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AAAHC Update: Writing a Disaster Plan for Your ASC

A good disaster plan can help any ASC meet the standards of accreditation or certification for CMS. But more importantly, a well-written and rehearsed plan could potentially save lives. So what does it take to create a plan that meets your facility’s needs and helps you to achieve accreditation standards? A good plan includes an overview of your facility and the various factors that will impact it in the event of a disaster. Defining what makes a disaster is the first step.

What Makes a Disaster?

Why does this matter? Not everyone understands that disasters are not limited to just weather occurrences like hurricanes and flooding; they can also include events as simple as a minor plumbing leak – a “disaster” that might prevent the safe use of the operating rooms. So start your plan with a definition of what types of disasters could affect your organization. A good way to further break down this definition is by identifying internal and external disasters. Ask your staff members this question: “What occurrences would make working a severe hardship and potentially impact the care we provide?” You might be surprised to hear some of them refer to the loss of phone service or medical records access as a disaster!

Hazards or Risk Assessment

This is the next step. According to FEMA, “A risk assessment is a process to identify potential hazards and analyze what could happen if a hazard occurs. A Business Impact Analysis (BIA) is the process for determining the potential impacts resulting from the interruption of time sensitive or critical business processes.” Make a list of the potential hazards or risks your facility could face. Then assess the probability and severity of those risks.

Once the risk assessment and description are completed, an authority and communications chart should be created. This will include a list of who will be in charge and which employees will be asked to respond. When completing the roster, consider:

• Assessing who is activated and their ability to respond

• Contact information – include cellphone and landline numbers

• Creating an authority chart

• Alternates (staff members designated to substitute for the primary contact in the event that person is unable to respond)

• Creating a call list

The call list is kept near the main phone area for your facility and tested periodically to verify contact information. A copy of the list should also be maintained offsite. Along with the internal contacts, a list of local/county and national resources should be created. This can include numbers or access information for:

• Police, Fire, Paramedics

• Building Management

• Building Security

• Telephone Company

• Power and Gas

• IT Resources

• Insurance Company

• County Office of Emergency Management

• City Street Department

• City Water Department

• City Sewer

• FBI Local Office

• Poison Control Center

• Medical Gases Suppliers

• State Police

• Road Conditions Reports

• National Weather Service

Protecting the Organization

A comprehensive disaster plan includes an overview of what steps would be taken to protect the lives and assets of the organization. This can include a description of the disaster drill schedules; fire drill plans and policies; quality assurance meetings that review the facilities functions; education relevant to disaster awareness such as OSHA training; security precautions; CPR classes; emergency back-up equipment in the building and how it is tested; availability of shelter-in-place plans; and the equipment needed to secure the building. If staff members are allowed time to participate in outside preparedness training programs such as those available through FEMA, the Medical Reserve Corps, or online training, this should also be included.

For a contingency such as mass illness in either employees or staff you will need to put in place an emergency pandemic plan. Assistance creating a good pandemic plan is available from the CDC at

Additional Plan Components

The disaster plan and drills need to have an evacuation plan in place that includes more than one location for assembly to cover all potential events. An annual disaster drill should allow practice for staff members to assemble at the evacuation point; and there should be a prior discussion about what equipment will be required during an evacuation. Hands-on practice with evacuation equipment such as emergency patient slides or transport materials should occur regularly.

Communicating your disaster plan with local, county and state authorities allows them to provide input regarding the details of your plan. Knowing what your emergency response plans are may be vital to the strength of your community’s emergency responders in times of disaster.

No plan is complete without giving serious thought to what will occur AFTER the disaster occurs. Putting a business back together and dealing with the psychological impact of severe disasters requires planning and compassion for the effect that a disaster may have on staff and the business clients served. Training in critical incident debriefing can be very helpful in getting the organization back on track.

Assessing the plan to accreditation standards and Medicare guidelines is critical and should be undertaken at least annually. CMS guidelines have been provided recently that include a checklist for health care facilities.

“The Centers for Medicare & Medicaid Services (CMS) Survey and Certification Group (SCG) has developed this site to provide useful information to CMS Central and Regional Offices, State Survey Agencies (SAs), their State, Tribal, Regional, and local emergency management partners, and health care providers, for developing effective and robust emergency plans and responses. This website provides information and tools, utilizing an “all hazards” approach for disruptive events “

Another great resource comes in the form of the AAAHC “Patient Safety Toolkit: Emergency Drills” available from the Accreditation Association for Ambulatory Healthcare (AAAHC).

Lastly, all staff members need to be educated about the plan’s use, location and implementation. A plan is only paper if the information in it isn’t disseminated to those impacted by the plan. Just as we regularly rehearse for cardiac emergencies to feel competent and be prepared, disasters require the staff to feel well trained and ready to respond.

Helpful Web Resources



Mary Sibulsky is Nurse Manager of an Ophthalmic ASC in North Idaho and has been a nurse since 1975. She is actively involved with the Medical Reserve Corps and was selected as part of the Federal Cadre team specially trained to respond to national emergencies including responding to Hurricanes Katrina and Rita. She has worked as an ASC Surveyor for AAAHC since 2007 and in the course of her work has been in facilities during major earthquakes, shortly after a tornado impacted the area, water main rupture, dust storms and power failures.



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