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Chapter 1: Overview of MSCC, Emergency Management and the Incident Command System

Medical Surge Capacity and Capabilities (MSCC) Handbook

​​Key Points of the Chapter

Mass casualty and/or mass effect[12] incidents create demands that often challenge or exceed the medical infrastructure of an affected community. A mass effect incident may be defined as a hazard impact that primarily affects the ability of the organization to continue its usual operations (in contrast to a mass casualty incident). For healthcare systems, the usual medical care capability and capacity can be compromised and the ability to surge prevented. The ability to provide adequate medical care under such circumstances is known as medical surge. There are two components of medical surge: (1) surge capacity is the ability to respond to a markedly increased number of patients; (2) surge capability is the ability to address unusual or very specialized medical needs. Strategies to enhance medical surge capacity and capability (MSCC) require a systems-based approach that is rooted in interdisciplinary coordination and based at the local level.

The MSCC Management System describes a framework of coordination across six tiers of response, building from the individual healthcare organization (HCO) and its integration into a local healthcare coalition, to the integration of Federal public health and medical support. The most critical tier is jurisdiction incident management (Tier 3) since it is the primary site of integration for public health and medical assets with other response disciplines. Each tier must be effectively managed internally in order to integrate externally with other tiers.

Emergency management and Incident Command System (ICS) concepts form the basis of the MSCC Management System. Within ICS, response assets are organized into five functional areas: Command establishes the incident goals and objectives (and in so doing defines the incident); Operations Section develops the specific tactics and executes activities to accomplish the goals and objectives; and the Planning, Logistics, and Administration/Finance Sections support Command and Operations. The Planning Section is particularly critical because it manages complex information across tiers and facilitates information exchange among responders to promote consistency within the overall system.

Because multiple agencies may have leadership responsibilities in a mass casualty and/or mass effect incident, a unified command approach is essential. Unified command enables disparate entities (both public and private) to collaborate and actively participate in the development of incident goals, objectives, and an overarching response strategy. Participation by public health and medical disciplines in unified command is important since these disciplines have a primary responsibility for ensuring the welfare of responders and the general public. Where unified command is not implemented due to sovereignty issues (e.g., across State borders or between private facilities), effective mechanisms for management coordination should be established.

1.1 What is Medical Surge

The concept of medical surge forms the cornerstone of preparedness planning efforts for major medical incidents. It is important, therefore, to define this term before analyzing solutions for the overall needs of mass casualty or mass effect incidents.

Medical surge describes the ability to provide adequate[13] medical evaluation and care during events that exceed the limits of the normal medical infrastructure of an affected community. It encompasses the ability of HCOs to survive a hazard impact and maintain or rapidly recover operations that were compromised (a concept known as medical system resiliency).

Beyond this rather simple explanation, medical surge is an extraordinarily complex topic that is difficult to comprehensively describe. The first step in doing so, however, is to distinguish surge capacity from surge capability.

1.2 The MSCC Management System

The MSCC Management System describes a system of interdisciplinary coordination that emphasizes responsibility rather than authority. In other words, each public health and medical asset is responsible for managing its own operations, as well as integrating with other response entities in a tiered framework. This allows response assets to coordinate in a defined manner that is more effective than the individual, ad hoc relationships that otherwise occur during a major emergency or disaster.

The six-tier construct (Figure 1-2) depicts the various levels of public health and medical asset management during response to mass casualty and/or mass effect incidents. The tiers range from the individual HCO or other healthcare assets and their integration into a local healthcare coalition, to the coordination of Federal assistance. Each tier must be effectively managed internally in order to coordinate and integrate externally with other tiers.

Figure 1-2. MSCC Management Organization Strategy

Figure 1-2 shows the six-tier construct depicting the various levels of public health and medical asset management during response to mass casualty and/or mass effect incidents.

1.3 Emergency Management and the Incident Command System

Emergency management and Incident Command System (ICS) concepts serve as the basis for the MSCC Management System.[18] However, unlike traditional descriptions of emergency management and ICS, which organize assets around a defined scene, the MSCC Management System has adapted the concepts to be more applicable to large-scale medical and public health response where there is no defined scene, or where multiple incident scenes may exist (e.g., infectious disease outbreak). Public health and medical professionals must understand the utility of emergency management and ICS concepts as they relate to public health and medical disciplines.[19]

The following pages examine key distinctions between emergency management and ICS and the roles that each is designed to fulfill during a major medical incident.

