Chapter 5: The Healthcare Coalition Emergency Management Program: Implementing Sustainable Solutions
5.1 Developing the Healthcare Coalition
The preceding chapters described potential roles for the Healthcare Coalition during an emergency to support its member organizations and promote integration of their efforts with the jurisdictional response (Tier 3). Achieving this desired capability requires specific developmental and preparedness efforts. The organizational structure and processes used to prepare the Coalition for an emergency will vary from the structure and processes used by the Coalition during emergency response.
The remaining chapters of this handbook examine strategies and actions that the preparedness element of the Healthcare Coalition can use to prepare the Coalition for effective emergency response.[47]
The initial steps in Coalition development should focus on defining the Coalition's intended function during emergency response.[48] The authors of this handbook recommend that planners who are developing a Healthcare Coalition or enhancing an existing one first describe the response objectives for the Coalition (see Section 2.1.2). A new Coalition with limited resources may decide to limit its initial response objectives to the following:
Provide initial and ongoing notifications regarding incident activity to relevant Coalition member organizations.
Provide a structured[49] ability to teleconference the liaisons from Coalition member organizations to share information.
In designing the Healthcare Coalition, it is important to consider the workload and expense that establishing and maintaining a Coalition places on its member organizations. The following characteristics for the Coalition are intended to minimize this burden while not compromising the Coalition's effectiveness during emergencies.
Simplicity: The preparedness and response configurations of the Coalition should be constructed as simply as possible to meet the Coalition's objectives. This might mean limiting the number and types of healthcare organizations included in a single Healthcare Coalition. Other Coalitions could then be established to cover the non-participating healthcare organizations.
Cost-effective: Development and maintenance costs should be controlled as much as possible. The Healthcare Coalition should be designed to be financially viable without depending heavily on short-term financial streams, such as grants. Cost-effective processes could include distributing preparedness assignments among the member organizations rather than having a large number of fulltime, dedicated preparedness positions within the Coalition. Use of existing facilities and personnel from member organizations for both preparedness and response will provide cost savings by limiting bureaucracy and personnel expenses.
Sustainable: Following initial development, some level of effort is required to sustain and improve the Coalition's capabilities over time, including training personnel, conducting exercises, and implementing corrective actions. However, maintenance activities should be designed so they are not overly burdensome to Coalition members. Sustainability can be promoted by factoring in maintenance and replacement costs for equipment and supplies purchased by the Coalition. Doing this prior to any major equipment or supply purchase promotes the optimal long-term investment of resources and funding.
An important early step in developing the Coalition is determining the geographic boundaries for the Healthcare Coalition. Factors to be considered include local government boundaries, physical impediments to coordination (rivers, mountains, etc.), as well as the number and type of potential member organizations. Other factors to consider include contractual obligations, integrated healthcare system relationships, and patient referral patterns. The critical point is that there is often no one controlling factor for defining the boundaries of the Coalition. The most important considerations should be those that have the greatest effect on the Coalition's ability to effectively respond under emergency conditions.
The following options can be used to help determine the geographic boundaries of a Healthcare Coalition.
Bounding the Healthcare Coalition within a single political jurisdiction. For example, healthcare organizations in a medium-sized city may decide to form a Coalition to support their needs during response.
Creating geographic subdivisions within a single jurisdiction due to the number of organizations and inherent complexities of the area. The number and types of potential Coalition members in a large metropolitan area may preclude the use of a single Healthcare Coalition response organization. Multiple Coalitions in any single jurisdiction should coordinate with each other and may consider joint preparedness activities (committee meetings, document development) for efficiency.
Creating functional divisions within a jurisdiction. In a large, complex jurisdiction, Healthcare Coalitions may form along functional lines: one for hospitals, one for health centers and other outpatient treatment facilities, and so on. Again, these Coalitions must coordinate with each other closely during both preparedness and emergency response.
Including healthcare organizations from multiple jurisdictions to form a regional Healthcare Coalition. Some Coalitions may have boundaries that stretch across two or more local governments. For example, a group of hospitals may be closely situated in neighboring counties or cities. Healthcare organizations that participate in an inter-jurisdictional Coalition must maintain their relationship with their respective Jurisdictional Agencies (Tier 3) and in some instances, they may form relationships directly with the State (Tier 4) if no Tier 3 entities exist.
