Hospital Risk Management and Incident Command System 醫院危機管理與應變指揮系統 Hospital Risk Management and Incident Command System 中國醫藥大學 醫務管理學系 郝宏恕 博士 2008

簡歷 學歷： 國立交通大學運輸管理系 美國紐約州立大學 管理學院 財務管理碩士(MBA) 管理系統博士(Ph.D) 經歷： 美國華盛頓大學醫務管理研究所　博士級講師(1991-1994) John Deere Health Care Inc. HMO 醫管顧問(1993-1994) 長庚大學 醫務管理學系所 副教授 (1994-1997) 中國醫藥大學 醫務管理學系所 主任兼所長(1997-2001) 中國醫藥大學 學術研究發展委員會 委員兼執行秘書(1999-2002) 中國醫藥大學 校務發展委員會 副主任委員兼執行秘書(2001-2002) 台灣醫務管理學會 教育研究委員會召集委員(2000-2006) 台灣醫務管理學會 常務理事(2003-2006)

大綱 前言 醫院危機管理 醫院應變指揮系統 結語

前言

前言 各國之醫療文化皆認為，醫護人員有極高的專業能力、值得信賴，幾乎不會犯錯。 美國國家科學院的附屬醫學研究機構（Institute of medicine，2001）發表針對醫療錯誤的調查報告”To Err is Human”，指出美國每年因可避免的醫療錯誤估計至少造成每年四萬四千人死亡，最多造成九萬八千人死亡。

To Err is Human!

前言 91.11.29北城醫院發生錯打疫苗事件。 91.12.9屏東崇愛診所誤將降血糖藥物當成抗組織胺藥使用。 國內醫療品質和病患安全議題成為媒體、輿論與醫界重視的焦點 。

醫院危機管理

前言 必2.9.1.1 建立醫院危機管理機制 必2.9.2.2訂定符合醫院危機管理需要之緊急災難應變計畫及作業程序 新制醫院評鑑－醫院危機管理機制 必2.9.1.1 建立醫院危機管理機制 必2.9.2.2訂定符合醫院危機管理需要之緊急災難應變計畫及作業程序

醫院風險管理的範圍 申報與審查 病歷管理 病患安全 與其他醫療機構的合作關係 病患權利 告知病患 與病患及其他顧客溝通 行政作業與臨床 財務 策略聯盟、顧客與社區關係 與其他醫療機構的合作關係 病患權利 告知病患 與病患及其他顧客溝通

醫院風險管理的範圍(續) 人力資源 缺勤/生產力 緊急事件的管理 職業安全管理 法律 科技 資訊科技 網際網路與遠距醫療 生物醫學科技

ECRI Risk Management Services 自評問卷 1. 跌倒的預防 2. 安全管理 3. 保全 4. 炸彈威脅 5. 醫療科技管理 6. 居家健康服務

ECRI Risk Management Services 自評問卷 7. 醫療人員專業證照 8. AIDS政策與處理程序 9. 預防尖銳物品的傷害 10. 洗腎 11. 靜脈注射 12. 病患走失或逃跑

ECRI Risk Management Services 自評問卷 13. 危險物品管理 14. 門診手術、病人出院計畫 15. 預防嬰兒綁架 16. 消毒 17. 備用系統與程序 18. 雷射安全

ECRI Risk Management Services 自評問卷 19. 用電安全 20. 新生兒加護病房 21. 門診部門 22. 急診部門 23. 精神科治療 24. 產科

ECRI Risk Management Services 自評問卷 25. 麻醉部門 26. 符合醫療相關法規 27. 暴力預防 28. 放射醫學 29. 病患安全評估 30. 用藥安全

風險管理 風險類型- 依據損失發生之對象可區分為 人身風險:疾病、傷害、死亡 財產風險:所得、營業收入損失、財產損失 責任風險:因疏忽導致病患傷亡所應賠償之責任

風險管理步驟 1. 確認風險-SARS秋冬再來、院內感染 2. 評估風險-病人就醫行為、陪病探病文化 3. 選擇並執行風險管理之策略

風險管理 策略 1.降低風險-限制探病時間、減少陪病人數 2.分散風險-樓層區隔、 人員分組 3.隔離風險-設立發燒門診 4.轉移風險-成立SARS專責醫院

風險管理 居安思危，有備無患 應對計劃：作最壞的打算 1.找出潛在危機與風險區 2.設立危機管理啟動機制，指派危機預警負責人 3.設立並訓練危機管理小組及成立危機聯絡中心 4.列出應知會之相關人士名單與排定先後順序 5.列出媒體名單並準備背景資料 6.指派並訓練發言人

