AARs each year for exercises and incidents.

      • Collaborating across clinical and operational areas to implement organization wide emergency management – The UTMB program is organization wide – it is institutional in scope. Members of the ISS and its sub-committees include all relevant operational areas.

      • Identifying and collaborating with community response partners – UTMB follows the National Preparedness Goal which defines what it means for the whole community to be prepared for all types of disasters and emergencies. Therefore, UTMB uses a whole community approach for its emergency management program. This includes sharing risk information with community partners, participating in partner exercises, organizing community training and exercises, and participation in joint planning and mutual aid. UTMB is an active participant in the regional healthcare coalition (HCC) and the HHS Assistant Secretary for Preparedness and Response (ASPR) Hospital Preparedness Program. UTMB also collaborates with the National Emerging Special Pathogens Education and Training Center (NETEC) for national training, planning, and exercises related to biocontainment. 

      Note: Education, training, and experience in emergency management should be taken into account when considering the qualifications of the individual who leads the program.

    • EP 3 - Emergency Management Committee

      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.

      The UTMB Institutional Safety & Security (ISS) Executive Committee serves this function. All disciplines listed are represented. Additional information is found in the ISS Charter.

    • EP 4 - Committee Involvement

      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 – The ISS oversees the completion of a Hazard Vulnerability Analysis for all UTMB campuses and clinics. A risk assessment is used as the basis for the all-hazards emergency management program. The risk assessment and formal risk prioritization is generally done at the September ISS meeting.

      • Emergency operations plan, policies, and procedures – The ISS maintains the UTMB Emergency Operations Plan (EOP). Scope and objectives are reviewed at least annually. The EOP is reviewed as part of the overall Emergency Preparedness annual program review (usually conducted at the December meeting of the ISS. Policies and procedures related to all aspects of emergency preparedness are overseen by the ISS. UTMB Resilience Policy established coordinated emergency management and business continuity programs. The institutional Command Team may delegate policy development to the Health System Command Team or to specific tasks forces as needed (e.g., Covid response, infection control, vaccination).

      • Continuity of operations plan – Institutional Preparedness and Information Services manage the low-level completion of departmental and institution-level business continuity plans (BCPs) while the ISS reviews and approves the high-level BCPs (e.g., Health System BCP). Updated BCPs are due at the June ISS meeting.

      • Training and education – The ISS annual emergency management program establishes education and training topics for the program year.

      • Planning and coordinating incident response exercises (seminars; workshops; tabletop exercises; functional exercises, full-scale, community-based exercises) – The ISS annual emergency management program establishes exercise and testing for the program year. Members of the ISS are on the UTMB Command Team and participate in real incident response and exercises.

      • After-action reports and improvement plans – The ISS reviews after-action reviews and manages and tracks improvement plans. 

      Note: An after-action report (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.

    EM.11.01.01 – The hospital conducts a hazard vulnerability analysis utilizing an all-hazards approach.

    EM.11.01.01 - Hazard Vulnerability Analysis

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    • EP 1 - HVAs (facilities-based, all-hazards approach)

      The hospital conducts a facility-based hazard vulnerability analysis (HVA) using an all-hazards approach that includes the following:

      • Hazards that are likely to impact the hospital’s geographic region, community, facility, and patient population. The ISS conducts an annual risk assessment. The risk assessment is usually reported at the September quarterly meeting. The risk assessment includes a macro-level risk assessment; Hazard Vulnerability Analysis; and a facilities risk assessment that is used to prioritize risk management and risk mitigation measures for campus facilities and infrastructure. The finished risk assessment reflects the risk profile for that location and population.

      • A community-based risk assessment (such as those developed by external emergency management agencies). UTMB shares its risk information with community partners. When available, UTMB will consider the risk assessments of jurisdictions or other agencies. 

      • Separate HVAs for its other accredited facilities if they significantly differ from the main site. Each UTMB hospital participates in the development of its community-based risk assessment. The finished risk assessment should reflect the risk profile for that location and population. Ambulatory Services conducts an HVA for each site that has a different risk profile. Clinics in the same building may work collaboratively and develop one HVA for the site (unless the clinic has a unique patient population that would alter its risk profile).

      The findings are documented.

      Note: A separate HVA is only required if the accredited facilities are in different geographic locations, experience different hazards or threats, or the patient population and services offered are unique to this facility.

