Management of Individual Healthcare Assets (Tier 1)
Tier 1 is the primary site for point-of-service (i.e., hands-on) medical evaluation and treatment. It includes hospitals, integrated healthcare systems, clinics, community health centers, alternative care facilities, private practitioner offices, nursing homes and other skilled nursing facilities, hospice, rehabilitation facilities, psychiatric and mental health facilities, and Emergency Medical Services (EMS). The Medical Reserve Corps and State and Federal healthcare assets (e.g., Veterans Affairs Hospitals) that are co-located within a jurisdiction also fall into Tier 1 because they may become local assets for emergency response.
Key Points of the Chapter
In a mass casualty and/or mass effect incident, the vast majority of medical care is provided at the local level in hospitals, outpatient clinics, community health centers, and private physician offices. The success of an incident response, therefore, depends in part on how well these and other point-of-service healthcare organizations (HCOs) are managed and their ability to coordinate with other response agencies.
The ability of an HCO to optimally manage its resources and to integrate with the larger response community is driven by its Emergency Management Program (EMP). The EMP includes all activities undertaken by the HCO to mitigate, prepare for, respond to, and recover from potential hazards. An integral component of the EMP is the Emergency Operations Plan (EOP), which defines the management structure and methodology to be used by an HCO during emergency response. The EOP is critically important because it also describes the management processes that enable the HCO to coordinate its actions with other responders.
The two Incident Command System (ICS) functions that facilitate cooperation among HCOs and integration with the larger response community are the Command element and the Planning Section:
- HCO Incident Command: As an incident unfolds, the HCO incident management team must rapidly transition from reactive to proactive management by establishing HCO incident objectives and setting an overall HCO strategy for response. Information will have to be obtained from both inside and outside the HCO to conduct adequate response planning. A defined management structure that specifies roles for HCO personnel facilitates internal organization and external integration.
- HCO Planning Section: The development of incident action plans (IAPs) and support plans allows the HCO incident management team to remain proactive, even as the incident parameters change. Likewise, a well-defined information function that is always operational (even at a minimal baseline during times of non-response) allows an HCO to rapidly process and disseminate vital incident- related data to divisions within the HCO and to outside responders. This promotes coordination with other entities and consistency across the response system.
2.1 The Role of the HCO in MSCC
Patient evaluation and care in emergencies or disasters is provided primarily at community-based hospitals, integrated healthcare systems, clinics, community health centers, private physician offices, and other point-of-service medical facilities. These assets, therefore, must be centrally involved in the development of MSCC strategies. To maximize overall MSCC, efforts must extend beyond optimizing internal HCO operations and focus on integrating individual HCOs with each other and with non-medical organizations. Such integration ensures that decisions affecting all aspects of the community response are made with direct input from medical practitioners, thus establishing medical care, along its continuum, as an essential component of incident management. This chapter examines management processes that effectively integrate HCOs into the larger response community. It is not intended to describe a comprehensive internal management system for individual HCOs.
2.2 HCO Emergency Management Program
To adequately provide MSCC, individual HCOs must have a comprehensive EMP that addresses mitigation, preparedness, response, and recovery activities for major public health and medical incidents. A valid hazard vulnerability analysis (HVA) forms the cornerstone of the EMP. The HVA is conducted by HCOs to define and prioritize a strategy for mitigation preparedness, response, and recovery based on the perceived risk (i.e., likelihood of hazard occurrence and vulnerability to the hazard impact) posed by potential hazards to HCO.
The primary objective of an HVA is to identify hazards and the vulnerability (i.e., susceptibility) to hazard impacts, and to prioritize EMP initiatives. Many models and guides are available to develop an HVA, but the critical components may be accomplished through the following steps:
- Hazard identification. Identify and list, by type, all hazards that could affect the location or asset of interest, and the relative likelihood of each hazard's occurrence ("threat").
- Vulnerability determination. For each hazard, develop an assessment of both the community and the response system's susceptibility to the hazard impact. For MSCC, this includes:
- The community vulnerability in terms of potential post-impact health and medical needs of the population
- The medical response system's vulnerability to each hazard (both the vulnerability of the system's baseline operations and its ability to surge).
