hospital core · preparedness gaps, selecting 3 of 5 facilities/organizations from bp2 report...

HOSPITAL CORE

Department of Health and Mental Hygiene

Office of Emergency Preparedness and Response

BP4 Contract Term

July 1, 2015 to June 30, 2016

Background

• Each of the 55 NYC hospitals will complete both required and elective deliverables

• Deliverables have been designed with the goal of strengthening both institutional and health care system emergency preparedness by:

• providing support for training, equipment purchases, planning activities for all hazards planning

• providing capacity and capability building through coalition development, and integrated planning with external response partners

Scope of Services

• Hospitals are required to complete 4 required deliverables and 3 elective deliverables

• Maximum Reimbursable Amount is $46,000 per hospital • Required Deliverables – all worth $6,250 each (x 4 = $25,000)

• Elective Deliverables – all worth $7,000 each (x 3 = $21,000)

• Hospitals will complete a survey by Oct 1 to select their electives.

• In addition to the scheduled deliverables outlined below, during the term of this contract, hospitals must: • Maintain accurate contact information for facility Emergency Preparedness Coordinator

(EPC) and Alternate EPC;

• Pick up antibiotic supplies provided through DOHMH for hospital antibiotic caches;

• Acknowledge 800 MHz radio calls during drills or actual emergency events; and

• Maintain compliance with National Incident Management System requirements

• This and other supporting documents will be at oeprmeetings.com.

Required Deliverables

Required Deliverable 1 [RD1]

Healthcare Facility Directory: Information Sharing

Description/Overview

• Maintain up-to-date contact information for key hospital personnel and share with DOHMH via the online Healthcare Facilities Directory

Activities

• Review and provide informational updates to DOHMH for key hospital personnel and services

• Complete all fields; the online interface will check for completeness

Required Documentation

• Update the online DOHMH Healthcare Facilities Directory twice yearly

Due Date(s)

• November 20, 2015

• May 20, 2016

• Two payouts of $3,125 each

Required Deliverable 2 [RD2]Emergency Preparedness Symposium (EPS): Health Care System Preparedness


• Activities to help hospitals plan for cyber security/health IT failure and participate in a healthcare system cyberattack discussion.

Activities• Attend 2 EPS/cyber security planning meetings in fall 2015 and winter 2016• Attend 1 EPS where DOHMH will facilitate a cyber security discussion in spring 2016


• Proof of participation in 2 EPS/cyber security planning meetings

• Proof of participation at 1 EPS/discussion/round table/TTX plus cyber/HIT security planning documentation

Due Date(s) Actual dates TBD

• October 2015

• January 2016

• March 2016 (meeting), April 30, 2016 (documentation)

• Three payouts of $2,000, $2,000 and $2,250

Required Deliverable 3 [RD3]

Coalition Development: Healthcare System Preparedness


• Activities to identify, discuss and build strategies to expand local and regional partnerships that support public health preparedness

Activities

• Follow up on the BP2 (July 1, 2013 – June 30, 2014) Community Linkages Deliverable; complete the preparedness strategies identified to address stated preparedness gaps, selecting 3 of 5 facilities/organizations from BP2 report

• Work with the 3 facilities/organizations to complete plan, training or exercise


• Proposal for plan, training or exercise with 3 preparedness partners outside of your hospital. Describe the activity, preparedness capability addressed, gaps mitigated, and partner(s) to support the activity, AND

• Evidence of completing the approved activities, showing participation of the 3 partners (e.g., completed plan, training materials and sign in sheets, or ExPlanAND AAR)

Due Dates

• Proposal due October 15, 2015

• June 1, 2016

Required Deliverable 4 [RD4]Mystery Patient Drill: Communicable Diseases Preparedness and Response

Description/Overview• Ensure Emergency Department capability to quickly identify, isolate, and use appropriate

infection control practices to manage patients presenting with communicable diseases (hospitals without emergency departments will have alternative infectious disease training deliverable)

Activities• At least one hospital representative must participate in in-person training for mystery patient

exercise program• Additional hospital staff (e.g. ED nursing and triage staff, physicians, emergency management

staff) must complete webinar training for the exercise program. Hospital will identify essential staff across all ED shifts and MUST include nursing, security, physicians; Emergency Management (may include ancillary staff)

• Participate in 2 mystery patient drills on two different shifts; one must be Ebola scenario; second may be other scenario and/or may be in Pediatric ED (at hospital’s discretion)

• Develop internal improvement plan in accordance with recommendations from AAR provided by DOHMH

Required Documentation• Attendance at in-person training (two dates will be offered)• Documentation of participation in webinar training (should demonstrate essential staff

completed webinar)*DOHMH will use pre- & post - test scores as evidence of completion• Hospital to submit improvement plan with corrective actions

Due Date(s)• June 10, 2016

Elective Deliverables

Elective Deliverable 1 [ED1]

Equipment Purchase


• Purchase up to $7,000 of FEMA approved equipment to enhance facility level preparedness

Activities

• Submit proposed purchase with prices for approval to DOHMH

• Upon approval, place order


• For reimbursement, hospitals must submit: Purchase order, Invoice, Proof of payment & delivery

Due Date(s)

• Oct 1, 2015 (elective deliverable selection)

• Dec 31, 2015 (proposal)

• May 31, 2016 (purchase order, invoice, proof of payment/delivery)

Elective Deliverable 2 [ED2 – select option A or B]

