Key Points of the Chapter
The concepts presented in the MSCC Management System are designed to complement ongoing initiatives to establish individual components of medical surge, such as identifying pools of qualified healthcare personnel. This handbook provides the management processes necessary to enhance coordination and integration of these components. Implementation of these concepts should take full advantage of the assets and processes already in place to address medical surge. Important areas of focus for implementation strategies include:
- Management of Individual Healthcare Assets (Tier 1): Develop processes in the healthcare organization (HCO) Emergency Operations Plan (EOP) that promote effective internal management of the HCO response and information management. This will significantly enhance the ability of HCOs to coordinate with one another and to integrate into the larger community response.
- Management of the Healthcare Coalition (Tier 2): Establish processes for cooperative planning and information sharing among HCOs that can be used in times of crisis, as well as during day-to-day operations. To the extent possible, standardize requirements so that HCOs know what to report, when to report, in what format, and to whom. Establish or revise mutual aid agreements that formally describe processes for requesting, receiving, and managing mutual aid support.
- Jurisdiction Incident Management (Tier 3): Bring together representatives of the various emergency response entities, including acute-care medicine and public health, to participate in joint planning. Determine how event notification, unified incident command, and information management will occur across the response system. Ensure that processes are in place so public health and medical input can be provided into unified incident command. The Hospital Preparedness Program and MMRS Program guidance may be of assistance.
- Management of the State Response (Tier 4): Determine critical information requirements for coordinating intrastate jurisdictions and specify how State primary incident command will occur when necessary. Conduct an inventory and assessment of existing mutual aid agreements and determine how they can be enhanced to specifically address public health and medical issues.
- Interstate Regional Management Coordination (Tier 5): Establish interstate mutual aid arrangements that address medical and public health needs. Determine critical information requirements and how information will be shared across State borders. Identify points of contact in neighboring States and formally establish processes for requesting, receiving, and managing support. Where possible, integrate these arrangements into the regulations and processes that maintain the State's Emergency Management Assistance Compact. The MMRS Program guidance may be of assistance in coordinating interstate regional preparedness response in a major metropolitan area.
- Federal Support to State, Tribal, and Jurisdiction Management (Tier 6): Establish processes to gather Statewide information, evaluate response capabilities, and to determine the need for Federal public health and medical assistance. Understand how Federal public health and medical resources are organized, how they are activated and where they come from, and establish processes to facilitate integration of Federal assets at the State and local levels.
Once the concepts of the MSCC Management System are implemented, responder training should examine how they are applied within tiers and across tiers to shape the overall response system. Training sessions should include representatives from each of the major organizations involved in mass casualty or mass effect incident response. The training may be structured in stages of varying complexity and difficulty so that participants of similar knowledge level and experience can learn together. Both didactic instruction and drills might be used to maximize comprehension and retention of key concepts. Trainers should have significant experience and demonstrated expertise in large-scale incident response, and they should be able to motivate people from diverse professions to work together.
The lack of system change after thorough incident review has been a major challenge for all response entities from the local to the Federal levels. To achieve and maintain effectiveness, the response system must continually evolve to incorporate best-demonstrated practices identified through exercises or after-action report processes. A mechanism should be built into the system to provide feedback on ways to address deficiencies. In all after-action analyses, input from medical and public health disciplines should be sought and incorporated with the recommendations of other disciplines. Findings must then be translated into organizational learning, where improvement in processes, procedures, training, equipment and supplies, EOP guidance, or other areas will create lasting organizational learning rather than the less permanent "lessons learned."
