Standard 38: Hospital Disaster and Emergency Preparedness (Version 11)

Why it matters. A hospital hit by a disaster must know who leads the response and what to do. A written plan that covers the whole facility, with a named lead, is the basis of the response.

Sample. Review the disaster plan, the incident lead rota and the activation records for the last 12 months.

1. A named incident lead and deputy are responsible for the plan.

Method. Check the approved plan and the on-call rota for the names and roles.

Evidence to show. Hospital disaster plan ownership and incident lead (DIS-POL-001).

Pass when. A named incident lead and deputy are recorded for every period in the sample.

2. The incident lead can be reached and can act at any hour.

Method. Make an unannounced test call to the incident lead at a time outside working hours.

Evidence to show. Hospital disaster plan ownership and incident lead (DIS-POL-001).

Pass when. The incident lead answers and can give the activation decision within the set time.

Immediate fail (any one means the criterion is not met). A flood cuts power at night, and no one has authority to activate the plan because the incident lead cannot be reached.

Why it matters. Hospitals face different hazards: floods, earthquakes, heat, power loss. A regular hazard assessment, including climate and utilities, shows which ones matter most.

Sample. Review the hazard and vulnerability assessment and its last update, and the controls set for high-scoring hazards.

1. The assessment covers natural hazards, technical failures, violence, outbreaks and the effects of climate change.

Method. Compare the list of hazards with each category required by the standard.

Evidence to show. Hazard and vulnerability assessment record (DIS-FRM-001).

Pass when. Every required category is covered by at least one scored hazard.

2. The assessment is completed and updated each year and after any event.

Method. Check the date of the last review and the events recorded since then.

Evidence to show. Hazard and vulnerability assessment record (DIS-FRM-001).

Pass when. The assessment was updated within the last 12 months and after each recorded event.

Immediate fail (any one means the criterion is not met). A known flood risk is scored low, and the facility has no plan for the basement pumps when the river rises.

Why it matters. When the power or water fails, the hospital must keep the essential services running. Backup supplies, tested on a schedule, make that possible.

Sample. Review the back-up test records for power, water, oxygen and medical gas, for the last 12 months.

1. Each back-up for power, water, oxygen and medical gas is tested on a defined schedule.

Method. Compare the test register with the schedule set in the plan.

Evidence to show. Utility back-up test register (DIS-REG-001).

Pass when. Every back-up was tested within its scheduled interval.

2. Tests are recorded, and failures are corrected before the next test.

Method. Check each failed test for the action taken and the date of the next passed test.

Evidence to show. Utility back-up test register (DIS-REG-001).

Pass when. Every failed test has an action recorded and a later test that passed.

Immediate fail (any one means the criterion is not met). The oxygen back-up was never tested, and the first power cut leaves ventilated patients without oxygen supply.

Why it matters. A disaster plan that staff have never practised will fail when used. Staff must know their role, and drills must be held and reviewed.

Sample. Review drill records and staff role records for the last 12 months.

1. Staff know their role in the plan.

Method. Ask a sample of staff from each area what they would do on activation.

Evidence to show. Drill evaluation record (DIS-FRM-002).

Pass when. Staff in every sampled area can state their role.

2. The drill result is recorded and used to improve the plan.

Method. Check the drill evaluation for findings and the plan changes that followed.

Evidence to show. Drill evaluation record (DIS-FRM-002).

Pass when. Every drill has a recorded result and each finding has a plan change or a reason.

Immediate fail (any one means the criterion is not met). No drill has been held in two years, and on activation staff do not know who leads the response.

Why it matters. After a real disaster, or a drill that exposes gaps, the plan must be changed. Reviewing it after each activation keeps it realistic.

Sample. Review every activation and every drill with significant findings in the last 12 months, and their review records.

1. A structured review is held after each real activation or significant drill.

Method. Check the review record for each activation and each drill with significant findings.

Evidence to show. Review after plan activation (DIS-SOP-003).

Pass when. Every sampled activation has a review record.

2. The review is held within 14 days.

Method. Compare the review date with the date of the activation or drill.

Evidence to show. Review after plan activation (DIS-SOP-003).

Pass when. Every sampled review was held within 14 days.

3. The review results in written changes to the plan.

Method. Check each finding for a written change to the approved plan.

Evidence to show. Review after plan activation (DIS-SOP-003).

Pass when. Every finding has a written change to the plan, with an owner and a date.

Immediate fail (any one means the criterion is not met). After a real activation, the review is never held, and the same evacuation fault happens at the next drill.