Chapter 7: Healthcare Coalition Administrative and Documentation Guidance

A common method used to document concurrence between parties on an intended course of action is a Memorandum of Understanding (MOU). In general terms, an MOU provides the structure and intentions of the understanding between parties, but is not legally binding unless specifically stated (Exhibit 7-2).

Exhibit 7-2. Memorandum of Understanding (MOU)*

A Memorandum of Understanding, or MOU, is a formal document embodying the firm commitment of two or more parties to an undertaking, and setting out its general principles, but falling short of constituting a detailed contract or agreement.

*Oxford Dictionary of Law, Elizabeth A. Martin (Ed.), Oxford University Press, 2006.

Depending on the specific circumstances of the Coalition, an MOU may be an attractive option for memorializing the agreements to participate in the Coalition, with its information sharing, agreed upon mutual aid relationships, and other collaborative commitments. The written instrument should acknowledge that the relationship is directly between the member organizations that comprise the Healthcare Coalition. The Coalition's response organization (HCRT) only facilitates the coordination between them during emergency response. The HCRT never controls or commands the Coalition's member organizations. The following elements should be considered in an MOU:

• Purpose: General statements regarding the situations in which the MOU may be used, who the participants are, and what they agree to do to support one another. The voluntary (rather than contractual) nature of the relationship among member organizations should be clearly delineated if that is the intent.
• Definition of terms: While it is expected that NIMS-consistent terminology will be used, each geographic area has terms that are specific to their healthcare organizations or current mutual aid construct. The terminology for preparedness and response should be explicitly defined in the written instrument. For example, consistent terminology and definitions for injury severity categories should be established for the purpose of accurately tallying aggregate casualty counts.
• Information sharing: The commitment to share incident data and other information necessary for developing the Healthcare Coalition should be described.
• Principles of mutual aid: If facilitating mutual aid becomes a Coalition response objective, the document should describe in specific terms how resources will be shared between Coalition member organizations (see mutual aid instruments below). Principles outlining other services facilitated by the Coalition should be described as well.
• Miscellaneous provisions: These include statements about the term of the written instrument (indicating when it would need to be renewed and any termination methods), terms of cooperation on addressing liability between members, statements referencing patient privacy, and/or other components that legal advisors believe important to incorporate.
• Attachments: Any preformatted tools that the agreement expects to utilize during response are best included as attachments to the agreement itself.

Responsibility for writing the MOU for the Healthcare Coalition may vary by locale. The process may be accomplished by operational level personnel to ensure the MOU addresses the operational details necessary for mutual aid actions under extreme circumstances. Legal advisors from each Coalition member organization should have the opportunity to review, provide input, and approve the document.

Another written instrument is the Memorandum of Agreement (MOA). In some legal arenas, the MOA is viewed as more binding than the MOU, while in others the terms "agreement" and "understanding" are used interchangeably. The Healthcare Coalition may write an MOA (Exhibit 7-3) specifically to define only "good faith" intent to provide assistance under emergency conditions. The materials that the MOA could cover are the same as those presented above for an MOU.

Exhibit 7-3. Memorandum of Agreement*

A Memorandum of Agreement (MOA) defines the general area of conditional agreement between two or more parties, but one party's action depends on the other party's action. The MOA can be complemented with support agreements that detail reimbursement schedules and specific terms and conditions.

* Adapted from FEMA National Preparedness Directorate, Memorandum of Agreement/Memorandum of Understanding Template and Guidance; March 2009.

Again, healthcare planners who are contemplating the development of a written instrument should consult with their legal advisors to determine the best option to establish their Healthcare Coalition. Because these written instruments define the legal relationship between Coalition members, they must undergo a careful legal review.

A contract is "an agreement between two or more persons to create an obligation to do or not to do a particular thing."^[75] Although they may have little applicability to a mutual aid instrument, contracts can be effective mechanisms for establishing commitment from external entities to individual healthcare organizations (Tier 1) and to the Coalition (Tier 2). For example, emergency contingency contracts can be established in which a vendor promises a specific service or item upon request after a hazard impact. An example might be an emergency services contract with the local water authority that can be activated if a water outage impacts healthcare organizations. The Healthcare Coalition may wish to address emergency services contracting through a collaborative approach. This can help avoid unmanaged competition between Coalition members for scarce resources during an emergency. Mechanisms for fair distribution of a critical resource or service can then be established.

A compact is "an agreement or contract between persons, nations or States. A compact is commonly applied to working agreements between and among States concerning matters of mutual concern."^[76] The most widely known compact in emergency management is the Emergency Management Assistance Compact (EMAC),^[77] which provides authorities and mechanisms for States to share public sector resources.

