550-23: Emergency Management

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Overview

Delineates campus, departmental, student, staff, and faculty responsibilities to ensure emergency preparedness and responsiveness.

Purpose

This policy delineates campus, departmental, student, staff, and faculty responsibilities to ensure emergency preparedness and responsiveness. It addresses certain statutory authorities and regulations listed below.

Definitions

By definition of Government Code 3100-3102 all public employees are disaster service workers. Employees of the University of California take the Oath of Affirmation when hired, as required by law. In the event of emergencies which result in conditions of disaster or extreme peril to life, property and resources, all State University employees are subject to disaster service activities assigned to them.

A written document required by OSHA standard 29 CFR 1910.38(a), the purpose being to facilitate and organize employer and employee actions during workplace emergencies.

An established system of planning and preparing for, responding to, recovering from and mitigating consequence of all-hazard disasters.

The Emergency Operations Plan (EOP) provides guidelines for the management of the immediate actions and operations required to respond to emergencies or disasters.

The Business Continuity Plan (BCP) provides guidelines for how UCSF will recover and restore partially or completely interrupted critical (urgent) functions within a predetermined time after a disaster or extended disruption. UC Ready is the technology platform in which the plans reside.

Policy

UCSF’s Office of Enterprise Emergency Management is responsible for managing all phases of the disaster life cycle – preparedness, mitigation, response, and recovery as well as business continuity. This policy details the Office of Enterprise Emergency Management’s objectives in responding to major incidents, emergencies, and disasters at all UCSF sites are to protect human and animal life, protect property, preserve research, and continue essential institutional operations.

  1. Authority:
    1. The Chancellor delegates the authority to declare an Enterprise-wide “State-of-Emergency” or Campus closure to the Senior Vice Chancellor (SVC) and her/his designated Alternate. For events that affect UCSF Health, this authority is delegated to the UCSF Health Chief Operating Officer and her/his delegate.
    2. The Chancellor delegates the authority to activate UCSF Emergency Operations Plan in times of crisis to the Senior Vice Chancellor or her/his designated Alternate. For events that affect UCSF Health, this authority is delegated to the UCSF Health Chief Operating Officer and her/his delegate.
  2. Emergency Operations Plan (EOP)
    1. The purpose of UCSF Emergency Operations Plan is to establish policies, procedures, and an organizational structure for response to a major incident, emergency, or disaster. The EOP plan does not automatically supersede or replace the procedures for safety, hazardous materials response, or other procedures that are already in place at the University. However, due to the severity of the emergency, its threat to life, safety, property and research, or the urgency to implement protective actions, the EOP may supplement or replace those procedures with a temporary crisis management structure and procedures, which provides for the immediate management of response operations and the early transition to recovery operations.
    2. Under the direction of the Enterprise Emergency Management Executive Director, the EOP encompasses the entire UCSF enterprise, including off-campus facilities and UCSF global activities, as well as all of UCSF Health, including Benioff Children’s Hospital Oakland, Langley Porter Psychiatric Hospital, and all ambulatory facilities.
