ATTACHMENT 5-JAMES H. QUILLEN VAMC MEMORANDUM NO. 00Q-12-06 EMERGENCY NOTIFICATION PLAN.docx

APPENDIX E

JAMES H. QUILLEN VETERANS AFFAIRS MEDICAL CENTER

(JOHNSON CITY)

MOUNTAIN HOME, TN 37684

July 17, 2012

MEDICAL CENTER MEMORANDUM

NO.......................................00Q-12-06

EMERGENCY NOTIFICATION PLAN

1. PURPOSE: This memorandum is published to provide procedural guidance for notifying the medical center Executive Leadership Team (ELT) and Veterans Integrated Service Network (VISN) office immediately in the event of a disaster, crisis, missing patient, sentinel event or untoward situation, including those with potential media, congressional or litigious implications at this facility and/or catchment area. Notifications will be made for Disaster Drills as well.

2. SCOPE: The contents of this memorandum apply to all medical center employees. The medical center will ensure the timely review and update of all cascade call rosters associated with the Emergency Notification Plan. This plan will consist of two basic areas of notification:

a. Plan A – Disasters requiring implementation of the Emergency Preparedness Plan

b. Plan B – Clinical or Administrative Issues and Information Security Issues

3. POLICY: This policy establishes a streamlined communication method and identifies key staff to be notified of any significant event, close call, disaster, sentinel event or untoward situation with potential media, congressional or litigious implications. The policy provides a mechanism to communicate that event, close call, disaster, sentinel event or untoward situation and Information Security issues to the ELT and the VISN 9 office. Staff is to immediately report any unusual occurrences, events that may be newsworthy, or incidents with unexpected outcomes to their supervisor, who will communicate this to the appropriate ELT member or the Chief of Quality Management. This includes high-risk missing patients, sentinel events, disasters, or untoward situations including those with potential media, congressional or litigious implications.

4. ACTION/RESPONSIBILITY:

a. Responsibilities of Medical Center Supervisors/Service Chiefs:

The medical center staff will communicate immediately any unusual occurrences, events that may be newsworthy, or incidents with unexpected outcomes to their supervisor. The supervisor will call the Chief of Quality Management, the Patient Safety Manager or the Director's secretary when the incidents described in paragraph 1 occur. These incidents include but are not limited to:

(1) Unexpected patient death

(2) High-risk missing patient

(3) Criminal matters involving felonies to include, but not limited to, theft of Government property over $1,000, false claims, false statements, drug offenses, crimes involving information technology systems, and serious crimes against the person, i.e., homicides, armed robbery, rape, aggravated assault and serious physical abuse of a VA patient.

(4) Sentinel events or untoward situations, including those with potential media, congressional or litigious implications.

(5) Activation of the Emergency Management Plan, including drills

b. Responsibilities of Medical Center Director or Designee:

(1) Immediately forward to VHAMOU Notification B Group an email with additional information, which should include:

(a) Statement of Issue

(b) Background

(c) Current status

(d) Action(s)

(2) Communicate via phone to the appropriate VISN staff within one (1) hour of learning of such event.

(3) E-mail communication within one (1) hour of learning of ALL events to include a brief description of the incident, using the VHA Alert Notification format (Appendix E) sent to all the following. This communication should be sent as text pasted into an Outlook message AND as an attachment in the same Outlook e-mail message, (with no boxes), with a message in the text version that the attachment is the same content:

(a) VISN 9 Notification – Plan A or B (as appropriate)

(b) For incidents involving information security, include the VISN Information Security Officer.

(c) For incidents involving any supplies or services provided by Acquisitions Service Line Staff, include the VISN Chief Logistics Officer and VISN Chief Material Management Officer.

(d) For incidents involving mental health, include the VISN Mental Health Officer.

(4) Email communication of ALL events with complete details and the supporting documentation outlining the issue, background, and implications within eight (8) hours of learning of the event, using the VHA Issues Briefing format (Appendix D), sent only to the VISN 9 Notification A or B e-mail group. This communication should be sent as text pasted into an Outlook message AND as an attachment in the same Outlook message, (with no boxes), with a message in the text version that the attachment is the same content.

(5) All incidents involving personally identifiable information, including reporting security incidents will be immediately reported (within one (1) hour) to frontline managers or supervisors who will notify a member of the ELT.