風險管理與危機管理 處理七種危機類型 1.天然危機-地震、水災、火災、瘟疫 2.科技危機-電腦病毒 3.衝突危機-醫病關係 4.惡意危機-美國911、星巴克 5.管理階層價值觀扭曲的危機 6.欺騙危機 7.管理不當所導致的危機

後SARS時代醫院風險管理之運用 勿恃SARS之不來， 恃吾有以待之 環境分析 : 政策-衛生署健保局之因應措施 社會-民眾就醫行為之改變 心理-對醫護專業認知、 態度之改變

醫院應變指揮系統

California Emergency Medical Services Authority MISSION STATEMENT The mission of the California Emergency Medical Services Authority is to ensure quality patient care by administering an effective, statewide system of coordinated emergency medical care, injury prevention, and disaster medical response.

Context for Hospital Emergency Management Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards (e.g., Environment of Care (EC) C 4.10, which requires a hazard vulnerability analysis, and EC.4.20, on emergency exercises) Emergency Medical Treatment and Active Labor Act (EMTALA)

Context for Hospital Emergency Management（續） National Fire Protection Association (NFPA) Standard 99 Healthcare Facilities, and Standard 1600 Disaster/Emergency Management and Business Continuity Occupational Safety and Health Administration – “Best Practices for Hospital-Based First Receivers of Victims from Mass Casualty Incidents Involving the Release of Hazardous Substances”

History of the Hospital Emergency Incident Command System (HEICS) Since its inception in the late 1980s, HEICS IV has evolved to become HICS.

Objectives of the Revision Update and incorporate current emergency management practices into the system Clarify the components of this system and its relationship to the National Incident Management System (NIMS) Enhance the system by integrating chemical, biological, radiological, nuclear, and explosive (CBRNE) events into the management structure

Objectives of the Revision（續） Develop a standardized and scalable incident management system to address planning and response needs of all hospitals, including rural and small facilities Develop core materials and guidance for Hospital Incident Command System (HICS) Develop suggested qualifications for HICS instructors to better ensure standardization

Contributors HICS was developed by a National Work Group of twenty hospital subject-matter experts from across the United States, representing all hospital types: large and small, rural and urban, and public and private facilities. Ex officio members represented the: U.S. Department of Homeland Security National Incident Management System Integration Center (NIC) U.S. Department of Health and Human Services Health Resources and Services Administration (HRSA) American Hospital Association (AHA) American Society for Healthcare Engineering (ASHE) Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

Incident Management Functions ICS is a management system—not an organizational chart. Every incident or event requires that certain management functions be performed. The problem encountered is evaluated, a plan to remedy the problem identified and implemented, and the necessary resources assigned. The ICS organization frequently does not correlate to the daily administrative structure of the agency or hospital. This practice is purposeful and done to reduce role and title confusion.

Incident Management Functions（續） The Incident Commander is the only position always activated in an incident regardless of its nature. In addition to Command, which sets the objectives, devises strategies and priorities, and maintains overall responsibility for managing the incident, there are four other management functions. Operations conducts the tactical operations (e.g., patient care, clean up) to carry out the plan using defined objectives and directing all needed resources. Planning collects and evaluates information for decision support, maintains resource status information, prepares documents such as the Incident Action Plan, and maintains documentation for incident reports. Logistics provides support, resources, and other essential services to meet the operational objectives set by Incident Command. Finance/Administration monitors costs related to the incident while providing accounting, procurement, time recording, and cost analyses.

Incident Management Functions（續） Depending on the incident, the Incident Commander may choose to appoint Command Staff that include a: Public Information Officer to serve as a conduit for information to internal personnel and external stakeholders, including the media or other organizations. Safety Officer to monitor safety conditions and measures for assuring the safety of all assigned personnel. Liaison Officer to be the primary contact for supporting agencies assigned to the hospital. In some cases the Liaison Officer may be assigned to represent the hospital at the local Emergency Operations Center (EOC) or field Incident Command post. Medical/Technical Specialist (s) who may serve as a consultant, depending on the situation. Persons with specialized expertise may be asked to provide needed insight and recommendations to the Incident Commander during and/or after a response.

Incident Management Functions（續） Distinct, standardized ICS position titles serve three essential purposes: They reduce confusion within a hospital or with outside agencies or other healthcare facilities by providing a common standard for all users. They allow the position to be filled with the most qualified individual rather than by seniority. They facilitate requests for qualified personnel, especially if they come from outside the hospital.

