FAQs

The Emergency Management Program (EMP) implements the mission, vision, goals and objectives of the organization as related to Emergency Management. The EMP utilizes organized analysis, planning, decision making and assignment of available resources to mitigate, prepare for, respond to, and recover from all-hazards. (Emergency Management Principals and Practices for Healthcare Systems, Department of Veterans Affairs, 2006).

The Emergency Operations Plan (EOP) provides the structure and processes that the organization utilizes to respond to and initially recover from an event. The EOP is therefore the response and recovery component of the EMP.

The Joint Commission Emergency Management Standards are very specific to the requirements of the hospital EOP, however it should be noted that some of these requirements cross over to mitigation and preparedness activities.

For a suggested outline of the EMP and for further guidance, see the following:

• Download CHA’s Key Components of a Hospital Emergency Management Program (EMP)
• Download CHA’s Hospital Emergency Management Program Checklist

The After Action Report (AAR) captures observations of an exercise and makes recommendations for post-exercise improvements. The AAR then is used to develop Improvement Plans (IP). HSEEP AAR examples can be found on the HSEEP website.

The Joint Commission requires a hospital designee whose sole responsibility during emergency response exercises is to monitor performance and document opportunities for improvement in EM.03.01.03 and specifies that all emergency response exercises include the identification of deficiencies and opportunities for improvement. Developing an AAR meets the criteria.

• Download the HSEEP AAR Template

The Recovery phase begins when hospital incident command determines that the event is de-escalating or over and that some or all de-mobilization and recovery activities can be initiated.

Activities involved in recovery phase will be dependent on the event and its impact on the hospital; these include assessing the six critical elements of operation and taking the steps necessary to ensure safe, normal operations (communications, resources and assets, safety and security, staff responsibilities, utilities, and [patient] clinical and support activities).

 Event response checklists and/or HICS Response Guides include recovery phase activities; recovery activities should include preparation of documentation for submission of claims for federal reimbursement as appropriate to the event.

If the hospital has facility damage or has evacuated the facility, then review and approval by appropriate regulatory agencies (e.g., state licensing, OSHPD, Fire Marshall) may be required before repatriating facilities or operations. Preparations for recovery should be initiated during the Mitigation, Planning and Response phases to minimize event impacts and optimize timely resumption of normal operations and recuperation of expenses. For example, mitigation activities may include information technology (IT) systems secure back-up to allow for recovery after an event involving loss of IT, planning may include the establishing procedures and appropriate documentation to account for event related expenses to maximize federal funding, and response may include de-escalation plans that allow for gradual resumption of normal operations.

The hospital should have a business continuity plan (BCP), or continuity of operations plan (COOP), that identifies non-critical functions and resources that may be reassigned during an emergency, as well as critical functions, services and their redundancy to support both response and recovery.

Federal statutes and regulations cannot be waived or suspended by the Governor. However, during a catastrophic disaster, the Governor may make a request to the federal Secretary of Health and Human Services requesting waiver of specific federal statutes and regulations. The following provisions could be waived.

• Requirement to Obtain Patient Consent to Speak with Family or Friends – 45 CFR 164.510
• Requirement to Honor Opt-Out Request Obtain for Facility Directory – 45 CFR 164.510
• Requirement to Distribute Notice – 45 CFR 164.520; 42 USC Section 1320b-5(b)(7)(B)
• Patients Right to Request Privacy Restrictions and Confidential Communications – 45 CFR 164.522; 42 USC Section 1320b-5(b)(7)(C)

The EMTALA requirement is based on federal law and cannot be waived by the Governor. However, the Governor may request that the Health and Human Services Secretary waive the EMTALA requirements under 42 USC Section 1320b-5.

Hospitals are required by The Joint Commission to monitor performance and evaluate each exercise or actual event using a multidisciplinary process that involves licensed independent practitioners. During an exercise, individuals are to be designated to observe performance and document opportunities for improvement. That evaluation process is to result in:

• Documented identification of deficiencies and opportunities for improvement
• Documented assignment and monitoring of improvement activities, including the hospital team/committee responsible for emergency management
• Modification of the hospital Emergency Operations Plan or supporting policies and procedures based on the evaluation; if modifications require substantive resources and cannot be accomplished by the next exercise, interim measures should be implemented
• Incorporation of modified or interim measures in subsequent emergency response exercises.
• The hospital should maintain clear and timely documentation of each step in after action evaluation, improvement planning and monitoring, resulting modifications to Plans policies and procedures, and exercising of modifications or areas identified for improvement.

Hospital Preparedness Program (HPP) participating hospitals are required to participate in community-wide after action evaluation and improvement planning meetings and to submit an exercise summary report form to the Local HPP Entity following each community-wide exercise in which the hospital participates.