(6) In addition to the above steps, additional reporting requirements for "Incidents Involving Personally Identifiable Information" include reporting security incidents to a federal incident response center. All incidents involving personally identifiable information will be reported to United States Computer Emergency Readiness Team (US-CERT) within one (1) hour of discovering the incident. In order for the Veterans Affairs Network and Security Operation Center (VA-NSOC) to meet the one-hour reporting requirement, it is imperative that all VHA offices immediately report all incidents involving personally identifiable information in electronic or physical form as soon as they are discovered. The incidents should be reported to the VA-NSOC via the Information Security Officer (ISO) or designee, and into the Privacy and Security Event Tracking System (PSETS) by the Privacy Officer (PO), and should not distinguish between suspected and confirmed breaches. Employees may report incidents to the ISO or PO by email, voicemail or enter the issue into the Privacy and Security Web access from the Mountain Home Web page via the “Special Programs” link.

(7) VA-NSOC reports described above should include a description of what corrective action will be taken (i.e., counseling plan to prevent future occurrences). This is required in order to close out the NSOC. Issue Alerts are not necessary unless the information breach is of an urgent need for the VA Central Office to know. Issue Briefs are not necessary if the information breach remained within the VA system; the NSOC report should state that it remained internal and what local actions were taken. If the information breach took place outside the VA system, an Issue Brief should be prepared to describe these events and should include the NSOC report number in the subject line and text of the e-mail.

c. Responsibilities of Medical Center Staff:

(1) Medical center staff will notify frontline managers or supervisors of any event that would require initiation of an incident report, a health or safety risk, activation of the Medical Center Emergency Management Plan or any other incident described in Medical Center Memorandum "Patient Safety Improvement/Risk Management Programs." Supervisors/managers will then determine the appropriate emergency plan (A or B) and activate the medical center Notification Cascade Call Plan (A or B) that has been identified by the manager/supervisor as appropriate for the situation.

(2) Telephone contact should be initiated and continued until telephone contact is made with the frontline supervisor/manager or next contact on the appropriate medical center Notification Cascade Call Plan identified in Appendix A-C.

(3) Medical center staff completing the Issue Alert and Issue Brief paperwork will minimize the use of acronyms or abbreviations, or will spell out the acronyms the first time they are used. When sending an Issue Alert or Issue Brief, in the subject line on the Outlook message, use the following guide:

(a) Issue Alert V9 + Date + Facility Name + Subject keyword(s)

(b) Issue Brief V9 + Date + Facility Name + Subject keyword(s)

(c) Example: Issue Brief V9-12-17-08 Mountain Home-Patient Suicide

(4) When there is an update, incorporate that information at the very beginning (in a different color font) of the Issue Brief. When there are updates to an Issue Brief, put the word “Update” at the end of the subject line. Example: Issue Brief V9-12-18-08 Mountain Home-Patient Suicide UPDATE.

(5) The following should be considered when preparing an Issue Brief regarding a Mental Health incident:

(a) Description of the event.

(b) Precipitating circumstances.

(c) Age and service connection of Veteran.

(d) Is the Veteran OEF/OIF/OND?

(e) Date last seen (prior to incident) with summary of visit.

(f) Was patient alert/oriented and considered competent at the time of incident?

(g) Was there suicidal or homicidal ideation?

(h) Was there evidence of substance abuse at the time of the visit/incident? If so, was a breathalyzer or drug testing done?

(i) Is there a history of substance abuse?

(j) Was treatment offered? What type – inpatient or outpatient?

(k) Was the Veteran homeless? If so, what housing or lodging options were offered?

(l) Was there family involvement? If appropriate, was family notified?

d. Plan A: Disaster requiring implementation of the Emergency Management Plan

(1) Staff responsibilities. Implement the medical center Emergency Management Plan. The Emergency Management Coordinator, Safety Manager or ELT designee should complete Appendix C, VHA Issue Brief, and forward to "VHAMOU Notification Group A" mail group.

(2) Medical Center Director Responsibilities.

(a) Implement Emergency Management Plan.

(b) The Medical Center Director or designee will implement the emergency notification procedures as instructed in VISN 9 Directive 10N9-20-11.

e. Plan B: Clinical or Administrative Issues

(1) Staff responsibilities.