8.1 Implementation Strategies
The concepts described in the MSCC Management System present an overall strategy for defining cohesive management and operational relationships for the diverse and often disparate entities that collaborate to provide MSCC. The MSCC Management System does not require an all-or-nothing approach; it may be partially implemented or fully implemented, but in a stepwise fashion over time. It is meant to complement ongoing initiatives that establish individual components of MSCC, such as identifying pools of qualified personnel, pharmaceutical and equipment caches, plans for medication-dispensing stations, plans for alternative care sites, and enhancements to laboratory capabilities. In addition, the MSCC Management System can serve as a comparison tool when assessing and revising current programs and plans, as a tool for planning and evaluating exercises, or even as a metric for conducting incident after-action review and analysis.
The concepts described in this handbook should be incorporated with existing assets and processes to limit the amount of new infrastructure that must be developed. Therefore, implementation efforts should focus first on evaluating established Emergency Management Programs (EMPs) and Emergency Operations Plans (EOPs) within individual tiers. If systems already in place meet the objectives of the MSCC Management System but operate differently than presented here, they most likely do not require change. If deficits are detected, this document could suggest where revisions to the system (rather than replacement) might enable the system to integrate more effectively into the overall response.
The Centers for Medicare and Medicaid Services (CMS), State survey agencies, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and other accrediting agencies require all HCOs (hospitals, integrated healthcare systems, nursing homes or other skilled nursing facilities, hospices, etc.) to have individual EOPs.[86] As stated in
Chapter 2, excellent models already exist that describe how HCOs can organize internally to respond to extreme events. Tier 1 focuses on the internal HCO processes that enhance external integration with other HCOs (Tier 2) and with jurisdictional assets (Tier 3). Persons reviewing existing HCO EOPs or developing new ones should consider the following major issues in applying MSCC concepts to their facility:
- Management of the HCO response: Review the qualifications and training of personnel expected to lead HCO efforts during a major response. These personnel must understand the full range of internal resources available during response and how to organize and manage the HCO effort to maximize integration with external assets. In addition, the HCO EOP should outline the steps necessary to institute a proactive management model, driven by action planning, during the early stages of response. This promotes internal HCO organization and information exchange with other entities.
- Information management: Establish quick, reliable, and redundant methods for sharing incident information. This will help link HCOs with other acute-care medical assets (Tier 2) and with the larger jurisdiction response (Tier 3). It is important not only to establish the modes of communication that will be used, but also to identify the type of information required for a coordinated response. Examinations of HCO procedures for obtaining and conveying incident information should be reviewed to determine:
- What internal linkages are necessary to ensure that initial survey data and ongoing incident information can be rapidly provided to internal HCO operations? Establishing a method for frequent situation assessments and, resource status reports across the range of assets within the HCO is invaluable for incident management.
- What mechanisms can be instituted to track patients internally during incidents of sudden surge, so that it can be quickly determined which patients are, or definitely are not, receiving care at the facility?
- What external linkages need to be made to facilitate information exchange with other medical assets, both in terms of providing data and soliciting information during a crisis?
- What types of information are appropriate to share externally during response and, therefore, can be formatted into an HCO incident action plan?
To the maximum extent possible, these efforts should be standardized across jurisdictional HCOs through Tier 2 mechanisms. Smaller entities that provide hands-on care in the community (community health centers, neighborhood outpatient clinics, nursing homes or other skilled nursing facilities, private physician offices, etc.) should not be neglected in preparedness efforts. Presenting methods for participation (as described in
Chapter 2) to individual practitioners and smaller HCOs may greatly enhance their participation in major response efforts.
HCOs are increasingly engaged in joint-planning efforts, particularly as they participate in Federally-funded bioterrorism preparedness initiatives.[87] Moreover, many localities already have established operational interaction between HCOs to monitor emergency department and critical care capacity, ambulance diversion, and other everyday situations. These activities provide an ideal opportunity for HCOs to come together to discuss and plan for coordinating major medical response.
Key issues to consider when implementing Tier 2 concepts include:
- Is there an organizational structure in place that allows HCOs to collaborate in a non-competitive environment? This organizational structure may be a local hospital association, local medical society, or local/regional EMS council.