Incident Management Functions（續） Sections are organizational levels with responsibility for a major functional area of the incident (e.g., Operations, Planning, Logistics, Finance/Administration). The person in charge is called a Chief. Branches are used when the number of Divisions or Groups exceed the recommended span of control. (e.g. Medical Care Branch, Service Branch). A Branch is led by a Director. Divisions are used to divide an incident geographically (e.g., first floor). A Division is led by a Supervisor. This command function is typically used more frequently among non-hospital response agencies, such as Fire and Law Enforcement authorities. Groups are established to divide the incident management structure into functional areas of operation. They are composed of resources that have been assembled to perform a special function not necessarily within a single geographic division. A Supervisor leads a Group. Units are organizational elements that have functional responsibility for a specific incident planning, operations, logistics, or finance/administration activity (e.g., Inpatient Unit, Situation Unit, Supply Unit). Single resources are defined as an individual(s) or piece of equipment with its personnel complement (e.g., perfusionist) or a crew or team of individuals with an identified supervisor.

The Incident Planning Process This planning involves six (6)essential steps: Understanding the hospital’s policy and direction Assessing the situation Establishing incident objectives Determining appropriate strategies to achieve the objectives Giving tactical direction and ensuring that it is followed (e.g., correct resources assigned to complete a task and their performance monitored) Providing necessary back-up (assigning more or fewer resources, changing tactics, et al.)

Emergency Management Program Development Hospital Emergency Management Programs (EMP) includes the following steps: Designating an Emergency Program Manager Program Establishing the Emergency Management Committee Developing the “all hazards ” Emergency Operations Plan Conducting a Hazard Vulnerability Analysis Developing incident-specific guidance (Incident Planning Guides) Coordinating with external entities Training key staff Exercising the EOP and incident-specific guidance through an exercise program Conducting program review and evaluation Learning from the lessons that are identified (organizational learning)

Emergency Management Committee Developing and updating a comprehensive “all hazards” Emergency Management Program on an annual basis Conducting a Hazard Vulnerability Analysis (HVA) on an annual basis Developing an Emergency Operations Plan (EOP) and standard operating procedures to address the hazards identified Providing for continuity of operations planning by writing needed hospital operations plans Ensuring that all employees and medical staff receive training in accordance with hospital requirements and regulatory guidelines and understand their role(s) and responsibilities for a disaster response

“All Hazards” Emergency Operations Plan Critical areas that should be comprehensively and succinctly addressed include: Management and planning Departmental/organizational roles and responsibilities before, during, and after emergencies Health and medical operations Communication (internal and external) Logistics Finance Equipment Patient tracking Fatality management Decontamination Plant, facility, and utility operations Safety and security Coordination with external agencies

Hazard Vulnerability Analysis Two primary elements of threat evaluation are considered in the HVA process: Probability is the likelihood of an event occurrence. It can be calculated through a retrospective assessment of event frequency or predicted through a prospective estimation of risk factors. Impact is the severity or damage caused by a threat and should include effects on human lives, business operations/infrastructure, and environmental conditions.

External Agency Coordination and Professional Support Other Hospitals and Healthcare Facilities, Primary Care Clinics Fire and Emergency Medical Services Law Enforcement Public Health Department Medical Examiner’s Office/Coroners Behavioral/Mental Health Specialists Local Emergency Management Agency State Response Teams Federal Response Teams American Red Cross Media

Methods of Instruction The required courses are outlined in the NIMS compliance requirements for hospitals and vary according to the command positions. Generally they include: Independent Study (IS) 100 - Introduction to ICS or IS100 HC-Introduction to Incident Command System for Health Care Personnel IS 200 - Basic ICS or IS 200 HC - Basic Incident Command for Healthcare Personnel IS 700 - NIMS, An Introduction IS 800 - National Response Plan, An Introduction

Department Level Command The leadership in each department should be identified in the department plan along with 24 hours/7 days a week contact information. In addition, the following should be maintained available for immediate access: Job Action Sheet Identification vest (or other preferred method) Radio/phone Appropriate HICS forms Predesignated resources (e.g., phonebook, procedures manual)

Department Level Command（續） It will also be important that each hospital department or unit have ready access to the necessary equipment and supplies. Flashlights and chemical lightsticks Bottled water RESTROOM CLOSED signs Chemical or standard portable toilets/toilet paper Handwashing foam/disinfectant wipes Evacuation chairs/sleds

