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STATEWIDE MEDICAL AND HEALTH FUNCTIONAL EXERCISE

EXERCISE GUIDEBOOK THURSDAY, NOVEMBER 15, 2012

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2011-2013 LOS ANGELES COUNTY MEDICAL AND HEALTH EXERCISE PROGRAM

2012 STATEWIDE MEDICAL AND HEALTH FUNCTIONAL EXERCISE

Exercise Guidebook i

PREFACE The template for this Exercise Guidebook was developed by the California Department of Public Health (CDPH) and the California Emergency Medical Services Authority (EMSA), in collaboration with the California Emergency Management Agency (Cal EMA), California Hospital Association (CHA), California Primary Care Association (CPCA), California Association of Health Facilities (CAHF), representatives from local health departments, healthcare, public safety and emergency management disciplines. Consistent with Homeland Security Exercise and Evaluation Program (HSEEP) doctrine, it has been further tailored for the 2012 Statewide Medical and Health Functional Exercise (SMHFE) at the direction of the SMHFE sponsors, CDPH and the Los Angeles County Emergency Medical Services (EMS) Agency, including specific SMHFE input from the Exercise Planning Team (EPT), comprised of representatives from the following agencies/organizations:

California Association of Health Facilities California Emergency Management Agency

Centinela Hospital – Prime Healthcare Services Children’s Hospital Los Angeles

Community Clinic Association of Los Angeles County Good Samaritan Hospital

Henry Mayo Newhall Memorial Hospital Hospital Association of Southern California

Los Angeles City Fire Department Los Angeles County Department of Coroner

Los Angeles County Department of Public Health Los Angeles County EMS Agency

Los Angeles County Fire Department Los Angeles County Office of Emergency Management

Los Angeles Department of Water and Power Memorial Hospital of Gardena

Schaefer Ambulance Service, Inc. Sherman Oaks Hospital – Prime Healthcare Services

St. John’s Health Center Torrance Memorial Hospital UCLA Healthcare System

This Exercise Guidebook provides planners from participating organizations the information they need to develop and conduct their exercise in conjunction with the SMHFE.



Exercise Guidebook ii




Exercise Guidebook iii

TABLE OF CONTENTS PREFACE .................................................................................................................... i

TABLE OF CONTENTS ............................................................................................... iii

ACRONYM LIST ........................................................................................................ iv

2012 STATEWIDE MEDICAL AND HEALTH FUNCTIONAL EXERCISE ......................... 1

INTRODUCTION ..................................................................................................... 1

HOMELAND SECURITY EXERCISE AND EVALUATION PROGRAM ...................... 1

CORE CAPABILTIES ................................................................................................ 3

EXERCISE OBJECTIVES ........................................................................................... 3

EXERCISE SCENARIO ............................................................................................. 3

LOS ANGELES COUNTY OPERATIONAL AREA PLAYERS ..................................... 3

PLANNING AND CONDUCTING THE EXERCISE ....................................................... 5

INTRODUCTION ..................................................................................................... 5

PROGRAM MANAGEMENT .................................................................................. 5

DESIGN AND DEVELOPMENT ............................................................................... 6

EXERCISE CONDUCT ........................................................................................... 15

EVALUATION ........................................................................................................ 19

IMPROVEMENT PLANNING ................................................................................. 20

RESOURCES ............................................................................................................. 21

APPENDIX A: JOINT COMMISSION STANDARDS ................................................. 23

APPENDIX B: LONG TERM CARE GUIDANCE ....................................................... 29

APPENDIX C: NATIONAL INCIDENT MANAGEMENT SYSTEM IMPLEMENTATION OBJECTIVES FOR HEALTHCARE .............................................................................. 30

APPENDIX D: EXERCISE EVALUATION AND IMPROVEMENT PLANNING ............ 33



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ACRONYM LIST AAC After Action Conference AAR After Action Report C/E Controller and Evaluator C&O Concepts and Objectives CAHF California Association of Health Facilities Cal EMA California Emergency Management Agency CDPH California Department of Public Health CHA California Hospital Association CPCA California Primary Care Association DHS Department of Homeland Security DOC Department Operations Center EOC Emergency Operations Center EEGs Exercise Evaluation Guides EMS Emergency Medical Services EMSA Emergency Medical Services Authority (State) EndEx End of Exercise EPT Exercise Planning Team EXPLAN Exercise Plan FE Functional Exercise FOUO For Official Use Only FPC Final Planning Conference FSE Full Scale Exercise HSEEP Homeland Security Exercise and Evaluation Program ICS Incident Command System IP Improvement Plan IPC Initial Planning Conference LAC DHS Los Angeles County Department of Health Services LAC DPH Los Angeles County Department of Public Health LAC OA Los Angeles County Operational Area LAC OEM Los Angeles County Office of Emergency Management MPC Mid-Term Planning Conference MSEL Master Scenario Events List NIMS National Incident Management System SimCell Simulation Cell SITMAN Situation Manual SMART Simple, Measurable, Achievable, Realistic, Task Oriented SME Subject Matter Expert SMHE Statewide Medical and Health Exercise SMHFE Statewide Medical and Health Functional Exercise StartEx Start of Exercise TEP Training and Exercise Plan TTX Tabletop Exercise



