Welcome to Oro Valley Hospital

PATIENT TRACKING: INTERNAL AND EXTERNAL

For the departments that will be receiving disaster patients such as the Emergency Room and patient care units, they will have patient trackers assigned to scan/track the patients entering and leaving the areas.  All patients will be assigned a triage tag and a hospital tracking number that will be scanned into the electronic patient tracking system, EMTracker.  That information is monitored by the Pima County Emergency Operations Center and the State Office of Emergency Management and Arizona Department of Health Services if a public health emergency.    That same information will be given to the Patient Tracking Manager who will track all the patients within the facility during disaster via the computerized tracking system and the HICS Form.  The form to use for patient tracking will be the HICS 254 – Disaster Victim Patient Tracking Form.

If patients are evacuated, the process should be the same except for the forms.  The individual patient tracking for evacuation will be the HICS 260 – Patient Evacuation Tracking Form.  When more than two are being evacuated, the HICS 255 – Master Patient Evacuation Tracking Form should be used to gain a master copy of all those that were evacuated.

According to the MOU, American Red Cross database, utilizing the EMTracker system or fax in tracking information to P.C EOC, information will be maintained for the regional tracking methods.  In some of these methods, there may be the possibility of families gaining access to this information to find their loved ones.

BUSINESS CONTINUITY/DISASTER RECOVERY PLAN

Oro Valley Hospital has a Business Continuity/Disaster Recovery Plan for its information systems.  For electronic systems, the plan includes plans for unscheduled interruptions, including end-user training with downtime instructions, contingency plans for operational interruptions, plans for minimal interruptions as well as a result of scheduled downtime, an emergency service plan, a backup system, either electronic or manual, or data retrieval, including retrieval from storage, and information presently in the operating system, retrieval of data in the event of a system interruption and the back up of data. The plan is tested periodically to ensure the business interruption back-up techniques are effective, and is implemented when information systems are interrupted.  Oro Valley Hospital Information Systems department has specific policies and procedures to support the Business Continuity and Disaster Recovery Plan.  Administration reviews and approves the policies that support the plan.

INFLUX OR MANAGEMENT OF INFECTIOUS PATIENTS

Oro Valley Hospital prepares to respond to an influx or the risk of an influx of infectious patients, and determines its response to an influx or the risk of an influx of infectious patients.  Oro Valley Hospital has a plan for managing an ongoing influx of potentially infectious patients over an extended period.  Under the direction of the Infection Control Practitioner, the hospital performs the following functions including how long it will keep abreast of current information about the emergence of epidemics or new infections that may result in the hospital activating its response: a) how it will disseminate critical information to staff and other key practitioners; b) how the facility will identify resources in the community through local, state, and/or federal public health systems for obtaining additional information.  The Infection Control Practitioner manages the functions described through the Infection Control Plan.  The Infection Control Plan is reviewed by Oro Valley Hospital Administration and the Medical Staff.

PATIENT FLOW

Leadership, including the Medical Staff, will plan to identify and mitigate impediments to efficient patient flow throughout the hospital. Leadership assesses patient-flow issues within the hospital, the impact on patient safety, and plan to mitigate that impact.  Planning encompasses the delivery of appropriate and adequate care to admitted patients who must be held in temporary bed locations.  Leadership and the Medical Staff share accountability to develop processes that support efficient patient flow.  Planning includes the delivery of adequate care, treatment, and services to non-admitted patient that are placed in overflow locations.  Specific indicators are used to measure components of the patient-flow process and address available supply of patient bed space, efficiency of patient care, treatment and service areas, safety of patient care, treatment and service areas, and support service processes that impact patient flow.  Indicator results are available to those individuals who are accountable for processes that support patient flow. Indicator reports are reported to Leadership on a regular basis to support planning. The hospital improves inefficient or unsafe processes identified by Leadership as essential to the efficient movement of patients through the hospital.  Criteria are defined to guide decisions about initiating diversion.  Oro Valley Hospital Leadership reviews all patient flow processes regularly with the clinical department heads and the Medical Staff.