    3. The EOP is an overarching plan that is divided into specific sections that speak to each of the entities of UCSF and UCSF Health. Independently licensed facilities Langley Porter Psychiatric Hospital and Benioff Children’s Hospital Oakland are required by regulatory agencies to have specific Emergency Operations Plans for their facilities. The UCSF Emergency Operations Plan integrates these plans. an
  3. Control Point Departmental/Division Coordination
    1. Control Points are Chancellor’s Direct Report-level or their designee will assure emergency plans and procedures are in place for their areas of responsibility to provide for the safety and security of personnel, property, research and mission continuity (Refer to EOP Appendix ESR: Emergency Status Assessment & Reporting). UCSF Emergency Management will assist control points in meeting this responsibility through consultation.
  4. Emergency Action Plans
    1. All UCSF Control Points shall comply with OSHA Standard 29 CFR 1910.38(a) and the California Code of Regulations, Title 8, Section 3220. Compliance includes creating and maintaining updated Emergency Action Plans (EAP) and training staff in EAP procedures and participating fully in mandatory annual fire drills scheduled by the UCSF Fire Marshal. Refer to EAP online tool, Preparing for Emergencies).  The Office of Emergency Management shall administer EAP compliance by Departments to assure EAPs are developed and maintained annually for all occupied workspaces. 
  5. Mass Notification System (MNS)
    1. UCSF uses an integrated communications system capable of delivering emergency alerts, notifications, and/or warnings to the entire University community, including UCSF Health, or specific groups or locations simultaneously, via multiple modalities including, but not limited to, desk and cell phones, e-mail, text messaging, pager, public address systems, and electronic display boards. In events that will may imminently threaten life safety, UCSF Police Department may help craft and disseminate messaging to the UCSF community.
  6. Business Continuity Plan 
    1. All UCSF Control Points shall assure all units with mission essential services or functions are capable to be restored within the agreed upon essential function's RTO (Return To Operations) standard after closure or disruption due to an emergency. These services or functions must maintain Business Continuity Plans in accordance with the UC Ready program (refer to beready.ucsf.edu/business.continuity.plans). The UCSF Business Continuity Program is responsible for assisting control points across all elements of the UCSF enterprise in meeting this responsibility. 
  7. Space Use for Emergency Operations
    1. The University reserves the right to assume control of University owned and operated spaces, such as conference rooms, meeting rooms, classrooms and auditoriums during emergencies or events which pose a threat to public safety or University property. During such emergencies or events the Emergency Operations Center staff may identify rooms for use as Incident Command Posts, Emergency Operations Centers, Hospital Command Centers, Emergency Shelters or other facilities necessary to protect public safety or University property during emergencies or threating events.
    2. Departments are required to relinquish use of the space and will be responsible for notifying event/meeting organizers the space use permission has been preempted due to emergency operation needs.
    3. Cancellation fees will not be charged for rooms reserved for public safety or emergency operations.

