Ohio Hospital Association. Disaster Exercise Handbook 2010

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1 Ohi Hspital Assciatin Disaster Exercise Handbk 2010 June 17, 2010

2 Table f Cntents 1.0 Intrductin Purpse Exercise Cmpliance Standards and Requirements fr Hspitals Department f Hmeland Security (DHS) Natinal Incident Management System Implementatin Objectives fr Healthcare Organizatins Department f Health and Human Services (HHS) Jint Cmmissin Other Entities Hmeland Security Exercise and Evaluatin Prgram (HSEEP) Hspital Based Exercise Prgrams Strategy and Planning Exercise Prgram Develpment Training and Exercise Plan (TEP) Develpment Cmmunity Exercise Prgram Participatin Exercise Design and Develpment Exercise Types Exercise Design Team Exercise Develpment Prcess Exercise Dcumentatin Exercise Enhancements Evaluatin FEMA 8 Steps related t the Evaluatin and Imprvement Prcess Imprvement Planning Appendix A: Wrkshp Checklist Appendix B: Tabletp Exercise Checklist Appendix C: Drill Checklist Appendix D: Exercise Prgram Websites Appendix E: Resurces Appendix F: Index f Attachments Funded by Ohi Department f Health / ASPRHPP, Office f Health Care Preparedness Prgram 1

3 1.0 Intrductin Cmmunities acrss the United States are heavily dependent n the resilience and capabilities f lcal, reginal and statewide healthcare systems. Within the last decade, accrediting bdies alng with the federal gvernment have placed increased demands and expectatins fr hspitals t be prepared fr a multitude f emergencies and disasters. Hspitals are expected t maintain a level f readiness t respnd t incidents that may mderately t severely impact their ability t prvide patient care. Disaster exercises have been recgnized as a crucial element f preparedness activities fr all types f rganizatins. While develping an exercise prgram may appear t be time cnsuming, the benefits f validating emergency preparedness training and planning effrts thrugh an all hazards exercise prgram can psitively impact an rganizatin s bttm line thrugh increasing emplyee cmpetency and cnfidence in the rganizatin s emergency peratins plans. 2.0 Purpse The purpse f this Disaster Exercise Handbk is t prvide hspitals with enhanced tls and resurces t augment existing exercise prgrams. 3.0 Exercise Cmpliance Standards and Requirements fr Hspitals This sectin highlights exercise standards, requirements and expectatins fr hspitals and healthcare rganizatins specifically fcusing n the Department f Hmeland Security, Department f Health and Human Services, Centers fr Medicare and Medicaid Services and the Jint Cmmissin. 3.1 Department f Hmeland Security (DHS) DHS published the Natinal Preparedness Guidelines and Target Capabilities List t fulfill a majr cmpnent f Hmeland Security Presidential Directive 8 (December 2003), "Natinal Preparedness," and t establish a framewrk fr understanding what it means fr the Natin t be prepared fr all hazards. Exercises shuld incrprate all fur elements f the Natinal Preparedness Guidelines Natinal Preparedness Guidelines The fur elements f Natinal Preparedness Guidelines include: (1) The Natinal Preparedness Visin prvides a cncise statement f the cre preparedness gal fr the Natin. (2) The Natinal Planning Scenaris depict a diverse set f high cnsequence threat scenaris f bth ptential terrrist attacks and natural disasters. The scenaris frm the basis fr crdinated Federal planning, training, exercises, and grant investments needed t prepare fr emergencies f all types. (3) Universal Task List (UTL) is a listing f 1, 600 unique tasks that facilitate effrts t prevent, prtect against, respnd t, and recver frm the majr events represented by the Natinal Planning Scenaris. The UTL uses cmmn vcabulary and identifies tasks that supprt essential capabilities. N entity will perfrm every task. Funded by Ohi Department f Health / ASPRHPP, Office f Health Care Preparedness Prgram 2

4 (4) Target Capabilities List (TCL) defines critical preventin, prtectin, respnse and recvery capabilities needed fr natinal preparedness. Currently, there are 37 target capabilities that states, cmmunities and private sectr entities shuld cllectively develp in rder t respnd effectively t disasters. Each TCL includes a definitin; an utcme; preparedness activities, tasks, measures and metrics; activity prcess flw; capability elements; linked capabilities; planning assumptins; planning factrs; natinal preparedness levels; and references. Of all the TCLs, the nes that the hspitals and ther healthcare rganizatins will mst frequently utilize will prbably be Medical Surge, Critical Resurce Lgistics and Distributin, Medical Supplies Management and Distributin, and Fatality Management. These TCLs, amng thers, will assist hspitals and healthcare preparedness planners as they develp training curriculum r design exercises that measure emergency management plans and prgrams. Hspital emergency management prfessinals shuld als include capability based planning activities as part f a cmprehensive preparedness prgram. Capability based planning fcuses decisin making n building and maintaining capabilities t prevent and prtect against challenges and t respnd and recver when events ccur using realistic scenaris. Planning cnsideratins include: rganizatin and leadership; persnnel; equipment and systems; training; exercises, evaluatins and imprvement plans. Resurce: T review the cmplete Natinal Preparedness Guidelines dcument visit: A Capability is delivered when any cmbinatin f persnnel, rganized in accrdance with plans, has been equipped, trained, and exercised and achieves the desired utcme. As nted by the Department f Hmeland Security at the G&T Cnference n Nvember 30, Natinal Incident Management System Implementatin Objectives fr Healthcare Organizatins Hmeland Security Presidential Directive (HSPD) 5 Management f Dmestic Incidents required the develpment f a single, all inclusive natinal incident management system. In March 2004, the Department f Hmeland Security prduced the Natinal Incident Management System (NIMS). This system calls fr a systematic, hands n apprach which guides rganizatins and agencies at all levels f gvernment, nn gvernmental rganizatins, and the private sectr. In 2006 the Incident Management Systems Integratin Divisin wrked in crdinatin with the Department f Health and Human Services and the Hspital Incident Cmmand System wrking grup t develp NIMS implementatin bjectives fr healthcare rganizatins. In FY 2007, 14 bjectives were presented t healthcare rganizatins after much review. The 14 bjectives are categrized in 5 sectins: Funded by Ohi Department f Health / ASPRHPP, Office f Health Care Preparedness Prgram 3