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Exercise Guidebook 1

2012 STATEWIDE MEDICAL AND HEALTH FUNCTIONAL EXERCISE INTRODUCTION The SMHFE is designed to assist participants in developing, strengthening and testing their emergency response plans, policies and procedures relative to medical and health emergency preparedness, response, recovery and mitigation as they pertain to a catastrophic earthquake incident. The exercise emphasizes the role of acute care facilities/hospitals, local health departments, community care clinics, long term care facilities, law enforcement, emergency medical services/ambulance providers, local emergency medical services agencies, coroners, emergency management, fire service, and utility authorities as well as partners who support the response to an interruption of the power supply due to an earthquake. The SMHFE will be conducted on November 15, 2012 in conjunction with the Statewide Medical and Health Exercise (SMHE). HOMELAND SECURITY EXERCISE AND EVALUATION PROGRAM HSEEP1 serves as exercise and evaluation doctrine that is flexible, scalable, and adaptable to the needs of stakeholders across the whole community. Revised in 2012, the use of HSEEP—in line with Presidential Policy Directive 8 the National Preparedness Goal, and the National Preparedness System—supports efforts to improve national capacity across the whole community to collectively build, sustain, and deliver core capabilities. HSEEP encourages planners to identify exercise program objectives that are informed by strategy documents, threat, hazard, and capability assessments, and results from previous exercises. These program-wide objectives guide the design and development for individual exercises, as planners develop exercise-specific objectives and associated core capabilities for validation and assessment during exercise conduct. Exercise evaluation assesses exercise performance against exercise objectives—documenting strengths, areas for improvement, core capability levels and gaps, and corrective actions in an After Action Report/Improvement Plan (AAR/IP). Through improvement planning, exercise

1 https://hseep.dhs.gov/

The Exercise Guidebook and accompanying exercise materials

provided by Los Angeles County

and their Exercise Planning Team

partners incorporate 2012 HSEEP revisions.




stakeholders prioritize, track and analyze corrective actions, ensuring that the corrective actions inform future exercise program objectives. The principles and proven methodology of the HSEEP approach ensures successful progression of exercise design, complexity, and execution, allowing for the appropriate training and preparation to take place in the organizations and jurisdictions carrying out the exercise. Using this approach, each organization can ensure the exercise scope and scale are tailored to their specific needs. Because each organization/jurisdiction will differ regarding core capabilities and objectives to be tested, this approach provides enough flexibility to allow for significant learning opportunities that complement, build on, and directly lead into one another effectively. Additionally, each organization or jurisdiction should plan and conduct exercises based on their identified needs and prior AAR/IPs. The Exercise Guidebook includes exercise objectives with reference to applicable elements of performance from The Joint Commission Chapters on Emergency Management, Environment of Care and Life Safety, as well as compliance elements for the National Incident Management System (NIMS). Utilizing the HSEEP guidelines, this Exercise Guidebook refers to accompanying exercise documents including:

• Tabletop Exercise Situation Manual (SITMAN) • Functional /Full Scale Exercise Plan (EXPLAN) • Exercise Evaluation Guides (EEGs) • Master Scenario Events List (MSEL) • Controller/Evaluator (C/E) Handbook • AAR/IP • Patient Profiles

Partners in emergency preparedness and response, from healthcare entities to public safety and coordinating agencies, use a combination of exercises to identify strengths, test emergency response plans and identify gaps in overall response. These exercises may include seminars, workshops, tabletop exercises (TTXs), games, drills, functional exercises (FEs) and full scale exercises (FSEs). The exercise guidebook provides a common framework for the development of an organization or jurisdiction-specific exercise program. For many partners, exercises are necessary to fulfill either grant or regulatory body compliance.