    • EP 2 - HVA Included Categories

      Each UTMB Hospital hazard vulnerability analysis includes the following:

      • Natural hazards (such as flooding, wildfires)
      • Human-caused hazards (such as bomb threats or cyber/information technology crimes)
      • Technological hazards (such as utility or information technology outages)
      • Hazardous materials (such as radiological, nuclear, chemical)
      • Emerging infectious diseases (such as Ebola, Zika Virus, SARS-CoV-2)
      • Modeling of campus buildings to indicate the vulnerability of each floor and critical building system to hurricane flood
    • EP 3 - Prioritizing Risks

      The hospital evaluates and prioritizes the findings of the hazard vulnerability analysis to determine what presents the highest likelihood of occurring and the impacts those hazards will have on the operating status of the hospital and its ability to provide services. The findings are documented.

      The ISS formally prioritizes risks and publishes a list of Priority Risks to be used in developing plans. While UTMB uses an all-hazards approach to planning, specific plans should be developed for priority risks (that can be addressed in a multi-year fashion). Mitigation of priority risks can include specific: planning, training and education, special supplies and equipment, response contract support, mutual aid agreements, insurance, et c.

      Given the risk of the highly concentrated chemical industry in the region, UTMB also develops an analysis of toxic industrial chemicals and publishes a list of Priority Risk Chemicals. Healthcare staff should generally be familiar with safety, decontamination, and treatment protocols for the highest priority risk chemicals (hydrogen fluoride, hydrogen cyanide, and hydrogen sulfide). Preparedness for non-priority risk chemicals is based on toxidromes. The regional Poison Center is located above the UTMB Main campus Trauma Center and Decontamination Facility. The Poison Center is used for technical response support and treatment protocols.

      Facilities/Utilities prepares an updated Facilities Readiness Report for the ISS on an annual basis. Because hurricanes/flooding is among the highest priority risks, a computer model of campus building floor levels (above mean sea level) is maintained. For each building the lowest point of vulnerability for critical building systems is listed. An inundation level can be entered into the system to identify the buildings/building systems that will be affected by the flood. This tool is used to identify and prioritize candidate mitigation projects as well as deferred maintenance projects that will enhance the resilience of the campuses.
    • EP 4 - Preparing For and Mitigating Prioritized Risks

      The hospital uses its prioritized hazards from the hazard vulnerability analysis to identify and implement mitigation and preparedness actions to increase the resilience of the hospital and helps reduce disruption of essential services or functions.

      The ISS-approved priority risk list is used as the basis for all preparedness and risk mitigation.  The Facilities Readiness Report and Prioritized Mitigation Recommendations are presented to the ISS for consideration. Completion of mitigation projects is subject to the availability of funding.

      UTMB develops a thorough Hazard Mitigation Plan that it submits to the Texas Division of Emergency Management and to FEMA for review and approval. Once approval is provided at the state and federal level, UTMB formally adopts the plan by a communication from the UTMB President. The plan is in effect for 5 years. The current plan was adopted in 2020.

      UTMB Business Operations and Facilities (BOF) has adopted a building elevation standard of 20 feet above mean sea level as “safe” for critical infrastructure on the main campus. New construction will be designed so that the elevation for critical infrastructure is at a minimum of 25 feet elevation.

      Structures below this elevation are considered more vulnerable to flooding during periods of extreme water accumulation and/or storm surges. Building elevation standards for new or acquired campuses will be developed based on the risk of inundation.

      BOF currently maintains a database that identifies the elevations of various buildings and the contents of their ground floor. These operations include automatic transfer switches needed to support back-up generators. (A multi-year mitigation plan is being implemented to move these facilities and functions to a higher elevation as funding allows).

      Each department on the ground floors of buildings shall develop a relocation plan, independently or as part of their business continuity plan, to allow uninterrupted operations during an event or immediately following any event that would make their current location unusable. BOF has evaluated the recommendations to relocate emergency power generators and transfer switches to locations above the 20-foot minimum elevation as renovations occur.

      Since Hurricane Ike (2008), UTMB has expended over $1.2B in recovery and mitigation incorporating the latest technologies. In building Jennie Sealy Hospital, the Clinical Services Wing, and the East Plant, UTMB exceeded FEMA flood requirements by an additional 5 feet.

    EM.12.#.# – Emergency Operations Plan

    Planning  /  Communications  /  Staffing  /  Patient Clinical & Support Activities  /  Safety & Security  /  Resources & Assets  /  Utilities  /  Crisis Standards of Care

    These Standards and Elements of Performance can be found on the Emergency Operations Plan webpage.

    EM.13.01.01 – The hospital has a continuity of operations plan.