The Incident Action Plan contains objectives reflecting the overall incident strategy and specific tactical actions and supporting information for the next operational period. The hospital’s IAP is generally comprised of:

• Form 201: Incident Briefing
• Form 202: Incident Objectives
• Form 203: Organizational Assignments
• Form 204: Branch Assignment List
• Form: 215A: Incident Action Plan (IAP) Safety Analysis
• IAP Quick Start (combines forms 201, 202, 203, 204, and 215A)

The IAP may also have a number of other forms as attachments such as Traffic Plans, Branch Assignments, etc.

Objective 12 of NIMS Implementations Objectives for Healthcare states Incident Command System (ICS) implementation must include the consistent application of incident action planning. IAPs are required anytime H.I.C.S. is implemented in a drill or exercise.

Hospitals may benefit substantially in achieving landline and cell communications and restoring communications after a disruption in service with and without a declared disaster.

GETS provides emergency access and priority processing in the local and long distance segments of the Public Switched Network (PSN). Federal, state, and local government, industry, and non-profit organization personnel performing their national security and emergency preparedness missions can apply for and receive the GETS card and access code.

WPS is a method of improving connection capabilities for a limited number of authorized national security and emergency preparedness cell phone users. In the event of congestion in the wireless network, an emergency call using WPS will wait in queue for the next available channel.

TSP does two things: It gives a higher priority to restoration of lost service by the hospital’s telecommunications provider, and in the event that new services are needed at the current/new hospital location, the new lines will be expedited in the installation process.

Redundant communication refers to having multiple back-up communication modalities and is imperative in emergency preparedness planning. Past experience demonstrates that hospitals cannot depend on just one or two means for communication. Some examples of redundant communication include:

• Basic telephone systems
• In-building wireless phone systems
• Overhead announcement and paging systems
• Nurse call system
• Voice over Internet Protocol systems
• Cell phones
• Beepers and pocket pagers
• Enterprise systems
• BlackBerries and similar devices
• Text messaging
• Text-to-voice translation
• Communication systems for the deaf and hearing impaired
• Telephonic translation lines and services
• Access control systems
• Fax machines
• Hospital television network systems
• E-mail
• Mass notification systems
• Hospital electronic bulletin boards
• Intranet message posting
• Bed-tracking and facility status reporting systems
• Electronic health record systems
• Enterprise systems for networked hospitals
• Resource and grant-asset tracking systems
• Evacuee and disaster patient tracking systems
• Emergency medical services communication systems
• Emergency desktop and mobile handheld programmed radios
• Communication with emergency operations centers
• Public health monitoring and notification systems (syndromic surveillance systems, threat notification systems, outbreak management systems)
• Satellite radio and communication systems
• Ham radio systems
• Human runners, paper and pen

Many hospitals used to develop specific plans for a variety of disaster and emergency situations. The Federal Emergency Management Agency (FEMA) now requires that hospitals use an emergency management system that is comprehensive, risk based, and all-hazard in nature. All-hazard planning is based on a general plan that works for many different emergency/disaster presentations, with incident specific responses found in annexes to the general plan. Hazard Vulnerability Analysis (HVA) ranks the likelihood and severity of the possible hazards occurring for the hospital and/or the Operational Area, and gives planners the ability to plan for the events posing the greatest threat.

Local public health departments, local emergency medical services agencies (LEMSA) and the Department of Homeland Security, are all working together to test readiness for various scenarios. Hospitals should participate in the planning for these events as well as working with the Hazard Vulnerability Analysis for each hospital to coordinate community participation with the specific needs of the hospital. Joint planning and sharing HVAs with community partners is an excellent way to demonstrate community involvement and participation by the hospital. Hospitals should maintain minutes and rosters from Hospital Preparedness Program meetings and any other planning events to demonstrate participation.

Effective emergency management requires planning, cooperation, training and exercising with the entire community. Collaboration should start at the planning phase and continue throughout the entire Emergency Management Program development and implementation.

Other community partners should be aware of the hospital’s EMP and be involved in integrating the various plans for other agencies. Community planning cannot be accomplished by hospitals developing Emergency Management Programs in a vacuum, there are too many shared and common resources used by multiple hospitals and multiple community agencies to have effective plans without joint planning.

Disaster Councils and County Emergency Medical Care Committees are two common forums where the broad community emergency operations planning often occur. Some communities use the local Public Health Departments’ Hospital Preparedness Programs (HPP) stakeholders meeting to perform these community-wide planning efforts. Local healthcare coalitions are also used to perform these community planning efforts.

A hazard vulnerability analysis is a process for identifying the hospital’s highest vulnerabilities to natural and man-made hazards and the direct and indirect effect these hazards may have on the hospital and community. An HVA provides the hospital with a basis for determining the most likely standards and potential demands on emergency services and other resources that could occur during a crisis so that effective preventive measures can be taken and a coordinated disaster response plan can be developed.

