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Chapter 8: Implementation, Training, and System Evaluation

Medical Surge Capacity and Capabilities (MSCC) Handbook

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.

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.

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