- Analysis of the vulnerabilities. Use a systems-based approach to:
- Break down each hazard vulnerability into its key components
- Identify components that are common across multiple hazards
- Identify issues that create extremely high-stakes weaknesses
- Compare relative cost-benefit ratios between the many possible mitigation and preparedness interventions.
While no HVA instrument can provide precise stratification of hazard threat and vulnerability for an asset or community, the HVA exercise should provide a basis for developing priorities among the many options that can reduce risk and enhance preparedness. From the HVA findings, the HCO can prioritize initiatives for mitigation and preparedness, and develop plans to address the identified vulnerabilities during response and recovery. If approached in this fashion, the HVA has maximum applicability to an EMP. In addition to guiding internal HCO mitigation and preparedness, the HVA activities can foster relationships with other local HCOs (Tier 2), with jurisdictional authorities (Tier 3), and with non-health-related organizations by highlighting common threats facing them.
Universities and other educational facilities may find it beneficial to address some aspects of preparedness planning in partnership with a nearby HCO. Because the threats they face may be similar, each should understand the other's vulnerability in order to effectively plan. For example, the HCO should have a sense of the number of students and staff that might be affected by identified hazards, and the university should know the patient-receiving capacity of the HCO so that it can plan for additional resources if necessary. This relationship can extend to the preparedness phase, with each organization's strengths offered to help address the other's vulnerabilities. The university may provide housing and temporary staging facilities for HCO evacuation, whereas the HCO's patient tracking and family assistance mechanisms may be used to rapidly inform the university of the location and status of students transported there for care (which addresses a significant area of university vulnerability in meeting parental expectations).
Senior executives at HCOs have ultimate responsibility for the development, implementation, and maintenance of their institution's EMP, and often appoint an emergency management coordinator to perform EMP activities. In addition, an EMP committee composed of senior-level representatives from major departments within an HCO is usually established to review all EMP-related work and to provide expert input into the development of the HCO's EOP. The following are brief descriptions of key activities in the four phases of the EMP that promote integration with the larger response community.
Mitigation is the process of planning for and implementing measures to prevent the occurrence of potential hazards. It also includes actions undertaken to minimize the impact of a hazard should one occur. It is advantageous to collaborate with other HCOs and with non-medical responders when identifying mitigation activities, as this (1) may help uncover hazards and vulnerabilities that the individual HCO might not otherwise consider and (2) allows for sharing of best practices or other solutions. Examples of mitigation activities include the following:
- Designing and constructing HCOs to avoid or minimize potential hazards (e.g., build electrical systems above ground level in flood- prone areas)
- Confining internal hazards, such as hazardous materials, in safe and secure areas to prevent their release during an internal event (e.g., a fire)
- Developing redundancy in hospital operating systems to ensure backup capability during an emergency. Backup systems should be evaluated for their vulnerability to hazards, particularly those most likely to affect primary systems (e.g., backup generators should be located above ground level in flood prone areas)
- Protecting communication systems (both internal and external) and computer infrastructure from accidental or deliberate disruption
- Establishing programs for testing, inspection, and preventive maintenance of backup systems and facility safety features.
Preparedness activities are undertaken to build capacity and capability within an HCO so that it can meet potential patient and staff needs that arise after a hazard impact. Preparedness centers on having an effective EOP in place that:
- Describes a well-defined management structure for emergency response
- Assigns important roles and responsibilities to the HCO incident management team and general staff during response
- Provides mechanisms to facilitate interfacility cooperation and integration into the community response (e.g., development of standardized data collection and information sharing protocols)
- Describes processes for requesting and receiving mutual aid, or for providing support to other HCOs whose operational thresholds have been exceeded
- Establishes mechanisms to conduct and evaluate semi-annual emergency response exercises.