    EM.13.01.01 - Continuity of Operations Plan

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    • EP 1 - Continuity of Operations Plan Developed with Executive Leaders

      The hospital has a written continuity of operations plan (COOP) that is developed with the participation of key executive leaders, business and finance leaders, and other departments leaders as determined by the hospital. These key leaders identify and prioritize the services and functions that are considered essential or critical for maintaining operations.

      Note: The COOP provides guidance on how the hospital will continue to perform its essential business functions to deliver essential or critical services. Essential business functions to consider include administrative/vital records, information technology, financial services, security systems, communications/telecommunications, and building operations to support essential and critical services that cannot be deferred during an emergency; these activities must be performed continuously or resumed quickly following a disruption.

      UTMB has a written continuity of operations plan that is developed with the participation of key executive leaders, business and finance leaders, and other department leaders as determined by the hospital (See the Planning Team members listed in the continuity plan). These key leaders identify and prioritize the services and functions that are considered essential or critical for maintaining operations. More information: Business Continuity Plans (BCP). As part of UTMB's integrated preparedness program, relevant information from this system-level continuity plan is then used in lower-level departmental continuity plans (note: departments do their own continuity planning first).

      The Health System Continuity Plan provides guidance on how the hospital will continue to perform its critical missions (delivery of healthcare services) as well as essential business functions to deliver essential or critical services. Essential business functions to consider include administrative/vital records, information technology, financial services, security systems, communications/telecommunications, and building operations to support essential and critical services that cannot be deferred during an emergency; these activities must be performed continuously or resumed quickly following a disruption.

      The Health System Incident Command has the flexibility to prioritize services offered and to shift services among UTMB hospitals to optimize the delivery of healthcare services in an emergency or disaster. The Health System command team, working with the UTMB Institutional Command Team may secure additional or temporary facilities in order to continue healthcare services. This may include the incorporation of state or federal resources if requested and provided.
    • EP 2 - Continuity Plan Addresses Continued Operations when Location Compromised

      The hospital’s continuity of operations plan identifies in writing how and where it will continue to provide its essential business functions when the location of the essential or critical service has been compromised due to an emergency or disaster incident.

      Note: Example of options to consider for providing essential services include use of off-site locations, space maintained by another organization, existing facilities or space, telework (remote work), or telehealth.

      The UTMB Health System continuity plan identifies in writing how and where it will continue to provide critical missions (delivery of healthcare services) and its essential business functions when the location of the essential or critical service has been compromised (Loss of Work Place) due to an emergency or disaster incident. (Example of options to consider for providing essential services include use of off-site locations, space maintained by another organization, existing facilities or space, telework (remote work), or telehealth.) While Joint Commission requires continuity plans specifically for Loss of Work Place, the full UTMB list for strategies and tactics should address:

      • Loss of Workplace (e.g. fire, flood)
      • Loss of Workforce (e.g. novel flu outbreak)
      • Loss of Technology (e.g. Cyber-attack, elevator failure)
      • Loss of Critical Utility (e.g. extended electric power outage)
      • Loss of Transportation / Access (e.g. areal flooding)
      • Loss or Shortage of Critical Medical Supplies or Equipment
      • Loss of Standard Communications (e.g. IP Phones and email down)

      SCOPE

      The scope of this healthcare continuity plan includes all UTMB Health System functions. This plan provides a set of unifying strategies approved by the Health System leadership that all departments should use to guide the development of their departmental plans.

      This continuity plan augments the UTMB Emergency Operations Plan. The three standing objectives for the UTMB Command Center in response to emergencies are:

      1. Protect Human and Animal Life
      2. Protect the Facilities, Infrastructure, and Communications and Computing Networks
      3. Continue Critical Missions

      These objectives provide a unifying framework for emergency planning which addresses the first two objectives; and continuity planning, which addresses the third objective. Therefore, emergency and healthcare continuity plans and response activities should be integrated through all phases of an emergency preparedness including:

      1. Prevention
      2. Mitigation
      3. Response
      4. Recovery

      UTMB has formally adopted the Hospital Incident Command System (HICS). The UTMB HICS implementation includes a Business Continuity Branch within the Operations Section. 

      OBJECTIVE

      The primary objective of this plan is to better assure that UTMB will be able to continue to provide healthcare despite disruptive incidents including disasters (when healthcare services are generally most needed by the community). If a disaster does cause sufficient damage to the facilities, the secondary goal of this plan is for UTMB to be prepared to restore full healthcare services as soon as possible.