5 1. Adptin 2. Preparedness: Planning 3. Preparedness: Training and Exercises 4. Cmmunicatins and Infrmatin Management 5. Cmmand and Management Three f the furteen bjectives directly relate t exercises. Objective 3. Revise and update emergency peratins plans (EOPs), standard perating prcedures (SOPs), and standard perating guidelines (SOGs) t incrprate NIMS and Natinal Respnse Framewrk (NRF) cmpnents, principles, and plicies, t include planning, training, respnse, exercises, equipment, evaluatin, and crrective actins. Objective 7. Prmte NIMS Cncepts and principles int all rganizatin related training and exercises. Demnstrate the use f NIMS principles and ICS Management structure in training and exercises. Objective 11. Manage all emergency incidents, exercises, and preplanned (recurring/special) events in accrdance with ICS rganizatinal structures, dctrine, and prcedures, as defined in NIMS. Resurce: Fr a cmplete listing f all NIMS Implementatin Objectives fr Healthcare Organizatins, visit: s%20fr%20healthcare%20organizatins.swf 3.3 Department f Health and Human Services (HHS), Assistant Secretary fr Preparedness and Respnse (ASPR), Hspital Preparedness Prgram The Office f the Assistant Secretary fr Preparedness and Respnse (ASPR), frmerly the Office f Public Health Emergency Preparedness, serves as the Secretary's principal advisry staff n matters related t biterrrism and ther public health emergencies. ASPR als crdinates interagency activities between HHS, ther Federal departments, agencies, and ffices, and State and lcal fficials respnsible fr emergency preparedness and the prtectin f the civilian ppulatin frm acts f biterrrism and ther public health emergencies. The Hspital Preparedness Prgram (HPP), which falls under the ASPR prgram, enhances the ability f hspitals and health care systems t prepare fr and respnd t biterrrism and ther public health emergencies. Current prgram pririty areas include interperable cmmunicatin systems, bed tracking, persnnel management, fatality management planning and hspital evacuatin planning. Over the past five years, HPP funds have supprted the imprvement f bed and persnnel surge capacity, decntaminatin capabilities, islatin capacity, pharmaceutical supplies, training, educatin, drills and exercises. Funded by Ohi Department f Health / ASPRHPP, Office f Health Care Preparedness Prgram 4

6 T enable hspitals, utpatient facilities, health centers, pisn cntrl centers, EMS and ther healthcare partners t access funding and develp healthcare system preparedness thrugh the ASPR prgram, each entity must wrk with the apprpriate state r lcal health departments. In general, funding is distributed directly t the Health Department f the State r plitical subdivisin f a State (cities and cunties are cnsidered plitical subdivisins f States). The HPP supprts pririties established by the Natinal Preparedness Gal established by the Department f Hmeland Security (DHS) in The Gal guides entities at all levels f gvernment in the develpment and maintenance f capabilities t prevent, prtect against, respnd t, and recver frm majr events, including Incidents f Natinal Significance. Additinally, the Gal is in place t assist entities at all levels f gvernment in the develpment and maintenance f the capabilities t identify, priritize and prtect critical infrastructure. The Pandemic and All Hazards Preparedness Act f 2006 transferred the Natinal Biterrrism Hspital Preparedness Prgram (NBHPP) frm the Health Resurces and Services Administratin t the Assistant Secretary fr Preparedness and Respnse (ASPR). The fcus f the prgram is nw all hazards preparedness and nt slely biterrrism. Resurce: Department f Health and Human Services, Hspital Preparedness Prgram In a recent update frm the Agency fr Healthcare Research and Quality (AHRQ) it was stated, Ensuring that hspitals are prepared t respnd apprpriately during any type f disaster situatin manmade r natural is a pririty fr HHS. As f September 2008, hspitals participating in the Hspital Preparedness Prgram, administered thrugh HHS, are required t prvide executive summaries f the results f disaster drills they cnduct. Ohi Department f Health, Reginal Healthcare Crdinatin Preparedness Prgram The Ohi Department f Health (ODH), Office f Health Preparedness (OHP) prvides ASPR grant funds that are passed frm the Department f Health and Human Services thrugh ODH t supprt the Reginal Healthcare Crdinatin (RHC) Preparedness Prgram. The gal f the RHC prgram is t build medical surge capability thrugh assciated planning, persnnel, equipment, training and exercise capabilities at the state, reginal, and lcal levels. The Ohi Department f Health requires hspitals t cnduct exercises as part f their cmpliance with receiving Assistant Secretary fr Preparedness and Respnse (ASPR) funds thrugh the Ohi Department f Health. Exercise requirements fr the ASPR grant will be cmmunicated t hspitals via the Reginal Healthcare Crdinatrs each grant year. Funded by Ohi Department f Health / ASPRHPP, Office f Health Care Preparedness Prgram 5