Additionally Oro Valley Hospital has established a Medical Surge Plan to utilize in case of Mass Causalities or a situation where large numbers of individuals are seeking medical treatment or admission to the hospital.   See Medical Surge Plan.

GRANTING DISASTER PRIVELEGES FOR VOLUNTEER-LICENSED PRACTITIONERS.

Disaster privileges may be granted only when the Emergency Operations Plan has been activated in response to a disaster and the hospital is unable to handle the immediate patient needs.  The medical staff identifies in its bylaw the individuals responsible for granting disaster privileges to volunteer license independent practitioners.  See policy EM.02.02.13 for more information.

EM 02.02.13.1
The hospital grants disaster privileges to volunteer licensed independent practitioners only when the emergency Operations Plan have been activated in response to a disaster and the hospital is unable to meet immediate patient needs. EM .02.02.13.1

EM 02.02.13.2
The medical staff identifies, in its bylaws, those individuals responsible for granting disaster privileges to volunteer licensed independent practitioners.

EM 02.02.13.3
The hospital describes how it will distinguish volunteer licensed independent practitioners from other licensed independent practitioners. (See also EM.02.02.07, EP 9)

EM 02.02.13.4
The medical staff describes, in writing, how it will oversee the performance of volunteer licensed independent practitioners who are granted disaster privileges (direction observation, mentoring, or medical records review)

EM 02.02.13.5
Before a volunteer practitioner is considered eligible to function as a volunteer licensed independent practitioner, the hospital obtains his or her valid government-issued photo identification (Driver's license or passport) and at least one of the following: - A current license to practice, -Primary source verification of licensure – identification indicating that the  individual is a member of a Disaster Medical Assistance Team (DMAT), the Medical Reserve Corps()MRC), - The Emergency System for Advanced Registration of Volunteer Health Professionals (ESAR-VHP), or other recognized state of federal response hospital or group.   – Identification indication that the individual has been granted authority by a government entity to provide patient care, treatment or services in disaster circumstances. – Confirmation by a licensed independent practitioner currently privilege by the hospital or a staff member with personal knowledge of the volunteer practitioner's ability to acct as a licensed independent practitioner during a disaster.

EM 02.02.13..6
During a disaster, the medical staff oversees the performance of each volunteer licensed independent practitioner.

EM 02.02.13.7
Based on its oversight of each volunteer licensed independent practitioner, the hospital determines within 72 hours of the practitioner's arrival if granted disaster privileges should continue.

EM 02.02.13.8
Primary source verification of licensure occurs as soon as the immediate emergency situation is under control or within 72 hours from the time the volunteer licensed independent practitioner presents him or herself to the hospital. Whichever comes first.   If primary source verification of a volunteer licensed independent practitioner's licensure cannot be completed within 72 hours of the practitioners' arrival due to extraordinary circumstances, the hospital documents all of the following: 1) Reason(s) why it could not be performed within 72 hours of the practitioner's arrival. (2) Evidence of the licensed independent practitioner's demonstrated ability to continue to provide adequate care, treatment, and services (3) Evidence of the hospital's attempt to perform primary source verification as soon as possible.

EM 02.02.13.9
If, due to extraordinary circumstances, primary source verification of licensure of the volunteer licensed independent practitioner cannot be completed within 72 hours of the practitioner's arrival; it is performed as soon as possible.   Note Primary source verification of licensure is not required if the volunteer licensed independent practitioner has not provided care, treatment or services in the disaster privileges.

GRANTING DISASTER PRIVELEGES FOR VOLUNTEER PRACTITIONERS WHO ARE NOT LICENSED INDEPENDENT PRACTITIONERS.

During a disaster, Oro Valley Hospital may assign disaster responsibilities to volunteer practitioners who are not licensed independent practitioners, but who are required by law and regulation to have a license, certification, or registration.