Bounding the Coalition in a large, sparsely populated region to provide a network of remotely located healthcare organizations. In some sparsely populated regions, a Healthcare Coalition may be established to support healthcare organizations across many jurisdictional boundaries. In this scenario, the distinction between MSCC tiers could be much less prominent. For example, many rural jurisdictions have little public health or other medical representation at the local government level and, therefore, little command and control authority in this sector. In these situations, a single collocated arrangement may be preferred in which local jurisdictional authorities (Tier 3) and the Healthcare Coalition (Tier 2) work together as a single healthcare MAC System to address emergency response issues.[50] The newly formed MAC System may also have a direct relationship with the State (Tier 4) through regional entities.
Issues that healthcare planners may consider in determining the size and scope of the Healthcare Coalition include the following:
The more jurisdictional boundaries crossed by the Healthcare Coalition, the more complex and difficult it can be to maintain.
The complexity of managing the Coalition typically increases with the number and diversity of participating organizations.
A politically-defined jurisdiction (city, county, etc.) is responsible for the health and well being of its citizens. Aligning the Coalition within that area of responsibility may be beneficial in terms of receiving funding and other support. In addition, municipal, public safety, and other emergency services are often situated along these same political divisions.
The Coalition may be defined by the pre-selected sponsoring organization. These administrative bodies may already have a select set of participants. For example, a hospital association that exists within or across jurisdictional boundaries may serve as the administrative body for the Coalition (see Section 5.3.1).
Coalition planners should be mindful of geographic boundaries that have been established for preparedness purposes rather than specifically for emergency response. For example, many States have created sub-divisions to distribute preparedness funding (e.g., Hospital Preparedness Program, Urban Area Security Initiative, Metropolitan Medical Response System). While these subdivisions can help bring healthcare planners into contact with other stakeholders, they may conflict with how healthcare organizations actually interact during emergency response (e.g., patient referral patterns). Their value in shaping the structure of the Coalition must be evaluated on an individual basis.
The following principles can be used to guide decisions on which organizations should be included as official members with decision-making (i.e., voting) authority of the Healthcare Coalition:
Participation may involve a variety of organizations, but each should have a primary role in medical care delivery (or some element thereof) during incident response.
Participants must be able and willing to commit the necessary preparedness resources and establish the response requirements to fully participate during incident response.
Participant organizations may be day-to-day business competitors, but must agree that fair representation should be assured for all Coalition member organizations.
Participation in the Healthcare Coalition must be voluntary.
Using these criteria, the following types of healthcare organizations could potentially participate in the Healthcare Coalition:
Hospitals, integrated healthcare systems, managed care groups that deliver healthcare services, community health centers, outpatient clinics, specialty healthcare services such as dialysis and surgery centers, and other point of service healthcare organizations.
Specialty hospitals that provide services in a geographic area (e.g., a "Woman's Hospital" that focuses on obstetrics and gynecology can provide support services during an emergency, such as offering to accept transfer of stable hospitalized female patients from impacted healthcare organizations).
Federal medical facilities that operate in a geographic area, including Department of Defense and Veterans Administration (VA) medical centers, as well as Federally-funded community health centers, clinics, or other facilities (Exhibit 5-2).
Exhibit 5-2. Participation of Federal healthcare assets in the Healthcare Coalition
Although Federal healthcare assets have demonstrated a willingness to participate in Healthcare Coalitions based on their geographic area, they have unique restrictions compared to private healthcare organizations. Potential issues include the following:
Participation cannot compromise their Federal mission(s). For example, VA Medical Centers have a primary responsibility for providing healthcare to veterans, plus they have secondary Federal missions during disasters (e.g., to the National Disaster Medical System (NDMS) and to the Department of Defense).
Participation is at the discretion of the Commanding Officer or executive leader of the organization.
Participation can occur during both Federally-declared and non-declared disasters, but it is subject to specific legislation and/or agency specific rules or standards. For example, VA Medical Center Directors are authorized under Title 38, U.S.C., Section 1711(b) to provide emergency care in mass casualty situations; however, patients must be charged for these services at rates established by the Secretary of Veterans Affairs.*
The mutual benefit of participation by Federal facilities has been demonstrated in many incidents. After Hurricane Katrina's landfall in 2005, the Biloxi, MS VA Hospital received veterans as well as private citizens needing healthcare. During a power failure in the primary and backup electrical systems at Walter Reed Army Medical Center in 2001, intensive care unit and medical-surgical beds were rapidly committed by other hospitals in Washington D.C. when Walter Reed was considering whether to evacuate critical care patients. Ultimately, backup power was restored and the transfer beds were never needed.