Surge Planning –Option A


• Enhance Patient Flow using the Integrated Response Plan developed in conjunction with the Critical Care Advisory Group (GNYHA) and NYC EPCs to improve patient throughput during surge events

Activities

• Determine barriers to patient flow during surge events in the most common critical care areas with bottlenecks – ED, ORs, Radiology, ICUs

• Key department leadership will plan to enhance patient throughput in critical care areas

• Develop a process improvement plan to eliminate identified barriers to patient flow

• Share improvement plan with staff and present at an internal EM meeting (required)


• Name, title, department of team members (key department leaders)

• Completed gap(s) analysis (i.e., completed checklists – DOHMH provided)

• Completed process improvement plan

• EM meeting agenda and sign-in sheet

Due Date(s)


• March 31, 2016


Surge Planning –Option B


• Enhance surge staffing by identifying and addressing barriers-to-staffing during surge events

Activities

• Form a team to explore and identify a list of your facility’s barriers to staffing during surge events

• Develop a process improvement plan to eliminate identified barriers to staffing

• Present improvement plan at an internal EM meeting (required)


• Name, title, department of team members

• Completed process improvement plan

• EM meeting agenda and sign-in sheet

Due Date(s)


• March 31, 2016


Pediatric Surge Planning Intensive Care Exercise

Description/Overview• Deliverable open to up to 15 hospitals that have existing pediatric intensive care

surge plans to participate in a multi-hospital drill using the Situational Awareness Tool (SAT)

Activities• Convene a hospital planning team• Attend at least 3 planning meetings plus controller/evaluator training.• Participate in the SAT Handshake (survey)• Participate in the drill at your facility• Invite DOHMH (or other agency) to participate in drill• Conduct an After Action Meeting

Required Documentation• Attendance sheets for planning meetings• Completed handshake survey• Individual After Action Report (AAR) & Process Improvement Plan

Due Date(s)• Oct 1, 2015 (elective deliverable selection)• March 31, 2016


Training –Hospital Staff

Description/Overview• Identify and attend trainings based on the specific needs of your facility, OR register

or renew emergency management memberships, OR become certified/obtain an emergency management credential.

Activities• Based on identified gaps or vulnerabilities, develop and deliver a training for at least

20 staff. Topics could include: Active Shooter, Evacuation, eFINDs, or others (OR)

Hospitals may also send at least 2 staff to FEMA, HHS approved training (e.g., HERT in Anniston, Alabama) (OR) Register/renew memberships for emergency management or business continuity associations/ organizations (e.g. IAEM, DRI) (OR) Register for and receive an emergency management credential (e.g. AEM, CEM, ABDP, CBCP, MBCI)

Required Documentation• Brief proposal of desired training topic and how this supports preparedness in your

facility (e.g., indicated in HVA, TJC visit, an exercise AAR, etc.), AND• Proof of attendance: either certificates of completion, sign in sheet or EPC

attestation (OR)

• Proof of credential/membership

Due Date(s)• Oct 1, 2015 (elective deliverable selection)• Oct 30, 2015 (training proposal)• May 27, 2016


Design Your Own Deliverable


• Design a healthcare system preparedness or medical surge-related deliverable for the unique needs of your hospital.

Activities

• Propose activities demonstrating a link to hospitals’ HVA, other risk assessment, an identified gap, or an improvement plan for a hospital exercise/real–world event that occurred during 2014- 2015 (BP3)

• List on 1 page action steps to implement the proposal. Include how impact of activity will be measured or described.

• Present best practices and lessons learned in completing this deliverable at an internal EM meeting, coalition meeting or city-wide EP meeting, AND

• Actively participate in a workgroup including in-person and telephonic meetings as requested by the workgroup leader


1. Submit a proposal for activity, including a summary of After Action Reports and Improvement Plans leading to the choice of

topic, timeline and action steps, proposed measures or assessment tools

2. Evidence that activity was completed (could include documents, protocols, ExPlan/AAR, assessment findings, training materials, etc)

For one workgroup:

1. Attestation email from workgroup leader of active participation

2. Tools/products submitted and presented at DOHMH convened meetings

Due Date(s)


• Proposal due October 15, 2015

• April 29, 2016

7 Project Managers, 1 email address

Core Deliverable Deliverable Project Manager

Healthcare Facility Directory (RD1) Wanda Medina

Emergency Preparedness Symposium (RD2) Darrin Pruitt

Coalition Development (RD3) Marc Jean

Mystery Patient Drill (RD4) Mary Foote, MD

Equipment Purchase (ED1) Matthew Khaled

Surge Planning (ED2) Bill Lang

Pediatric Surge Planning Intensive Care Exercise (ED3) Wanda Medina

Training Hospital Staff (ED4) Darrin Pruitt

Design your Own Deliverable (ED5) Marsha Williams

[email protected]

mailto:[email protected]

Business Process

• PHS sends contract to EPC for signature

• EPC returns signed contract (+ other required documentation) to PHS

• PHS sends copy of executed contract to EPC

• EPC submits deliverable documentation and voucher by specified due date to Project Manager

• Project Manager reviews deliverable, notifies EPC of approval and signs voucher

• If deliverable not approved, Project Manager communicates to EPC what modifications are needed

• EPC resubmits deliverable for approval

• Project Manager submits voucher to OEPR GMA

• OEPR GMA reviews/approves and submits voucher to PHS for payment

• PHS remits payment

hospital core · preparedness gaps, selecting 3 of 5 facilities/organizations from bp2 report...

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