7 3.4 Jint Cmmissin The Jint Cmmissin (JC) serves as an accreditatin bdy fr healthcare rganizatins. The JC prduces a set f standards that utline requirements and elements f perfrmance in specific areas t ensure patient care is prvided in a safe and secure envirnment. In rder fr hspitals t receive Medicare and Medicaid funding they must be accredited by the JC r anther ther apprved accreditatin bdy and cmply with the Centers fr Medicare and Medicaid Services (CMS) Cnditins fr Participatin. A hspital accredited by the Jint Cmmissin r AOA is deemed t meet all Medicare requirements fr hspitals (except the requirements fr Utilizatin Review, the special cnditins fr psychiatric hspitals, the Skilled Nursing Facility Requirements fr swing bed designatin, and any higher than natinal standards apprved by the Secretary). Centers fr Medicare and Medicaid Services In 2009, the Jint Cmmissin released its 2009 Emergency Management Standards. Listed belw is a summary f the Elements f Perfrmance as they relate t emergency and disaster exercises. Jint Cmmissin Summary f Exercise Elements f Perfrmance Twice a year, the hspital activates their EOP as an exercise. Fr each site f the hspital that ffers emergency services r is a cmmunity designated disaster receiving statin, at least ne f the tw exercises a year includes an influx f patients. Fr each site f the hspital with a defined rle in its cmmunity s respnse plan, at least ne f the tw exercises must include participatin in a cmmunity wide exercise. Fr at least ne f tw exercises, the scenari includes an escalating event in which the lcal cmmunity is unable t supprt the hspital. Exercises fcus n likely scenaris that allw the hspital t evaluate its handling f cmmunicatins, resurces and assets, security, staff, utilities, and patients. The hspital designates an individual(s) whse sle respnsibility during exercises is t mnitr perfrmance and dcument pprtunities fr imprvement. The hspital mnitrs the effectiveness f the fllwing: Internal cmmunicatins External cmmunicatins Resurce mbilizatin and asset allcatin Management f safety and security Management f staff rles and respnsibilities Management f utility systems Management f patient clinical and supprt care activities Funded by Ohi Department f Health / ASPRHPP, Office f Health Care Preparedness Prgram 6

8 Based n all mnitring activities and bservatins, the hspital evaluates all exercises and all respnses t actual emergencies using a multidisciplinary prcess (which uses licensed independent practitiners). The evaluatin f all exercises and all respnses t actual emergencies is dcumented and includes the identificatin f deficiencies and pprtunities fr imprvement. All deficiencies and pprtunities fr imprvement are cmmunicated t an imprvement team respnsible fr mnitring envirnment f care issues. The hspital mdifies its EOP based n its evaluatins f exercises and actual emergencies. Subsequent exercises shuld reflect mdificatins and interim measures as described in the mdified EOP. 3.5 Other Entities with Exercise Cmpliance Standards and Requirements fr Hspitals In additin t the rganizatins listed abve, the fllwing entities may als require hspitals t adhere t specific exercise cmpliance standards and requirements: Centers fr Medicare and Medicaid Services: Natinal Fire Prtectin Assciatin: Occupatinal Safety and Health Administratin: It is advised that hspital exercise design teams review all exercise requirements frm all ptential accreditatin and gverning bdies during the initial phases f exercise develpment. This prcess will help ensure cmpliance standards are met and maximize the effectiveness and participatin in the exercise. 3.6 Hmeland Security Exercise and Evaluatin Prgram (HSEEP) HSEEP is a capabilities and perfrmance based exercise prgram which prvides a standardized plicy, methdlgy and terminlgy fr exercise design, develpment, cnduct, evaluatin, and imprvement planning. HSEEP Plicy and Guidance is presented in detail in HSEEP Vlumes I III. Adherence t the plicy and guidance presented in the HSEEP Vlumes ensures that exercise prgrams cnfrm t established best practices and helps prvide unity and cnsistency f effrt fr exercises at all levels f gvernment. Funded by Ohi Department f Health / ASPRHPP, Office f Health Care Preparedness Prgram 7

9 Figure 3.6.1: HSEEP Cycle HSEEP Vlumes: Vlume I: HSEEP Overview and Exercise Prgram Management Vlume II: Exercise Planning and Cnduct Vlume III: Exercise Evaluatin and Imprvement Planning Vlume IV Library: Sample Exercise Materials The intent f HSEEP is t prvide cmmn exercise plicy and prgram guidance capable f cnstituting a natinal standard f all exercises. HSEEP includes cnsistent terminlgy that can be used by all exercise planners, regardless f the nature and cmpsitin f their spnsring agency r rganizatin. The HSEEP Tlkit, which includes the Natinal Exercise Schedule (NEXS) System, Design and Develpment System (DDS), and Crrective Actin Prgram (CAP) System, allws users t schedule, plan, evaluate and track crrective actins frm exercises. In additin, there are several exercise training curses, including independent study (IS 120a, IS 130, etc.), mbile (HSEEP Training Curse), and residence curses (Master Exercise Practitiner Prgram) that educate students n the principles f exercise planning, cnduct, evaluatin, and imprvement planning. The purpse f a prgressive emergency management exercise prgram is t prmte hspital and cmmunity resilience by imprving peratinal readiness. DQE News, Vl.13, Issue 3, Fall 2008 As f June 2010, individual hspitals are nt required t fllw HSEEP guidance. Hwever, if a hspital receives grant funding, sme grants may require HSEEP cmpliance. The Center fr Dmestic Preparedness anticipates that HSEEP cmpliance will be mandated fr hspitals within the next 3 5 years. Althugh individual hspitals are nt currently required t adhere t the HSEEP guidance, Ohi Reginal Healthcare Planning Regins that receive and utilize ASPR grant funds fr exercises must cmply with HSEEP dctrine. Resurce: The HSEEP website ( prvides additinal infrmatin regarding HSEEP Plicy and Guidance, HSEEP Vlumes I IV, as well as the HSEEP Tl Kit. Funded by Ohi Department f Health / ASPRHPP, Office f Health Care Preparedness Prgram 8

10 Cnclusin: The Federal gvernment, accreditatin bdies and cmmunities expect hspitals t prvide critical services and patient care in times f disasters and emergencies. Exercises prvide a prven methd fr validating emergency peratins plans, plicies and prcedures while meeting the expectatins and requirements f thse wh rely n hspitals and healthcare rganizatins during crises. Funded by Ohi Department f Health / ASPRHPP, Office f Health Care Preparedness Prgram 9