Regular meetings of the EMP committee should be conducted as part of preparedness activities, and there should be an annual evaluation (and revision, if necessary) of the EOP. In addition, preparedness includes all training and drills, to impart knowledge and skills, plus exercises that are performed to stress and evaluate the HCO EOP. These activities are best performed in conjunction with other HCOs (Tier 2) or the jurisdiction (Tier 3) to enhance their integration.
Response actions address a specific hazard impact that has occurred (or an impending impact, such as a hurricane or tornado) and are guided by the HCO EOP. The primary goals of response actions are to:
- Prevent or limit the extent of a hazard impact on HCO staff, patients, and operations (e.g., proper isolation/quarantine measures)
- Maximize patient and population resistance to a hazard after exposure (e.g., administration of appropriate vaccination or medication prophylaxis)
- Promote healing of incident victims and the general population from a hazard impact (e.g., provision of definitive care, rehabilitation and mental health services).
While these response goals (i.e., control objectives) should be universal to all HCOs during response, operational period objectives, strategies, and tactics to achieve these goals may vary. It is important to coordinate response strategies among HCOs (or at least clearly communicate preferred strategies to individual HCOs) through a collective response planning process (Tier 2).
The activities of the recovery phase seek to return response personnel and the HCO to normal operations (or to a defined "new normal") as quickly as possible. Recovery efforts should include a thorough evaluation of how the response system performed under stress, making note of specific strengths, weaknesses, and strategies to improve the HCO's ability to respond to future emergencies and disasters. Other important recovery activities include the following:
- Accounting accurately for all costs incurred by the HCO as a result of a response, and applying for financial remuneration for those costs
- Attending to acute and long-term physical and mental health effects incurred by HCO staff during response (e.g., providing counseling services)
- Replacing or servicing equipment and supplies used during response
- Evaluating, cleaning, and/or repairing damage to the facility.
Recovery activities should be coordinated with other tiers. Moreover, it is critical that each HCO report to the designated jurisdictional (Tier 3) incident management authority when its recovery is complete and the facility has returned to normal operations.
2.3 HCO Emergency Operations Plan
In the past, the HCO EOP was commonly (and inaccurately) referred to as the disaster plan. Fortunately, this has begun to change as the EOP evolves into a guide to address less overwhelming emergencies and hazard threats. For early response activities, the EOP uses operational checklists (or job action sheets) for designated functions. Later stages of response, and initial stages of recovery, should be addressed by a proactive management method that emphasizes documentation of response objectives, strategies, and specific tactics.
Key Components of the HCO EOP:
- The management structure and methodology that will be used in an emergency, including the organization and operation of the internal HCO Incident Command Post (ICP). This should be easily identifiable to external coordinating agencies.
- General organizational descriptions of Operations, Planning, Logistics, and Administration/Finance Sections, which personnel perform them, and the processes/procedures to be used.
- Essential activities to be performed during each stage of emergency response. These activities should be coordinated with other HCOs (through Tier 2) and with jurisdictional incident management (Tier 3) to maximize MSCC across the system.
- Methods for adequately processing and disseminating information during an emergency, including names and contact information for external liaisons and contacts at other HCOs and the jurisdictional level (Tier 3).
- Processes to promote continuity of HCO operations, including patient care, business continuity, and pre-identified sources for external support (e.g., mutual aid partner facilities).
- Guidance on how to develop and release public messages during emergencies, including coordination with the jurisdiction (Tier 3) public information function.
- Guidance for very unusual hazards or for special circumstances, such as hospital evacuation or "shelter in place." Typically addressed in annexes to the EOP, this guidance should use the same processes established for other emergencies.
The structure of the EOP in emergency management is becoming more standardized, and HCOs should consider conforming to this structured approach. Figure 2-1 provides a synopsis of the EOP structure demonstrated in the National Response Plan (NRP) and the example below provides an EOP structure and format specifically for HCOs.
Figure 2-1. Organization of the National Response Plan
The material developed for the EOP should be formatted for ease of use during response and recovery yet must remain comprehensive. This EOP format is consistent with the common format of other disciplines and is consistent with the NRP format:
- List of changes (with dates) to the EOP
- Table of contents
- Executive summary: Provides an awareness level of proficency with the EOP.