* Barbera JA, Macintyre AG, Shaw G, et al, Emergency Management Principles and Practices for Healthcare Systems, Glossary (2006).
Long-term care facilities, including skilled nursing and assisted living facilities, rehabilitation centers, chronic and hospice care, and others, should be considere d for inclusion in the Healthcare Coalition. These organizations can serve as important resources to assist the more traditional healthcare organizations, and promoting their resiliency to avoid the need for evacuation is in the best interest of hospitals. The information processed by the Healthcare Coalition and other support during emergencies (such as facilitating mutual aid and other resource assistance) can be valuable for these organizations as well.
Healthcare assets that provide outpatient services, including community health clinics, private practitioner offices, and home healthcare organizations, could all be contributing members of a Coalition. While these entities may not have the infrastructure or personnel available to develop complex procedures for incident response, they should be considered for inclusion for the following reasons:
During an emergency, patients will seek care in the most familiar settings.
Hospitals may become severely challenged or crowded, leading patients to seek care in other settings.
Some patients may have treatment needs that can be adequately managed by outpatient-oriented assets, thus relieving the burden on hospitals.
Hazards that impact these organizations may lead to patients presenting to similarly impacted hospitals.
The approach to incorporating these resources into the Coalition's preparedness and response can be relatively simple. They may elect to integrate with the Healthcare Coalition in one of two ways:
Associate within a larger organizational structure that represents them in the Coalition. Mechanisms for this coordination can be established through the Coalition. For example, individual practitioners or a small group practice could organize under the umbrella of a(n):
Hospital
Integrated healthcare system
Large outpatient facility where they have professional privileges
Professional society or association (e.g., local Medical Society), if practitioners within the society provide the representation.
The organizing body for these assets must be able to conduct Coalition preparedness activities, such as attending meetings and keeping member organizations informed. It must also be able to perform emergency response services, such as collecting and disseminating information to the organizations that it represents.
Participate only in the Coalition's situational awareness activities. In lieu of the arrangement described in the preceding bullet, individual providers or group practices may benefit primarily by participating in the information exchange function of the HCRT.
Exhibit 5-3. Participation of smaller healthcare assets in the Healthcare Coalition
The emergency response planning that is conducted by an individual practitioner's office may be limited. Procedures that most effectively allow a private practitioner to integrate into the jurisdictional response focus on information issues, such as:
Obtaining information:
Obtaining incident-specific guidance on personal protection and other safety measures for practitioners, their staff, and other patients (e.g., appropriate Personal Protective Equipment for an infectious agent).
Obtaining information on the specific medical evaluation of incident cases, such as the availability of confirmatory lab tests and the specific limitations of these tests.
Obtaining pertinent information on population risk (e.g., for a biological exposure, understanding the community-wide approach to risk stratification for potentially exposed patients).
Obtaining reliable incident information on medical needs such as unusual patient treatment requirements.
Reporting information:
Knowing where to report and what information to transmit on patients who have been evaluated or treated at the practitioner's location (to help the jurisdiction authorities define the size and scope of the affected population).
Knowing whether public health emergency powers have been invoked (e.g., allowing release of private patient information).
In some jurisdictions, these issues may already be addressed by an effective public health response system (e.g., advisory for the providers in the jurisdiction). This does not negate the utility of a Coalition, which can facilitate delivery of messages or collect responses for the public health system.
Other potential participants in the Healthcare Coalition include specific public sector assets that provide direct medical care (e.g., medical care units in non-medical agencies) and home health organizations. As an example, the Washington, D.C. Healthcare Coalition includes the Office of the Attending Physician at the U.S. Capitol. Although this office has few resources that can be shared with other Coalition members, it actively participates in information exchange. This is important since this office provides medical services and recommendations to the Capitol Hill workforce in the D.C. area.
In addition, other organizations that do not typically provide "point of service" medical care may be considered for inclusion in a Healthcare Coalition. For example, the King County Healthcare Coalition in the State of Washington includes Airlift Northwest (an air medical transport service), Puget Sound Blood Center, American Red Cross, Washington Poison Center, and many other entities.[51] Other organizations, such as local public health departments, have different primary responsibilities and may report directly to State (Tier 4) authorities. They also have statutory "command and control" authorities that would be restricted in a Tier 2 Healthcare Coalition. Therefore, these entities may best relate to the Healthcare Coalition through interface at the jurisdictional level (Tier 3), but still provide advice and support to Coalition preparedness activities.
