Shared on behalf of Craig Kozlowski, Director, Corporate Patient Flow (Executive Sponsor)
The Hospital’s Code Green (EMER-90) policy has been revised.
Actions required:
- Read this memo and review the updated Code Green – Evacuation Plan (EMER-90) policy and sub plan template to familiarize yourself with important process changes.
- Managers to ensure that the updated policy is added to their area’s emergency binder and that all workers review the attached policy.
- Areas are to update their sub plans (see template attached) by June 20, 2025 (ensure you recycle previous versions of the policy/sub plan). Please submit a copy to yolanda.karpowich@tbh.net.
Policy changes:
- Additional focus on Code Green – STAT: formatted to stress that an impacted unit is empowered to activate and clear a STAT; does not require Senior Leader on Call approval.
- “Appendix 5 – Important Phone Numbers” has been removed as these numbers may change and/or should be captured in applicable departmental sub plans.
- “Appendix 8 – Code Green Patient Tracking Form” has been removed from the policy and converted into an official form CS-1118.
- Expanded definitions section.
- Revised response algorithm in the appendices.
Sub Plan changes:
- “Staff Meeting Area” definition updated to Muster Point and Headcount method added; matching Code Red – Fire (EMER-30).
- Streamlined instructions, particularly for non-patient care areas, to remove redundancies and non-applicable actions.
- Additional instructions and examples provided in the comments to aid in timely updating.
Process Reminders:
- Code Green – Evacuation instructions apply to the Hospital building (980 Oliver Rd) only. For external buildings see Emergency Planning & Response to External Buildings (EMER-200).
- Code Green sub plans provide important department specific instructions to supplement the policy that must be reviewed annually by the department manager.
If you have any questions, please reach out to Mēsha Richard, Lead, Emergency Preparedness (ext. 6552 or mesha.richard@tbh.net).