CORE CAPABILTIES The exercise program is designed to allow planning and response partners to tailor their level of exercise participation and determine local impact from the threat scenario. The exercise is designed to test the following identified capabilities:

• Communications • Fatality Management • Medical Evacuation/Shelter in Place • Medical Surge • On-Site Incident Management • EOC Management • Critical Resource Logistics and Distribution

EXERCISE OBJECTIVES Exercise design objectives focus on improving understanding of a response concept, evaluating emergency response procedures, identifying areas for improvement and achieving a collaborative response. Exercise planners are expected to tailor these objectives to their specific exercise needs and capabilities or develop additional objectives, as necessary. Objectives for the SMHFE can be found in the EXPLAN. EXERCISE SCENARIO A customizable scenario has been developed for the SMHFE. Exercise planners for the organization/jurisdiction should work with local stakeholders, jurisdictions and organizations to provide the opportunities to test the plans and procedures and meet the objectives identified for the exercise. LOS ANGELES COUNTY OPERATIONAL AREA PLAYERS Los Angeles County, along with numerous agencies and organizations within its boundaries, will participate in the exercise. In addition, the Los Angeles County Department of Health Services (LAC DHS) will activate and staff their Department Operations Center (DOC) to support exercise play, including messaging and resource requesting. Several key stakeholders have initiated planning efforts for a SMHFE that is tailored for the Los Angeles County Operational Area (LAC OA).




PLANNING AND CONDUCTING THE EXERCISE INTRODUCTION This section provides a brief overview of the process of planning, conducting, and evaluating exercises, and comes directly from the HSEEP. It is not intended to act as a substitute for formal exercise training and education, but is to provide a common framework of exercise program management to exercise planners. Successfully conducting an exercise involves considerable coordination among participating organizations and officials. Before organizations or jurisdictions conduct an exercise, the appropriate senior officials and executives should be briefed to gain their support. Establishing this base of support indicates that the exercise purpose and objectives are concurrent with strategic and organizational goals and objectives. Additionally, senior officials often have the ability to garner participation from potential exercise players and planning team members. The HSEEP methodology is applicable to all national preparedness mission areas and ensures a consistent and interoperable approach to exercise program management, design and development, conduct, evaluation and improvement planning. PROGRAM MANAGEMENT Exercise program management is the act of overseeing a variety of individual exercises and supporting activities sustained over time. An effective exercise program helps whole community stakeholders maximize efficiency, resources, time, and funding by ensuring that individual exercises are part of a coordinated, integrated approach to building, maintaining, and delivering core capabilities. Key elements of HSEEP’s approach to exercise program management include:

• Exercise Program Objectives. An exercise program should be guided by a set of overarching exercise program objectives linked to core capabilities. These overarching objectives can inform the development of exercise-specific objectives, ensuring that individual exercises build and maintain core capabilities in a coordinated and integrated fashion across the whole community of stakeholders. They may also support national training and exercise program guidance as described in the National Preparedness System.

• Multiyear Training and Exercise Plan (TEP). A TEP aligns training and exercise objectives and schedules, encouraging stakeholders to coordinate efforts to validate, assess, and enhance core capabilities.




• Corrective Action Process. A critical output of any exercise is the AAR/IP, which defines and assigns corrective actions needed to address issues observed during exercise evaluation. The use of HSEEP encourages organizations to track progress on all corrective actions, releasing periodic reports that document progress in resolving corrective actions and highlighting those corrective actions that are incomplete or behind schedule.

DESIGN AND DEVELOPMENT The exercise design and development process builds on exercise program management to select participants for an exercise planning team, schedule planning conferences, identify and develop exercise- specific objectives and scope, design the scenario, create documentation, plan exercise conduct, select a focus for evaluation, and coordinate logistics. EXERCISE PLANNING TEAM The EPT manages and is ultimately responsible for the successful execution of all aspects of an individual exercise to include exercise design, development, conduct and evaluation. The EPT works with exercise stakeholders to determine or refine exercise objectives based on core capabilities, tailors the scenario to adequately test the entities objectives and develops supporting documentation to guide exercise conduct and evaluation. EPT members also help with developing and distributing pre-exercise materials and conducting exercise planning conferences, briefings, and training sessions. The EPT should be of manageable size yet represent the full range of participating organizations as well as other relevant stakeholders. For multijurisdictional exercises, planning team members should include representatives from each jurisdiction and participating functional area or relevant disciplines. The membership of an EPT should be modified to fit the type or scope of an exercise, which varies depending on exercise type and complexity. An exercise planning team leader manages the planning team. The EPT’s organization and management principles should reflect those of the NIMS, with clearly defined roles and responsibilities and a manageable span of control. To design and develop exercises most effectively, EPT’s should:

• Adhere to a clear organizational structure, with a distinct chain of command, roles and responsibilities, and accountability ending in the exercise planning team leader;

• Use proven management practices, processes, and tools, such as project plans and timelines, status reports, and other communications;

• Clearly identify and understand the desired objectives for the exercise and design and develop the exercise accordingly;




• Use subject-matter experts (SMEs) to develop a realistic and challenging scenario; and

• Follow a standardized exercise design and development process. Support agencies/organizations working with children and adults with and without disabilities who have access and functional needs must also be included from the beginning of the planning process to ensure that issues facing this population are included and addressed during the exercise. In doing so, exercise planners can better understand their perspectives and promote early understanding of roles and responsibilities and planning assumptions to identify potential problems, inaccuracies, inconsistencies, omissions, and questionable assumptions.