      This plan provides a common set of objectives and response strategies for departmental and business unit plans within the Health System:

      • The Health System will coordinate with the Office of the President, Academic Enterprise, Research Enterprise and UTMB Support functions in continuous improvement of emergency and continuity plans.
      • The UTMB Command System will be used to coordinate healthcare continuity strategies.
      • Per the UTMB Emergency Operations Plan, the Institutional Incident Commander may authorize the Health System to establish a Sub-Command to address healthcare-specific planning. In this case, emergency and continuity planning will still be coordinated with the UTMB Command Center.
      • UTMB may designate a location other than main campus for the institutional command center and healthcare continuity operations based on the nature of the emergency, or they may implement a virtual command center.
      • UTMB’s Inclement Weather Policy addresses the need to remain open to serve patients. Staff members are expected to report to work or to remain at work if it is safe to do so. This applies to all Health System hospitals, ambulatory locations, and support functions.
      • If possible, Health System hospitals will remain open. Staff members should always be prepared to remain on duty until relieved. If needed, the Health System will establish a plan to rotate staff and may implement a staff shelter plan.
      • The Health System hospitals may implement a Shelter-in-Place with Patients strategy.
      • The Health System hospitals may implement a census reduction in anticipation of notice incidents such as a hurricane or other dangerous situation; or on notice of a major regional mass casualty incident using a strategy of Immediate Bed Availability where the goal is to reduce the census by 20% if possible. If an 1135 waiver is approved because of the incident, appropriate patients may be transferred to long-term care facilities in order to make beds available for incident victims.
      • League City Campus, Clear Lake Campus, Angleton Danbury Campus, and Ambulatory Services on the mainland are authorized to establish command centers on mainland locations, and if communication between the mainland and the island are down, those command centers are authorized to begin recovery and healthcare continuity operations.
      • All Health System continuity plans should address loss of: workplace, workforce, technology, critical utility, transportation/access, shortage of critical medical supplies and equipment, and standard communications. More information on each of these losses is found HERE.

      Additional Information on the Business Continuity Planning webpage.

    • EP 3 - Order of Succession Plan

      The hospital has a written order of succession plan that identifies who is authorized to assume a particular leadership or management role when that person(s) is unable to fulfill their function or perform their duties.

      UTMB includes a written order of succession plan that identifies who is authorized to assume a particular leadership or management role when that person(s) is unable to fulfill their function or perform their duties. The Health System succession plan is included in the Health System Continuity Plan. Each departmental plan will include a succession plan as part of their Departmental Continuity Plan.

      CHAIN OF COMMAND

      The President of UTMB is the authority for activation of the Institutional Emergency Operations Plan and Institutional Command Center. If not available the President may designate an official to take the role of Institutional Incident Commander. If not available to make a designation, the following officials have delegated authority from the President to activate the EOP and Institutional Command Center.

      1. Institutional Executive Vice Presidents; Chief Academic Officer
      2. Institutional Emergency Preparedness Officer
      3. Ranking administrative official on site
      4. Associate Vice President Institutional Preparedness

      After hours, emergency plans may be activated by:

      1. Health System Administrator on Call
      2. Clinical Operations Administrator
      3. Business Operations and Facilities Executive On-Call

      For League City Campus, Clear Lake Campus and Angleton Danbury Campus: When time for emergency response is of the essence, the following officials have delegated authority from the UTMB President to activate campus plans and incident command:

      1. Campus Administrator
      2. Campus Emergency Preparedness Officer
      3. Campus Health System Administrator On-Call
      4. Campus Facilities Representative On-Call

      For Facilities-related incidents, emergency plans may be activated by the Vice President for Business Operations and Facilities or his/her designee. In any case, the first UTMB staff member to become aware of an emergency incident, or the first to arrive at the scene of an emergency should report the emergency and if trained, establish an Incident Command to respond to the emergency in accordance with the National Incident Management System / Incident Command System. As soon as is practical, the incident should be reported to the officials listed above.

      For Police actions, the Chief of Police may activate a law enforcement incident command as needed and may delegate authority to police officers as needed.
    • EP 4 - Delegation of Authority Plan

      The hospital has a written delegation of authority plan that provides the individual(s) with the legal authorization to act on behalf of the hospital for specified purposes and to carry out specific duties.

      Note: Delegations of authority are an essential part of an organization’s continuity program and should be sufficiently detailed to make certain the hospital can perform its essential functions. Delegations of authority will specify a particular function that an individual is authorized to perform and includes restrictions and limitations associated with that authority.

      The UTMB Health System written continuity plan serves as the written delegation of authority plan that provides the individual(s) with the legal authorization to act on behalf of the hospital for specified purposes and to carry out specific duties. Departmental continuity plans serve as the written delegation of authority for that department. Departmental plans should should be sufficiently detailed to make certain the department can perform its essential functions. Delegations of authority will specify a particular function that an individual is authorized to perform and includes restrictions and limitations associated with that authority.