Compacts may be valuable written instruments for Healthcare Coalitions that have the following characteristics:

• Coalition that extends across State boundaries: If a Healthcare Coalition has been established in a geographic area that crosses State boundaries, the compact may address mutual aid and cooperative assistance between the States. Issues that could be addressed include healthcare licensure, certifications, liability, and other issues related to personnel crossing State lines. This would be an instrument between State authorities that benefits the Healthcare Coalition, rather than an instrument between Coalition member organizations.
• Coalition that borders State boundaries: If a State boundary separates two Healthcare Coalitions that are pursuing regional cooperation, EMAC or a more specific compact between the involved States may be used to address interstate concerns. Since EMAC has historically covered primarily government-owned assets, a separate compact may be necessary to address sharing of private sector resources across State lines.

Written mutual aid instruments frame and document the processes for providing mutual aid, as well as the manner in which resources will be shared between healthcare organizations during emergencies. These instruments should address any expected reimbursement for the costs of assistance (invoicing, timing of payment, etc.).

Healthcare Coalitions may develop mutual aid instruments that provide an initial period (i.e., eight hours) of personnel mutual aid that is uncompensated. Any assistance provided after a certain time interval or preset threshold is then reimbursed. Traditionally, expenses incurred by donor organizations providing uncompensated mutual aid have not been recoverable through Robert T. Stafford Act^[78] disaster funds because a documented expense has not been generated by the supported organization. In deciding how to address compensation for mutual aid, Coalition members should consult their legal advisors and consider how this issue is addressed by their local and State governments.

Regardless of the path chosen for a particular Healthcare Coalition, it is important to establish a formal process in which prospective members of the Coalition have input (Exhibit 7-4).

Exhibit 7-4. Example process for establishing a Master Mutual Aid Agreement for a Healthcare Coalition*

A regional Healthcare Coalition in the State of Oregon employed a multistep process in developing its Master Mutual Aid Agreement, which is briefly outlined below.

1. Research "best practices" for mutual aid agreements that have been developed and used in other areas
2. Select models from best practices and modify as necessary to fit existing structure
3. Refine the end document
4. Gather stakeholders and present the concept, explain the mission, and seek buy-in or suggested improvement
5. Model in a single hospital that is representative of the region
6. Seek legal review from model hospital with feedback
7. Refine the end document
8. Distribute the end product and communicate date due back once executed
9. Provide continuous follow-up and support, as needed
10. Remind stakeholders of due date periodically and check status of process on their end
11. Share what other hospitals have signed once a few are onboard to encourage broader participation
12. Once all executed copies of the document are secured, plan a signing or celebratory ceremony to recognize the collaborative process

* Personal communication with regional coordinator for Oregon HPP Region 2. All hospitals in Oregon HPP Region 2 have executed a Master Mutual Aid Agreement that defines sharing, reimbursement, and other legal aspects including that the provision of resources is done on a voluntary, not mandatory basis.

The resource category that may require the most attention in written mutual aid and cooperative assistance instruments is the sharing of personnel. A range of healthcare professionals could be shared between Coalition members during emergency response. In addition to the usual attention to healthcare providers, important assistance may be obtained through the sharing of security officers, facility engineers, mid-level managers, and others. The following issues should be addressed:

Credentialing, Licensure, and Privileges

The differences between credentialing, privileging, and badging were explained in Section 6.2.1. Healthcare organizations typically use a credentialing and privileging process on a day-to-day basis before allowing healthcare providers to practice in the organization. During normal operations, the verification of credentials is designated "primary source verification," since it involves contacting each credential granting organization directly and verifying credentials submitted by the applicant. This process is time and labor intensive, and for these reasons it is prohibitive for granting emergency privileges during the response to an emergency. The following alternative processes may be incorporated into the Coalition's mutual aid documents:

• Procedures may be established to expedite the credentialing and privileging process for donated personnel. These processes rely on "secondary source verification" in which the work performed by another accredited healthcare organization is temporarily used as adequate verification for granting privileges. Thus, verification that an individual is credentialed and privileged at a similar accredited healthcare organization within the Coalition may suffice for granting emergency privileges. The Joint Commission has addressed this issue in its standards and requires primary verification of licensure within 72 hours of granting emergency privileges.^[79]
• Primary source verification of basic healthcare credentials may be accomplished pre-incident for people who enroll in volunteer registration programs (e.g., Medical Reserve Corps, State ESARVHP programs). However, the receiving organization must still grant emergency privileges to donated personnel. A method must be established to verify the credentials before clinical privileges are granted. For example, the organization donating personnel may verify that they are currently employed with full clinical privileges and without pending investigation or sanctions.

Liability Coverage

Mutual aid instruments should stipulate how tort liability coverage will be maintained for healthcare providers that are shared between Coalition organizations. As this can be a complex issue, the emergency managers for Coalition members should seek advice from their legal counsel when writing these instruments.

