Chapter 6: The Healthcare Coalition Emergency Management Program: Mitigation and Preparedness Activities

A central focus of any preparedness organization is the development of an Emergency Operations Plan (EOP). The EOP is an "all hazards" guidance document that specifies actions to be taken in response to an emergency or disaster.^[63] Exhibit 6-1 presents the primary uses for the Healthcare Coalition EOP.

Exhibit 6-1. Primary uses of the Healthcare Coalition EOP
The EOP describes how the Healthcare Coalition response organization is structured and how it will respond during an emergency. The EOP is helpful in developing and conducting education, training, and exercises, as well as in evaluating the Healthcare Coalition's performance in exercises or actual emergencies.
The EOP must be usable under emergency conditions to guide response actions, demobilization, recovery, and return to readiness. The components of an EOP designed for use during response are the specific "tools," including call-down lists, operational checklists, mobilization and demobilization procedure checklists, reporting templates, and other standard operating procedures (SOPs).

Regardless of the Healthcare Coalition's size or complexity, the following considerations are important for developing the EOP:

• Establish the EOP writing team: Personnel developing the EOP should include representatives from the various members of the Coalition. If the development team is large (i.e., greater than 5-7 individuals), it may be advisable to break down the EOP into its component parts, have sub-groups address these parts, with the work products then reviewed by the larger group.
• Establish a review process: Each Coalition member should have the opportunity to review and comment on EOP products as they are developed. In addition, it may be helpful to get feedback from external reviewers – most notably all relevant Jurisdictional Agencies (Tier 3), key vendors (e.g., hospital suppliers), or other stakeholders.
• Promote buy-in from Coalition members and jurisdictional authorities: Executive leaders at each member organization, as well as key Jurisdictional Agencies, should be briefed whenever major elements of the EOP are completed. The briefings should highlight the advantages of participating in or supporting the Healthcare Coalition.
• Incorporate NIMS principles: NIMS principles should be incorporated into the Coalition's EOP so that personnel are training on and using a response plan that is specific to the Coalition rather than one containing generic ICS. The HVA provides the foundation for developing and refining the Coalition's EOP (through the development of incident specific SOPs, etc.).

At a minimum, the Healthcare Coalition EOP should describe the structure of the Healthcare Coalition Response Team (HCRT), including an organizational chart with response positions, and the processes and procedures ("Concept of Operations") that the Coalition follows through the progressive stages of response and recovery. It should also describe the specific interactions with Coalition member organizations and jurisdictional authorities (see Chapter 4).

FEMA resources offer widely accepted guidance on the format of an EOP.^[64],[65] Key elements to consider for the EOP are summarized below.

• Goals and objectives: The EOP should describe the goals and objectives of the Healthcare Coalition response organization (those presented in Chapter 2 may serve as a template that can be adapted to a specific Coalition). These objectives can be relatively simple or robust depending on the type of support that the Coalition will provide in an emergency. In addition to providing strategic guidance, these statements can serve as outcome (goal) and output (objectives) metrics when evaluating the Coalition's performance.
• Scope: This includes a brief description of the emergency conditions when the EOP would be used, a list of Coalition partners, and a statement that the Coalition EOP does not supplant the plans, authorities, and responsibilities of the Coalition member organizations.
• Authorities: Relevant authorities upon which the Healthcare Coalition is based should be cited. Generally, the authority is derived from the voluntary commitment of member organizations to participate in the Coalition. At the same time, the independent decision-making authority of Coalition members may be recognized. This section may also reference any formal instruments that establish or maintain the Coalition, such as a Memorandum of Understanding (see Chapter 7).
• Base Plan: The EOP should contain a basic description of how the Coalition will be organized during emergency response. This is often addressed in a Concept of Operations and a separate System Description is not developed. However, Coalitions with a more complex structure may benefit from writing a detailed System Description.^[66] The Concept of Operations focuses on the processes and procedures that the Coalition will follow during response and may be organized by the successive stages of response outlined in Chapter 3.
• Functional Annexes: This section contains emergency response and recovery guidance that addresses sections of the Coalition's response in greater detail than the Base Plan. Often, this section is written to address the five "functions" of ICS (i.e., Command, Operations, Planning, Logistics, and Finance/Administration). Functional annexes may not be necessary for a basic Coalition if the appropriate information is contained within the Base Plan. For Coalition EOPs that use functional annexes, the number and types will vary based on the complexity of the Coalition. As an example, a public information annex might be developed, which outlines how the Coalition will integrate the public message of Coalition members with the Jurisdictional Agency (Tier 3).
• Hazard or Incident Specific Annexes: Concise guidance for priority hazards or specific situations should be outlined in these annexes. The hazards addressed should be determined by the Coalition's HVA and the material should not duplicate information covered in the Base Plan or functional annexes. Potential examples might include a widespread power outage or the emergency evacuation of patients from one of the Coalition member's facilities.
• Tools/attachments: The most useful portions of an EOP during response are often the tools and attachments that can be included (as appendices) in the above listed sections. Job action sheets or operational checklists, mobilization checklists, call down lists, and pre-formatted forms for Coalition members to submit incident information can promote an effective HCRT response.