    EM.14.01.01 – The hospital has a disaster recovery plan.

    EM.14.01.01 - Disaster Recovery

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    • EP 1 - Disaster Recovery Plan Strategies

      The hospital has a disaster recovery plan that describes in writing its strategies for how and when it will do the following:

      • Conduct hospital wide damage assessments
      • Restore critical systems and essential services
      • Return to full operations.

      UTMB has a detailed Disaster Recovery Plan which uses its prioritized hazards as identified as part of its hazard vulnerability assessment. It describes in writing UTMB's strategies for how and when it will conduct organization wide damage assessments, restore critical systems and essential services, and return to full operations.

      Damage Assessment, Repairs, and Debris Removal: The Support Operations Section /BOF will conduct campus wide damage assessments and identify critical needs for repairs, additional  power or air conditioning. BOF will coordinate the ordering of repair supplies and contract labor to effect repairs. Debris removal, if required will be coordinated by BOF who will be responsible for securing contract services, equipment, roll-off containers or other materials required. Debris removal contractors should be monitored by an independent contractor familiar with federal laws and regulations regarding compensation for debris removal. To the degree possible all contracts should include accurate scopes of work. Time and materials contracts should be avoided if possible. BOF and the IC or designees will assess any area of any UTMB building which may be compromised for occupancy and will coordinate with local building inspection officials on the decision to abandon a site, or declare any area suitable for use.

      University facilities may only be reopened and reoccupied when the all-clear notice is issued by the President or IC. Unsafe or contaminated areas must be reported to EH&S before commencing business operations. The Texas Division of Emergency Management may also be contacted for assistance.

      UTMB and UT System have contracts in place with disaster response companies. These contractors are listed in the disaster mutual aid plan. Contractors can supply emergency generators, chillers, water, fuel, and other necessities in preparation for or after a disaster. Additional state contracts exist with disaster response companies.

      UT System annually negotiates contracts for essential services necessary immediately following a disaster event. These services (water damage restoration, emergency power generators, and similar services) are available to each UT component under the agreement and can be requested as needed.

      UTMB participates in the UT System Inter-Campus Services Agreement which specifies that each UT System campus will assist any other campus which requests resources that the affected campus cannot supply. Services and resources provided under this agreement can include (but is not limited to):

      1. Supplement personnel such as Police, Environmental Health, Safety or Physical Plant
      2. Services such as remote work sites or remote information services hosting
      3. Equipment
      4. Supplies
      5. Housing for displaced students, faculty or employees

      The UT System Inter-Campus Services Agreement specifies the mechanism to initiate a request for assistance and the appropriate person to initiate the response. The agreement also specifies the responsibilities for any UT Component employee or UT System employee who is a member of a Disaster Response Team (DRT) deployed to assist any component.

      Members of any UT System – sponsored DRT will have previously completed a Volunteer Agreement (found in the Inter-Campus Services Agreement) and are credentialed for their specific skills. As such, UT Systems component employees deployed as DRT are not considered Volunteers as defined later in this plan.

      DRT members must report to the UTMB Command Center for instructions and assignments.
    • EP 2 - DR Family Reunification & Coordination

      The hospital’s disaster recovery plan describes in writing how the hospital will address family reunification and coordinate with its local community partners to help locate and assist with the identification of adults and unaccompanied children.

      Family Reunification is addressed in UTMB's Disaster Recovery Plan.

      To deal with family reunification and to collaborate with local community partners to help locate and assist with the identification of adults and unaccompanied children, UTMB is prepared to set up Family Reception Centers (FRC) on campuses as part of disaster response and recovery. The general concept of operation with local jurisdictions is that UTMB Family Reception Centers may be set up prior to the ability of the affected County, City, agency, or industry is able to set up a formal Family Assistance Center (FAC). Operational control will shift from the FRC to the jurisdictional FAC as the FAC is mobilized.

    EM.15.01.01 – The hospital has an emergency management education and training program.

    EM.15.01.01 - Staff Education & Training Program

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    • EP 1 - Education & Training Program in Emergency Management

      The hospital has a written education and training program in emergency management that is based on the hospital’s prioritized risks identified as part of its hazard vulnerability analysis, the emergency operations plan, and policies and procedures.

      Note: If the hospital has developed multiple hazard vulnerability analyses based on the location of other services offered, the education and training for those facilities are specific to their needs.