- Purpose/Mission: goal and objectives
- Situation and assumptions
- Concept of Operations (including a System Description)
- Each functional annex provides the general response objective for the functional area, the response structure, activation and mobilization procedures specific to that function, and its concept of operations
- Position descriptions and qualifications, operational checklists (job action sheets) for positions
- Forms (including ICS forms) and other jobs aids to accomplish the tasks.
- Common administrative requirements
- Continuity of operations process and procedures
- Occupant emergency procedures
- Worker safety and health procedures
- Media policy and procedures
- Resource ordering procedures
- Response and recovery financial management procedures
- Emergency credentialing and privileging of volunteers and mutual aid personnel
- Pre-plans for common hazards:
- Weather emergencies
- Hazardous materials
- Infectious disease outbreak
- Explosive threat
- Security situations
- Infant abduction
- Care for the High Level Protectee
- Civil disturbance
- Others as identified through HVA
- Authorities (if not incorporated into the Introduction)
- Compendium of pertinent local and regional response plans and procedures
- Resource lists and content information
It is important to recognize that many private physician offices, neighborhood clinics, and other "smaller" Tier 1 assets do not have the management infrastructure or personnel necessary to establish complex processes for incident preparedness and response. However, these entities may find themselves, during a major incident, compelled to participate in the community response beyond simply referring patients to a hospital or closing down their clinical operations. This is because:
- Victims often seek medical care in settings they are familiar with, such as a personal physician's office
- When medical surge demands severely challenge hospitals, patients may seek care at alternative facilities
- Some victims' treatment requirements, or persons with medical special needs, may be adequately managed in these smaller settings
- Certain events, such as a biological agent release, may be prolonged in duration and generate patients that can be safely evaluated in these settings, thus relieving some of the burden on larger HCOs.
The approach to emergency preparedness and response for these Tier 1 assets can be relatively simple. They may elect to integrate with each other and with the community response in one of two ways:
- Associate with a larger Tier 1 organization (e.g., hospital, integrated healthcare system, large outpatient facility) where they have privileges, or with a local professional medical society. The organizing body must have the ability to manage ongoing EMP activities and, during response, to perform incident management processes, such as incident action planning and disseminating information to its participants.
- Participate in at least the information processing function of the ICS. For this to occur, the smaller Tier 1 asset must know where to obtain authoritative information and where to report information. The exchange of incident-related informaton should include the following:
- Where to obtain information on personal protection and other incident-specific safety measures for practitioners, their staff, and patients.
- Where to obtain reliable incident information that allows anticipation of medical needs, such as unusual patient treatment requirements.
- Where to obtain guidance on the specific medical evaluation of incident cases, such as the availability of confirmatory lab tests and the test limitations.
- Where to obtain pertinent information on populations at risk (e.g., for a biological event, understanding the community- wide approach to risk stratification for potentially exposed patients).
- Where to obtain information on whether public health emergency powers have been invoked, allowing release of private patient information, and other deviations from standard medical practice.
- Where to send reports and what information to transmit on patients who have been evaluated and/or treated at the practitioner's location. This helps jurisdictional authorities (Tier 3) determine the size and scope of the event and monitor incident parameters.
2.4 Integration With Other Tiers
The comprehensive EMP should establish processes that enable the HCO to coordinate and integrate with other response entities. This helps the HCO adequately provide MSCC and becomes critically important when an asset is severely challenged and must seek external assistance.
Why is it important for individual health and medical assets to have an effective interface with other tiers?
Consider the scenario of a bombing incident with large numbers of casualties. Patients may self-refer or be transported by official jurisdictional assets to multiple treatment locations. This occurred after the Pentagon attack on 9/11, as patients were transported to hospitals around the region and others self-referred to hospitals and at least two clinics (one of which was in the Pentagon). Having individual HCOs effectively integrated with other tiers will facilitate:
- Patient tracking: location of individual patients within a community's medical system.
- Tracking the status of healthcare assets to determine:
- HCOs that received large numbers of casualties that require outside support and diversion of additional patients
- Individual assets that may be available to assist other HCOs
- HCOs that can accept additional patients.