It may be helpful to establish requirements for participation in the Healthcare Coalition at the outset of Coalition development. Defining requirements that are too prescriptive, however, can inadvertently leave some vital partners out. For example, not all participants may be able or willing to enter into a Mutual Aid commitment to share resources, yet they can still play an important role by sharing information. The lack of potentially available resources for sharing should not preclude participation in the Healthcare Coalition.
The following are two reasonable requirements for participation in the Coalition:
Participants must be able to commit personnel time to Coalition preparedness meetings. For many healthcare assets, this could mean simply having a representative present for the Coalition's preparedness meetings. Smaller assets may be represented by an umbrella organization. They maintain awareness by reviewing and commenting on the proceedings of the Coalition's preparedness efforts.
Participants must be willing to share information (strategic and tactical) related to their activities during emergency response. It is up to the HCRT to establish the format and methods for sharing this information. The requirements may be as simple as reporting bed availability or more complex, such as reporting patient evaluation strategies. This will depend on the complexity of the Coalition and the incident.
In some situations, organizations deemed "highly valuable" to the Healthcare Coalition may decline participation. Though ultimately their prerogative, it is important to clearly explain the benefits of Coalition participation and address their specific concerns. The following concepts should be conveyed to potential participants to demonstrate the value of participating in the Healthcare Coalition.
Participation does not deter from or change the participant's inherent and autonomous decision-making authority.
Participation may enhance the organization's emergency preparedness efforts through a collaborative Hazard Vulnerability Analysis (HVA) and by sharing strategies for mitigation and preparedness.
Participation may improve the organization's performance during emergencies because information shared between Coalition organizations promotes situational awareness for responding healthcare organizations.
Participation may facilitate access to resources through mutual aid arrangements that otherwise could take more time to access if pursued through other channels.
Participation may assist in meeting standards and regulations (e.g., The Joint Commission accreditation standards and others) related to community preparedness and integration into emergency response.
5.2 Establishing the Healthcare Coalition Emergency Management Program (EMP)
When establishing processes to sustain and enhance the Coalition's response capability, it is important to consider the need to address recurring issues, such as training staff and evaluating performance. The Healthcare Coalition's Emergency Management Program (EMP) provides the structure and guidance for preparedness activities.
One of the most important concepts in Comprehensive Emergency Management is organizing the EMP by the four phases of emergency management: mitigation, preparedness, response, and recovery. These phases are summarized below.[52]
Mitigation: Activities that are performed to reduce or eliminate the probability of a hazard occurrence or to eliminate or reduce the impact from a hazard if it should occur. Mitigation activities are generally performed prior to an imminent or actual hazard impact.
Preparedness: Actions that are designed to build organizational resiliency and/or foster capacity and capabilities for response to and recovery from disasters and emergencies.
Response: Activities performed to address the immediate and short-term effects of the emergency. It includes activities immediately before (for an imminent threat), during, and after a hazard impact.
Recovery: Activities and programs implemented during and after response to return the organization to its usual state or to a "new normal." For response organizations, this includes return-to-readiness status and resumption of baseline operations.
The Hazard Vulnerability Assessment (HVA) provides the basis for informed planning in all phases of emergency management. The HVA process is described in relation to the Healthcare Coalition at the end of this chapter.
A coordinating or organizing body should be created to conduct the Healthcare Coalition's preparedness and mitigation activities (Chapter 6). Maintaining consistency with emergency management terminology, this can be addressed through an Emergency Management Committee (EMC). The EMC assures a fair and balanced process for Coalition preparedness and mitigation activities among all member organizations. For this to occur, the following requirements must be in place:
There should be balanced representation of Coalition members on the EMC. Similar types of healthcare organizations should have the same level of representation on the EMC if desired by the organizations. While ceding control or influence to one or several organizations may seem like the fastest way to establish the Coalition, this approach can lead to future problems.
Decision-making by the Coalition must be transparent. Processes used for making decisions should be pre-established and conveyed to Coalition organizations. It may necessitate that minutes are taken during meetings and that preparedness meetings are open to all Coalition participants. Moreover, the Coalition may draft and adopt a Charter and Bylaws for the EMC.
There may be situations in which individual organizations cannot agree to a majority decision that has been made by the EMC. This should be expected and opt-out policies for the individual organizations should be established.
Actual or perceived conflicts of interest should be recognized and addressed. An example might be the award of a large grant or appropriation earmarked "for the Coalition" but used to primarily benefit only a few partners. This could create distrust among the Coalition members and compromise the effectiveness of the Coalition.