- Are mechanisms available that allow HCO managers to interact with one another in time of need, as well as during day-to-day operations? Current processes and systems should be reviewed for their ability to support this interaction. Hospital communication centers established for private patient transport, or as EMS command centers for a jurisdiction, may be expanded or adapted to fulfill this requirement.
- Have communication and information management processes been standardized among Tier 2 coalition members, including formats for recording data? Consideration should be given not only to technology needs, but also to the methods that will be used to facilitate consensus decision-making.
- Do existing tactical mutual aid arrangements among HCOs clearly establish the processes for requesting, receiving, and managing mutual aid support? An initial assessment may be needed to inventory and evaluate support mechanisms that already exist, and to determine how to prioritize new efforts to maximize MSCC. Consideration of such issues as staff credentialing, liability coverage, worker compensation, and reimbursement mechanisms is critical.
Implementation of MSCC concepts at the jurisdictional level should follow a process in which representatives of various response disciplines (including public health and acute-care medicine) assemble to examine how to improve the delivery of public health and medical care during extreme events. The process should examine specific questions, such as:
- How will the various response entities notify one another of an impending or occurring event?
- What critical information should be included in the initial notification messages?
- How will response entities establish jurisdictional incident management for the wide range of events that may potentially result in human casualties?
- How will response entities organize and interact with one another during a response, and how will the input of individual agencies be given to the lead management agency?
- How will representatives of the medical community (traditionally private sector) provide input into the unified command or UC (e.g., through a designated position in a unified command team, a senior advisory role, or some other mechanism)?
- What critical information should be shared among response entities? How will needs be addressed, while including such private-sector entities as hospitals and clinician offices?
- What type of support from the jurisdiction's non-medical entities may be needed to enhance the ability of public health and medical assets to provide MSCC?
- What critical demobilization issues are there for HCOs?
- How can representatives of the healthcare community be included in after-action analyses?
Initiatives undertaken to address these questions should use currently available assets and processes to enhance operational relationships. For example, most jurisdictions have 911 emergency communication centers (ECCs) for everyday emergency services. The ECC may be adapted to perform the notification and early planning function for the jurisdiction's (Tier 3) EOP until this can be established at the Incident Command Post (ICP). In addition, the ECC and its paging/messaging services can provide initial notification to on-call representatives of the UC and be used for the early teleconference that initiates unified incident planning.
Examinations of the jurisdictional (Tier 3) response system should focus on identifying processes that promote unified incident command. Below is a series of basic steps that can be followed to incorporate UC processes into the jurisdictional EOP. In addition, each response entity should be assessed for its ability to integrate into the system. Assets that do not reach a threshold of desired management capability (e.g., effective incident information processing, incident planning, and informed decision-making) should be prioritized for improvement through jurisdiction EMP actions.
The following is a general guide for establishing unified incident command techniques in the jurisdiction's EOP.
- Review the jurisdiction's hazard vulnerability analysis (HVA) to identify key management needs for all identified hazards.
- Identify agencies that repeatedly are included in the list of key management needs and designate these agencies as standard participants in UC.
- Identify other organizations that might be called on for management input during specific incidents (e.g., public school system for a foodborne outbreak in a school cafeteria). A decision support tool should be established to determine which agencies should be included as UC participants for specific events.
- Identify the lead agency for each type of hazard (recognizing that the lead may shift by response stage and by incident issue).
- Define how the UC will come together during response, whether physically or via remote teleconference.
- Define how transition of lead authority in the UC will occur as indicated during a response.
- Define the incident planning capability for the UC (who will plan and how). This position is the Planning Section Chief and conducts management and planning meetings, operations briefings, and situation updates.
- Define the site where the ICP will be located, if it is not defined by a hazard scene.
- Define how the site and capability for UC will be established if the ICP is scene-defined. For example, if the designated lead agency in the UC has a command vehicle, this may become the ICP during field response.