Hospitals should develop specific mitigation and event specific response plans for the top 3 to 5 hazards they have identified, and should emphasize training and exercises around responding to those hazards.

While there are a number of ways to conduct an HVA, Kaiser Permanente has developed a widely used tool that can help identify and assess the most common hazards. The Kaiser model is available here.

It is important to note that cities and counties are also required to prepare HVAs; the hospital HVA should consider hazards identified in the community plans that may impact the hospital. In some communities the hospital and community HVAs are developed together. Hospitals should document a review of their HVA every year and share it with the community.

The Joint Commission in EM.03.01.03 requires the deficiencies and opportunities for improvement, identified in the evaluation of all emergency response exercises be communicated to the improvement team responsible for monitoring environment of care issues.

NFPA 1600 requires that procedures shall be established to take corrective action on any deficiency identified.

1. Communication (EM.02.02.01)
2. Resources and assets (EM.02.02.03)
3. Safety and security (EM.02.02.05)
4. Staff responsibilities (EM.02.02.07)
5. Utilities management (EM.02.02.09)
6. Patient clinical and support activities (EM.02.02.11)

• Get more information on this topic

ICS 300/400 courses are not a requirement for healthcare under the “NIMS Implementation for Healthcare Organizations Guidance”.

While ICS 300/400 are not required courses for healthcare personnel, Emergency Managers and interested individuals may find the training of value.  Courses may be found from the links on this website under Training & Exercises.

For more information on NIMS:

• Federal Emergency Management Agency (FEMA)
• Texas A&M Engineering Extension Service (TEEX)
• California Office of Emergency Services (CAL OES)

No. A stand alone HICS course does not take the place of ICS 100, 200 and 700, which are specific requirements of the NIMS Objectives. ICS 100 provides an Introduction to the Incident Command System. ICS 200 provides training on personnel who may assume ICS command positions and ICS 700 provides training on the National Incident Management System.

No. Completion of ICS courses by appropriate personnel satisfies two of the 14 NIMS Compliance Objectives for Healthcare Organizations (Objective 5 and Objective 6). The remaining objectives must also be met to make a hospital NIMS compliant.

According to the Federal Emergency Management Agency, the NIMS Integration Center is responsible for facilitating the development of national guidelines for incident management training and exercises at all jurisdictional levels, while individual agencies and organizations are responsible for establishing and certifying instructors. The NIMS Center provides the following guidelines for ICS instructors:

• ICS-100 Instructors
• Lead and Unit Instructors should have successfully completed ICS-100, ICS-200 and IS-700 NIMS
• Lead Instructor should have training and experience in adult education and have served as Incident Commander or in a command staff or general staff position

ICS-200 Instructors

• Lead Instructor should have successfully completed ICS-300
• Unit Instructors should have successfully completed ICS-200
• Lead Instructor should have training and experience in adult education and have served as Incident Commander or in a command staff or general staff position

IS-700 Instructor Requirements

• Two instructors are recommended to teach IS-700 classes, but are not required
• Lead and Unit Instructors must have successfully completed IS-100, IS-200 and IS-700
• Lead Instructors must have training and experience in adult education and have served as an Incident Commander or in a command staff or general staff position

ICS-700 Instructors

• According to the National Integration Center, there are several acceptable types of formal adult education experience and instructor training to meet the requirements to present NIMS training:
• DHS Office of Grants and Training’s Instructor Training Certification Course or equivalent state course
• National Wildfire Coordinating Group Facilitative Instructor M-410 course
• Emergency Management Institute Master Trainer Program
• National Fire Academy Instructional Methodology class
• College education courses
• USAF Academic Instructor School
• American Red Cross, National Safety Counsel, American Heart Association, or American Safety Health Institute instructor development training

It is immaterial to the NIC if someone takes the courses from USFA, EMI, NWCG, USDA, EPA, Coast Guard, State Agencies, CAP, a private vendor etc., as long as the courses meet the content and objectives outlined in the National Standard Curriculum Training Development Guidance.

Yes, a hospital may utilize a vendor-created or delivered training course. The National Integration Center (NIC) recognizes that many operational aspects of the NIMS, including ICS training, are available through, state, local and tribal training agencies and private training vendors. It is not necessary that the training requirements be met through a federal source.

The hospital verifies that it is NIMS compliant by meeting the fourteen NIMS Objectives for Healthcare Organizations.

A free course on IS100/200/700 is available on this site for hospital staff who wish to self-study, take the post test, and print a certificate of completion.

FEMA also offers free online training courses in IS 100/200/700/800 for hospital staff that wish to self-study, take the post test, and print a certificate of completion.