SOPs are useful to include in the Healthcare Coalition's EOP and may be used in both functional and hazard specific annexes. Potential SOPs for the functional annexes of the EOP may include:

• Resource support: Describes specific procedures for assisting member organizations in sharing resources between them during emergencies. Attachments to this SOP might include a Memorandum of Understanding for a Strategic National Stockpile distribution plan.
• Patient tracking: Describes specific procedures for tracking patients among different healthcare facilities and the actions that Coalition member organizations should conduct (e.g., reporting patient lists) to facilitate patient tracking.
• Public information: Describes processes for coordinating the public message among Coalition member organizations (Tier 1) and the relevant Jurisdictional Agency(s) (Tier 3).
• Volunteer management: Describes how a Healthcare Coalition might facilitate the management of solicited and unsolicited volunteers for integration into healthcare organizations (Tier 1) and coordinate this with the Jurisdictional Agency(s) (Tier 3).

Two examples of SOPs that might be included in hazard or incident specific annexes of the Coalition's EOP are provided below. While the format of an SOP may vary, Exhibit 6-2 presents a template that captures the key elements.

• Patient evacuation from a healthcare facility: Most Coalitions face the potential of a hazard impact that would require the evacuation of a healthcare facility. Clearly defined procedures for how the Coalition might support this should be included within the context of a hazard or incident specific annex. This material should be presented in a format that is useful during response operations.
• Mass fatality: Describes procedures that will be used when the number of fatalities exceeds the normal capacity for managing fatalities at individual healthcare organizations. The SOP may address issues such as how the Coalition could facilitate victim tracking or the acquisition of storage sites for human remains through appropriate jurisdictional channels.

Exhibit 6-2 Sample format for a Standard Operating Procedure (SOP)*
Standard Operating Procedure No. __
Subject: (insert hazard, threat, or event** name)

1. Description of the threat/event (may include related symptoms, potential impact, etc.)
2. Impact on mission critical systems (e.g., any potential adverse impacts within the Coalition or individual organizations).
3. Key personnel with responsibility for managing the threat/event
4. Response/Recovery from the threat/event, including objectives and strategies for the following:
1. Hazard control and resource issues
2. Hazard monitoring
3. Recovery
5. Notification procedures addressing such issues as:
   
1. If a threat/event occurs, who within the Coalition should be notified?
2. Which community agencies should be notified?
3. What other agencies should be notified (e.g., nearby Healthcare Coalitions, etc.)?
6. Review Date
   

*Adapted from the Veterans Health Administration, Emergency Management Guidebook (2005).
** An "event" is a scheduled activity where the EOP is used to provide incident management. It is distinguished from an "incident," which is when the EOP is activated for an unscheduled activity.

Once the EOP is written, it must be implemented and regularly evaluated for adequacy, with organizational improvement actions conducted as necessary. Most Coalitions should develop a Base Plan first and then address other components of the EOP using a priority scheme that is based upon identified risks. The remaining sections of this chapter address other critical activities that provide a truly effective EOP (i.e., resource management, training).