- Define the process for action planning in the UC. What critical information will be required from both public and private sectors, and what time frames (i.e., planning cycles and operational periods) periods could potentially be used?
- Define how information management functions will be integrated between the various response entities in a jurisdiction.
- Define the demobilization requirements for UC, including whether agencies can decrease their participation in UC as objectives are met (and, if so, how this will be accomplished).
- Define methodology, participants, and responsibilities for conducting after-action analyses.
A starting point for implementing State level MSCC is to establish the management processes that would occur if the State were to assume primary incident command responsibility. Preparedness activities should examine how State public health and medical assets would be incorporated into UC, and how State managers would interact with jurisdictional (Tier 3) response entities.
The State must examine critical information requirements to coordinate intrastate jurisdictions:
- What type of information and/or data will be important for the State to obtain from jurisdictional incident management (Tier 3)?
- How will this information/data be obtained from jurisdictions, and how will it be collated and analyzed at the State level?
- Have standardized formats for reporting incident information/data (including situation assessments and resource status reports) been developed and provided to jurisdictional management?
- Are procedures in place, and does the infrastructure capability exist, to facilitate rapid dissemination of aggregate information/ data back to local jurisdictions?
Other important implementation tasks include conducting an inventory and assessment of existing tactical mutual aid arrangements. These plans should be reviewed to determine possible ways to address the medical (e.g., licensure, liability) and financial (e.g., lack of guaranteed reimbursement) barriers for private HCOs that provide mutual aid services. State level incident management systems that do not incorporate the private medical sector should consider adopting a healthcare coalition (Tier 2) function to address the concerns of HCOs. Recognizing medical and health assets (Tier 1) as crucial players in public safety emergency response may promote their participation in an incident command system. It may also promote an understanding by State officials of the specific requirements of medical and health assets.
Activities to improve interstate regional management coordination should focus on expanding current initiatives to better address MSCC in the private health and medical sector. Processes should specify key information requirements, explain how data will be shared between States, and identify key points of contact at the State level and their counterparts in neighboring States. The organization of State incident command (Tier 4) should be shared between partner States to enhance coordination of management activities, such as the exchange of incident action plans and support plans.
Examinations of strategic, or "master," mutual aid guidelines should ensure that key "top-line" issues for medical and public health entities have been addressed. Important issues include licensing, liability coverage, and worker's compensation for out-of-State healthcare personnel, as well as reimbursement mechanisms for medical and public health assets. Tactical mutual aid agreements may provide the specific methods for requesting, receiving, and managing interstate mutual aid, transporting and distributing assets, and demobilizing public health and medical resources. Preparedness activities should examine Emergency Management Assistance Compact (EMAC) legislation and regulations to ensure that public health and medical requirements for MSCC are adequately addressed.
Because of significant changes in the Federal response system following 9/11 and, more recently, Hurricane Katrina, State emergency planners should review and understand the Federal response capability, how Federal public health and medical assistance may be obtained, and under what authority it may be activated. The State and jurisdictional EMP should determine what their own response capabilities are (i.e., what can the system handle, and what can it definitely not handle), and identify what types of information will be critical in demonstrating the need for Federal assistance. Before an emergency or disaster occurs, State and local response systems must identify the criteria they will use to determine that their system has reached capacity and that additional support, through mutual aid or Federal assistance, is necessary.
States and local jurisdictions should also have operational plans (within their EOP) describing how Federal resources (personnel, supplies, equipment, or facilities) will be integrated into the State and local response effort. Among other issues, it is important to consider:
- Where will Federal public health and medical assets be staged upon arrival?
- To whom will Federal personnel report for tactical direction?
- How will State emergency management (usually located at the State EOC) interact with HHS Regional Emergency Coordinators (RECs) and accommodate the Incident Response Coordination Team (IRCT), (see
Chapter 7) and other deployed liaisons?
- What management processes will direct the distribution of Federal resources, such as Strategic National Stockpile (SNS) medications, vaccines, and supplies?
