CHA Hospital Activation of the Emergency Operations Plan Checklist

The initial response to an emergency begins with recognition that an incident may, or has, occurred. In cases where the
incident is likely to impact or disrupt routine operations and may require coordination of efforts and response involvement
among hospitals, Health Care Coalition partners, EMS, public health, and environmental health. Key management issues
involving situational status, incident characteristics and resource capabilities must be quickly determined and communicated
amongst response partners in order to establish a common operating picture.
1. Activation Date/Time Initials
A. Initiate policy and procedure for activation of the Emergency Operations Plan
B. Activate Hospital Command Center
C. Activate Hospital Incident Management Team
• Incident Commander activates needed positions down to the Chief Level and holds an initial
briefing
• Each Chief (Operations/Planning/Logistics/Finance) activates needed Branches/Units in
their Section
• Provide Job Action Sheet to each activated position
• Provide HICS 214 Activity Log to each activated position. Each activated position initiates
the 214 to document basic incident activity and details notable details.
• Provide position identification (e.g. vests, hats)
D. Provide associated HICS Incident Response Guides (IRG) to each Chief and above position as
appropriate
2. Assessment Date/Time Initials
A. Incident Commander completes HICS 201 Incident Briefing. The 201 provides basic information
regarding the incident, current situation, and resources allocated to the response. (If the
Incident Commander does not activate the Planning Chief and Safety Officer, then the Incident
Commander is also responsible for completing HICS 202 and HICS 215A)
B. Planning Chief completes HICS 202 Incident Objectives. The 202 describes basic incident
objectives and safety considerations. These overarching objectives are applicable to and used
throughout the response. (Examples of Incident Objectives can be found on the front page of
the Incident Response Guide for the associated emergency)
C. Safety Officer. Patient, visitor, and staff health and safety is the highest priority during any
emergency response. The Safety Officer completes HICS 215A Incident Action Plan Safety
Analysis. HICS 215A is an Operational Risk Assessment to prioritize hazards, safety, and health
issues, and assigns mitigation actions.
D. Section Chiefs complete a separate HICS 204 Assignment List for the Section and each Branch
activated. The 204 documents objectives for the Operational Period, strategies and tactics,
and resources required to accomplish those objectives, and lists those assigned.
E. Infrastructure Branch Director (or Operations Chief if Infrastructure Branch not activated)
completes HICS 251 Facility System Status Report. HICS 251 determines facility operating
status.
When air quality is compromised, be sure to review supply levels of N-95 respirators, HEPA
filters, epinephrine, air scrubbers, etc. (Be aware of facility impacts such as exhaustive
cleaning, water mitigation, pharmaceutical and nutritional supply damage, etc.)
F. Develop Situational Status Report according to Operational Area procedure (Coordinate with
MHOAC)

