Hospital emergency action plans should be reviewed and updated at least every two years, with employee reviews when roles or the plan change.
Hospitals run on clear routines, then everything tilts during a fire, flood, outage, or cyber hit. The emergency action plan (EAP) keeps care moving when alarms ring. The question leaders ask is: how often should that plan be reviewed so surveyors say “yes” and teams know what to do? Here’s a clean, practical cadence rooted in federal rules and common accreditation playbooks.
What “Review” Means In A Hospital
“Review” is more than skimming a binder. It’s a cycle: confirm risks, check the plan’s fit, refresh procedures, retrain people, and prove it with records. In hospitals, two regimes drive the schedule. The Centers for Medicare & Medicaid Services (CMS) sets hard minimums for hospitals that bill Medicare. OSHA sets employee training and review triggers. Your accreditor may add detail, but the beats below will keep you compliant and ready.
Who Says What: Review Cadence At A Glance
| Requirement | Who Sets It | Review Cadence |
|---|---|---|
| Emergency preparedness plan (hospital) | CMS §482.15 | Review and update at least every 2 years |
| Policies and procedures | CMS §482.15(b) | Review and update at least every 2 years |
| Training and testing program | CMS §482.15(d) | Evaluate and update at least every 2 years |
| Employee EAP review | OSHA 29 CFR 1910.38 | Review with each worker at plan rollout, role change, and any plan change |
| Emergency management program | Joint Commission EM chapter | Ongoing evaluation with program updates following exercises and events |
How Often Should An Emergency Action Plan Be Reviewed In Hospitals: Rules And Reality
For hospitals that follow CMS, the emergency preparedness plan must be reviewed and updated at least every two years. That same biennial clock applies to policies, procedures, and the training and testing program. Staff need refresher training on a cycle that tracks with that program, and leaders must keep evidence of completion. OSHA adds a separate layer: each employee reviews the EAP at rollout, with duty shifts, and whenever the plan changes; no set time gap.
So the safe answer is a biennial minimum for the written plan, paired with change-driven reviews for staff. Many hospitals run an annual touchpoint anyway. Annual touchpoints line up with drills, fresh hazards, and budget cycles, and they make surveys easier. If your accreditor follows the Joint Commission format, the program is expected to show regular evaluation and updates after exercises and real events. That rhythm keeps lessons from fading.
Translating The Rules Into A Working Calendar
Think in beats you can repeat. Start with a biennial formal review where you open each section, mark edits, and approve changes. Then add lighter checkpoints that sync with drills, construction projects, or service launches. Tie staff refreshers to unit huddles and new hire orientation. Keep a single register of changes with dates, approvers, and the reason for each edit. That register saves time during surveys.
Why Biennial Is The Floor, Not The Ceiling
Hazards shift with renovations, new equipment, staffing patterns, and local threats. Weather trends change surge plans. New software changes downtime steps. A flat schedule can miss those shifts. Small, routine refreshes catch drift before it reaches patients. When a real incident hits, the after-action notes should lead straight to edits, retraining, and proof that the plan changed.
What To Review In The Emergency Action Plan
Risk Picture And Assumptions
Start with the hazard vulnerability analysis. Validate the top risks and the service lines most exposed. Check off-site clinics, owned practices, and mobile units. Verify assumptions on staffing, vendor capacity, and local partners. If the risk picture changed, the plan probably needs edits.
Command, Roles, And Call Trees
Open the incident command section. Names move. Titles change. Phones and pagers get replaced. Cross-check the call trees, duty rosters, and role cards. Confirm alternates for each critical role. Make sure the command center location, backup space, and activation triggers still match current layouts.
Clinical Operations And Patient Flow
Walk through surge intake, diversion triggers, and cohorting rules. Reconcile the plan with current triage, ED flow, labor and delivery, and ICU load limits. Match transport routes with construction maps. Align evacuation levels with current building zones and smoke compartments.
Utilities, Power, And Water
Map generator capacity to new loads like imaging, IT closets, and pharmacy fridges. Confirm fuel contracts and refill triggers. Check water outage plans for dialysis, sterile processing, and dietary. Validate manual workarounds for lifts, doors, and pneumatic tubes.
IT Downtime And Cyber Events
Compare the downtime playbook to the live EHR build. Update paper forms, order sets, and labeling. Verify read-only portals and imaging access paths. Practice patient ID checks when bracelets and scanners fail. Link cyber alerts to command activation.
Supplies, Vendors, And Mutual Aid
Review par levels for PPE, tubing, and critical meds. Confirm vendor alternates and drop-site instructions. Update mutual aid pacts with nearby hospitals and coalitions. Note any single points of failure and add backups.