The desired construct of the EMC includes representation from each organization in the Coalition. In very large or complex Coalitions, this may not always be feasible and the actual composition may reflect a fair and balanced representation of the different types of organizations. To ensure fairness, a process to rotate EMC participation should be designed into the Coalition's EMP.
The participants on the EMC should have the delegated authority to represent their respective organizations. This does not mean that they can make all decisions on behalf of the organization, especially decisions with major financial or legal implications. But it does mean that they can speak for their institution within defined parameters and are responsible for communicating information related to Coalition preparedness activities back to the leadership of their respective organization. It is up to the organization to establish the level of decision-making authority that its representative has on the EMC.
Representatives on the EMC should also have some level of expertise in healthcare system emergency management. The ideal representative is knowledgeable of emergency management principles and practices, including NIMS and ICS, and understands the organization that they are representing.
How the EMC operates is another area to address during the initial development of the Coalition. The following concepts may be helpful in establishing the EMC:
Strategic planning: One way to focus the EMC's efforts is to define strategic guidance, including goals and objectives, for the EMC itself. Objectives should be constructed with a specific, measurable end-point and a timeframe.
Leadership: A Committee Chair is usually elected by Coalition participants to lead the EMC's efforts. To promote a sense of fairness, the Committee Chair may be determined on a rotating schedule. This can also help enhance the long-term sustainability of the EMC.
Conduct of the EMC: Pre-established rules for the EMC should address issues such as voting on initiatives and how meeting minutes will be preserved. Rules that promote response-oriented procedures can be beneficial. For example, conduct of meetings using protocols established for response teleconferences can promote familiarity with these processes and keep the meetings efficient.
Structure: The EMC forms the core structure for EMP activities outside of emergency response. Subcommittees or work groups may be established to address specific issues, such as on-going exercises for the Coalition or ad hoc subcommittees stood up to coordinate the purchasing of a specific item.
Document control: An agreed upon process for managing the EMC's documents (e.g., Coalition's EOP, training plan) is essential. These documents should be stored so they are easily accessible.
Corrective action process: A corrective action process for the Healthcare Coalition response organization is described in Chapter 6. Similarly, the EMC itself should undergo periodic evaluation to ensure it is meeting its goals and objectives.
It may be beneficial to establish some level of executive oversight to the EMC. An executive committee can be established that is composed of executive administrators or their designees from Coalition organizations. This committee can review the development of Coalition elements as they evolve, provide strategic input into the EMC, and approve major financial commitments. While meetings to address these tasks are expected to be less frequent than EMC meetings (e.g., bi-annually), they require significant preparation to efficiently inform the representatives.
5.3 Programmatic Issues for the Healthcare Coalition
Additional programmatic issues relevant to the Coalition EMP and EMC should be addressed before examining preparedness and mitigation activities.
An administrative body for the Coalition should be established concurrently with the selection of member organizations. It is important to distinguish the role of this body from the decision-making role of the EMC. The administrative body supports the Healthcare Coalition during mitigation and preparedness by fulfilling specific administrative needs that are distinct from those required during emergency response and recovery. For example, the administrative body may:
Provide meeting space and administrative support for regularly scheduled meetings of the EMC
Serve as a repository and financial controller for Coalition funds
Manage document control and archiving for the EMC.
Options for the Coalition's administrative body will vary by region, but may include the following:
Hospital associations: Because they usually include all of the hospitals in a defined area, they already provide some measure of a "level playing field." At the same time, they are limited by the fact that they lack representation of long-term care facilities, outpatient centers, private practitioners, and other potential Coalition participants.
Local Emergency Planning Committees (LEPCs):[53] While the original intent of LEPCs was to increase community awareness and response capabilities for hazardous materials, LEPCs have served in some jurisdictions as a valuable multidisciplinary platform to coordinate preparedness of medical resources. The Healthcare Coalition could be organized under the auspices of an existing LEPC.
Administrative bodies constructed de novo for this role: Another option is to establish a non-profit organization to serve as the administrative body for the Coalition. While this may require more effort and cost to establish and maintain, it has the benefit of allowing specific by-laws for the organization to focus primarily on this preparedness role rather than attempting to piggy back onto existing missions (Exhibit 5-4).
Individual partners of the Healthcare Coalition: A member organization within the Coalition may volunteer to serve as the administrative body. In such cases, care should be taken to prevent potential conflicts of interest.