1.4 The Incident Command Process

The incident command process describes an ordered sequence of actions that accomplishes the following:

  • Activates the system and defines the incident response structure
  • Establishes incident goals (where the system wants to be at the end of response; these are referred to as "control objectives"[23] in NIMS) to any single operational period (thus distiguishing them from operational period objectives).
  • Defines incident operational period objectives (measurable steps that contribute to reaching the goal) and strategies to meet the defined objectives
  • Adequately disseminates information, including the following, to achieve coordination throughout ICS:
    • Response goals, objectives, and strategies
    • Situation status reports
    • Resource status updates
    • Safety issues for responders
    • Communication methods for responders
    • Assignments with individual assignment objectives and operating parameters
  • Evaluates strategies and tactics for effectiveness in achieving objectives and monitors ongoing circumstances
  • Revises the objectives, strategies, and tactics as dictated by incident circumstances.

Actions during the initial phases of incident response should be guided by checklist procedures established in the EOP. For any response of more than a few hours, management should transition to a method of proactive response by establishing incident-wide objectives. These overarching "control objectives" are further qualified by establishing measurable and attainable objectives for each operational period, and by defined strategies and tactics. All are documented in an IAP. Because event parameters and the status of the components of an asset will change, incident objectives will have to change as the response evolves.

This flux in incident and response conditions is best managed using a deliberate planning process that is based on regular, cyclical reevaluation of the incident objectives. Commonly known in ICS as the planning cycle (see Figure 1-5), this iterative process enhances the integration of public health and medical assets with other response agencies that operate planning cycles.

Figure 1-5. Basic Presentation of a Planning Cycle.[24]

Figure 1-5 shows the basic presentation of a planning cycle. 

The timing of the development of incident action plans should be coordinated among disciplines so that updated information may be shared before strategies and objectives are established. As shown in Figure 1-5, the key steps in the planning cycle are:

  • Transitional management meeting: This marks the transition from reactive to proactive incident management. The transitional meeting brings together the leadership of key response disciplines, defines the primary incident management team, and allows managers to be briefed on the known incident parameters. If the lead incident commander determines that formal incident planning is warranted, the command staff set initial incident goals (i.e., control objectives) and operational period objectives and the planning cycle process moves forward.
  • Planning meeting: Using the objectives set during the transitional (or a subsequent) management meeting, the incident management team, with leaders of key functional areas, sets strategies, general tactics, and major assignments. These are documented by the Planning Section and become a central component of the IAP. For public health and medical disciplines, documentation of an IAP has rarely been undertaken as an essential action during response, and yet it is one of the most effective means for coordinating between multiple locations, resources, and levels of government (see appendix C for an example of an IAP). The addition of supportive plans[25] completes the IAP for the upcoming operational period.
  • Operational briefing: All components of the response system are briefed on the operational period objectives, strategies, tactics, and assignments. The purpose of the operational briefing is to impart information and to raise emergent issues, not to discuss alternative plans, debate choices made in the planning process, or undertake extensive problem solving. In traditional descriptions of ICS, the operational briefing occurs in person, but it may also occur telephonically or through electronic communications. A defined briefing process imposes discipline for the operational briefings so that time constraints are met, distractions are limited, and questions are kept to a minimum.
  • Management meeting: This marks the onset of the next planning cycle. The incident command staff reevaluates the control objectives and progress made in meeting the operational period objectives, based on information collected throughout the operational period. Objectives are revised and new ones are established as appropriate.

The following critical points should be made about the planning cycle:

  • Tiers, and assets within tiers, should attempt to coordinate their planning cycles with that of the primary incident command. This allows information exchange between assets and tiers to promote consistency in the development of incident objectives and strategies.
  • A planning cycle is timed so the operational briefing occurs just before the beginning of work that is guided by the recently completed IAP. This work interval is usually referred to as an operational period. It is beneficial, therefore, for assets directly managed by the IAP to establish common operational periods.
  • Throughout the action planning process, the Planning Section plays a critical role by stewarding the planning activities and processing data into information that is relevant to incident decision-making.

1.5 Concept of Operations

The management process delineated in the MSCC Management System is best presented in relation to the various stages of incident response.

Figure 1-8. Stages of Incident Response

Figure 1-8 shows the different stages of incident response: incident recognition, notification/activation, mobilization, incident operations, demobilization, and transition to recovery. 

These stages provide the context in which to describe the critical actions that must occur at different times during incident response.

1.6 The Public-Private Divide

This chapter has presented several key concepts of ICS on which the MSCC Management System is based. A difficulty with applying traditional ICS in major medical and public health incidents is that it is designed primarily for management participation by public safety personnel. It is difficult within ICS to identify defined mechanisms for incorporating private sector assets into incident management, even if they are essential in providing leadership-level expertise for the incident. This problem was apparent in New York City after 9/11, where it was challenging to efficiently incorporate engineering deconstruction expertise (largely a private sector asset) into incident management.[32] This issue is particularly problematic for medical input into incident management because specialty medical expertise in the United States resides primarily in the private sector.