- Are guidelines in place specifying who has priority access to limited vaccines, personnel, or supplies, and how this will be communicated to the general public?
- Have plans for demobilization addressed the demobilization of Federal public health and medical assets?
8.2 Training Strategies
Training that incorporates the MSCC Management System could follow the same strategies presented under implementation. A course that orients participants to the overall system and its functions is important in establishing the key concepts for preparedness planners and incident response managers. A shorter version of the course must be available to brief healthcare executives. Other training activities could be assessed and revised so that they convey the appropriate knowledge and teach the skills necessary to operate the indicated MSCC integration actions.
Training sessions ideally include representatives from all of the major organizations involved in mass casualty and/or mass effect incident response, including the following:
- Hospital personnel
- Healthcare coalition (Tier 2) representatives
- Public health officials
- EMS personnel
- Fire service personnel
- Law enforcement officers
- Emergency management personnel
- State-level emergency managers
- Other organizations that may be involved in major incident response (e.g., State Survey Agency, State Medicaid Agency, American Red Cross, Salvation Army, local pharmacy association).
To maximize the value of training, participants should have relatively comparable levels of knowledge and experience with regard to the management component of emergency preparedness and response. This may be achieved by providing training in stages that present progressively more advanced concepts. For example, the beginner level might focus on important medical and health issues in EMP and EOP development, such as incident action planning and UC. More advanced training might address the interaction of medical and health assets with other response agencies at the jurisdictional, State, and Federal levels. Even at the beginner level, however, it is critical that participants understand the basic applications of emergency management and the Incident Command System (ICS, see
Appendix B).
Individuals providing training should be senior-level personnel with significant experience and demonstrated expertise in large-scale incident response. Beyond demonstrating a subject matter expertise, trainers should be effective instructors with exceptional communication skills. They should possess the skills needed to do the following:
- Effectively communicate complex topics in easy-to-understand language
- Help trainees work through real-life scenarios while integrating many diverse perspectives into decision-making processes and incident planning
- Motivate trainees from different professional disciplines to work together in support of improving overall strategy for medical surge.
To complement didactic instruction, exercises may be used to evaluate systems, processes, and skills.[88] The evaluation objectives are established as the first step in exercise planning, so the incident scenario and other parameters may be designed to meet these objectives. Exercises that are intended to evaluate the functional effectiveness of the MSCC Management System should have objectives that focus on coordination between tiers and integration of individual assets within the tiers.
Incorporating concepts from the MSCC Management System into existing response plans promotes ongoing training through their use during response to small or low-intensity events. This is important in familiarizing incident managers and response personnel with the system and facilitates coordination and integration under more severe incident stress. Frequent practice will also help emergency planners identify how plans can be revised to enhance interorganizational coordination and multidisciplinary integration.
8.3 Ongoing System Evaluation
An effective response system is one that continually evolves to incorporate best-demonstrated practices identified in analyses of training exercises or actual events. Therefore, the response system should have a built-in mechanism that provides feedback on the strengths and weaknesses of preparedness and response initiatives, and that identifies strategies to improve the overall system. One primary vehicle for this feedback is a thorough and timely after-action report process. This process must look at medical and public health components of incident response and, therefore, must have clearly defined participatory roles for acute-care medical and public health responders. Moreover, there should be processes attached to the after-action reports to promote organizational learning rather than just an awareness of "lessons learned."[89]
86. In past guidance, JCAHO referred to emergency operations plans as "emergency management plans."
87. Information on the Hospital Preparedness Program (HPP).
88. The
Department of Homeland Security's Homeland Security Exercise and Evaluation Program (HSEEP) helps State and local jurisdiction governments develop, implement, and evaluate exercise programs to enhance preparedness.
89. Additional information on organizational learning may be found in
Emergency Management Principles and Practices for Healthcare Systems, Unit 4.
