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Title: Emergency Management Annual Evaluation Template
Effective Date: / Reviewed : / Revised: /

Function: Environment of Care

Annual Performance Evaluation

Emergency ManagementPlan-<YEAR>

{This is a sample format and text for the conducting the Annual Evaluation for the Emergency Management Plan (EC.9.10.5). The Reviewer should evaluate the Scope, Objectives, Performance, and Effectiveness of their program based on the information for the previous year. Use this Evaluation to develop the Management Plan for the next year. Be sure to give an “evaluation statement” for Scope, Objectives, Performance, and Effectiveness and remove instruction in { } when finished}

Reviewer: <assigned person >

Review Date: <Date>

Review of Program Scope

Scope Statement {Include Scope Statement from the Management plan being evaluated}

The Emergency Management Program is designed to assure appropriate, effective response to a variety of emergency situations that could affect the safety of patients, staff, and visitors, or the environment of Facility Name, or adversely impact upon the hospital’s ability to provide healthcare services to the community. The program is also designed to assure compliance with applicable codes and regulations. The Emergency Management Plan is developed to assure availability of resources for the continuation of patient care during an emergency. The Plan also addresses the medical needs of victims of a hospital or community based incident

The program is applied to Facility Name, and its affiliated clinics and medical practices.

Evaluation:{include statement of scope, such as below}

No changes to the facilities served or the programs provided were made during the past year. The scope still accurately reflects the intent of the program.

Review of Program Objectives{Include “Objectives” listed in Management Plan}

<YEAR>Objectives / Met / Not Met / Action Plan

Review of Performance

Performance Measures {List performance measures identified in Management Plan}

  1. <Performance measure>
  2. Year average is __ %
  3. Threshold is __%
  4. Performance is <acceptable or unacceptable, and stable or unstable>
  1. Performance measure>
  2. Year average is __%
  3. Threshold is _ %
  4. Performance is <acceptable or unacceptable, and stable or unstable>

See attached data {Insert data or attach Spreadsheet of data at the end of Evaluation}

Evaluation Summary of Performance Measures {Analysis of performance such as follows}

The performance measures were: {summarize the analysis of above stated performance measures}

Review of Program Effectiveness

This program was considered generally effective, but the citation found during environmental tours needs to be improved.

Planning Objectives for <Year>{Include any items noted for improvement through the current year process and/or some goals for next year that could become “Objective” in the revised Management Plan}

EM.03.01.01 EP 3a Emergency Management Annual Evaluation Templ.doc