One potential method to address tort liability coverage is to extend liability coverage from the assisting organization to its personnel who are working at the supported organization. This may be accomplished by including mutual aid services within the organization's scope of practice for that category of healthcare providers. The mutual aid instrument may stipulate that the costs of addressing legal issues under this liability coverage will be borne by the requesting organization for actions incurred during the emergency.

Other methods for addressing liability issues may be through State legislation. It is recommended that Coalitions consult their legal advisors when examining this area.

Worker's Compensation

Worker's compensation should also be addressed in the Healthcare Coalition's written agreements. Similar to tort liability, this may involve extending coverage from the donating organization, but with reimbursement of costs if an adverse event occurs (e.g., medical bills, lost wages). Relevant insurance carriers who provide this coverage should be involved when examining solutions for a specific Coalition. It may become important to detail the safety practices that should be employed with personnel donated for emergency tasking (maximum shift length, safety supervision, etc.) when establishing this section of the written mutual aid agreement.

Supervision of Deployed Personnel

The Healthcare Coalition should consider the supervision of deployed personnel when developing the terms of mutual aid. Some issues that may be addressed include the following:

• Establishing the location where deployed personnel should initially report to in a supported institution
• Mandating briefing procedures to provide orientation and tasking for deployed personnel
• Badging procedures for deployed personnel
• Assigning a supervisor for donated personnel and establishing reporting requirements so the supported organization maintains control through its incident management processes
• Out-briefing donated personnel, which may include addressing any medical issues related to disease exposure or work-related injury
• Performance evaluations provided by an immediate supervisor.

Pre-Deployment Preparation

It may be useful for the Healthcare Coalition mutual aid instrument to stipulate a minimum level of preparedness for personnel who may be deployed, including training and pre-deployment briefing requirements. The following information should be provided to deploying personnel:

• Known details about the incident
• Expected roles for deployed personnel (e.g., specific assignment if known, the supervised nature of the assignment, the reporting requirements)
• Safety issues specific to the incident and a review of general safety measures
• Review of some of the protections afforded (e.g., tort liability and worker's compensation coverage)
• Review of deployment checklists that may be developed to address items that personnel should have when deploying (bottled water, several changes of universal precautions equipment, other PPE, change of clothes, personal medications and toiletries, etc.).

When developing mutual aid instruments, the following categories of items should be considered:

• Pharmaceuticals
• Sterile supplies
• Blood products (many regions already have established agreements through the American Red Cross)
• Critical care equipment (e.g., ventilators, suction)
• Decontamination equipment and supplies (e.g., Personal Protective Equipment and other supplies)
• Equipment for evacuation (e.g., stretchers, chairs)
• Infrastructure equipment (e.g., generators, water purification equipment)
• Others (e.g., potable water stores, linen supplies).

An important resource distinction is differentiating between durable and non-durable supplies. The mutual aid instrument should address whether non-durable supplies (e.g., pharmaceuticals, sterile supplies) will be returned to the donating organization if unused and what storage conditions are necessary for the supplies to remain suitable for return. For durable items, the mutual aid instrument should specify any rehabilitation requirements or reimbursement to the donor organization for rehabilitation and the time frame for when durable items are to be returned after use.

"Facilities" for healthcare mutual aid usually refers to staffed beds available for accepting patient transfers. The Healthcare Coalition's mutual aid instrument should address the "typing" of staffed beds so Coalition members use consistent terminology when tracking the availability of beds. The Agency for Healthcare Research and Quality (AHRQ) has developed standardized hospital bed definitions.^[80] It is important to ensure consistency with national standards.

In rare situations, the management of an entire facility or a portion of a facility might be turned over to another organization. For example, an outpatient care center could be used by another healthcare organization to screen patients who have been potentially exposed to an infectious agent. The Healthcare Coalition may want to address the following issues in its mutual aid instrument:

• How the facility could be used?
• What support from the facility's owners will be required?
• How costs will be reimbursed?
• How rehabilitation of the facility will occur?

The following issues should be considered in developing procedural guidance for resource requests:

• Resource descriptions: Resource typing is the methodology used in ICS to provide standardized descriptions of resources that may be shared. This helps to assure accuracy in meeting resource requirements. It is especially relevant to the medical profession, as there can be subtle yet important differences between similarly sounding requests. A Federal initiative is underway to address healthcare resource typing and credentialing, and a limited list of resource types currently exist for medical and public health teams.^[81] Mutual aid instruments should delineate the process in which resources will be described to minimize inaccuracies, particularly for resources that are not described in the FEMA listing.
• Format for resource requests: This should be kept simple and include the name, response position title, and contact information of the individual making the request, along with the name of the requesting organization. The request should specify a reporting location for deployed personnel, a brief description of duties, and the start time and anticipated length of service.
• Authority to request or offer resources: This involves specifying who within a Healthcare Coalition member organization has the authority to request and offer resources.
• Transmission of requests: This involves specifying how requests are transmitted to the HCRT for rapid dissemination to other Coalition members. Donor organizations can contact the requesting organization directly or any offers of assistance can be aggregated by the HCRT Operations Section and provided to the requesting organization.
• Completing the resource sharing arrangement: The specific agreement for assistance is made directly between the requesting and the donating organizations, facilitated by the HCRT if desired by the involved parties. An agreement template for this purpose may be helpful.