      UTMB has a written education and training program in emergency management that is based on the UTMB’s prioritized risks identified as part of its hazard vulnerability analysis, the emergency operations plan, and policies and procedures. The Institutional Safety and Security Executive Committee conducts an annual review of the previous year’s preparedness program (including training), and this information is incorporated into the following calendar year’s program proposal. The program proposal is usually scheduled in December and carried out the following calendar year. UTMB uses a calendar year so as not to divide hurricane season into two program years.

      The hospital provides emergency preparedness training to staff, volunteers, individuals providing service at the following intervals:

      • Initial training
      • At least every two years
      • When roles or responsibilities change
      • When policies or procedures are significantly updated

      UTMB has developed multiple hazard vulnerability analyses based on the location of other services offered. Education and training for those facilities are specific to their needs.

      Emergency preparedness is included for all staff members when they come onboard at UTMB; and is included in Annual Compliance Training. Any staff member that does not complete annual compliance training is subject to cutoff of pay and network access. UTMB also uses an Annual Acknowledgment Process for essential personnel. In this process, managers assign an appropriate essential level to the staff member and have an opportunity to discuss the role and expectations for performance. This is recorded in a web-based application that is managed by Human Resources.

      • Staff demonstrate knowledge of emergency procedures through participation in drills and exercises, as well as post-training tests, participation in instructor-led feedback, or other methods determined and documented by the organization.

      Since assignment to formal roles on the command team is based on expertise, and because the UTMB Command Team activates frequently, training for these roles is on-the-job, though a ‘UTMB Command Team Operations’ training is available to anyone that requests it. FEMA ICS training is not required.   

      More information found under the "Training" navigation tab at the top of this page, and on the Emergency Annual Preparedness webpage.
    • EP 2 - Initial Education & Training in Emergency Management

      The hospital provides initial education and training in emergency management to all new and existing staff, individuals providing services under arrangement, and volunteers that is consistent with their roles and responsibilities in an emergency. The initial education and training include the following:

      • Activation and deactivation of the emergency operations plan
      • Communications plan
      • Emergency response policies and procedures
      • Evacuation, shelter-in place, lockdown, and surge procedures
      • Where and how to obtain resources and supplies for emergencies (such as procedures manuals or equipment)

      UTMB provides initial/onboard education and training in emergency management to all new and existing staff, volunteers, physicians, and other licensed practitioners that is consistent with their roles and responsibilities in an emergency. The initial education and training includes all of the points bulleted above. For example, the Office of Training and Development will present information on the Emergency Plan for each new employee, including the basic design of the Plan, expectations of each employee, their role(s) in disaster situations, and an explanation of the system of Essential Personnel designations.

      A very basic overview is provided in the Onboard Training presentation. Topics are covered in greater detail when new employees meet with their supervisor shortly afterwards. Employees are also required to complete their Emergency Classification review (UTMB employees only) at this time, and annually.
    • EP 3 - Ongoing Education & Training for Emergency Responsibilities

      The hospital provides ongoing education and training to all staff, individuals providing services under arrangement, and volunteers that is consistent with their roles and responsibilities in an emergency:

      • At least every two years
      • When roles or responsibilities change
      • When there are significant revisions to the emergency operations plan, policies, and/or procedures
      • When procedural changes are made during an emergency or disaster incident requiring just-in-time education and training

      Note 1: Staff demonstrate knowledge of emergency procedures through participation in drills and exercises, as well as post-training tests, participation in instructor-led feedback (for example, questions and answers), or other methods determined and documented by the organization.

      Note 2: Hospitals are not required to retrain staff on the entire emergency operations plan but can choose to provide education and training specific to the new or revised elements of the emergency management program.

      UTMB provides ongoing education and training to all staff, volunteers, physicians, and other licensed practitioners that is consistent with their roles and responsibilities in an emergency:

      • At least every two years
      • When roles or responsibilities change
      • When there are significant revisions to the emergency operations plan, policies, and/or procedures
      • When procedural changes are made during an emergency or disaster incident requiring just-in-time education and training

      UTMB's staff demonstrate knowledge of emergency procedures through participation in drills and exercise, participation in after-action reviews and resulting improvement activities, participation in instructor-led feedback, and other methods determined and documented by the organization. 

      UTMB is not required to retrain staff on the entire emergency operations plan but can choose to provide education and training specific to the new or revised elements of the emergency management program.
    • EP 4 - Incident Command Staff Training

      The hospital requires that incident command staff participate in education and training specific to their duties and responsibilities in the incident command structure.