GRANTING DISASTER PRIVILEGES

Disaster privileges may be granted when the Emergency Management Plan has been activated and the hospital is unable to handle the immediate patient needs.  The medical staff identifies, in writing, the individuals responsible for granting disaster privileges.  The medical staff describes, in writing, the responsibilities of the individuals responsible for granting disaster privileges.  The medical staff describes, in writing, a mechanism to manage individuals who receive disaster privileges.  The medical staff includes a mechanism to allow staff to readily identify these individuals.  The medical staff addresses the verification process as a high priority. The medical staff begins the verification process of the credentials and privileges as soon as the immediate situation is under control.  The verification process is identical to the process established under the medical staff bylaws or other documents for granting temporary privileges to meet an important patient-care need.  The CEO or president of the medical staff or designee may grant disaster privileges upon presentation of the following including a current picture hospital ID; a current license to practice; and a valid picture ID issued by the state, federal or regulatory agency; identification indicating the individual is a member of a Disaster Medical Assistance Team (DMAT); identification indicating the individual has been granted authority to render patient care, treatment, and services in disaster circumstances; and presentation by current hospital of medical staff members with personal knowledge regarding practitioner's identity.    The same standards apply to volunteer practitioners who are not licensed independent practitioners as those who are volunteer licensed independent practitioner.   See policies EM 02.02.13 and EM 02.02.25.   These processes are reviewed by the medical staff and Leadership regularly.

This applies to employees of other institutions and volunteer in the medical profession who are called to or volunteer for work at a CHS facility during time of a declared disaster.  This process assumes that all loaning institutions are Joint Commission accredited with HR contingencies.   Worker's Compensation and Professional Liability Insurance are the responsibility of the loaned employee or volunteer's institution.  If permitted in the state of the receiving hospital, volunteers will be covered by the volunteer accident policy associated with the receiving hospital.   This process assumes that all loaned employees or volunteer have undergone appropriate primary source verification for professional licenses or certifications, background checks and drug screenings to the satisfaction of the loaning institution.

EM 02.0.215.1
The hospital grants disaster privileges to volunteer practitioners who are not licensed independent practitioners only when the emergency Operations Plan has been activated in response to a disaster and the hospital is unable to meet immediate patient needs. EM 02.02.15.1

EM 02.02.15.2
The hospital identified, in writing, those individuals responsible for training disaster privileges to volunteer practitioners who are not licensed independent practitioners.

EM 02.02.15.3
The hospital determines how it will distinguish volunteer practitioners who are not licensed independent practitioners from other licensed independent practitioners (see also EM 02.02.07, EP9)

EM 02.02.15.4
The medical staff describes, in writing, how it will oversee the performance of volunteer practitioners who are not licensed independent practitioners who are granted disaster privileges (for example, by direction observation, mentoring, or medical record review.)

EM 02.02.15.5
Before a volunteer practitioner is considered eligible to function as a volunteer licensed independent practitioner, the hospital obtains his or her valid government-issued photo identification (Driver's license or passport) and at least one of the following: - A current license to practice, -Primary source verification of licensure – identification indicating that the  individual is a member of a Disaster Medical Assistance Team (DMAT), the Medical Reserve Corps()MRC), - The Emergency System for Advanced Registration of Volunteer Health Professionals (ESAR-VHP), or other recognized state of federal response hospital or group.   – Identification indication that the individual has been granted authority by a government entity to provide patient care, treatment or services in disaster circumstances. – Confirmation by a licensed independent practitioner currently privilege by the hospital or a staff member with personal knowledge of the volunteer practitioner's ability to acct as a licensed independent practitioner during a disaster.

EM 02.02.15.6
During a disaster, the medical staff oversees the performance of each volunteer licensed independent practitioner.
EM 02.02.15.7
Based on its oversight of each volunteer licensed independent practitioner, the hospital determines within 72 hours of the practitioner's arrival if granted disaster privileges should continue.