In the context of emergency management, "resources" generally include personnel, facilities, equipment, and supplies. According to NIMS, "efficient and effective deployment of resources requires that resource management concepts and principles be used in all phases of emergency management and incident response."^[67]

Personnel

Chapter 2 described specific positions within the HCRT. For these positions to function as intended, the EOP requires the following:

• Documented position descriptions: The qualifications, roles, and responsibilities of Healthcare Coalition personnel during response should be clearly established, as well as the instructional activity they should complete to effectively staff specific positions. This is applicable whether the HCRT will be staffed by a relatively small number of positions (1 or 2) or significantly more.
• Recruitment of qualified personnel: A roster with primary and backup assignments for each key position should be developed, with rotation at defined intervals for the on-call individual at each position.
• Education and training to promote operational proficiency in a specified role: This education and training does not have to be technically advanced or time consuming, but it should be formal training that is tracked by the preparedness organization. Only fully qualified and trained personnel should be on the activation roster. A "just-in-time" training may be helpful and can take the form of a quick briefing to remind individuals of their specific roles in an emergency.

These requirements should also be applied to personnel who are staffing the Organizational Liaison positions for each Coalition member organization.

The Healthcare Coalition preparedness organization may also address how volunteers or other "donated" personnel will be integrated into the Healthcare Coalition during emergency response. Examples of preparedness activities related to personnel management include:

• Establishing common credentialing, privileging, and badging requirements. Credentialing should be distinguished from privileging and badging (Exhibit 6-3). The Healthcare Coalition may establish common requirements for its member organizations, but these efforts must be coordinated with similar efforts being conducted by jurisdictional (Tier 3) or State (Tier 4) authorities (e.g., credentialing for MRC or ESAR-VHP).
  Exhibit 6-3. Differentiating credentialing, privileging, and badging for personnel*

  Credentialing: According to NIMS, "the credentialing process entails the objective evaluation and documentation of an individual's current certification, license, or degree; training and experience; and competence or proficiency to meet nationally accepted standards, provide particular services and/or functions, or perform specific tasks under specific conditions during an incident."
  Privileging: The process where appropriately credentialed personnel are granted permission to provide specified services within the healthcare organization.
  Badging: The process of providing outside personnel with identification that gives them access (usually limited) to the designated facilities of the organization requesting assistance.
  * Credentialing the Nation's Emergency Responders: Working Group Guidelines – Draft Version 1.6 (November 2005), NIMS Integration Center, Federal Emergency Management Agency, Washington D.C.

• Developing a volunteer processing and management capability: The Healthcare Coalition may support Volunteer Management Centers that process and assign spontaneous medical volunteers. This can be a complex activity^[68] and should only be done by the Coalition if a methodology is well established during preparedness planning. It is imperative that such activity, if undertaken by the Coalition, is coordinated closely with the appropriate authorities (e.g., Jurisdictional Agency(s), State authority).

Facilities

The response functions of the HCRT may occur at multiple facilities (i.e., in a distributed manner) rather than at one location like a typical EOC. For some Coalitions, this may be the most cost-effective approach. Integration is accomplished through voice and Internet links. At a minimum, a fixed location should be identified for information gathering and distribution (i.e., Coalition Notification Center function). Other locations convenient to Coalition members (usually hosted by a Coalition member) can be used as meeting space for Coalition action planning, for Coalition task forces, or for additional data collection and analysis. Issues to consider when selecting facilities for the Healthcare Coalition include:

• The facility host may vary across Healthcare Coalitions. In some situations, public sector emergency facilities (e.g., from EMS or a public health organization) may be offered to host the HCRT. A potential benefit of this arrangement is the ability to co-locate the HCRT with other emergency response managers. However, care should be taken to ensure that the HCRT has access to adequate facility space, equipment, and other required support at all times, not just when the jurisdiction activates its response.
• The facility should be able to support rapid mobilization for the HCRT, particularly the Coalition Notification Center function. Having these locations hosted in a facility that serves everyday as a communications center that can address Coalition actions may be very beneficial.
• The "resiliency" of the facility (or its ability to survive a hazard impact) is an important factor to examine. Public or private facilities that have backup power (e.g., fire stations, healthcare facilities) may be good options. In addition, a good continuity of operations practice is to identify backup facilities that the Healthcare Coalition can use.
• Potential facilities should be examined for whether they have adequate parking and meeting space, communications linkages, restrooms, furniture, and other basic support requirements.