Exhibit 5-4. Example of a non-profit organization serving as the preparedness body for a Healthcare Coalition*
The Northern Virginia Hospital Alliance (NVHA) is a non-profit organization that was formed in October 2002 for the purpose of improving community-wide preparedness for and response to mass casualty incidents. The NVHA serves approximately 12 acute-care hospitals (including one military hospital) and several free-standing emergency care centers in the region. The NVHA collaborates with hospitals and other emergency response entities from Washington, D.C., Maryland, and Virginia to address mass casualty medical response.
* Northern Virginia Hospital Alliance, Information about the Virignia Hospital and Healthcare Association, Accessed August 12, 2025
Certain types of "political" support may be necessary to ensure the success of the Healthcare Coalition. This may be particularly important during the initial development stage and may be addressed at both the healthcare organization (Tier 1) and jurisdiction (Tier 3) levels.
The executive leadership of Coalition member organizations will need to agree to the proposed principles (the membership, structure, and methodologies) for the Coalition during preparedness and response. This may require buy-in from their parent corporations and boards. Executive level briefings on the purpose, vision, and potential value of the Healthcare Coalition during emergency response can help secure buy-in and commitment from senior leadership at member organizations.
At the jurisdictional level (Tier 3), endorsement from public agency executives and elected officials should be sought. This can provide the "push" that is needed for the Healthcare Coalition initiative to succeed. Support from political leaders can be demonstrated in multiple ways, such as providing funding for Coalition development and maintenance or sharing information for preparedness. It may be helpful to conduct presentations for these officials on the mission of the Coalition and how it can benefit the community response. Some Coalitions may elect to invite public health and other public sector officials to participate in advisory positions.
As noted earlier, every effort should be taken to keep the Coalition as lean as possible and many Coalitions will not require significant amounts of direct financial support. The main costs for developing and maintaining the Coalition will be the personnel time contributed by member organizations.[54] Equipment costs may vary substantially based on the technological requirements of the particular Coalition. Radio communications, computer software, and paging systems could add development and maintenance costs. It is important to establish financial management processes in order to track costs and ensure transparency in how funding for the Coalition is spent. Some representative sources for funding of the Coalition are presented in Exhibit 5-5.
Exhibit 5-5. Potential sources of funding for development and maintenance of the Healthcare Coalition
Federal programs: Federal programs and grants for emergency preparedness, emergency management, and homeland security may provide one source of funding for Coalitions. Grants made to jurisdictions to increase hospital preparedness can be distributed fairly to Coalition members, thus enhancing the "team" concept of the Coalition.[55]
Public sector support: Jurisdictional (Tier 3) or State (Tier 4) authorities may be able to provide some financial support for Coalition development and maintenance.
Private sector internal support: In some situations, Coalition member organizations may provide direct or indirect funding support for elements of the Healthcare Coalition.
Private sector external support: Donations from corporations may be available to assist with Coalition financing as a public service initiative.
Healthcare Coalitions should establish collaborative relationships with any external entities in their geographic area that are involved in emergency response. Coordination with these entities can enhance preparedness, improve service integration, and avoid perceptions that the Coalition is acting independent of the community response.[56] The Coalition should consider relationships with the following types of external entities:
Public health: Public health departments vary considerably from State to State and even between intra-State regions in their construct, capabilities, and procedures. Depending on where the Coalition is located and the public health capabilities in the area, it may be beneficial to have public health personnel participate as advisors in the Healthcare Coalition's preparedness meetings.
EMS: Emergency Medical Services are an important partner, like public health, in establishing viable processes and procedures for the Coalition's response activities. Individuals representing EMS may provide key insights for the Coalition's preparedness efforts.
Fire Service: Fire and rescue services should be considered as well for advisory participation in the Coalition's preparedness efforts. These services can play multiple roles during response, including providing direct support to healthcare organizations.
Law Enforcement: Coordination with Law Enforcement can be critical for many reasons. For example, collaborating with Law Enforcement about which healthcare personnel should be allowed to cross security perimeters in an area of police action may be essential to maintain an adequate healthcare workforce during civil unrest, mass gatherings, and other incidents.
Federal partners: The Healthcare Coalition should include appropriate regionally-based Federal personnel (e.g., HHS Regional Emergency Coordinator) in the Coalition's preparedness and response efforts, even if just on an "information-only" basis.[57]
Nearby Healthcare Coalitions: Inviting a representative from a nearby Coalition to participate as an observer or advisory in preparedness efforts may strengthen regional coordination. This builds trust and familiarity that can be helpful in an emergency.