      Note: The hospital may choose to develop its own training, or it may require incident command staff to take an incident command–related course(s) such as those offered by the Federal Emergency Management Agency.

      UTMB conducts on the job training for Command Staff members. For those that request individual training, a tutorial is available on UTMB Command Center Operations. The hospital requires that incident command staff participate in education and training specific to their duties and responsibilities in the incident command structure. For Notice Incidents, UTMB has a standard agenda for conducting the Command Team meeting. Participants are expected to be familiar with this agenda and they are expected to come to the Institutional Command Team meeting prepared to provide a situation update specific to their Command Team Section. They should also come prepared to notify the Command Team of any information, resources, or coordination needed. Their situation update should address any constraints that they face for incident response or recovery.

      The Incident Commander will establish objectives for the next operational period. Operational Sections will conduct a task analysis to determine the tasks required to address each objective. Standing Objectives for UTMB are to:

      • Protect Life
      • Protect the Facilities, Infrastructure, Network and Communications Networks
      • Continue Critical Missions

      After determining each task required to address an objects, the Operations Sections will determine if they have sufficient resources to complete the task. If additional resources are required, the Operational Sections will coordinate with Logistics and Finance Sections. If needed, the resource needs will be addressed at the next Command Team meeting.

      Each campus hospital has a command team, and the Health System as a whole has a command team. These are constituents of the UTMB Institutional Command Team (click the link for more information).

      UTMB does not require that Command Staff members take course(s) such as those offered by the Federal Emergency Management Agency.

    EM.16.01.01 – The hospital plans and conducts exercises to test its emergency operations plan and response procedures.

    EM.16.01.01 - Testing the Emergency Operations Plan

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    • EP 1 - Written Plan to Test EOP & Response Procedures

      The hospital describes in writing a plan for when and how it will conduct annual testing of its emergency operations plan. The planned exercises are based on the following:

      • Likely emergencies or disaster scenarios
      • Emergency operations plan and policies and procedures
      • After-action reports (AAR) and improvement plans
      • The six critical areas (communications, resources and assets, staffing, patient care activities, utilities, safety and security)
      • Changes in in the emergency operations and/or emergency response procedures (Plans should be retested after a change to evaluate the effectiveness of the change)

      Note 1: The planned exercises should attempt to stress the limits of its emergency response procedures in order to assess how prepared the hospital may be if a real event or disaster were to occur based on past experiences.

      Note 2: An AAR is a detailed critical summary or analysis of an emergency or disaster incident, including both planned and unplanned events. The report summarizes what took place during the event, analyzes the actions taken by participants, and provides areas needing improvement.

      UTMB's plan does all of these things. UTMB has/conducts over a dozen incidents/exercises each year for at least the past decade. Exercises are guided by our priority risks (guided by our HVA) and preparedness level related to each risk. Incidents, Exercises, AARs and Improvement plans are viewable by authorized personnel. 

      UTMB hospitals will generally conduct two exercises per year based on Priority Risks. The exercises will be included in the ISS-approved calendar year Institutional Preparedness Program. Responses to real incident can be substituted for planned exercises. UTMB will also support Whole Community Preparedness efforts and Healthcare Coalition efforts by participating in community-based preparedness and exercises. UTMB ambulatory service site clinics will complete at least one exercise per year and may substitute a real incident as long as an After Action Review and Improvement Plan is completed. Multi-year exercise plans should strive to vary exercise scenarios so that over time – most if not all priority risks are addressed.  

      When conducting exercises, UTMB should attempt to stress the limits of its emergency response procedures in order to assess how prepared the hospital may be if a real event or disaster were to occur based on past experiences.
    • EP 2 - Two Exercises Per Year to Test EOP (Hospital)

      The hospital is required to conduct two exercises per year to test the emergency operations plan.

      • One of the annual exercises must consist of an operations-based exercise as follows:
      • Full-scale, community-based exercise; or
      • Functional, facility-based exercise when a community-based exercise is not possible
      • The other annual exercise must consist of either an operations-based or discussion-based exercise as follows:
      • Full-scale, community-based exercise; or
      • Functional, facility-based exercise; or
      • Mock disaster drill; or
      • Tabletop, seminar, or workshop that is led by a facilitator and includes a group discussion using narrated, clinically relevant emergency scenarios and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.

      Exercises and actual emergency or disaster incidents are documented: Viewable by authorized personnel at Incidents, Exercises, AARs and Improvement plans.

      Note 1: The hospital would be exempt from conducting its next annual operations-based exercise if it experiences an actual emergency or disaster incident. For each event(s), an exemption(s) only applies if the hospital provides documentation in an after-action report(s), improvement plan(s), and review of the emergency operations plan.