Training, Exercises, And After-Action
List drills done since the last review and the findings. Pull out the top fixes and show where they landed in the plan, policies, or layouts. Set the next exercise slate with dates, scope, and teams. Keep the thread from findings to edits clear in your files.
Linking Rules: Two Authoritative Anchors
CMS sets the baseline for Medicare hospitals. See the Appendix Z emergency preparedness rule for the biennial review language. OSHA sets when each worker must review the plan. See OSHA 1910.38 EAP review for the employee trigger rules. Link both in your policy index so managers can find them fast.
Who Owns The Review And What Proof Surveyors Want
Clear Owners
Give the emergency manager day-to-day control of edits and records. Pair that role with a physician leader, nursing leadership, facilities, security, pharmacy, lab, IT, HR, and communications. Name a backup for each. Use a recurring meeting slot with a short agenda so updates don’t slip.
Audit-Ready Paper Trail
Keep a dated master file: plan version, policies, procedures, training calendar, exercise reports, and after-action items. Add sign-offs from the safety committee and executive leadership. Store proof of staff training by unit and role. Keep evidence for off-site locations in one place, labeled by site.
Common Triggers That Should Prompt An Off-Cycle Review
Facility And Equipment Changes
New wings, closed units, or relocated services shift evacuation routes and surge plans. New imaging or lab platforms alter power loads and downtime steps. Treat any of these as a review flag.
Staffing And Role Changes
When departments merge, outsource, or add new teams, role cards and call trees move with them. HR feeds should flag these shifts so the EAP and training get a quick refresh, and staff review happens under the OSHA rule.
Clinical Program Shifts
Adding stroke, ECMO, or transplant capacity changes transport, surge, and vendor needs. The plan should reflect those changes before go-live.
External Signals
Regional fires, floods, supply shocks, or alerts from public health can expose new weak spots. Use those signals to run a targeted mini-review. Capture edits in the register and push a quick staff brief.
Second Table: Proof-Of-Compliance Checklist
| Component | What To Check | Proof/Record |
|---|---|---|
| Plan document | Version, approvals, scope, roles | Version log with dates and approvers |
| Policies & procedures | Unit-level steps match plan | List of policies tied to plan sections |
| Training program | Initial and refresher schedule | Roster by unit, role, and date |
| Exercises | Type, scope, participants, fixes | After-action with assigned owners |
| Staff EAP reviews | New hires, duty changes, plan edits | HR record or LMS entry per worker |
| Vendors & mutual aid | Alternates, contracts, delivery points | Current MOUs and contact list |
| Power & utilities | Loads, fuel, test results, outages | NFPA test logs and fuel records |
| IT downtime | Forms, read-only access, recovery | Downtime kit contents and check logs |
| Off-site locations | Site-specific risks and contacts | Site binders and drills list |
| Change register | What changed and why | Single spreadsheet with links |
A Simple Biennial Cycle You Can Run
Year One
Quarter 1: Validate hazards, open the plan, and mark edits. Quarter 2: Update policies, train units on changes, and run a tabletop. Quarter 3: Fix gaps, test backups, and update vendor files. Quarter 4: Run a regional drill and finalize the change register.
Year Two
Quarter 1: Recheck roles, call trees, and off-site contacts. Quarter 2: Tune surge and diversion, then walk evacuation routes. Quarter 3: Run a full-scale exercise with partners. Quarter 4: Close findings, sign approvals, and publish the next version.
Tips That Keep Reviews Smooth
Keep The Plan Easy To Use
Short, linked sections beat a giant PDF. Use clear labels, quick-hit checklists, and short role cards. Place phone numbers and radio channels where hands can find them fast.
Make Training Part Of Daily Work
Drop five-minute refreshers into shift huddles. Rotate small drills through nights and weekends. Offer short e-learning clips for downtime tasks.
Practice Change Control
Route edits through one owner. Stamp each change with the reason, the date, the approver, and the training plan. Close the loop with a quick read-receipt or quiz.
Show Your Math During Surveys
When surveyors ask “how often,” lead with the biennial rule, then show the calendar, the change register, and the training rosters. Tie each fix to a finding or a trigger. That line of sight builds trust.
Answer Recap: How Often Should A Hospital Review The EAP?
Use a biennial formal review for the written plan, policies, procedures, and the training and testing program, matching CMS language. Layer staff reviews at plan rollout, duty changes, and any plan change, matching OSHA. Add an annual touchpoint to catch drift. Document each step so you can show the work in minutes.