EM 02.02.15.8
Primary source verification of licensure occurs as soon as the immediate emergency situation is under control or within 72 hours from the time the volunteer licensed independent practitioner presents him or herself to the hospital. Whichever comes first.   If primary source verification of a volunteer licensed independent practitioner's licensure cannot be completed within 72 hours of the practitioners' arrival due to extraordinary circumstances, the hospital documents all of the following: 1) Reason(s) why it could not be performed within 72 hours of the practitioner's arrival. (2) Evidence of the licensed independent practitioner's demonstrated ability to continue to provide adequate care, treatment, and services (3) Evidence of the hospital's attempt to perform primary source verification as soon as possible.

EM 02.02.15.9
If, due to extraordinary circumstances, primary source verification of licensure of the volunteer licensed independent practitioner cannot be completed within 72 hours of the practitioner's arrival; it is performed as soon as possible.   Note Primary source verification of licensure is not required if the volunteer licensed independent practitioner has not provided care, treatment or services in the disaster privileges.

In the event a declared disaster requires a CHS facility to use additional personnel, the following process will be used:

A.     Approval of the CEO or other individual assigned disaster responsibility should be obtained prior to
requesting additional personnel from other institutions.   The CEO, CNO or other responsible individual will determine the number and type of needed positions.   The Human Resources Director or designee will request or assist in requesting personnel from other healthcare facilities as needed.   The Human Resources Department will assist with the transportation needs of loaned employees or volunteer practitioners (See CHS Disaster Preparedness Plan dated 8/1/06 from Workgroup Planning and for CHS Facility Support List.
B.     Processing loaded employees or volunteer practitioners into a CHS institution:
        1. Loaned employee or volunteer practitioner will:
a. report to Human Resources or other designated Disaster Staffing Registration Area
b. provide appropriate IS X2
(1)  At a minimum a valid government-issued photo identification issued by a state or federal
       agency (e.g. driver's license or passport) and at least one of the following:
A current health care organization (such as long term care, ambulatory care, laboratory or hospital) picture ID card that clearly identifies professional designation
A current license, certification or registration
The Model State Emergency Health Power Act authorized license reciprocity during periods of declared emergencies
The Interstate Civil Defense and Disaster Compact Act authorizes volunteers who are licensed in one sate to practice in another sate during emergencies.
Primary source verification of licensure, certification, or registration (if required by law and regulation to practice a profession and should be obtained by the receiving HR department)
Identification indication that the individual is a member of a Disaster Medical Assistance Team (DMAT), MRC, ESAR-VHP, or other recognized state or federal organization(s) group(s).
Copy of License, CPR or other appropriate certification, if required and available.
2) The Receiving HR Department will:
a. Perform primary source verification of applicable licensure or certification:
(1) In the extraordinary circumstance that primary source verification of
Licensure, certification, or registration (if required by law and regulation to practice a profession) cannot be completed in 72 hours (for example, no means of communi9cation or lack of resources), it is expected that it be done as soon as possible,   In this extraordinary circumstance, there must be documentation of the following:
Why primary source verification could not be performed in the required time frame;
Evidence of a demonstrated ability to continue to provide adequate care, treatment, and services; and
An attempt to rectify the situation as soon as possible.
(2) Primary source verification of licensure, certification, or registration (if required by law and regulation to practice a profession) would not be required if the loaned employee or volunteer practitioner has not provided care, treatment and services under the disaster responsibilities.
b. Contact loaned employee or volunteer practitioner's Human Resources Department, if l
       available to:
                                     (1)    Validate that the loaned employee or volunteer practitioner is currently employed at
                                               loaning hospital in good standing.
  (2)    Validate the scope of the loaned employee or volunteer practitioner's credentials
            and/or privileges.
  (3)     Determine if there were any restriction placed on loaned employee or volunteer
           practitioner.
  (4)    Determine which institution pays the person and at what rate of pay
  (5)    Determine how long the assignment will be, if possible.