Generally, planning team members are not exercise players. However, for cases in which resources are limited, EPT team members who act as both planners and players should be especially careful not to divulge exercise information in advance. EXERCISE PLANNING ACTIVITIES Effective exercise design and development involves a combination of exercise planning activities, often in the form of planning meetings and conferences. These planning activities bring together exercise stakeholders to discuss and agree on key aspects of the exercise’s design and development. The EPT members decide the type and number of planning activities needed to successfully plan a given exercise, based on its scope, type and relative complexity. For example, exercise planners generally employ longer timelines for TTXs than for workshops and seminars, and even longer timelines for complex or multi-jurisdictional FSEs. Meeting and exercise site locations should take into consideration those individuals who require assistance or accommodations during their attendance. Example timelines for scheduling exercise planning activities can be found online2. The following describes the types of planning conferences most useful in exercise design and development.

• Concept and Objectives (C&O) Conference. A C&O Conference is the formal beginning of the planning process. It is held to identify the type, scope, objectives, and purpose of the exercise. For less complex exercises and for organizations with limited resources, the C&O Conference can be conducted in conjunction with the Initial Planning Conference (IPC). Representatives from the sponsoring agency or organization, representatives from potentially participating

2 Example timelines can be found at https://hseep.dhs.gov




organizations, the exercise planning team leader, and senior officials typically attend the C&O Conference. The C&O Conference helps planners identify the capabilities and tasks that are going to be assessed, design objectives based on those capabilities and tasks, and identify exercise planning team members.

• Initial Planning Conference. The IPC marks the beginning of the exercise development phase, and, regardless of whether a C&O Conference is held, an IPC should be conducted for all exercises. Its purpose is to determine exercise scope by gathering input from the exercise planning team; design requirements and conditions (e.g., assumptions and artificialities); objectives; extent of play; and scenario variables (e.g., time, location, hazard selection). The IPC is also used to develop exercise documentation by obtaining the planning team’s input on exercise location, schedule, duration, and other relevant details. During the IPC, EPT members are assigned responsibility for activities associated with designing and developing exercise documents—such as the EXPLAN and the SITMAN—and logistics.

• Mid-Term Planning Conference (MPC). MPCs are typically used in more complex exercises such as FEs and FSEs. MPCs provide additional opportunities to settle logistical and organizational issues that may arise during planning. The MPC is a meeting to discuss exercise organization and staffing concepts, scenario and timeline

development, scheduling, logistics, and administrative requirements. It is also held to review draft documentation. If only three planning conferences are scheduled (i.e., IPC, MPC, and Final Planning Conference [FPC]), a portion of the MPC should be devoted to developing the MSEL. See the next section, MSEL Conference, for more information.

• Master Scenario Events List Conference. For more complex exercises, one or two additional planning conferences—or MSEL Conferences—may be held to review the scenario timeline. If not held separately, topics typically covered in a separate MSEL Conference can be incorporated into the MPC and FPC. The MSEL Conference focuses on developing the MSEL. The MSEL is a chronological list that supplements the exercise scenario with event synopses; expected participant responses; capabilities, tasks, and objectives to be addressed; and responsible personnel. It includes specific scenario events (or injects) that prompt players to implement the plans, policies, procedures, and protocols that require testing during the exercise, as identified in the capabilities-based planning process. It also records the methods that will be used to provide the injects (e.g., phone call, radio call, e-mail).

• Final Planning Conference. The FPC is the final forum for reviewing exercise processes and procedures. An FPC should be conducted for




all exercises to ensure that all elements of the exercise are ready for conduct. Prior to the FPC, the exercise planning team receives final drafts of all exercise materials. No major changes to the exercise’s design, scope, or supporting documentation should take place at or following the FPC. The FPC ensures that all logistical requirements have been met, outstanding issues have been identified and resolved, and exercise products are ready for printing.

SIMPLE, MEASURABLE, ACHIEVABLE, REALISTIC, AND TASK-ORIENTED (SMART) OBJECTIVES The cornerstone of exercise design is the selection of capabilities to be assessed and determination of exercise objectives based on those capabilities. The exercise planning team determines core capabilities and objectives based on the overall exercise program objectives. The objectives should reflect the exercise sponsor’s specific needs, environment, plans, and procedures, while providing a framework for scenario development and a basis for evaluation. Exercise planners should create objectives that SMART. The Federal Emergency Management Agency3 (FEMA), defines SMART objectives as:

• Simple: the objective is clearly written and simply phrased. It is brief and easy to understand.

• Measurable: the objective should set the level of performance, so that results are observable, and you can tell when the objective has been achieved. It does not necessitate a quantifiable standard, but completion of objective is easily demonstrated.

• Achievable: achieving it should be within the resources that the organization is able to commit to an exercise.