Equipment

The basic critical equipment is the information and communications technology required for healthcare organizations (Tier 1) to communicate with the HCRT and vice versa. The ability of the Coalition to connect with the relevant Jurisdictional Agency(s) (Tier 3) and other external organizations is also critical.

The specific technological solutions to these communications issues are beyond the scope of this handbook. Modalities include telephone landlines, text and cellular technology, Internet, and radios. The use of fax machines has been common in the past, but can be unreliable and should be avoided if possible or combined with other modalities that enable confirmation of message receipt by the intended recipient. Important concepts to consider when establishing communications equipment for response activities include the following:

• Redundancy: Multiple communications methods may be used simultaneously to accomplish Coalition response objectives. For example, radio notification of an emergency may be ideal for ensuring the receipt of information by participants, but Internet programs that can begin to collate information minimizes radio traffic and makes more efficient use of responders' time.
• Route Diversity: Telephone lines and wired or wireless Internet connectivity often have a single point of failure that if disrupted brings down the entire system. Back-up systems that work around these potential failure points are desirable.
• Established protocols: Communications and other technologies provide optimal benefit if protocols for their use are established, implemented, and sustained through training and drills. In addition, using trained facilitators and adhering to meeting agendas promotes efficient utilization.
• Availability of established products: Coalition planners are encouraged to develop their response requirements, based upon their response objectives, before selecting particular technologies to support their system. If a Coalition defines what information will be collected and in what manner, it may be easier to select the most appropriate product to meet the Coalition's needs.

Implementation of the Coalition's EOP requires that personnel at the MSCC Tiers 1, 2, 3, and 4 levels fully understand the response role of the Healthcare Coalition. This can be achieved through specific instructional activities. The following personnel should receive training:

• Personnel staffing the Coalition response organization (e.g., HCRT, Senior Policy Group, and Organizational Liaisons): Position roles, responsibilities, and procedures should be clearly described for personnel staffing the HCRT, Organizational Liaisons to the HCRT, and the Senior Policy Group. For the latter, instructional activity may be brief and include just-in-time training.
• Personnel managing the response of Coalition member organizations: Personnel expected to staff senior IMT positions at Coalition member organizations should have an operational knowledge of the HCRT's role during emergency response and recovery. Personnel trained to staff the Organizational Liaison position for the specific Coalition member organization may be best positioned to provide this training.
• Public sector personnel interfacing with the Coalition: Public sector personnel (Tier 3) who interface with the Coalition during response should be offered training on the Coalition's roles and procedures for coordinating with the HCRT.

Drills focus on the execution of specific skills that might be required during response. Examples of drills that a Coalition might regularly conduct are provided below.

• Notification procedures: Regular testing of the notification and initial confirmation procedure is important to verify that the equipment is functioning, that contact lists are current, and that personnel understand the appropriate response to the notification message. This can become a routine procedure that ensures effectiveness and may include regular radio checks or sending text messages to the notification groups.
• Resource requests: Drills focusing on the availability of specific Coalition resources (e.g., patient beds, equipment, and supplies) can promote an understanding of the range of potentially available resources. These resource request drills may be combined with notification drills.
• Mobilization of personnel: Drills focusing on the mobilization of personnel can ensure that procedures are in place to rapidly activate the HCRT during an incident.

Education and training may be provided in a variety of formats and include web-based modules or other forms of "distance learning." Classroom training, particularly when first establishing the Healthcare Coalition, provides an opportunity for personnel from different organizations to meet each other and establish a working relationship.

The Healthcare Coalition should use exercises to evaluate the Coalition's EOP once the EOP has been implemented and personnel have received appropriate education and training. Exercises may evaluate specific elements of a Coalition's EOP or evaluate the EOP in a broader context. Common elements that may be evaluated during an exercise include SOPs, organizational structure, or the effectiveness of specific technologies used by the Coalition during emergency response. An important consideration in designing an exercise is that the areas to be evaluated are pre-determined and an evaluation plan is established.

The Homeland Security Exercise and Evaluation Program (HSEEP) contains mandatory requirements if Federal emergency preparedness funds are used to develop and conduct the exercise.^[69] While a full discussion of exercise preparation is beyond the scope of this handbook, key considerations for healthcare planners are presented in Exhibit 6-4.