c. Provide to loaned employees:
(1) Abbreviate orientation (Basic Competency Assessment) to the person before he/she
       begins to work in ensure understanding of the essential safety requirements for that
        facility, local required policies and understanding of various emergency codes
        (provide card with current codes)
(2)    Temporary ID, so the staff will know they have been accepted by HR
(3)   Blank timesheets to loaned employee or volunteer
       (4)    Introduction of the loaned employee or volunteer to his/her immediate supervisor for
                Departmental safety orientation and job assignment.

d. Develop a mechanism of assessment in writing (for example, direct observation,
mentoring and clinical record review) to oversee the professional performance of loaned employees or volunteer practitioners who are assigned disaster responsibilities.
e. Record the dates, identify, position, employer, and department assigned of the loaned
employees or volunteer practitioners who are assigned disaster responsibilities. (See CHS Disaster Preparedness Plan dated 8/1/06), page 220).

3.    The Immediate Supervisor will:
a.   Distribute appropriate position description or assignment to loaned employee or volunteer
                   independent practitioner.  If this is unavailable, an abbreviated list of duties may be
                   distributed to the loaned employee or volunteer practitioner.
                           b.  Provide any distinctive clothing or PPE
                           c. Verify weekly timesheets and return to HR Department
                            d.   Provide oversight of the care, treatment, and services and services provided to the loaned
                               employee or volunteer practitioner.
                          e.   Oversee the provision of meals and other services to loaned employee or volunteer
                                practitioner.

C.  Out-Processing (demobilization) of loaned employees and volunteer practitioners:
       4.  Immediate Supervisor or Department Director will:
a.      Obtain for return any items issued to loaned employee or volunteer practitioner.
b.       Notify HR Department date of departure.
c.        Submit remaining completed and verified time sheets to Human Resources
           Department.  (Please see CHS Disaster Preparedness Plan dated
           8/1/06, page  222).
                  5.  The Receiving Human Resources Department will:
a.       Notify the loaning Human Resources Department that the loaned employee or
          volunteer practitioner is no longer working at the facility.
b.       Provide time/attendance sheets to the individual's HR Department.
c.       Submit appropriate financial documents and previously agreed upon
           arrangements to the Finance department if applicable.

ASSIGNING DISASTER RESPONSIBILITIES

Disaster responsibilities are assigned when the Emergency Operations Plan is activated and the hospital is unable to meet immediate patient needs. Oro Valley Hospital defines in writing, individuals responsible for assigning disaster responsibilities.  The hospital describes a mechanism to oversee the professional performance of volunteer practitioners assigned disaster responsibilities, and the hospital has a process to identify the volunteer practitioners.  For volunteer practitioners, Oro Valley Hospital obtains photo identification including a hospital photo ID with professional designation, a current license or certification,  a primary source verification of the same, verification the volunteer is part of a DMAT team or other federal organization or group, identification stating the individual is authorized to provide care and treatment in disaster situations, or identification the current member of the organization who posses knowledge of the practitioner's qualifications.

Primary source verification of licensure occurs as soon as the immediate emergency situation is under control or within 72 hours from the time the volunteer licensed independent practitioner presents him or herself to the hospital, whichever comes first.  If primary source verification of a volunteer licensed independent practitioner's licensure cannot be completed within 72 hours of the practitioner's arrival due to extraordinary circumstances, the hospital documents all of the following:

Reason(s) it could not be performed within 72 hours of the practitioner's arrival

Evidence of the licensed independent practitioner's demonstrated ability to continue to provide adequate care, treatment, and services

Evidence of the hospital's attempt to perform primary source verification as soon as possible.

If, due to extraordinary circumstances, primary source verification of licensure of volunteer-licensed independent practitioner cannot be completed within 72 hours of the practitioner's arrival, it is performed as soon as possible. Note: Primary source verification of licensure is not required if the volunteer-licensed independent practitioner has not provided care, treatment, or services under the disaster privileges.

US Patent Numbers 7,720,998 B2, 7,836,207