Business Continuity Operations The function of the Business Continuity Branch is to assist impacted areas with ensuring that critical business functions are maintained, restored, or augmented to meet the designated Recovery Time Objective (RTO) and recovery strategies outlined in the areas’ business continuity and business resumption plans. The Business Continuity Operations Branch will: Facilitate the acquisition of and access to essential recovery resources, including business records (e.g., patient medical records, purchasing contracts) Support the Infrastructure and Security Branches with needed movement or relocation to alternate business operation sites Coordinate with the Logistics Section Communications Unit Leader, IT/IS Unit Leader, and the impacted area to restore business functions and review technology requirements Assist other branches and impacted areas with the restoring and resuming of normal operations

Security Operations Lock-Down vs. Restricted Visitation Supplemental Security Staffing Traffic Control Personal Belongings Management Chain of Custody Considerations

Planning Section

Planning Section -Documentation The various HICS forms for documentation needed during an incident. Details about the actual incident as they are learned (e.g., fire, plane crash, widespread illness) (HICS 201) Organizational assignments (HICS 203) Critical problems encountered and incident command actions taken (HICS 202, HICS 213) Patient location (HICS 254) Resources on hand and requests for supplementation (HICS 256, HICS 257) Personnel time and accountability (HICS 252, HICS 253) Internal and external communications (HICS 205) Facility status (HICS 251) Archiving Sharing Information with Outside Agencies

Logistics Section.

Finance/Administration Section

Life Cycle of an Incident Alert and Notification Situation Assessment and Monitoring Emergency Operations Plan Implementation Establishing the Hospital Command Center Design Features Equipment and Supplies Staffing Alternative Hospital Command Center Activating the Incident Command System Building the Incident Command System Structure Incident Action Planning Communications and Coordination Staff Health and Safety

Life Cycle of an Incident（續） Operational Considerations issues Personnel Loss of staff who become victims of the event Lack of adequate staff Longer work shifts Staff fatigue leading to slower delivery of, or compromise in, patient care Loss of staff who evacuate or become victims of the event Absenteeism Fear Concerns for family or personal situations Need for time off to assess and manage their home situations Integration of outside relief personnel into daily operations and incident command structure

Life Cycle of an Incident（續） Operational Considerations issues Patient Care Lack of needed staff/expertise Lack of needed beds, equipment, medications, and supplies Need to alter the standard of care (austere care) Documentation demands while caring for greater than normal patient volume Equipment and Supplies Lack of needed equipment and supplies More than normal type and quantities needed Moving cumbersome/heavy items up/down stairs when elevators not working Repair and replacement issues Staff not being familiar with borrowed equipment

Life Cycle of an Incident（續） Operational Considerations issues Behavioral/Mental Health Increased acute and long-term demand for limited behavioral health resources Natural fear, anxiety, and apprehension among patients, family, and staff Rumors Preventing post traumatic stress disorder Security Implementing and sustaining enhanced security measures Staff and visitor compliance with security procedures being used Increased risk of patient or visitor violence from impatience or dissatisfaction with service delivery Parking needing to be controlled and supplemented Controlling media access

Life Cycle of an Incident（續） Operational Considerations issues Infrastructure Support Meeting and sustaining increased demand on various clinical and nonclinical services Recovery of utility services to the hospital; operating under reduced capability in the interim Unavailability or delay in receiving needed assistance (fuel, repairs, replacement parts, medical gases, et al.) Increased need for food/water supplies and meal preparation Normal and hazardous waste pick-up Clean-up from damage

Life Cycle of an Incident（續） Operational Considerations issues Information Sharing Need to keep patients, family members, and staff informed of the situation Establishing, maintaining, integrating, and interpreting multiple databases, files, and reports Meeting information management need when daily IT/IS service is compromised Responding to multiple information requests (local, state, and federal) Media Relations Requests for information, interviews with staff and patients, and filming Family making media statements Efforts of unscrupulous media trying to infiltrate a secure facility Need for risk communication to inform the public on pertinent health-related issues Integrating efforts with other hospital, public health, and community public information officers

Life Cycle of an Incident（續） Legal and Ethical Considerations Demobilization System Recovery Response Evaluation and Organizational Learning

任務職責清單 Job Action Sheets 每一個職位都有制式化的任務清單 每一張都是標準格式 職位名稱 上級 無線電中的稱呼 任務 工作清單 以背心來標示

服裝容易解決，但是如何規劃…..

謝謝指教