Exhibit 6-4. Key considerations for exercise preparation

• The purpose of the exercise should be clearly stipulated in the Exercise Plan. This drives the scenario to ensure that areas of focus receive proper attention during the exercise. The level of anticipated play by the participating entities should be established. Coalition members that are not able to participate should be kept informed of the exercise development process and the findings from the exercise.
• The exercise scenario should be selected from hazards identified in the Coalition's HVA and should not present a "doomsday" event. This will ensure a realistic test of the Coalition's EOP and avoid a demoralizing "can't win" situation.
• Exercise evaluation should focus on the policies, processes, and procedures defined in the EOP and not on the performance of individuals. An evaluation plan should be developed prior to the exercise describing the evaluative process that will be used. Personnel should be designated to specifically evaluate the systems or processes that are objectives for the exercise.
• The exercise schedule should promote broad participation by Coalition member organizations and any relevant Jurisdictional Agency(s) (Tier 3) or regional Coalitions (Tier 2), if applicable. Representatives from individual healthcare organizations and Jurisdictional Agency(s) should be involved in exercise development and scheduling.
• A team should be designated to manage the exercise while it is being conducted. The size and complexity of this team will likely vary depending on the specific Coalition. The first priority of the management team should be the safety of exercise participants.

Feedback for the exercise evaluation may be gathered in the form of assessments from the evaluators, role players, and the exercise participants. Two methods that are commonly used to obtain input from exercise participants include the following:

• Post-exercise "hot wash." This activity is usually conducted immediately following an exercise to identify key successes or challenges while they are still "fresh" in the minds of the participants. Representatives from all entities that participated in the exercise should be included.
• After Action Report (AAR) process.^[70] The AAR process is a formal and comprehensive process conducted after the exercise to analyze data and observations, positive and negative, related to system performance.

In addition to exercises, the AAR process is used after an actual incident. This process should go beyond the documentation of "lessons learned" and drives system change through a corrective action process that produces true organizational learning. The AAR process may include the following characteristics:

• A management team assigned to oversee the AAR process. This team can vary in size depending on the size and complexity of the Coalition and the incident that is being evaluated.
• Prior to conducting an AAR conference, all exercise-related observations and data should be collected and reviewed to steer the discussion. A short survey from responding organizations that assesses the HCRT performance may also be very beneficial. Incident or exercise-related documents (e.g., ICS forms used during the response, notification messages) should be analyzed to steer the AAR discussion and inform the AAR findings.
• As part of the AAR conference, participants develop an Improvement Plan (IP) that articulates specific corrective actions by addressing issues identified through the AAR process.^[71]
• The timing of the AAR conference should provide stakeholders with sufficient time to recover from the incident or exercise and allow adequate preparation by the management team. Too long of a delay, however, may allow critical recollections to be lost.
• The AAR conference should be facilitated in accordance with a pre-established agenda. It may be advisable to have the HCRT Planning Section Chief, or someone trained for that position, facilitate the conference.

A final report should be developed that documents the findings of the AAR process. The report should document both positive and negative findings, with recommendations on how the former might be incorporated permanently into Coalition processes and procedures. Recommendations should be as specific as possible to highlight steps for system improvement.

The Healthcare Coalition response organization should be continuously evaluated based on its response to both exercises and real world emergencies. The goal should be to transform this experience into lasting improvements in Coalition performance.^[72] The following concepts are provided for consideration:

• The AAR and IP are finalized as a combined AAR/IP, and IP corrective action items are tracked to completion as part of a continuous Corrective Action Program.^[73]
• Individuals should be assigned responsibility for implementing recommendations made in the AAR/IP. This commonly would be a Healthcare Coalition EMC subcommittee.
• Assigned personnel should review proposed changes for clarity and their potential impact on the Coalition. This should include an assessment of the priority of the recommended changes (e.g., life safety issues should be assigned the highest priority).
• Proposed recommendations may be accepted, accepted with revision, declined (with a reason given), or deferred. The latter option may be preferred if a proposed change is contingent on upcoming funding and should be readdressed if/when the funding is obtained.^[74]
• Changes in Coalition processes and procedures should then be evaluated during follow-on exercises or actual incidents.