Other medical support entities: Included in this group may be large vendors, laboratories, or other businesses that support multiple healthcare assets in the Coalition. Establishing formal relationships with these entities may promote a more robust commitment to support Coalition member organizations during emergency response.
Section 1.2 briefly described a systems-based approach to program development. This approach has tremendous utility for the Healthcare Coalition EMP. Establishing a set of sequential management steps to use during any major undertakings (e.g., EOP development) helps keep the projects focused and "on track" while evolving in a logical manner.
An example series of management steps as applied to development of the Coalition EMP is presented below for consideration:[58],[59]
Step 1: Establish goals and objectives.
The goal of the Healthcare Coalition EMP process should be explicitly described. For example, a candidate goal statement might be to "establish and maintain a robust Healthcare Coalition response organization that is supported by a comprehensive and inclusive method to coordinate Healthcare Coalition partners across the phases of mitigation, preparedness, response, and recovery." Objectives are then developed representing the interim steps necessary to achieve the goal (Exhibit 5-6).
Exhibit 5-6. Sample programmatic objectives for the Healthcare Coalition EMP
Establish a Healthcare Coalition response organization to effectively manage the coordination between healthcare organizations and the Jurisdictional Agency(s) during incident response and recovery.
Create and maintain a preparedness organization (EMC) to manage Healthcare Coalition participants' mitigation and preparedness activities.
Conduct a joint Hazard Vulnerability Analysis and share the information as a basis for coordinated, consistent preparedness and response efforts.
Establish guidance for participating healthcare organizations to enhance their individual EOPs so they can fully participate in Healthcare Coalition actions during incident response.
Conduct joint training, exercises, and other preparedness activities with local response agencies to integrate the Healthcare Coalition into the local emergency response community.
Step 2: List key assumptions about the environment, organizations, and other factors that might influence development of the Coalition. Sample assumptions may include the following:
Incidents that could impact Healthcare Coalition member organizations may occur suddenly and without warning.
Each Coalition member retains decision-making authorities inherent to their organization.
Jurisdictional authorities (Tier 3) have responsibilities in supporting the Healthcare Coalition, and the Coalition has responsibility for supporting these authorities, as indicated by incident circumstances.
Funding will be necessary from government or non-government sources, as well as the member organizations themselves, to establish and maintain the Coalition.
Long-term funding may be limited and sustainability is an important consideration in designing the Healthcare Coalition. The Coalition should be as lean as possible while maintaining the ability to fulfill its mission requirements.
Step 3: Develop a System Description and Concept of Operations. The System Description outlines how an effort will be organized. For the Coalition EMP, it is worth first considering the intended function of the Coalition during emergency response (i.e., defining the Coalition's response objectives). Then, the programmatic issues can be delineated, such as the construct of the EMC, how representatives are selected, and who the EMC reports to beyond the administrators at the individual organizations. The Concept of Operations describes the processes and procedures that the Coalition will use to achieve its goals. For the Healthcare Coalition EMP, this may entail outlining the specific methods for meetings, response coordination, and interaction with senior executives at member organizations (Tier 1) and jurisdictional authorities (Tier 3).
Step 4: Identify resource needs (personnel, facilities, equipment, supplies, etc.). Needs are identified to staff, equip, and operate the EMP, including the organizing body or support organization(s).
Step 5: Implement the system. Upon completion of the preceding steps, the Coalition EMP must be implemented and maintained.
Step 6: Develop and conduct education and training designed to familiarize personnel with the system. For the Healthcare Coalition EMP, implementation may require briefings to executive leaders of member organizations and public agency officials supporting the effort.
Step 7: Exercise, evaluate, and revise the system. A process should be established to continually exercise, evaluate, and improve the Coalition EMP.
5.4 Hazards Vulnerability Analysis
A Hazard Vulnerability Analysis (HVA) provides the Coalition with a common understanding about the hazard risks that it faces and helps to prioritize issues for the EMP to address.[60] In other words, a properly developed HVA provides the "needs assessment" for the EMP and guides its direction. The basic components of an HVA for healthcare organizations are well described elsewhere, but general steps related to Healthcare Coalitions are presented below.[61]
The first step in a comprehensive HVA is to identify and prioritize the likely hazards that the Coalition could face. These will often overlap with the hazards confronted by the Coalition member organizations and are typically identified using historical and current data from multiple sources.