(a) Staff will notify managers/supervisors immediately via telephone or in person. In the event that the individual is not reached, the next person on the Medical Center Notification Cascade Call Plan B is to be contacted until telephone contact is made with supervisory staff and will continue up through the service chiefs, ELT members to the Medical Center Director. The Public Affairs Officer, Chief, Quality Management, Patient Safety Officer, or ELT designee should complete Appendix D, VHA Issue Brief, and forward to the "VHAMOU Notification Group B" mail group.

(b) All employees are required to immediately report potential or actual criminal events to their immediate supervisor, upper level management, the Compliance and Business Integrity Officer (CBI Officer), VA Police, or Facility Leadership. For any potential or actual criminal matters, VA Police or Facility Leadership will refer such matters to the VA OIG upon notification of such. All fact-finding or investigative efforts will cease until the VA OIG provides guidance or instruction. After notification to the VA OIG, Facility Leadership will submit a Heads-Up promptly to the VISN Office and follow with a full Issue Brief within 24 hours in accordance with VISN Directive 10N9-20-11. After review at the VISN level, the Issue Brief will be forwarded to VA Central Office with annotation of the date and time of VA OIG notification. In the event of a suspected felony the Chief, Police Service is required to notify the VA OIG promptly. Examples of felonies include but are not limited to, theft of Government property valued over $1000, false claims, false statements, drug offenses, crimes involving information technology systems, and serious crimes against the person (i.e., homicides, armed robbery, aggravated assault, and serious physical abuse of a VA patient).

(2) Medical Center Director Responsibilities. The Medical Center Director or designee will implement the emergency notification procedures, as instructed in VISN 9 Directive 10N9-20-07.

5. REFERENCES: VA Handbook 1545 and VA Handbook 1528 VISN 9 Directive 10N9-20-11 DUSHOM Memorandum - Referrals Regarding Criminal Violations dated March 7, 2012

6. RESCISSION: Medical Center Memorandum 00Q-11-11

7. RESCISSION DATE: 07/17/2015

8. FOLLOW-UP RESPONSIBILITY: Chief, Quality Management & Improvement Service (QM&IS)

//s//

Charlene S. Ehret, FACHE Medical Center Director

Attachments:

Appendix A – Mountain Home Notification Plan – Cascade Plan A (All Disasters) Appendix B – Mountain Home Notification Plan – Cascade Plan B (Clinical or Administrative Issues) Appendix C – VHA Issues Briefing Format Appendix D – VHA Alert 36C24925R0067

Appendix E – Sample Suicide VHA Issue Brief

MOUNTAIN HOME NOTIFICATION

CASCADE PLAN A*

* Plan A – All Disasters Dual Reporting – Refer to Emergency Management Plan MCM 138-10-03.

IMPLEMENT DISASTER PLAN CASCADE CALL

NOTIFY FIRST LINE SUPERVISOR/MAA/POLICE AS INDICATED BY DISASTER PLAN

NOTIFY MEDICAL CENTER DIRECTOR WHO WILL IMPLEMENT THE CASCADE CALL PLAN

Charlene S. Ehret Ext: 7101, Cell: 974-0150

Cascade Call List

ELT member or Chief of QM will notify VISN when Disaster plan activated or if a "drill" is underway.

A-1

MOUNTAIN HOME NOTIFICATION

CASCADE PLAN B*

*Plan B – Clinical or Administrative Issues:

Staff will notify managers/supervisors immediately via telephone or in person. In the event that the individual is not reached, the next person is to be contacted until telephone contact is made with supervisory staff on up through Service Chiefs, Chief, Quality Management, ELT members to the Medical Center Director. The Chief, Quality Management, or ELT designee should complete Appendix D, VHA issue brief and forward to each member of the Plan B Notification Cascade Call plan.

Public Affairs Officer Judy Fowler-Argo Ext: 7126;

Home: 282-0043;

Cell: 202-5500 Service Chief/MAA 1st Line Manager/Supervisor

Medical Center Director (Implement V9 Notification Directive) Charlene S. Ehret Ext: 7101, Cell: 974-0150

ELT MEMBERS

Daniel Snyder Ext: 7103 Cell: 767-5953

David Hecht, MD Ext: 7117 Cell: 342-5470

Linda McConnell Ext: 7215 Blackberry: 557-4270

Chief, Quality Improvement Lori Hagen, Ext: 979-3717 Cell: 963-0011 Patient Safety Manager Teresa Pickett, Ext 7306 Cell: 795-0049 Pager: 552-4126