• Realistic: The objective should present a realistic expectation for the situation. Even though an objective might be achievable, it might not be realistic for the exercise.

• Task Oriented: The objective should focus on a behavior or procedure. With respect to exercise design, each objective should focus on an individual emergency function.

Generally, planners should limit the number of exercise objectives to enable timely exercise conduct, facilitate reasonable scenario design, and support successful evaluation. Capabilities, tasks, and objectives are initially prepared during a C&O Conference or IPC. For seminars, workshops, TTXs and games, objectives typically focus on strategic, policy-oriented issues; whereas for drills, FEs and FSEs, objectives typically focus on operational issues.

3 Exercise Design Steps: www.training.fema.gov/emiweb




EXERCISE SCOPE Determining exercise scope enables planners to “right-size” an exercise to meet the objectives while staying within the resource and personnel constraints of the exercising organizations. Key elements in defining exercise scope include exercise type, participation level, exercise duration, exercise location, and exercise parameters. Some of these elements are determined, or initially discussed, through program management activities. However, the exercise planning team finalizes the scope based on the individual exercise objectives. Alterations to the scope are reviewed with the exercise objectives in mind; planners must consider whether a change in the scope will improve or impede the ability of players to meet the objectives. The following are exercise types to be tailored per the exercise objectives:

• Seminars. Seminars generally orient participants to, or provide an overview of, authorities, strategies, plans, policies, procedures, protocols, resources, concepts, and ideas. As a discussion-based session, seminars can be valuable for entities that are developing or making major changes to existing plans or procedures. Seminars can be similarly helpful when attempting to gain awareness of, or assess, the capabilities of interagency or inter-jurisdictional operations. Seminars do not typically result in a formal, comprehensive AAR/ IP; however, a final report, or Summary Report, can be developed to capture the discussions; issues raised; and, when appropriate, corrective actions that will address these issues.

• Workshops. Although similar to seminars, workshops differ in two important aspects: participant interaction is increased, and the focus is placed on achieving or building a product. Effective workshops entail the broadest attendance by relevant stakeholders. Products produced from a workshop can include new standard operating procedures, emergency operations plans, continuity of operations plans, and mutual aid agreements. To be effective, workshops should focus on a specific issue, and the desired outcome, product, or goal must be clearly defined.

• Tabletop Exercises. A TTX is typically held in an informal setting intended to generate discussion of various issues regarding a hypothetical, simulated emergency. TTXs can be used to enhance general awareness, validate plans and procedures, rehearse concepts, and/or assess the types of systems needed to guide the prevention of, protection from, mitigation of, response to, and recovery from a defined incident. Generally, TTXs are aimed at facilitating conceptual understanding, identifying strengths and areas for improvement, and/or achieving changes in attitudes. During a TTX, players are encouraged to discuss issues in depth, collaboratively examining areas of concern and solving problems. During a TTX, all participants should be encouraged to contribute to the discussion




and be reminded they are making decisions in a no-fault environment. Effective TTX facilitation is critical to keeping participants focused on exercise objectives.

• Games. A game is a simulation of operations that often involves two or more teams, usually in a competitive environment, using rules, data, and procedures designed to depict an actual or hypothetic situation. Games explore the consequences of player decisions and actions and are therefore excellent tools to use when validating or reinforcing procedures or evaluating resource requirements.

• Drills. A drill is a coordinated, supervised activity usually employed to validate a specific operation or function in a single agency or organization. Drills are commonly used to provide training on new equipment, validate procedures, or practice and maintain current skills. For example, drills may be appropriate for establishing a community-designated disaster receiving center or shelter. Drills can also be used to determine if plans can be executed as designed, to assess whether more training is required, or to reinforce best practices. A drill is useful as a stand-alone tool, but a series of drills can also be used to prepare several agencies and organizations to collaborate in a FSE. For every drill, clearly defined plans, procedures, and protocols need to be in place. Personnel need to be familiar with those plans and trained in the processes and procedures to be drilled.

• Functional Exercises. FEs are designed to validate and evaluate capabilities, multiple functions and/or sub-functions, or interdependent groups of functions. FEs are typically focused on exercising plans, policies, procedures, and staff members involved in management, direction, command, and control functions. In FEs, events are projected through an exercise scenario with event updates that drive activity at the management level. An FE is conducted in a realistic, real-time environment; however, movement of personnel and equipment is usually simulated.

• Full-Scale Exercises. FSEs are typically the most complex and resource-intensive type of exercise. They involve multiple agencies, organizations, and jurisdictions and validate many facets of preparedness. FSEs often include many players operating under cooperative systems such as the Incident Command System (ICS) or Unified Command. In an FSE, events are projected through an exercise scenario with event updates that drive activity at the operational level. FSEs are usually conducted in a real-time, stressful environment intended to mirror a real incident. Personnel and resources may be mobilized and deployed. The FSE simulates reality by presenting complex and realistic problems that require critical thinking, rapid problem solving, and effective responses by trained personnel.