11 4.0 Hspital Based Exercise Prgrams 4.1 Strategy and Planning Whether a hspital is in the beginning stages f develping an exercise prgram r seeking t enhance an existing prgram, sme may ask, Why exercise? Besides the reality that many hspitals are required t test and validate their emergency peratins plan as nted in Sectin 3 abve, exercises als prvide the pprtunity t: Validate training Test plicies, prcedures, plans and equipment Reveal strengths and areas fr imprvement in written dcuments Clarify rles and respnsibilities Satisfy regulatry requirements Demnstrate peratinal capability Build cnfidence and cmpetency amng thse assigned rles in a disaster respnse. 4.2 Exercise Prgram Develpment The fllwing actins shuld be cnsidered during the develpment f a hspital based exercise prgram. 1. Assemble an Exercise Planning Team. This Team will supprt the rganizatin s exercise prgram. Members shuld represent varius departments, levels f authrity, and shuld have knwledge f the facility s emergency peratins plans. 2. Review the facility s current Hazard Vulnerability Assessment (HVA) as well as emergency peratins plans, plicies and prcedures and identify risks, threats and activities t be tested. 3. Reference After Actin Reprts/Imprvement Plans frm previus exercises and actual events fr items t be re evaluated. 4. Identify regulatry, funding, accreditatin and any ther requirements that must be satisfied and incrprate thse int the verall exercise plan. 5. Create an exercise prgram budget. Because exercises are part f the brader preparedness cycle that als invlves planning, equipment purchases and training activities, multi year exercise scheduling shuld cmplement the full range f preparedness effrts and pririties being undertaken by the hspital. DQE News, Vl.13, Issue 3, Fall Training and Exercise Plan (TEP) Develpment Once the fundatin fr an Exercise Prgram is established, a detailed Training and Exercise Plan (TEP) shuld be develped. The TEP shuld utline prgram pririties, target capabilities, training, exercises and a multi year schedule that reflects a building blck prgressin with an emphasis n crdinatin. The key is t link training and exercises. The exercises shuld validate the investment in training. Funded by Ohi Department f Health / ASPRHPP, Office f Health Care Preparedness Prgram 10

12 The TEP shuld utline hw the rganizatin will utilize a building blck apprach that allws fr increasingly cmplex training curses t be delivered and exercises t be perfrmed that build upn lessns learned frm previus training and exercises. The fllwing shuld be addressed as the Training and Exercise Plan is develped: What are the critical tasks that must be perfrmed accurately t ensure an effective respnse t an emergency r disaster affecting ur building and rganizatin? What persnnel / psitins / departments are essential in perfrming these tasks? What cmmunity agencies are cnnected t the rganizatin s capabilities t respnd? What are the mst cmmn risks? What shuld be tested: emergency peratins plans; plicies and prcedures; r the verall respnse system? "What hspitals need t d is develp an integrated cmmunity respnse." Fr example, hspitals shuld wrk with lcal agencies t define rles and respnsibilities in the event f a disaster and t create redundant cmmunicatin systems. A veteran f many drills, Massey stressed the imprtance f bringing all the cmmunity players tgether : law enfrcement, fire departments, emergency medical services, public health fficials, cmmunity health care prviders, and lcal industries. This isn't a battle t see which agency is best; this is a battle t prepare yur cmmunity. Mary Massey, Disaster Crdinatr at Anaheim Memrial Medical Center, n the imprtance f a cmmunity wide plan. A critical first step in creating a TEP is t facilitate a meeting with key departments and units wh shuld have input n the updating and review f this multi year plan. This frum shuld als be used t translate pririties int specific bjectives and exercises; crdinate exercise activities; track imprvement planning against current capabilities, training and exercises; and tie int reginal r lcal training and exercise plans. During this frum, remember t review recent Hazard Vulnerability Analysis (HVA) reprts t assess pririties and risk. Resurce: T btain a cpy f the HSEEP Training and Exercise Planning Wrkshp User s Handbk, visit: Cmmunity Exercise Prgram Participatin By engaging cmmunity partners t be a part f internal hspital exercises and by designating a hspital representative n cmmunity based exercise teams, hspitals will ensure exercises are designed using realistic scenaris and bjectives that will reveal strengths and gaps in hspital/healthcare emergency peratins plans, plicies, and prcedures. Typically full scale and functinal exercises are designed fr multi agency invlvement. Whenever pssible, hspitals shuld cnnect with their lcal Emergency Management Agency; First Respnders such as Fire, EMS and Law Enfrcement; Public Health and lcal rganizatins that receive and manage grants such as Urban Area Security Initiative, Metrplitan Medical Respnse System and Assistant Secretary fr Preparedness and Respnse t engage in cmmunity wide exercises. The mre hspitals engage cmmunity partners in hspital preparedness activities, the greater the chance f imprving verall cmmunity preparedness. Funded by Ohi Department f Health / ASPRHPP, Office f Health Care Preparedness Prgram 11

13 Cnclusin: By taking the time t assemble an exercise planning team, reviewing the rganizatin s hazard vulnerability assessment, emergency peratins plans, plicies and prcedures; referencing After Actin Reprts and Imprvement Plans; identifying regulatry, accreditatin and grant requirements; creating an exercise budget; develping a training and exercise plan; and engaging cmmunity partners, hspitals will lay the fundatin fr a successful exercise prgram. Funded by Ohi Department f Health / ASPRHPP, Office f Health Care Preparedness Prgram 12