Note: This Checklist is based on the Hospital Incident Command Guidebook and California Public Health and Medical Emergency
Operations Manual located at www.emsa.ca.gov.
Version: March 2020 Page 1 of 5
 Hospital Emergency Management Program Checklist
3. Response Plan Date/Time Initials
A. The Planning Section gathers and compiles the individual components of the Incident Action
Plan (IAP) from the Hospital Incident Management Team. The Planning Chief and/or the
Incident Commander conducts the Planning Meeting attended by Section Chiefs and the
Command Staff to finalize the Incident Action Plan for the initial Operational Period.
Minimum components of the IAP: (See also CHA IAP Checklist)
• HICS 201 Incident Briefing (by the Incident Commander)
• HICS 202 Incident Objectives (by the Planning Chief)
• HICS 204(s) (by Chiefs and Branch Directors)
• HICS 215A (by the Safety Officer)
May use HICS Incident Action Plan Quick Start combined 201, 201, 203, 204, and 215A
form). All forms are to be given to the Planning Section to assimilate into the Incident
Action Plan, which provides preliminary guidance for the response effort for each
Operational Period.
B. Activate additional or relevant Specialty Plans or Annexes, for example:
• Surge (See also CHA Surge Planning Checklist)
• Pandemic
• Highly Infectious Disease
• Burn Surge
• Trauma Surge
• Active Shooter (See also CHA Active Shooter Checklist)
• Business Continuity/Continuity of Operations Plan (COOP)
• Mass Fatality (See also CHA Mass Fatality Checklist)
• Electronic Medical Record downtime
• Evacuation Plan (See also CHA Evacuation Checklist) Coordinate all evacuations with the
Medical and Health Operational Area Coordinator (MHOAC)
• Shelter-in-Place (See also CHA Shelter-in-Place Checklist)
(In a community wide event, alternative staffing plans and policies to support impacted
employees and physicians may be critical. )
4. Notifications (Note: Some notifications may be done immediately and others simultaneously Date/Time Initials
with other functions)
A. Activate redundant communication modalities as needed and appropriate
• Voice systems (landline, cellular, VOIP, satellite)
• Radio (amateur, commercial, Walkie-Talkies, and public safety 2-way radio)
• Data Systems and Emergency Communications Systems (e.g. EMSystem, ReddiNet, Live
Process)
• Health Alert Network (California is CAHAN) – can include email, telephone, and pager
B. Utilize facility’s internal system to declare Emergency Codes
C. Internal Notification

Note: This Checklist is based on the Hospital Incident Command Guidebook and California Public Health and Medical Emergency
Operations Manual located at www.emsa.ca.gov.
Version: March 2020 Page 2 of 5
 Hospital Emergency Management Program Checklist
The Public Information Officer (PIO) notifies:
• Staff
• Patients (Keeping patients and visitors informed provides insight on what happened, what is
being done, and provides assurance)
• Visitors
D. External Notification
• The Liaison Officer (or designee) notifies the Operational Area Medical Health Operational
Area Coordinator (MHOAC), who is the facility’s principal point-of-contact, with Situation
Reports (SitRep). Such reports both immediately, and periodic updates which include
relevant information to create a common operating picture. The MHOAC will route
situational updates and information up the Operational Area level, to the Region, and
state, as appropriate to the situation. Hospitals are identified as “Field Level” under
Standardized Emergency Management (SEMS) levels.
E. The Liaison Officer (or designee) contacts other area response partners as needed (Coordinate
contact with Medical Health Operational Area Coordinator – MHOAC)
a. Health System/Corporate Offices
b. Other Hospitals
c. Fire
d. Law
e. EMS
f. Local Health Department
g. American Red Cross
h. Licensing and Certification – request authorization for regulatory/statutory flexibility
i. Emergency Management
j. Ambulance Providers
k. Coroner/Medical Examiner
l. Utilities
m. Office of Statewide Health Planning and Development (OSHPD)
n. Other emergency response partners
(Developing a hazard-specific compliance checklist in advance can help ensure timely and
appropriate reporting including reopening approvals by key agencies)
E. The Public Information Officer (or designee) provides briefings and press releases to the media
and public
F. Communications Unit Leader (or designee) completes HICS 205A Communications list. 205A
provides information on all communication devices assigned.
G. If evacuation occurs, communication with patient families with relocation information
H. If using Alternative Care Sites (such as hospital expansion sites or government authorized
Alternate Care Sites), the Liaison Officer (or designee) will communicate between sites
5. Resource Requests Date/Time Initials
A. The HICS 258 Hospital Resource Directory that is completed by the Planning Section lists
methods of contact to assist in the procurement of hospital resources for an incident
B. Complete HICS 257 Resource Accounting Record. HICS 257 records the request, distribution,
return, and condition of equipment and resources allocated to the response.