SCENARIO A scenario is an outline or model of the simulated sequence of events for the exercise. It can be written as a narrative or depicted by an event timeline. For seminars, workshops, TTXs, and games, a scenario provides the backdrop that drives participant discussion, and it is contained in a SITMAN. For drills, FEs, and FSEs, a scenario provides background information about the incident catalyst(s) of the exercise—the overall scenario is provided in the C/E Handbook, and specific scenario events are contained in the MSEL. Exercise planners should select and develop scenarios that enable an exercise to meet its capabilities, tasks, and objectives. There are a number of factors that should be taken into consideration when developing a scenario, including level of realism, type of threat/hazard, site selection, weather variables, and optimal date and time for exercise conduct. All scenarios should be realistic, plausible, and challenging; however, designers must ensure the scenario is not so complicated that it overwhelms players. Scenario development should also take into account the capabilities and tasks that an exercise seeks to validate. EXERCISE DOCUMENTATION Thorough exercise documentation is a critical component of effective exercise design and development. There is a range of exercise documentation available to planners. Factors such as exercise scope, type, and complexity inform the types of documentation needed. The list below briefly describes the various types of documents associated with most exercises. These documents must be customized to each organization/jurisdiction’s specific exercise.

• Situation Manual. SITMANs are provided for TTXs and games as the core documentation that provides the textual background for a facilitated exercise. The SITMAN supports the scenario narrative and serves as the primary reference material for all participants during conduct.

• Exercise Plan. EXPLANs are general information documents that help drills, FEs, and FSEs run smoothly by providing participants with a synopsis of the exercise. They are published and distributed to the participating organizations following development of most of the critical elements of the exercise. In addition to addressing exercise objectives and scope, EXPLANs assign activities and responsibilities for exercise planning, conduct, and evaluation. The EXPLAN is intended to be seen by the exercise players and observers—therefore, it does not contain detailed scenario information that may reduce the realism of the exercise.

• Facilitator Guide. A Facilitator’s Guide is designed to help facilitators manage a seminar, workshop, TTX, game, or planning meeting. It




usually outlines instructions and key issues for discussion during the event and provides background information to help the facilitator answer questions from participants or players.

• Controller/Evaluator Handbook. The C/E Handbook specifically describes the roles and responsibilities of exercise controllers and evaluators and the procedures they should follow. Because the C/E Handbook contains information about the scenario and about exercise administration, it is distributed to only those individuals specifically designated as controllers or evaluators. The C/E Handbook supplements the EXPLAN and contains more detailed information about the scenario. It points readers to the EXPLAN for more general exercise information, such as participant lists, activity schedules, required briefings, and the roles and responsibilities of specific participants.

• Master Scenario Events List. A MSEL is typically used in drills, FEs, and FSEs and contains a chronological listing of the events that drive exercise play. The MSEL is a chronological timeline of expected actions and scripted events (i.e., injects) to be inserted into operations-based exercise play by controllers in order to generate or prompt player activity. It ensures necessary events happen so that all exercise objectives are met.

• Exercise Evaluation Guides. The EEGs help evaluators collect and interpret relevant exercise observations. These documents are aligned to a core capability and applicable performance objective, providing guidance on assessing capabilities being validated by the exercise. Each EEG provides evaluators with information on what they should expect to see demonstrated or hear discussed, space to record their observations, and criteria to consider after the exercise. EEGs are not meant as report cards. Rather, they are intended to guide an evaluator's observations so that the evaluator focuses on capabilities and tasks relevant to exercise objectives to support development of the AAR/IP.

• Participant Feedback Form. Players and observers receive a Participant Feedback Form after the end of the exercise that asks for input regarding observed strengths and areas for improvement that players identified during the exercise. Providing Participant Feedback Forms to players during the exercise Hot Wash allows them to provide evaluators with their insights into decisions made and actions taken. A Participant Feedback Form also provides players the opportunity to provide constructive criticism about the design, control, or logistics of the exercise to help enhance the planning of future exercises.

• After Action Report/Improvement Plan. The AAR/IP is the final product of an exercise. The AAR/IP has two components: an AAR, which captures observations and recommendations based on the exercise




objectives as associated with the capabilities and tasks and an IP, which identifies specific corrective actions, assigns them to responsible parties, and establishes targets for their completion. The lead evaluator and the EPT draft the AAR and submit it to conference participants prior to an After Action Conference (AAC). The draft AAR is distributed to conference participants for review no more than thirty (30) days after exercise conduct. The final AAR/IP is an outcome of the AAC and should be disseminated to participants no more than 60 days after exercise conduct.