• Access CHA’s ICS Web Training Course (IS-100, IS-200 & IS-700)
• Access FEMA’s NIMS and ICS Courses

NIMS courses ICS-100, ICS-200 and IS-700 or their equivalents should be completed by:

• Hospital personnel who are likely to assume a leadership ICS position in the Hospital Command Center or who have a primary responsibility for emergency management
• Hospital Emergency Preparedness Committee Members/persons responsible for the Emergency Management Program
• The Emergency Program Manager

In addition, the Emergency Program Manager should complete IS-800.B or equivalent.

These courses are offered online or by self study through the CHA website (satisfies the requirements of ICS-100, ICS-200 and IS-700). Alternately, these classes may be completed on the FEMA website.

• Go to the CHA Course: IS100/200/700
• View additional training opportunities on FEMA’s Website

The hospital’s Hazard Vulnerability Analysis (HVA) assists exercise planners in identifying threats facing the facility. The facility’s HVA provides a list of top scenarios to base future drills and exercises on. Additionally, past after action reports and improvement plans provide previously identified areas for improvement that can be tested.

Community-wide discussions and planning with local and regional emergency preparedness committees take into account the Multi-Year Training and Exercise Plan, which includes specific capabilities and objectives that could also be evaluated in future exercises. The identified objectives help address general exercise program goals, provide a framework for scenario development, guide development of individual organizational objectives, and supply evaluation criteria.

Additionally, The Joint Commission lists specific activities and observations to be monitored in exercises in EM.03.01.03 that can be used in future exercises.

The initial steps to planning an exercise include identifying:

• Exercise purpose
• Proposed exercise scenario, capabilities, tasks, and objectives
• Available exercise resources
• Proposed exercise location, date, and duration
• Exercise planning team and exercise participants

An exercise Interim Planning Meeting can establish:

• The exercise planning schedule
• Clearly defined, obtainable, and measurable exercise capabilities, tasks, and objectives
• Identified exercise scenario variables (e.g., threat scenario, scope of hazard, venue, conditions)

Additional information and tools for exercise planning and assistance can be found at the Homeland Security Exercise and Evaluation Program Website.

According to the Homeland Security Exercise Evaluation Program (HSEEP) there are seven types of exercises, each of which is either discussion-based or operations-based.

Discussion-based exercises familiarize participants with current plans, policies, agreements and procedures, or may be used to develop new plans, policies, agreements, and procedures. Types of discussion-based exercises include:

• Seminar: A seminar is an informal discussion, designed to orient participants to new or updated plans, policies, or procedures (e.g., a seminar to review a new Evacuation Standard Operating Procedure).
• Workshop: A workshop resembles a seminar, but is employed to build specific products, such as a draft plan or policy (e.g., a Training and Exercise Plan Workshop is used to develop a Multi-year Training and Exercise Plan).
• Tabletop Exercise (TTX): A tabletop exercise involves key personnel discussing simulated scenarios in an informal setting. TTXs can be used to assess plans, policies, and procedures.
• Games: A game is a simulation of operations that often involves two or more teams, usually in a competitive environment, using rules, data, and procedure designed to depict an actual or assumed real-life situation.
• Operations-based Exercises validate plans, policies, agreements and procedures, clarify roles and responsibilities, and identify resource gaps in an operational environment. Types of operations-based Exercises include:
  • Drill: A drill is a coordinated, supervised activity usually employed to test a single, specific operation or function within a single entity (e.g., a fire department conducts a decontamination drill). 
• Functional Exercise (FE): A functional exercise examines and/or validates the coordination, command, and control between various multi-agency coordination centers (e.g., emergency operation center, joint field office, etc.). A functional exercise does not involve any “boots on the ground” (i.e., first responders or emergency officials responding to an incident in real time).
• Full-Scale Exercises (FSE): A full-scale exercise is a multi-agency, multi-jurisdictional, multi-discipline exercise involving functional (e.g., joint field office, emergency operation centers, etc.) and “boots on the ground” response (e.g., firefighters decontaminating mock victims).

Additional information and tools for exercise planning and assistance can be found at the Homeland Security Exercise and Evaluation Program Website.

There are different requirements for the various accrediting bodies and grant requirements. For example, the Hospital Preparedness Program grant may require participation in the Annual Statewide Medical Health Exercise.

The National Incident Management System (NIMS) Compliance for Healthcare Objective 7 states that NIMS concepts and principles are promoted into all organization-related training and exercises.

The Joint Commission in EM03.01.03 outlines requirements for hospitals in this area. The hospital must activate it’s Emergency Operations Plan twice a year and at least one of them must include an escalating event in which the local community is unable to support the event, and at least one includes participation in a community-wide exercise.

The California Code of Regulations 70741 (d) states the disaster plan shall be rehearsed at least twice a year. 70743 © requires fire and internal disaster drills shall be held at least quarterly for each shift of hospital personnel and under varied conditions.

NFPA 5.14 requires the entity shall evaluate program plans, procedures, and capabilities through periodic reviews, testing, and exercises.