      Note 2: See the Glossary for the definitions of full-scale exercise and functional exercise.

      For the past two year, UTMB has responded to significant real incidents that will be used in lieu of exercises.

      • In 2020, UTMB responded to the Covid19 outbreak in addition to a hyperactive hurricane season with 31 named storms, 11 of which entered the Gulf of Mexico (potentially threatening UTMB). UTMB activated its EOP for Hurricane Laura and Tropical Storm Beta.
      • In 2021, UTMB continued its Covid19 response, including initiation of a Unified Command with County and other agencies to implement a mass vaccination program. AARs and Mid/Final-Course Reviews were completed and Improvement Plans were developed. UTMB also activated its EOP for the February Freezing Weather Incident that resulted in loss of water, power, sterilization, and heat. An after-action review and improvement plan were developed. In addition to improvements to ourselves, UTMB led an effort to improve community planning for dialysis care during disasters. 

      For real incident where UTMB expects that a FEMA Public Assistance or insurance claim will be made, the Institutional Command Team may direct that Command Team summaries and objectives are recorded and preserved. The Command Team may direct that specific cost accounts (Chart-Filed Strings) be used so that response and recovery costs are documents.
    • EP 3 - One Exercise Per Year to Test Emergency Response Procedures (Clinic)

      Each accredited freestanding outpatient care building that provides patient care, treatment, and services is required to conduct at least one operations-based or discussion-based exercise per year to test its emergency response procedures, if not conducted in conjunction with the hospital’s emergency exercises. Exercises and actual emergency or disaster incidents are documented.

      UTMB's freestanding outpatient care buildings are required to conduct at least one operations-based or discussion-based exercise per year to test their emergency response procedures, if not conducted in conjunction with the hospital’s emergency exercises.

      UTMB documents these exercises and actual emergency or disaster incidents. 

    EM.17.01.01 – The hospital evaluates its emergency management program, emergency operations plan, and continuity of operations plans.

    EM.17.01.01 - Evaluation of Emergency Management Program

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    • EP 1 - Committee Evaluates Exercises & Actual Incidents

      The multidisciplinary committee that oversees the emergency management program reviews and evaluates all exercises and actual emergency or disaster incidents. The committee reviews after-action reports (AAR), identifies opportunities for improvement, and recommends actions to take to improve the emergency management program.

      The AARs and improvement plans are documented: Viewable by authorized personnel at Incidents, Exercises, AARs and Improvement plans.

      Note 1: The review and evaluation addresses the effectiveness of its emergency response procedure, continuity of operations plans (if activated), training and exercise programs, evacuation procedures, surge response procedures, and activities related to communications, resources and assets, security, staff, utilities, and patients.

      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 provides areas needing improvement.

      The ISS, relevant sub-committees, and other department leaders review and evaluate all exercises and actual emergency or disaster incidents. UTMB Institutional Preparedness drafts after-action reports and identifies opportunities for improvement.

      A sample template for UTMB's After-Action Review can be viewed using this hyperlink.
    • EP 2 - Leadership Reviews After-Action Reports & Improvements

      The after-action reports, identified opportunities for improvement, and recommended actions to improve the emergency management program are forwarded to senior hospital leadership for review. (See also LD.04.01.10, EP 2).

      The UTMB Health System CEO and Chief Medical Officer (Institutional Emergency Preparedness Officer) as well as other senior Health System officials are members of the Institutional Safety and Security (ISS) Executive Committee and participate directly in program reviews and subsequent program proposals.  

      AAR Reports and Improvement Plans are forwarded to the ISS. Improvement Plans are tracked at a high level by this committee (Example: Major Improvement Tracking). The department of Institutional Preparedness tracks AARs and improvements at a lower, more-detailed level.
    • EP 3 - Hospital Improvements in Several Categories Based on AARs

      The hospital reviews and makes necessary updates based on after-action reports or opportunities for improvement to the following items every two years (UTMB does this annually), or more frequently if necessary:

      • Hazard vulnerability analysis
      • Emergency management program
      • Emergency operations plan, policies, and procedures
      • Communications plan
      • Continuity of operations plan
      • Education and training program
      • Testing program

      The ISS process is an annual process. After Action Reviews and Improvement Plans are tracked by the ISS. Annually the ISS considers risks and prioritizes them at the September meeting. Analysis is incorporated into a Program Proposal for the following calendar year at the December meeting. Read more about the ISS process HERE.

      ISS Quarterly Topics