Responsibilities

  1. Senior Vice Chancellor: The Senior Vice Chancellor or her/his designated Alternate has responsibility for activation, oversight and demobilization of the Emergency Operations Center (EOC) and UCSF emergency responders.
  2. UCSF Health SVP Chief Operating Officer (COO): The COO is responsible for the administrative functions of the Office of Emergency Management including budgeting and accordingly recharging the campus for expenses. The COO is also responsible for ensuring that UCSF Health emergency operations, including activation, oversight, and demobilization of Hospital Command Centers (HCCs) comply with regulatory requirements.
  3. Enterprise Emergency Management Executive Director
    1. UCSF Emergency Management Executive Director is responsible for the Office of Emergency Management (OEM). OEM responsibilities include:
      1. Overall Campus Emergency Management 
      2. Development, ongoing maintenance, and updating of the UCSF Emergency Operations Plan (EOP), including Health, Langley Porter Psychiatric Hospital, and Benioff Children’s Hospital Oakland-specific Emergency Operations Plans.
      3. Development, maintenance, and administration of the primary and alternate Emergency Operations Centers (EOC) and Hospital Command Centers (HCC).
      4. Oversight and approval authority of UCSF Health Emergency Management Plans including:
        1. Emergency Action Plan (EAP) administration to ensure compliance with development and annual maintenance for all occupied workspaces.
        2. EAP plan review and approval.
        3. Along with the Office of Environment, Health & Safety (EH&S) [see Sec. G.2], all-hazard, risk-based emergency preparedness technical assistance to departments in the emergency plan development, providing hazardous reduction guidelines, monitoring compliance for implementation, assisting site coordinators in planning and conducting evacuation exercises, and providing and/or organizing relevant training.
        4. EAP templates are found in UCSF MyAccess: UC Ready.
    2. Administration of the Business Continuity Program:
      1. OEM administers the UC Ready online Business Continuity Planning tool. 
      2. OEM facilitates BCP development by departments/divisions/schools/units with mission essential services or functions that must be restored to each function's RTO (Recovery Time Objectives) after closure or disruption due to an emergency.
      3. UCSF Health shall assume responsibility for UCSF Health's Mission Continuity Planning.
  4. EOC Director
    1. In consultation with the Chancellor’s Executive Team (CET), the EOC Director is responsible for providing leadership to direct all EOC operations during a UCSF emergency declaration and EOC activation.
    2. The EOC Director has overall responsibility for the management of all emergency activities, including development, implementation, and review of strategic decisions, and post event (After Action Report) assessments and corrective action plans.
    3. The EOC Director can appoint a qualified designee and/or deputy director, as appropriate.
  5. Emergency Operations Center (EOC)
    1. The EOC Director is responsible for ensuring UCSF emergency response operations interagency coordination, as appropriate, with the University of California Office of the President, City & County of San Francisco EOC and other operational area jurisdictions, California Office of Emergency Services (CalOES), and the Federal Emergency Management Agency (FEMA).
    2. The EOC coordinates with the Hospital Command Center (HCC) and other UCSF Departmental Operation Centers (DOC) activated during campus-wide emergencies.
  6. Mass Notification Systems (MNS)
    1. The mass notification system is managed and maintained by the Office of Emergency Management. This group approves other users as system users and administrators and is the main part responsible for overall system use and sending messages related to confirmed or potential emergency situations.
    2. The UCSF Police Department has primary responsibility across the UCSF enterprise for all Public Safety and designated use of mass notification systems, as outlined in UCSF Police General Orders. This refers especially to potential or confirmed events that may/will pose a life safety risk to any part of or the whole of the UCSF community.
  7. Office of Environment, Health & Safety (EH&S)
    1. In compliance with applicable regulations, EH&S is responsible for worksite safety assessments, technical assistance, exposure reduction guidelines, monitoring implementation compliance, assisting site coordinators in planning and conducting exercises, and providing or organizing relevant training.
    2. Emergency Action Plans: The Office of Environment, Health & Safety may assess staff knowledge of the worksite EAP, inspect emergency preparedness equipment and supplies, safety equipment or elements described in the EAP during worksite safety assessments.
    3. Campus Fire Marshal: The Fire Marshal shall schedule, conduct and evaluate fire drills for all occupied UCSF worksites annually.
  8. Emergency Management Control Points
    1. Emergency Management Control Points shall make staff available to develop and maintain Emergency Action Plans (refer to EAP online tool), Department Emergency Plans, and Mission/Business Continuity Plans (Refer to EOP Annex REC: Recovery) and fulfill the emergency planning, coordination and response functions and responsibilities required of those plans.
    2. Emergency Management Control Points will develop and maintain an Emergency Coordinator system at the Division, Department and Control point levels in order to assess the impact of emergencies upon operations with the Control Point's organization areas or responsibilities.  (Refer to EOP Appendix ESR:  Emergency Status Assessment & Reporting)
    3. Upon request of the Chancellor’s emergency management designee (SVC) a Department shall designate staff to fulfill permanent positions on the Emergency Operations Center’s Incident Management Team and upon activation of the EOC will release designated Incident Management Team personnel from their routine responsibilities to fulfill emergency support functions (ESF).
  9. Students, Faculty, Staff
    1. All Students, faculty and staff are to familiarize themselves with worksite Emergency Action Plans, emergency procedures outlined in electronic “Campus Emergency Procedures” and UCSF Safe (mobile app), participate in fire drills, and register emergency contact information in the UCSF emergency warning system “WarnMe” (operates on the Everbridge system platform) and follow directions provided by emergency responders during emergencies. Additional information can be located at UCSF Preparing for Emergencies website. (Refer to EOP Appendix SE: Emergency Expectations for Staff, Students, Faculty.)

References

Subject area

Health & Safety

Policy number

550-23

Responsible office

Financial and Administrative Services

Primary content owner

Emergency Management

Effective

Reviewed