- Notification of response actions that could affect an individual asset's operations, such as street closures that limit a facility's ability to get personnel to work.
The two major functional areas that facilitate cooperation among HCOs and integration of individual HCOs with non-medical responders at the jurisdiction (Tier 3) level are the Command element and Planning Section.
There must be a clearly defined and tested command structure in place within an HCO in order for the facility to coordinate externally with other response entities. As an incident unfolds and details begin to emerge, the HCO incident management team should quickly transition from reactive to proactive management; this is best accomplished by establishing HCO control and operational period objectives for the response. These objectives should be defined and documented through incident planning—a process in which the incident management team outlines a response strategy and specific actions for the HCO. The result is often a formal IAP for the facility.
The IAP should be shared with HCO staff so that they understand the "larger picture" of what is happening and how their facility is responding. The IAP should also be shared externally with other local HCOs and with jurisdictional authorities (Tier 3) to enhance their understanding of the event, the response parameters, and the status of the HCO. Because some facilities may be reluctant to share their IAPs due to concerns about proprietary information, critical components (e.g., updated situation reports, resource status reports, safety and communication plans) can be isolated from internal, more sensitive material. The latter may be designated as an internal support plan and not distributed externally.
Within the Command element of ICS are multiple subfunctions that help integrate individual HCOs with other responders:
- Safety Officer: Recommendations for staff safety during emergency response should be standardized, if possible, across the healthcare coalition (Tier 2) and the jurisdiction (Tier 3). They should also carry the affirmation of the jurisdiction's public health authority. This includes traditional workplace safety (e.g., everyday precautions), preventive medical/health safety (e.g., vaccination prophylaxis), and security safety. Guidance should allow for variations among HCOs based on incident circumstances; however, any differences among HCOs should be identified and explained to patients and staff.
- Senior Liaison Officer: The senior liaison officer shares information and knowledge with other response leaders outside the HCO to determine the best available strategy, set priorities, and identify major actions for the HCO incident management team. Ideally, this is accomplished through Tier 2 activities (e.g., conference calls or disseminated written materials) where information is shared among all HCOs. The liaison officer should participate in HCO management decisions to ensure that objectives from outside the HCO are considered. This position should be distinguished from operational-level liaisons that focus on tactical issues (e.g., the liaison between the emergency department and EMS units).
- Senior Advisor: The senior advisor provides expert input to the HCO incident management team on medical issues that are directly relevant to strategic decision-making (e.g., provides knowledge about the stages of treatment for burn casualties so management staff may anticipate what resources will be needed at each stage). This helps the incident management team determine support needs that might have to be requested through mutual aid. The role of the senior advisor differs from that of the technical specialist, who advises the general staff on tactical issues related to patient care (e.g., specific medical and nursing procedures, medications, and other interventions).
- Public Information Officer: This position promotes an accurate and consistent message across tiers by coordinating any information transmitted to the public and the media with the message developed at the jurisdiction level (Tier 3). Information released by the HCO should focus specifically on the situation at the HCO and its operations, training, and preparedness. It should not conflict with Tier 3 public messages, nor should it speculate on strategy beyond the HCO.
The Planning Section plays a critical role because of its involvement in processing information and developing IAPs for the HCO. When shared with other local HCOs (through Tier 2) and jurisdictional (Tier 3) authorities, the HCO IAP provides strategic information to help coordinate response efforts, and may give advance warning if mutual aid support will be necessary. For example, a strategy outlined in an HCO IAP to vaccinate staff enables other organizations to decide whether they want to proceed similarly. Even if uniform measures are not adopted across a jurisdiction, this knowledge allows HCOs to reassure their staff and the public as to why they elected a particular course of action. In addition, HCOs use long-range planning to predict extended resource needs (e.g., supplies, personnel), and contingency planning to identify alternative response actions should incident parameters change. Both long-range and contingency planning will necessarily involve close integration with organizations external to the HCO.