14 5.0 Exercise Design and Develpment Exercises identify an rganizatin s practices, prcedures and prtcls that are prficient and thse that need imprvement. Lessns learned frm exercises can be used t revise peratinal plans and prvide a basis fr training t imprve prficiency in executing thse plans. This sectin is designed t intrduce yu t the fundamentals f exercise design and t prepare yu t design and cnduct exercises fr yur rganizatin. It will prvide an verview f the types f exercises, addresses the exercise develpment prcess, rganizatin f the design team, exercise dcumentatin, and the steps in designing an exercise. 5.1 Exercise Types There are seven types f exercises defined within HSEEP, each f which is either discussins based r peratins based. Discussin based exercises: familiarize participants with current plans, plicies, agreements, and prcedures, r may be used t develp new plans, plicies, agreements, and prcedures. Types f discussin based exercises include: Orientatin and Seminars Orients participants tward, r prvides participants with an verview f plans, plicies, prcedures, prtcls r ther respnse cncepts Infrmal discussin led by a facilitatr Effective with bth small and large grups Wrkshps Fcuses n the develpment f a prduct such as a draft plan r plicy Aided by facilitatrs r breakut sessins Tabletp (TTX) Fcuses n senir level staff, elected fficials r ther key persnnel in an infrmal setting Designed t stimulate discussin f issues using simulated scenaris Used t assess and/r validate plans, plicies and prcedures Games Simulates peratins, ften invlving tw r mre teams Depicts an actual r assumed real life situatin Des nt invlve actual respnse Uses a sequence f events affected by the decisins made by the players Funded by Ohi Department f Health / ASPRHPP, Office f Health Care Preparedness Prgram 13

15 Examples f When t Use Discussin Based Exercises Capability Orientatin/Seminar Wrkshp Tabletp Exercise Game Interperable Cmmunicatins Demnstrate hw a piece f equipment wrks (e.g. MARCS Radi) Review and train persnnel n the hspital s cmmunicatin plan Discuss hw, wh and when cmmunicatin mdalities wuld be activated N/A Patient Tracking Hspital Evacuatin Prvide an verview f OHTrac Patient Tracking Demnstrate the use f hspital evacuatin equipment (e.g. MedSled) Review and train persnnel n the hspital s patient tracking plan and/r prcedures Review and train departmental staff n the hspital s evacuatin plan Prvide a scenari in which patient tracking is required and allw staff t discuss their actins Discuss the indicatrs and rles and respnsibilities assciated with cnducting a partial evacuatin N/A Split the Hspital Cmmand Center and Department Staff int teams t make decisins abut evacuatin Operatins based Exercises: validate plans, plicies, agreements and prcedures; clarify rles and respnsibilities; and identify resurce gaps in an peratinal envirnment. Types f peratins based exercises include: Drills Crdinated, supervised activity emplyed t test a single, specific peratin r functin within a single entity Measures training, tests plicies and practices skills Cnducted in a realistic envirnment Functinal Exercise (FE) Examines and/r validates the crdinatin, cmmand, and cntrl between varius multi agency crdinatin centers (i.e. Emergency Operatins Centers, Jint Field Office) Examines inter agency/jurisdictinal relatinships Utilizes a simulatin cell t activate resurces There is n mvement f resurces. Full Scale Exercises (FSE) Mbilizes persnnel and resurces frm multiple agencies, jurisdictins and/r disciplines in a real time envirnment Tests majr prtins f peratins plans under field cnditins Funded by Ohi Department f Health / ASPRHPP, Office f Health Care Preparedness Prgram 14

16 Examples f When t Use Operatins Based Exercises Capability Drill Functinal Full Scale Disaster Triage Cnduct a 30 minute drill in the Emergency Department t test staff n triage criteria using paper patients N/A Assess pre hspital and hspital staff n their knwledge and use f disaster triage criteria Medical Surge Decntaminatin Utilizing paper patients, assess the length f time it takes t decmpress the Emergency Department Evaluate hw lng it takes fr the Decn Team t set up the decn tent As part f a cmmunity wide exercise, evaluate hw patients will be distributed amng area hspitals N/A Utilizing victim actrs, evaluate all prcedures assciated with the facility s medical surge plan Assess the hspital s decn plan frm activatin thrugh dembilizatin 5.2 Exercise Design Team The exercise planning team is respnsible fr the successful executin f all aspects f an exercise, including exercise planning, cnduct, and evaluatin. The planning team determines exercise bjectives; tailrs the scenari t the entity s needs; and develps dcuments used in exercise simulatin, cntrl, and evaluatin. While each exercise has its wn planning team, persnnel may carry ver frm ne exercise t the next, and entities may find it advantageus t include team members with previus exercise planning experience. The exercise planning team shuld seek t incrprate representatives frm each majr participating entity, but shuld be kept t a manageable size. The membership f an exercise planning team can be mdified t fit the type r scpe f an exercise. In the design and develpment phase, the exercise design team shuld first decide which exercise type is best suited fr intent f the exercise bjectives. 5.3 Exercise Develpment Prcess Once the exercise design team has determined the type f exercise t be cmpleted, planning cnferences are cnducted t ensure the exercise is designed, develped, and executed using agreed upn design elements such as scpe, purpse and bjectives. The HSEEP methdlgy utlines a variety f planning cnferences. The need fr each f the cnferences varies depending n the type and scpe f the exercise. The varius cnference types include: Funded by Ohi Department f Health / ASPRHPP, Office f Health Care Preparedness Prgram 15