EXERCISE CONTROL PLANNING Exercise control maintains exercise scope, pace, and integrity during conduct under safe and secure conditions. The control structure in a well-developed exercise ensures that exercise play accommodates objectives in a coordinated fashion at all levels and at all locations for the duration of the exercise. In the design and development phase, exercise planners should consider control-related issues such as the staffing, structure, training, safety, security and communications of the control staff. EXERCISE EVALUATION PLANNING Exercise evaluation activities begin as soon as exercise objectives are identified. In the design and development phase, exercise planners should account for issues such as the staffing, structure, training, and communications of evaluation staff members. Thorough planning and organization prior to an exercise is imperative to effective and successful exercise evaluation. This process should include:

• Appointing a lead evaluator; • Defining evaluation requirements based on exercise objectives; • Recruiting, training, and assigning evaluators; • Finalizing the evaluation sections of the C/E Handbook or EvalPlan;

and • Conducting a C/E Briefing.

Through this process, an evaluation team can organize itself appropriately and develop a comprehensive plan to address how the exercise will be evaluated.




LOGISTICS PLANNING Effective logistics are essential to a successful exercise. They can make the difference between a smooth, seamless exercise and one that is confusing and ineffective. Exercise planners should consider the full range of logistics-related issues, such as venue layout and capabilities, access to restrooms, food and refreshments, badging and identification, parking and transportation, onsite communications, and site security. EXERCISE CONDUCT After design and development activities are complete, the exercise is ready to take place. Exercise conduct involves activities such as preparing for exercise play, managing exercise play, and conducting immediate exercise wrap-up activities. For a seminar, workshop, TTX or game, conduct also entails presentation, facilitation, and discussion. For a drill, FE or FSE, conduct encompasses all operations occurring between the designated start of the exercise (StartEx) and end of the exercise (EndEx). Core elements of exercise conduct include preparing for exercise play, conducting the exercise, and wrap-up. Exercise practitioners are encouraged to apply and adapt HSEEP doctrine on exercise conduct to meet their specific needs. EXERCISE PLAY PREPARATION SET UP Immediately prior to exercise play, exercise planners conduct a series of activities to prepare for exercise play. These activities include finalizing venue-related setup and confirming important venue- or exercise-specific logistical details. The exercise planning team should arrange and begin event setup as many days prior to the event as necessary, depending on the scope of the simulated environment. Setup entails arranging any briefing or exercise related rooms needed, testing audio/visual equipment, placing props and effects, marking the appropriate areas and their perimeters, and checking for potential safety issues. On the day of the exercise, planning team members should arrive several hours before the scheduled start to handle any remaining logistical or administrative items pertaining to setup and to arrange for registration and conduct a communications check if necessary. BRIEFINGS Presentations and briefings are important tools for delivering necessary exercise-related information to participants on their roles and responsibilities prior to an Exercise. Exercise planners hold a series of briefings targeted to different types of exercise participants (e.g., controllers, evaluators, players). These briefings are an opportunity to distribute exercise documentation, provide necessary instructions and administrative information, and answer any outstanding questions prior to exercise play beginning.




• Controller and Evaluator Briefing. The C/E Briefing is generally conducted the day before an operations-based exercise. It begins with an exercise overview and then covers location and area, schedule of events, scenario, control concept, C/E responsibilities, and any miscellaneous information.

• Player Briefing. Approximately fifteen (15) to thirty (30) minutes before the start of the exercise, a controller conducts a briefing for all players to address individual roles and responsibilities, exercise parameters, safety, badges and any remaining logistical exercise concerns or questions. Following the exercise, controllers ensure that appropriate players attend the post-exercise hot wash in their respective functional area.

• Actor Briefing. The Actor Briefing should be conducted before the exercise, prior to the actors taking their positions. The actor controller leads this briefing and includes the following information: exercise overview, safety, real emergency procedures, symptomatology, acting instructions, and schedule. Identification badges and symptomatology cards are distributed before or during this briefing.

• Observer Briefing. An observer briefing informs exercise observers and VIPs about program background, scenario, schedule of events, observer limitations, and any other miscellaneous information. Often, observers will be unfamiliar with public safety procedures and will have questions about the activities they see. Designating someone, such as a public information officer, to answer questions prevents observers from asking questions of players, controllers, or evaluators. The observer briefing is generally conducted the day of an exercise.

EXERCISE PLAY The EPT leader normally serves as the senior controller of exercise play. This person is responsible for announcing the start of the exercise. No exercise activities should commence prior to this announcement. Play continues in the exercise environment as controlled by the exercise staff. During exercise conduct, participants play various, specific roles. These roles may depend on the type of exercise being conducted. The following are types of exercise participant roles.