The World Trade Center experience in the aftermath of 9/11 and the response to Hurricane Katrina demonstrated many factors that can exacerbate the public-private divide:

  • Private assets may have conflict-of-interest issues when participating in public management.
  • Public agency officials may be reluctant to accept high-level management advice because they may not be comfortable with the source's objectivity or expertise. This is more likely if in-depth familiarity was not established during preparedness planning.
  • Private-sector assets do not have the liability immunity for public management that is enjoyed by public officials when acting within their established capacity. This may create a reluctance to engage in public decision-making without reliable assurance that they will not incur unacceptable legal risk.

Response systems for public health and medical incidents must identify and implement methods to bridge the public-private divide. Depending on the type of incident, qualified medical experts may provide strategic advice through a formal position in UC or as senior advisors to the UC. Alternatively, they may serve as technical specialists when their input is provided at a tactical level. Regardless of the approach, qualified medical experts must know when and how to interface with incident management (as they are rarely in charge of major response), and understand other implications of mass casualty and/or mass effect events. These experts should be selected from the medical community for their ability to accurately and fairly represent the collective interests of the private sector by providing the following:

  • Advice as it relates to medical operations
  • Evaluation of management options for addressing medical issues
  • Peer review of public messages for medical accuracy and clarity
  • Peer review of messages to the professional medical community to promote accuracy of the message and acceptance by participating medical responders
  • Other assistance or expertise, as indicated.

12. A mass effect incident may be defined as a hazard impact that primarily affects the ability of the organization to continue its usual operations (in contrast to a mass casualty incident). For healthcare systems, the usual medical care capability and capacity can be compromised and the ability to surge prevented.
13. Throughout this document, the term adequate implies a system, process, procedure, or quantity that will achieve a defined response objective.
14. Readers are encouraged to visit the Agency for Health Research and Quality Web site ( for information on alternate care facilities and allocation of scarce resources.
15. Traditionally, patient needs are matched with available resources by evenly distributing large numbers, or very ill/injured patients, to available facilities. This is logistically difficult because, in a mass casualty and/or mass effect incident, many victims self-refer for medical care (i.e., arrive outside the formal EMS system).
16. Cooperative agreements provide the same services as mutual aid, but they establish a mechanism for payment for the responding services by the affected jurisdiction. This may also be referred to as "reimbursed" or "compensated" mutual aid (the term "mutual aid" otherwise implies assistance without remuneration).
17. The authority for the Secretary of HHS to declare a Federal public health emergency or disaster is granted under Section 319 of the U.S. Public Health Service Act.
18.Appendix A highlights several critical assumptions that were made in developing the MSCC Management System.
19.Appendix B describes the basic ICS for public health and medical personnel.
20. Many of these procedures increase the efficiency of preparedness activities, while essentially training participants on the procedures to be used during response and recovery. Examples include the use of emergency notification procedures for disseminating preparedness information, the use of a management- by- objective approach when planning preparedness tasks, and using tightly managed meetings with detailed agendas.
21. A function is a key set of tasks that must be performed during incident response. They are grouped according to similarity of purpose but are not positions, per se, because each could entail multiple persons working to fulfill that function.
22. Key components of an incident action plan are presented in Appendix C.
23. "Control objectives" is the NIMS term for overall incident response goals and are not limited
24. While ICS descriptions of the meetings in the planning process vary across versions, this diagram encompasses the principle actions in all versions of the ICS planning cycle.
25. Supportive plans include the Safety Plan, the Medical Plan (for responders), communications plan, contingency plans, and others.
26. Agency Executive is defined as the Chief Executive Officer (or designee) of the agency or jurisdiction that has responsibility for the incident (FEMA ICS definition).
27. Additional information on MACS can be found in Chapter 2 of the NIMS
28. The components of MACS (per NIMS) include facilities, equipment, emergency operation centers (EOCs), specific multiagency coordination entities, personnel, procedures, and communications. These systems assist agencies and organizations to fully integrate the subsystems of the NIMS (NIMS glossary).
29. Multiagency Coordination Group: A Multiagency Coordination Group functions within a broader multiagency coordination system. It may establish the priorities among incidents.
30. ICS 300 Unit 5: Multiagency Coordination; available through FEMA Emergency Management Institute, Emmitsburg, MD.
31. ICS 300 Unit 5: Multiagency Coordination; available through FEMA Emergency Management Institute, Emmitsburg, MD.
32.This observation was made by Dr. Joseph Barbera, who was present at the World Trade Center site in the days and weeks following the attacks.

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