17 Cncepts and Objectives Meeting Primary Fcus: A Cncepts and Objectives (C&O) Meeting is the frmal beginning f the planning prcess. It is held t identify the type, scpe, bjectives and purpse f the exercise. Fr less cmplex exercises and fr entities with limited resurces, the C&O Meeting can be cnducted in cnjunctin with the IPC; hwever, when exercise scpe dictates, the C&O Meeting is held first. Fr example, the C&O Meeting is held befre the IPC fr large scale exercises, cmplex full scale exercises (FSEs), r any high prfile exercise that necessitates a high level f supprt frm executives r authrities. The C&O Meeting will help planners identify the capabilities and tasks that are ging t be validated, design bjectives based n thse capabilities and tasks, and exercise planning team members. Attended By: Representatives frm the spnsring agency r rganizatin, representatives frm ptentially participating rganizatins, the exercise planning team leader and senir fficials typically attend the C&O Meeting. Length: Depending n the scpe f the exercise, the C&O Meeting can range frm 2 t 4 hurs. Discussin Pints: Pssible tpics r issues fr a C&O Meeting include the fllwing: Exercise purpse Prpsed exercise scenari, capabilities, tasks and bjectives Available exercise resurces Prpsed exercise lcatin, date, and duratin Exercise planning team and exercise participants Exercise assumptins and artificialities Initial Planning Cnference (IPC) Primary Fcus: The IPC marks the beginning f the exercise develpment phase. Unless a separate C&O Meeting is cnducted, the IPC is typically the first fficial step in the planning prcess. Its purpse is t determine exercise scpe by gathering input frm the exercise planning team, design requirements and cnditins (e.g., assumptins and artificialities), bjectives, extent f play and scenari variables (e.g., time, lcatin, hazard selectin). The IPC is als used t develp exercise dcumentatin by btaining the planning team s input n exercise lcatin, schedule, duratin, and ther relevant details. During the IPC, exercise planning team members are assigned respnsibility fr activities assciated with designing and develping exercise dcuments such as the Master Scenari Events List (MSEL) and the Situatin Manual (SitMan), which are described later in this vlume and lgistics, such as scene management and persnnel. In additin t cnducting the cnference, the exercise planning team gathers apprpriate phtgraphs and audi recrdings t enhance the realism and infrmatinal value f the final dcument(s) and/r multimedia presentatin(s) presented during the exercise. Attended by: Exercise Planning Team Members Funded by Ohi Department f Health / ASPRHPP, Office f Health Care Preparedness Prgram 16

18 Length: Depending n the scpe f the exercise, the IPC can range frm 3 t 6 hurs. Discussin Pints : Pssible tpics r issues fr an IPC include the fllwing: Understanding the ratinale fr exercise develpment Ensuring clearly defined and measurable capabilities, tasks, and bjectives Incrprating cmmunity emergency peratins plans (EOPs), memranda f agreement (MOA), participating agency standard perating prcedures (SOPs), and/r ther relevant plicy int the exercise design Identifying lcal issues, cncerns, r sensitivities Determining the extent f play fr each participating entity by establishing what each entity will demnstrate and be evaluated n at the exercise, allwing fr apprpriate lgistical needs t be arranged in rder t supprt thse activities Ensuring that exercise planners cnsider themselves trusted agents and understand that, in mst cases, they will participate as facilitatrs, cntrllers, r evaluatrs (rather than as players) Chsing subjects fr phtgraphs and/r audi/visual (A/V) recrdings t incrprate int exercise dcuments and multimedia presentatins (t enhance realism) Deciding whether r nt t recrd exercise prceedings (audi r vide) Determining the ptimum duratin f the exercise Ensuring that exercise planners understand that the exercise is cnducted in a n fault envirnment intended t validate plans and prcedures and identify prblems and ptential slutins Selecting r custmizing the apprpriate Exercise Evaluatin Guides (EEGs) t determine whether r nt exercise capabilities, tasks, and bjectives were achieved and t allw participants t prvide feedback Reaching a cnsensus regarding the date, time, and lcatin fr the next cnference Mid Term Planning Cnference (MPC): Mid Term Planning Cnferences (MPCs) are typically used in mre cmplex, peratins based exercises such as functinal exercises (FEs) and fullscale exercises (FSEs). MPCs prvide additinal pprtunities t settle lgistical and rganizatinal issues that may arise during planning. Primary Fcus: The MPC is a wrking sessin t discuss exercise rganizatin and staffing cncepts, scenari and timeline develpment, scheduling, lgistics, and administrative requirements. It is als a sessin t review draft dcumentatin (e.g., scenari, Exercise Plan [ExPlan], Cntrller and Evaluatr [C/E] Handbk, MSEL). At the cnclusin f the MPC, selected planners shuld cnduct a walkthrugh f the prpsed exercise site. If nly three planning cnferences are scheduled (i.e., the IPC, MPC, and Final Planning Cnference [FPC]), the secnd half f the MPC shuld be devted t develping the MSEL. See the next sectin, Master Scenari Events List Cnference, fr mre infrmatin. Attended by: Exercise Planning Team Members Length: Depending n the agenda, the MPC is generally a full day cnference (especially if n MSEL planning cnference is scheduled). The exercise planning team shuld allw sufficient time t cnduct a walkthrugh f the exercise site and gather supprting pictures, maps, and ther visual aids. Funded by Ohi Department f Health / ASPRHPP, Office f Health Care Preparedness Prgram 17

19 Discussin Pints Pssible tpics r issues fr an MPC include the fllwing: Cmments n draft exercise dcumentatin Identificatin f exercise venue artificialities and/r limitatins Agreement n final lgistical items Assignment f additinal respnsibilities Cnstructin f the scenari timeline usually the MSEL if an additinal MSEL planning cnference will nt be held Master Scenari Events List (MSEL) Cnference: Fr mre cmplex, peratins based exercises, ne r tw additinal planning cnferences r MSEL cnferences may be held specifically t review the scenari timeline. If nt held separately, MSEL cnferences are incrprated int the MPC and FPC. Primary Fcus: The MSEL Cnference fcuses n develping the MSEL. The MSEL is a chrnlgical list that supplements the exercise scenari with event synpses; expected participant respnses; capabilities, tasks, and bjectives t be addressed; and respnsible persnnel. It includes specific scenari events (r injects) that prmpt players t implement the plans, plicies, and prcedures that require testing during the exercise, as identified in the capabilities based planning prcess. It als recrds the methds that will be used t prvide the injects (e.g., phne call, facsimile, radi call, e mail). Attended by: Exercise Planning Team Members Length: The length f a MSEL Cnference varies accrding t the scpe f the exercise and variability f the injects. The exercise planning team allws 4 t 8 hurs t cnduct a MSEL Cnference and assigns a persn t be respnsible fr incrprating suggestins and cnstructing the MSEL after the cnference. Discussin Pints : In develping a MSEL, the exercise planning team must first cnsider the tasks, cnditins, and standards set frth by each exercise bjective. As described in Chapter 4 f HSEEP Vlume I, cmpleting a task is ne step tward demnstrating a capability. A cnditin is the envirnment in which a task is perfrmed it can be prvided by the scenari r thrugh the MSEL. If scenari cnditins d nt stimulate perfrmance f the apprpriate task, the exercise planning team must develp a MSEL entry t simulate the desired situatin. A well written entry cnsiders the fllwing questins: Is the event key (i.e., is it directly related t meeting an exercise bjective)? What is the desired task? Wh will demnstrate the task? What will stimulate the behavir (e.g., curse f play, phne call, actr, vide)? Wh riginates the stimulant? Wh receives it and hw? What actin is the player expected t cmplete? Shuld a cntingency entry be develped fr injectin int the exercise in case the players fail t demnstrate the task? Funded by Ohi Department f Health / ASPRHPP, Office f Health Care Preparedness Prgram 18