Transportation of resources should be considered when developing the mutual aid instrument. Stipulations should include how the resources will be delivered to the supported organization and returned to the assisting organization (as appropriate). A range of transportation options may be available, including the following:

• Healthcare organizations may own adequate transportation assets that can be used during incident response (e.g., hospital based ambulance services).
• Arrangements may be made during preparedness planning with public sector agencies, such as EMS, departments of transportation, or mass transit agencies to supply transportation assets for emergency assistance.
• Similarly, private sector assets may exist within the community that could be engaged in contingency contracts or other written mutual aid instruments.

Procedures governing the day-to-day transfer of patients between healthcare organizations are typically well delineated, but can be time and labor intensive. Modifications may be needed to expedite this process during an emergency and should address the following:

• Assigning receiving facilities: For routine patient transfer, it is usually the responsibility of the individual practitioner or healthcare organization to locate an appropriate and available receiving facility and care provider. During emergencies, this may be better coordinated through the HCRT by communicating requests for assistance to all participating organizations at one time. The HCRT Operations Section may then aggregate offers of assistance and connect the most appropriate to the requesting organization. This takes on critical importance in situations such as the emergency evacuation of a healthcare facility.
• Transfer procedures and related details: Issues related to the transfer of patients should be addressed during preparedness and may include the following:
• Who is responsible for arranging patient transport?
• When does responsibility for the transferred patient transition from the sending organization to the patient receiving facility?
• What patient records (including family contact information) will be included? Is remote access to electronic medical records an option?
• What other minimum documentation is required to accompany patients being transferred?
• How will patient transfer actually occur?
• What authority does the patient receiving facility have to assign a new medical provider?
• Will courtesy or temporary privileges be assigned to the patient's regular treating physician?
• What procedures will be used to confirm arrival and acceptance of transferred patients?
• What equipment, supplies, or medication should be transferred with the patient?
• How will payment for care at the new facility be processed and submitted to third party payers (see below)
• Notification of transfer: This includes messages to the receiving facility that a patient is en route, confirmation by the receiving facility that the patient has arrived, responsibility for notification of patients' families regarding the emergency transfer and points of contact at the receiving facility, and confirmation by the patient receiving facility to the patient's family that the transfer has been completed.
• Integration with other organizations: During large incidents, mechanisms such as the National Disaster Medical System (NDMS) and its associated Federal Coordinating Centers (FCC) may become active. Coalitions should consider including regional representatives from NDMS and the regional FCC in discussions of these issues during Coalition preparedness.

After emergency evacuation of a healthcare facility, it may be appropriate to grant courtesy privileges at receiving facilities so that the personal physician of a transferred patient can provide continuity of care in the receiving facility. The methodology to address this could be similar to granting emergency privileges. This may need to be addressed through medical staff by-laws and other administrative avenues.

Payment for healthcare services rendered in the care of patients who are transferred in an emergency may be another consideration to address in the Coalition's mutual aid instrument. Resolution of issues may require discussion with major regional insurers, relevant government health insurance, and consumer advocacy agencies to address:

• Payment for services when the patient(s) is transferred to a facility that is not "approved" by the involved insurer.
• Insurance policies that do not recognize an emergency transfer as a "new" hospitalization for the patient.
• Timely payments to healthcare providers not typically within the provider coverage of the third party payer.
• During a large-scale or complex incident, certain government authorized waivers may be enacted.^[82] The HCRT should work closely with its government representatives to understand these implications before any emergency. Coalitions should also be prepared for incidents that do not meet this level of governmental action/declaration.

During a large-scale incident, certain government authorized waivers may take precedent. The HCRT should work closely with its government partners to understand these implications prior to any emergency.

When establishing resource-sharing procedures, it is important to consider at least general guidance for rehabilitation and return of the shared assets. Issues for the Coalition to consider include:

• Responsibility for arranging and paying for return transportation
• Timeframe in which reimbursement to the donor organizations should occur
• Special vendors for servicing durable equipment
• Re-order information for non-durable goods
• Procedures related to employee health for evaluating and "rehabbing" deployed personnel or providing long-term tracking and follow-up of deployed personnel potentially exposed to a health hazard
• Recertification procedures before facilities that have been used for a special purpose can return to their normal function.

Finally, a dispute resolution method should be established to address difficult issues that could arise between donor and requesting organizations during emergency response and recovery.