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What requirements do hospital have related to creating a Corrective Action Plan (CAP) or and Improvement Plan (IP) after an event or exercise?

Hospitals are required by The Joint Commission to monitor performance and evaluate each exercise or actual event using a multidisciplinary process that involves licensed independent practitioners. During an exercise, individuals are to be designated to observe performance and document opportunities for improvement. That evaluation process is to result in:

  • Documented identification of deficiencies and opportunities for improvement
  • Documented assignment and monitoring of improvement activities, including the hospital team/committee responsible for emergency management
  • Modification of the hospital Emergency Operations Plan or supporting policies and procedures based on the evaluation; if modifications require substantive resources and cannot be accomplished by the next exercise, interim measures should be implemented
  • Incorporation of modified or interim measures in subsequent emergency response exercises.
  • The hospital should maintain clear and timely documentation of each step in after action evaluation, improvement planning and monitoring, resulting modifications to Plans policies and procedures, and exercising of modifications or areas identified for improvement.

Hospital Preparedness Program (HPP) participating hospitals are required to participate in community-wide after action evaluation and improvement planning meetings and to submit an exercise summary report form to the Local HPP Entity following each community-wide exercise in which the hospital participates.

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