20 Final Planning Cnference (FPC) Primary Fcus: The FPC is the final frum fr reviewing exercise prcesses and prcedures. Prir t the FPC, the exercise planning team receives final drafts f all exercise materials. N majr changes t the design r scpe f the exercise, r its supprting dcumentatin, shuld take place at the FPC. The FPC ensures that all lgistical requirements have been met, all utstanding issues have been identified and reslved, and all exercise prducts are ready fr printing. Attended by: Exercise Planning Team Members Length: Generally, the FPC is a half day cnference fr discussin based exercises and a full day fr peratins based exercises. Discussin Pints: The fllwing items are addressed during the FPC: Reslve any pen issues related t exercise planning and identify last minute cncerns that may arise. Review all exercise lgistical activities (e.g., schedule, registratin, attire, special needs). Cnduct a cmprehensive, final review f and apprve all exercise dcuments (e.g., SitMan, ExPlan, MSEL, C/E Handbk) and presentatin materials. Resurce: Additinal infrmatin regarding each f the types and purpses f the cnferences can be fund at the HSEEP website: ( 5.4 Exercise Dcumentatin Exercise dcuments are utilized t infrm participants abut varius aspects f the exercise. Depending n the exercise type and the rle f the participant, the apprpriate dcument will be issued. Creatin f these dcuments is assigned t exercise planning team members and they are reviewed and discussed during exercise planning cnferences. The list f dcuments belw is a summary f the mre frequently used dcuments assciated with mst exercises. Additinal infrmatin abut the dcuments described belw can be fund in HSEEP Vlume II: Exercise Planning and Cnduct. Resurce: HSEEP Vlume II: Exercise Planning & Cnduct: Situatin Manual (SitMan) is a participant handbk fr discussin based exercises, particularly TTXs. It prvides backgrund infrmatin n exercise scpe, schedule, and bjectives. It als presents the scenari narrative that will drive participant discussin during the exercise. Exercise Plan (ExPlan) typically used fr peratins based exercises, prvides a synpsis f the exercise and is published and distributed t players and bservers prir t the start f the exercise. The ExPlan includes the exercise bjectives and scpe, safety prcedures, and lgistical cnsideratins such as an exercise schedule. The ExPlan des nt cntain detailed scenari infrmatin. Funded by Ohi Department f Health / ASPRHPP, Office f Health Care Preparedness Prgram 19

21 Cntrller and Evaluatr (C/E) Handbk supplements the ExPlan fr peratins based exercises, cntaining mre detailed infrmatin abut the exercise scenari and describing exercise cntrllers and evaluatrs rles and respnsibilities. Because the C/E Handbk cntains infrmatin n the scenari and exercise administratin, it is distributed nly t thse individuals specifically designated as Cntrllers r Evaluatrs. Master Scenari Events List (MSEL) is a chrnlgical timeline f expected actins and scripted events (i.e. injects) t be inserted int peratins based exercise play by cntrllers in rder t generate r prmpt player activity. It ensures that necessary events happen s that all exercise bjectives are met. Exercise Evaluatin Guides (EEGs) help evaluatrs cllect and interpret relevant exercise bservatins. EEGs prvide evaluatrs with infrmatin n what tasks they shuld expect t see accmplished during an exercise, space t recrd bservatins, and questins t address after the exercise as a first step in the analysis prcess. The EEGs are nt meant as reprt cards. Rather they are intended t guide the evaluatr s bservatins s that the evaluatr fcuses n capabilities and tasks relevant t exercise bjectives t supprt the develpment f the After Actin Reprt/Imprvement Plan (AAR/IP). After Actin Reprt/Imprvement Plan (AAR/IP) is the final prduct f an exercise. The AAR/IP has tw cmpnents: an AAR, which captures bservatins and recmmendatins based n the exercise bjectives and an IP, which identifies specific crrective actins, assigns them t specific parties, and establishes targets fr their cmpletin. An After Actin Cnference prvides participants with an pprtunity t review and validate the AAR/IP. The final AAR/IP is an utcme f the After Actin Cnference and shuld be disseminated t participants n mre than 60 days after exercise cnduct. 5.5 Exercise Enhancements Exercise enhancements such as maps, paper victims, radi messages and mulage assist with creating a realistic envirnment fr players. Fr full scale exercises and drills, the utilizatin f victim actrs greatly enhances exercise play fr hspital participants. Listed belw is a list f mulage kit supplies as recmmended by HSEEP Mulage Kit Supplies Mulage is makeup applied t victim actrs t add realism t an peratins based exercise. Lcal drama clubs, cmmunity theaters, mrtuaries and prfessinal make up artists can be recruited as mulage staff. Funded by Ohi Department f Health / ASPRHPP, Office f Health Care Preparedness Prgram 20

