Our Healthcare Preparedness columnist picks the brains of three highly experienced hospital emergency managers about the whens, whys, hows and how-not-tos of healthcare disaster exercises. 

By Mitch Saruwatari, Vice President, Quality and Compliance
LiveProcess
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The ability to pre-assign and train personnel for a hospital emergency is a daunting task for any emergency manager, requiring extensive documentation and skills in communication and coordination. But it doesn’t have to be, if a comprehensive exercise program is established that builds on response competencies learned over time.

Disaster and emergency exercises let a hospital test its disaster preparedness plans and response, as well as monitor and maintain the healthcare facility’s state of readiness. A good model to follow is outlined in the Homeland Security Exercise and Evaluation Program (HSEEP), which provides all the critical components for building a long-term exercise program, as well as creating and summarizing individual exercises and drills. It is also a useful way to meet accreditation standards and improve collaboration with local response agencies.

For this column, I wanted to identify successes and challenges to creating and implementing drills and exercises, so I spoke with three leading healthcare emergency management professionals from around the country who also represent diverse facilities and communities. Each of our contributors has many years of emergency management experience and been involved in numerous exercises and several real-life incidents.

Charlotte S. Clark, A.S., CHSP, CHEC-III is the emergency manager, Regional Coordinating Hospital - Region D, Grady Memorial Hospital, Atlanta. Rick Davis is the manager for environmental health and safety at Kaiser Permanente Riverside Medical Center, Riverside, Calif. And Bonnie Kaido, MS, is the director of emergency preparedness for Bassett Healthcare, Cooperstown, N.Y.

Please describe how you prepare for a functional exercise.

Davis: You first have to decide what your objectives are, then start planning around that. You get objectives from previous exercises and work with things that didn't go well.

Kaido: As defined by the Homeland Security Exercise and Evaluation Program, operations-based exercises such as functional exercises validate plans, policies, agreements and procedures, clarify roles and responsibilities, and identify resource gaps in an operational environment. A functional exercise examines and/or validates the coordination, command and control between various multi-agency coordination centers (emergency operations center, Joint Field Office, etc). Unlike a full-scale exercise, a functional exercise does not involve any “boots on the ground” (first responders or emergency officials responding to an incident in real time).

Clark: Most Georgia hospital emergency managers have already been trained in the HSEEP standards, which are required for receiving federal grant funds. These standards are very strict; when preparing for an exercise, we have to begin with objectives.

How long does it take?

Davis: It depends on whether you’re doing it internally or with outside agencies in the community. If it’s internal, it’s probably a 4- to 5-hour process that you’ll do over time, but you can write it up and get the outline done and gather input from your disaster or emergency preparedness committee. Area-wide exercises take up to a year to plan. A lot of coordination is required.

Kaido: Good planning would dictate at least six months, if not more. The actual exercise takes as long as needed to test the goals.

Clark: Six to nine months. In order to be compliant, you need to do a planning session with objectives. A second plan session and two workshops are also needed in order to educate participants. Two months later, we do a tabletop exercise, which gives us the time to implement policies and train people, and six months after the tabletop, a full-scale exercise.

Who is involved in planning?

Davis: You try to get a cross-section of people from the departments most affected or involved, such as the emergency room, education and infection control. It’s a very diverse committee.

Kaido: Depending on the type of exercise, hospital staff members, regional hospital representatives, county public health and emergency services, local emergency services, and for some events, state health department, emergency management, and Homeland Security officials.

Clark: An emergency management person from the healthcare organization, who partners with EMS providers, EMAs, public health (local and state), Red Cross, people who take part in planning. You need this input and have to have their injects to satisfy their roles.

Who participates in the exercise?

Davis: Actually people from all departments participate at one level or another. You want as broad participation as possible. It may just be paperwork so they can submit their staff level so people in the Hospital Command Center know those levels and what their resources are. This allows command staff such as the incident commander, materials management, finance, planning, operations, public relations and others involved in the Hospital Incident Command System (HICS) insight to perform activities for initial response and future planning. Some of them will perform other duties, such as ensuring the flow is right, doing the evaluations and things like that. Broader exercises require agencies such as other hospitals, public health and EMS agencies.

Kaido: Again, this is dependent on the goals. We have worked with a three-county group of hospitals and our local partners to test communications capabilities, response to a severe winter weather emergency and movement of resources. With state involvement, it could include participation at the community, county, regional and state levels.

Clark: Inside the hospital, anyone involved directly with the HICS participates. Regionally, those involved should be EMS, hospitals, public health and other affected partners. For example, we did a lot of planning at the airport for one exercise. This involved the Border Patrol, Customs agents, the Red Cross, airport security officials, etc.

How do you control the timing of events?

Davis: You always have someone who is a controller. In our case, there’s always a controller with an outline and timeline. If things are going too fast, they slow it down; if too slow, they speed it up. You always follow your master sequence of events list.

Kaido: We use a Master Scenario Events List to insert actions and scenarios to test our goals. We recently purchased an emergency management software system that will enable us to automate this process and make our exercises more true to life.

Clark: When you’re doing the planning, it’s common sense more than anything. You need to make full use of the event log. Based on discussions, you have to build in time to do all of the tasks, use your best judgment and knowledge. That’s why it’s helpful to have all of the knowledge you can at the planning table.

How do you evaluate?

Davis: You must first have objectives. Evaluators at different places look at different things. We use different reports, plus those from participants, to gather feedback and create an action plan from all of those comments. When the drill is complete, we usually have a hot wash, in which we bring all the ED people and HICS together and ask them for strengths and weaknesses, etc. From that, I write an after-action plan which states what went well, what went wrong, what we need to fix, what tools we need. This plan goes back to our emergency preparedness committee, which then assigns follow-up to various people. This is how you build upon your next drill. It’s an ongoing process.

Kaido: We designate observers at various steps of the exercise. For example, if we are testing the performance of our emergency operations center, also referred to as the Hospital Incident Command Center, we have observers placed there to follow different HICS roles. If we are testing our evacuation plan, we place observers on each floor, in stairwells and at the point where patients would be dispersed to other facilities. We are now using the Exercise Evaluation Guides <https://hseep.dhs.gov/pages/1002_EEGLi.aspx> as part of the process.

Clark: Grady has two trained evaluators. We are healthcare HSEEP compliant on this. Whoever is doing the compliance part depends on several factors. The University of Georgia has evaluators who are contracted for by the state health department. They also write the after-action reports.

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