Emergency Management Program

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.

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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. Also see UTMB's Multi-Year Framework to address priority risks approved at the September ISS meeting.
- 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. Another resource is UTMB's Multi-Year Framework.
- 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 Clinical Enterprise 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
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 (Organ Procurement Organization). 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.

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

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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.

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

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

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

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

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