Information from other local health and medical assets will be critical to allow optimal coordination and operation of internal HCO divisions. By operating a well-established information management function at baseline, HCOs can receive the earliest reports of an event and immediately begin processing and distributing information within the facility and externally. Similarly, data generated by an HCO (e.g., number of emergency department visits) may provide first warning of an impending crisis and can be quickly sent to other HCOs, jurisdictional emergency managers, and public health officials to establish incident parameters.
Information on the numbers of patients seeking care in the emergency department for potential exposure to anthrax can be important to the HCO for both internal and external reasons. HCO managers could use this information to determine if objectives are being accomplished, to anticipate staffing needs for the next operational period, and to determine the need for external assistance. The data might also be analyzed for operational relevance (e.g., did patient concerns about potential exposure arise from a lack of information from jurisdictional incident management?). Similarly, it is important to transmit this information (through the HCO's senior liaison) to jurisdictional (Tier 3) incident management. Both the absolute numbers and the analysis that patients presented because of a lack of jurisdiction information would be important for Tier 3 in analyzing the effectiveness of their strategy and tactics.
An important part of information management is deciding who does not need specific information. In this example, regular inpatient units may not require detailed information about emergency department operations (though this information would be available to them, as requested, through an adequately disseminated HCO IAP). Instead, a brief status report indicating the number of patients evaluated and discharged in the emergency department may give inpatient staff an adequate sense of what is occurring without providing overly detailed information.
Provided below are several mechanisms to promote HCO integration with other tiers through an adequate information management function:
- Establish regular reporting intervals that synchronize with the operational periods of Tier 2 (preferable) or Tier 3.
- Determine early in response where, how, and in what format to transmit situation reports, resource status updates, IAPs, and other information for further aggregation and analysis.
- Regularly provide situation reports and resource status updates for the HCO to appropriate external response entities. This can be easily accomplished by sharing the HCO IAP along with a list of incident- generated patients.
- Obtain from public health authorities recommendations on prophylaxis or evaluation of potentially exposed individuals, or other pertinent information (e.g., global situation status reports from Tier 3).
- Ensure that reliable and redundant systems are in place to accurately track, account for, and report on incident victims. Beyond just tracking patients in the HCO, the system must also reliably determine that a missing person is definitely not under the HCO's care.
- Maintain an information function that is always operational, even at a minimum baseline during periods of non-response. This allows for a rapid, smoother ramp-up in operations during the initial phases of an event. It also enables information that is important for EMP activities to be relayed during times of non-response (e.g., jurisdictional exercise information, upcoming event announcements).
33. EMS is not usually included in this category and is not a facility per se. In a major emergency or disaster, however, EMS may provide definitive medical care in the field and should be integrated into Tier 1.
34. In contrast, the traditional Incident Command System (ICS) model assumes that incident management is no longer responsible for patients once EMS transports patients to HCOs.
35. In this document, an HCO is any hospital, integrated healthcare system, private physician office, clinic, nursing home or other skilled nursing facility, or other resource that may provide point-of-service medical care.
36. Many other descriptions exist for individual HCO management, including the Hospital Incident Command System (HICS), State of California, Emergency Medical Services Authority, and Emergency Management Principles and Practices for Healthcare Systems, The Institute for Crisis, Disaster, and Risk Management (ICDRM) at the George Washington University; for the Veterans Health Administration (VHA)/U.S. Department of Veterans Affairs (VA), Washington, D.C., June 2006.
37. For a detailed discussion of the HVA for healthcare systems, see
Emergency Management Principles and Practices for Healthcare Systems: Unit 1, Lessons 1.3.3 and 1.3.2.
38. J. A. Barbera and A. G. Macintyre. Jane's Mass Casualty Handbook: Hospital. Surrey, UK: Jane's Information Group, Ltd., 2003.
39. "Control objectives" is the NIMS term for overall incident response goals and are not limited to any single operational period (thus distinguishing them from operational period objectives).
U.S. Department of Homeland Security, National Response Plan, August 2004
Emergency Management Principles and Practices for Healthcare Systems: Unit 1.
42. A more detailed description of incident action plans, including an example of a hospital IAP, is provided in