22 Mulage Kit Makeup (varius clrs) Mixing palette Cttn balls Effects gels (bld, clear, flesh clred) Sterile gauze pads Effects gel applicatrs Glycerin Stage bld Palette knife Scissrs Brushes (varius sizes) Utility knife Tngue depressrs Plastic wrap Spnges Liquid starch Pcket cmb Rubbing alchl Petrleum jelly Liquid adhesive and adhesive remver Empty mixing bttles Flesh putty (varius clrs) Prsthetics (varius injuries such as blisters, burnt skin, bne fractures, pen wunds) Cnclusin This sectin prvided an verview f the resurces and tls available t establish an exercise design prgram. If hspitals utilize the infrmatin prvided, it will help ensure that the exercises are designed in such a manner that bjectives are reasnable and challenge the preparedness levels f the hspital. In additin, a prperly designed exercise will incrprate the crrect persnnel, cmply with identified grant funding and accreditatin requirements, as well as challenge the exercise players in a realistic manner. Fr mre detailed infrmatin n exercise design and cnduct, please visit Sectin 6.0 Evaluatin, will discuss the eight steps as utlined by the Federal Emergency Management Agency (FEMA). The eight step prcess will prvide the framewrk fr hspitals t apprpriately capture the bservatins and perfrmance results f exercises. Funded by Ohi Department f Health / ASPRHPP, Office f Health Care Preparedness Prgram 21

23 6.0 Evaluatin Frm exercise design thrugh cnduct, evaluatin serves as a critical piece f the facility s exercise prgram. Exercise evaluatin is defined as the act f reviewing r bserving and recrding exercise activity r cnduct, applying the behavir r activity against exercise bjectives, and nting strengths, areas fr imprvement, deficiencies, and ther bservatins. The evaluatin f an exercise is ne f the mst imprtant activities within an exercise prgram. Cnducting a straightfrward assessment f a facility s plans and/r training can reveal strengths and areas fr imprvement. By demnstrating a cmmitment t a thrugh evaluatin f the facility s plans, plicies and prcedures, the hspital will have the pprtunity t strengthen the cmpetency and cnfidence f staff with rles in a disaster respnse by enhancing expected actins and/r mdifying nes that need imprvement. 6.1 FEMA has utlined 8 Steps related t the Evaluatin and Imprvement Prcess 1. Plan and Organize the Evaluatin: This includes assigning a lead evaluatr wh will versee the evaluatin prcess. Specific lead evaluatr tasks include: Assigning evaluatrs based n the knwledge and skills required t effectively evaluate a specific bjective. (The evaluatin team shuld be chsen fr their knwledge f a particular functinal area and shuld be familiar with the chsen plans and prcedures.) Cnducting evaluatr training a day r tw befre the exercise. Prviding exercise evaluatin guides fr the exercise. 2. Observe the Exercise and Cllect Data the Day f the Exercise: Evaluatrs shuld reprt everything which is related t their assigned bjective. This requires the evaluatrs t be bjective, fcusing n decisins made r actins taken, nt a specific persn. 3. Analyze Data: Evaluatrs shuld identify cmmn issues amng bjectives; determine rt causes f decisin making and/r actins taken by Players; develp recmmendatins fr imprvement per capability, activity r task if they are nt achieved; and address what changes t a specific dcument shuld be made. 4. Develp and Draft the After Actin Reprt (AAR): The AAR is drafted by the lead evaluatr and the Exercise Planning Team within 30 days f the exercise. The AAR prvides feedback t Players n bservatins nted during the exercise. It includes a summary f events, analysis f perfrmance and demnstrates capacity and recmmendatins fr imprvements. 5. Cnduct an After Actin Cnference (AAC): Within 30 days f the exercise, the exercise planning team shuld cnduct an After Actin Cnference (AAC) t present, discuss and refine the draft After Actin Reprt (AAR). This cnference als leads t the develpment f an Imprvement Plan (IP). Funded by Ohi Department f Health / ASPRHPP, Office f Health Care Preparedness Prgram 22

24 The After Actin Cnference is a critical cmpnent f the exercise planning prcess t ensure that exercises are results riented and cntribute t preparedness by translating AAR/IP analyses int cncrete imprvements fr validatin in subsequent exercises. Shuld the healthcare facility r rganizatin experience a real event, an After Actin Cnference and Reprt shuld be cmpleted clse t the same manner as fr an exercise. 6. Identify Imprvements: Imprvements shuld be targeted t a specific timeframe and shuld take int cnsideratin budget and resurce limitatins. 7. Finalize After Actin Reprt: The AAR shuld be finalized within 60 days f the exercise accrding t HSEEP standards. Any crrectins r clarificatins related t bservatins, recmmendatins and imprvement steps prvided at the AAC shuld be incrprated int the final AAR. 8. Track Implementatin: It is recmmended that ne persn be assigned t track prgress and cmpletin f tasks listed in the Imprvement Plan. The eight step prcess prvides an easy, straightfrward apprach t capturing bservatins and perfrmance data related t an exercise. While this methdlgy may appear simplistic, cmmitting t prviding an hnest evaluatin f the facility s capabilities will strengthen and enhance the hspital s preparedness and readiness during emergencies. Resurce: FEMA IS 130: Exercise Evaluatin and Imprvement Planning Resurce: HSEEP Vlume III Exercise Evaluatin and Imprvement Planning Cnclusin: Sectin 6.0 prvided eight essential steps in capturing the perfrmance f exercise participants and validating the plans r training being assessed. The evaluatin prcess is ne f the mst imprtant elements f the exercise prcess as it justifies the need fr n ging preparedness activities, validates mnetary and time investments related t training and equipment, as well as identifies deficiencies in a simulated envirnment. Sectin 7.0 will utline the Imprvement Prcess. Funded by Ohi Department f Health / ASPRHPP, Office f Health Care Preparedness Prgram 23

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