Note: This Checklist is based on the Hospital Incident Command Guidebook and California Public Health and Medical Emergency
Operations Manual located at www.emsa.ca.gov.
Version: March 2020 Page 3 of 5
 Hospital Emergency Management Program Checklist
C. Utilize emergency assistance agreements – both formal and informal, Memoranda of
Understanding (MOUs) and other agreements as needed
D. Direct Resource Requests using ICS Form 213 RR (Resource Request) to Medical and Health
Operational Area Coordinator (MHOAC) if necessary resources cannot be obtained through
existing agreements or agreements such as Memorandums of Understanding (MOUs).

The Public Health and Medical System for California uses a common framework and operating
procedures. Requests typically include resources needed to complete your mission. Examples
include medical supplies, staff, pharmaceuticals, PPE, tents, transportation, etc.
Important tenants include:
• The resource need is immediate and significant
• The supply of the requested resource has been exhausted or exhaustion is imminent
• The resource is not available from internal or regular supply chain
• The resource or an acceptable alternative is unavailable from other vendors, providers, or
Pubic Health caches
• Payment/reimbursement issues addressed
• Provider Resource Request is specific and descriptive and asks for:
- Priority
- Item Description
- Kind (size, strength, specialty)
- Type (number of cases, concentration, cert)
- Quantity
- Duration of Use
- Delivery Information

6. Tracking (Patient/Staff/Volunteers/Resources) Date/Time Initials

A. Patient Tracking Manager completes HICS 254 Disaster Victim/Patient Tracking. HICS 254
records the triage, treatment, and disposition of victims/patients of the event seeking medical
attention.
B. Each Section Chief ensures completion of HICS 252 Section Personnel Time Sheet for each
position activated under their specific Section. HICS 252 is used to record each Section’s
personnel time and activities for each Operational Period.
C. If volunteers are utilized, Labor Pool and Credentialing Unit Leader completes HICS 253
Volunteer Registration. HICS 253 documents volunteer information for each operational
period.
D. Procurement Unit Leader (or designee) competes the HICS 256 Procurement Summary Report.
HICS 256 summarizes and tracks procurements either by Operational Period, or entire incident
duration.
E. Complete HICS 257 Resource Accounting Record. HICS 257 records the request, distribution,
return, and condition upon receipt and return of equipment and resources.
F. For casualty and fatality tracking the Planning Section completes HICS 259. HICS 259 tracks
number for each Operational Period of:
• Casualties
• Fatalities
• Patients seen
• Patients admitted

Note: This Checklist is based on the Hospital Incident Command Guidebook and California Public Health and Medical Emergency
Operations Manual located at www.emsa.ca.gov.
Version: March 2020 Page 4 of 5
 Hospital Emergency Management Program Checklist
• Critical Care
• Medical/Surgical
• Other
• Patients discharged
• Patients transferred
• Patients transferred to the morgue
• Patients waiting to be seen
G. If under evacuation, Situation Unit Leader (or designee) to complete HICS 255 Master Patient
Evacuation Tracking. HICS 255 records information concerning patient disposition during an
evacuation.
H. If under evacuation, Inpatient/Outpatient Unit Leader or Casualty Care Unit Leader will
complete HICS 260 Patient Evacuation Tracking Form for each patient evacuated. ICS 260
details and accounts for patients transferred to another facility or alternate care site.
I. If under evacuation, Labor Pool will track staff being assigned and sent to another location,
facility or Alternate Care Site.
J. Staff who become ill or injured as a result of their participation in the emergency response
should be tracked and cared for immediately under the Logistics Section Employee Health and
Well-Being Unit. Worker’s compensation issues associated with illness or injury incurred as a
part of the emergency response activities are tracked and addressed under the Finance Section
Compensation and Claims Unit.
K. Finance Section tracks expenses from the beginning of the incident activation including
personnel, patient care, resources, equipment repair or replacement, hospital repair and
operations in order to identify expenses (potentially) eligible for reimbursement and other
forms of assistance

Note: This Checklist is based on the Hospital Incident Command Guidebook and California Public Health and Medical Emergency
Operations Manual located at www.emsa.ca.gov.
Version: March 2020 Page 5 of 5