Based on the list of hazards generated, the general vulnerabilities for Coalition member organizations and the specific vulnerabilities for the Coalition itself are identified.
The product of the likely hazards and associated vulnerabilities constitutes "risks" to the Coalition and its member organizations. These are then sorted and prioritized. Significant impact on personnel and mission critical elements contributes to the ranking of the risk for each hazard.
Steps are taken to prevent or reduce the risks (mitigation) or to address the consequences post-impact (preparedness). For example, a backup notification system can be developed (mitigation) or procedures established that will guide participants if the notification system fails (preparedness). This demonstrates the important link between the HVA process and other EMP activities.
The HVA process is iterative and should be reviewed on an annual basis or after major incidents.
Because the HVA is typically discussed within the context of one organization, the HVA for the Coalition is somewhat unique. Provided below are some considerations for the Coalition's HVA:
While there will likely be significant overlap between the HVA for the Coalition and the HVA for an individual healthcare organization, these must be separate and distinct processes. A specific vulnerability may not exist across all Coalition member organizations; however, Coalition members will generally face many of the same hazards. The Healthcare Coalition EMC can conduct an HVA for the Coalition and each organization could use the findings to inform their respective HVA. A benefit of this approach is that it helps to satisfy certain standards, such as The Joint Commission criteria for coordinating HVA efforts with external partners.[62]
The Coalition may start by examining the HVAs at individual member organizations and its respective local jurisdiction (Tier 3) before conducting its own.
The external organizations listed in Section 5.3.3 should be given an opportunity to participate in and/or review the Coalition's HVA efforts. They can provide important information related to hazards and vulnerabilities, as well as guidance on risk interventions. In addition, public sector organizations can factor these HVA results into their respective planning efforts.
The outputs of the Coalition HVA (hazards, vulnerabilities, risk interventions) should be used by the EMC to structure and prioritize its efforts. This can range from modifying the EOP to improving resource management (e.g., collective purchases).
47. While the structure and processes differ, healthcare planners may consider using specific response procedures during preparedness to enhance familiarity with response methods. For example, notifications for Coalition preparedness meetings may be conveyed via the notification messaging procedures used for response, but with a lower level of assigned urgency.
48. Defining what the Healthcare Coalition will do during emergency response will help guide preparedness efforts. This is the primary reason why the initial chapters of this handbook focus on the Coalition response organization.
49. "Structured" refers to supporting with an agenda, facilitation, and minute taking.
50. It is important to distinguish this Tier 2 Coalition arrangement from a jurisdictional Tier 3 organization that carries local government authority to operate as command and control, or as area command. The Tier 3 local authority or Tier 4 regional organization (i.e., with State command authority) may set incident objectives and specify resource priorities. This is common in many areas of the U.S. and appears to work well, and may be the primary interface for the Tier 2 Healthcare Coalition.
51. King County Healthcare Coalition, Members, Partners, and Staff: Accessed February 9, 2009.
52. Barbera JA, Macintyre AG, Shaw G, et al, Emergency Management Principles and Practices for Healthcare Systems (2006).
53. The Emergency Planning and Community Right-to-Know Act, also known as Title III of the Superfund Amendments and Reauthorization Act (SARA), established the requirements of LEPCs.
54. The contribution of personnel time is a significant issue that Coalition organizations should address at the outset. Those who contribute significantly to the development and maintenance of the Coalition should have their efforts recognized and acknowledged by their employer as an important cost of doing business.
55. An example is The Hospital Preparedness Program, which is administered by the Office of the Assistant Secretary for Preparedness and Response within HHS. Additional information on this program is available.
56. The participation of these entities in Coalition preparedness may vary from full participation (e.g., assistance in developing work products and attendance at all meetings) to more limited participation (e.g., review of select work products).
57. Contact information for HHS Regional Emergency Coordinators is available.
58. Barbera JA, Macintyre AG, Shaw G, et al, Emergency Management Principles and Practices for Healthcare Systems (2006).
59. It should be noted that these same steps can be used to develop the Coalition EOP or other major EMP products.
60. The definition of a Hazard Vulnerability Analysis is provided in Appendix B.
61. Barbera JA, Macintyre AG, Shaw G, et al, Emergency Management Principles and Practices for Healthcare Systems. Department of Veterans Affairs, Veterans Health Administration (2004).
62. The Joint Commission, Emergency Management Standards, Hospital Accreditation Program (2008). Accessed October 13, 2008.