B-1 E-mail communication of ALL events with complete details and the supporting documentation outlining the issue, background, and implications within eight (8) hours of learning of the event, using the VHA Issue Briefing format, sent only to the VISN 9 Notification A or B e-mail group. This communication should be sent as text pasted into an Outlook message AND as an attachment in the same Outlook e-mail message, (with no boxes), with a message in the text version that the attachment is the same content. Per your discretion, Issue Briefs that contain sensitive information may be sent pki.

a) Be specific and succinct – answer the question of who, what, when, where and why.

b) Identify which medical center the issue brief is about.

c) Submit timely, immediately following the Issue Alert.

d) Clearly state status of situation and briefly annotate chronology of events.

e) Avoid use of acronyms; spell out abbreviations.

f) Minimize use of technical/medical terminology.

g) Do not use patient identifiers; i.e. names, SSNs, etc.

h) Include status/location of veteran, meaning outpatient, inpatient on type of ward etc. and when the veteran was last seen by VA provider.

i) Succinctly summarize issue(s).

j) Include status of planned corrective actions and target completion date.

k) Indicate any media, VSO or congressional involvement.

l) Note whether a Root Cause Analysis (RCA) or Board of Investigation (BOI) is to be conducted and its target date for completion.

m) Note whether OIG or other program offices within VA have been contacted.

This box is directions for completing the process; please do not include it when you submit the Issue Brief or Issue Alert.

VHA ISSUE BRIEF

Medical Center:

Issue Title:

Date of Report:

Brief Statement of Issue and Status:

Actions, Progress and Resolution Date:

Indicate if applicable”

· Institutional Disclosure ____YES; ____NO; ____N/A

· Clinical Disclosure ____YES; ____NO; ____N/A

Contact for Further Information:

*Plan A – All Disasters

Dual reporting - The Medical Center Director or his/her designee should make Notification by telephone to the Network Director and Chief Communications Officer. In the event that neither individual may be reached, the next person is to be contacted until telephone contact is made with a member of the VISN staff.

For tracking purposes when submitting issue briefs, use the following format in the subject line of the e-mail message: Issue Brief V9 + Date + facility name + subject keyword(s)

C-1 D-1

E-mail communication within one (1) hour of learning of the event to include a brief description of the incident, using the VHA Alert Notification format, sent to ALL of the following:

(a) VISN 9 Notification – Plan A or B (as appropriate)

(b) Others as appropriate to the issue

n) Be specific and succinct – answer the question of who, what, when, where and why.

o) Identify which medical center the issue brief is about.

p) Submit timely, immediately following the Issue Alert.

q) Clearly state status of situation and briefly annotate chronology of events.

r) Avoid use of acronyms; spell out abbreviations.

s) Minimize use of technical/medical terminology.

t) Do not use patient identifiers; i.e. names, SSNs, etc.

u) Include status/location of veteran, meaning outpatient, inpatient on type of ward etc. and when the veteran was last seen by VA provider.

v) Succinctly summarize issue(s).

w) Include status of planned corrective actions and target completion date.

x) Indicate any media, VSO or congressional involvement.

y) Note whether a Root Cause Analysis (RCA) or Board of Investigation (BOI) is to be conducted and its target date for completion.

z) Note whether OIG or other program offices within VA have been contacted.

This box is directions for completing the process; please do not include it when you submit the Issue Brief or Issue Alert.

VHA ALERT

Medical Center:

What occurred:

When:

Have you notified other offices or programs outside the VISN or facility? (For example, OIG, local police, VACO program offices.) If yes, please list:

Additional Details will be provided by (when):

If there are questions before that time, you may contact:

For tracking purposes when submitting issue alerts, use the following format in the subject line of the e-mail message: Issue Alert V9 + Date + facility name + subject keyword(s)

D-1 Sample Suicide Issue Brief

VHA ISSUE BRIEF

Issue Title:

Date of Report:

Brief Statement of Issue and Status:

Actions, Progress and Resolution Date:

• Date last seen (prior to incident) with summary of visit:

• Was patient alert/oriented and considered competent?

• Was there suicidal or homicidal ideations?

• Is there history of substance abuse?

• Was treatment offered? If so, what type? Inpatient/Outpatient

• Was Veteran homeless? If so, what housing or lodging options were offered?

• What family involvement is there? If appropriate, was family notified?

Contact for Further Information:

Name of Staff Member Title of Staff Member Mountain Home, VAMC Phone number and extension of staff member E-1