• Exercise Director: The exercise director oversees all exercise functions during exercise conduct; oversees and remains in contact with controllers and evaluators; debriefs controllers and evaluators following the exercise; and oversees setup and cleanup of the exercise as well as positioning of C/Es. (All exercise types)

• Facilitator. During a seminar, workshop, TTX, or game, the facilitator(s) is responsible for keeping participant discussions on track with exercise objectives and ensuring all issues and objectives are explored as




thoroughly as possible within time constraints. If an exercise uses breakout groups, more than one facilitator may be needed. (Seminar, Workshop, TTX, game)

• Evaluator. Evaluators, selected from participating agencies, are chosen based on their expertise in the functional areas they will observe. Evaluators use EEGs to measure and assess performance, capture unresolved issues, and analyze exercise results. Evaluators should passively assess and document players’ performance against established emergency plans and exercise evaluation criteria without interfering in exercise flow. (All exercise types)

• Lead Evaluator. The lead evaluator should participate fully as a member of the exercise planning team and should be a senior-level individual familiar with all relevant issues associated with the exercise, including plans, policies, and procedures of the exercising entity; Incident Command and decision making processes of the exercising entity; and interagency and/or inter-jurisdictional coordination issues relevant to the exercise. The lead evaluator must have the management skills needed to oversee a team of evaluators over an extended process as well as the knowledge and analytical skills to undertake a thorough and accurate analysis of all capabilities being tested during an exercise. (all exercise types)

• Controller. In a game, drill, FE, or FSE, controllers plan and manage exercise play, set up and operate the exercise incident site, and possibly take the roles of individuals and agencies not actually participating in the exercise. Controllers direct the pace of exercise play, provide key data to players, and may prompt or initiate certain player actions and injects to the players as described in the MSEL to ensure exercise continuity. Controllers issue exercise materials to players as required, monitor the exercise timeline, and monitor the safety of all exercise participants. Controllers are the only participants who should provide information or direction to players. All controllers should be accountable to one senior controller. (game, drill, FE, FSE)

• Senior Controller. The senior controller is responsible for the overall organization of the exercise. The senior controller monitors exercise progress and coordinates decisions regarding deviations or significant changes to the scenario caused by unexpected developments during play. The senior controller monitors actions by controllers and ensures they implement designated and modified actions at the appropriate time. The senior controller debriefs controllers and evaluators after the exercise and oversees the setup and takedown of the exercise. (game, drill, FE, FSE)

• Safety Controller. The safety controller is responsible for monitoring exercise safety during exercise setup, conduct, and cleanup. All exercise controllers assist the safety controller by reporting any safety




concerns. The safety controller should not be confused with the safety officer, who is identified by the incident commander during exercise play. (drill, FE, FSE)

• Simulator. Simulators are control staff personnel who role play as nonparticipating organizations or individuals. They most often operate out of the Simulation Cell (SimCell), which is used to generate injects for, receive player responses for, and provide information in place of nonparticipating organizations that would likely participate actively if exercise events were real. Simulators function semi-independently under the supervision of SimCell controllers, enacting roles in accordance with instructions provided in the MSEL. All simulators are ultimately accountable to the exercise director and senior controller. (drill, FE, FSE)

• Observer. Observers do not directly participate in the exercise; rather, they observe selected segments of the exercise as it unfolds, while remaining separated from player activities. Observers view the exercise from a designated observation area and are asked to remain within the observation area during the exercise. A dedicated controller or public information officer should be assigned to manage these groups. In a seminar, workshop, TTX, or game, observers may support the development of player responses to the situation during the discussion by delivering messages or citing references. (all exercise types)

• Players. Players have an active role in preventing, responding to, or recovering from the risks and hazards presented in the scenario, by either discussing or performing their regular roles and responsibilities. Players initiate actions that will respond to and/or mitigate the simulated emergency. (all exercise types)

• Actors. Actors are typically volunteer personnel responsible for simulating a specific role in an exercise. Actors are vital to creating a realistic scenario and can play a variety of roles. (drill, FSE)

EXERCISE WRAP-UP Immediately following the end of exercise conduct, exercise planners conduct a series of activities to conclude exercise conduct. Key wrap-up activities often include a Player Hot Wash and various debriefing sessions in which exercise players, controllers, and evaluators can discuss exercise performance and identify strengths and areas for improvement from exercise play. The information from these wrap-up activities informs subsequent exercise evaluation and improvement planning activities.

• Debriefings. Immediately following the exercise, a short debriefing should be conducted with exercise planning team members to ascertain their level of satisfaction with the exercise, discuss any issues or concerns, and propose improvements. Planners should collect




exercise attendance lists, provide copies to the exercise planning team leader, collect Participant Feedback Forms, and develop debriefing notes that can be integrated into the meeting minutes.

• Player Hot Wash. For drills, functional, and full-scale exercises, a Hot Wash should be conducted for each functional area by that functional area’s controller or evaluator immediately following an exercise. The Hot Wash should be led by an experienced facilitator who can ensure that the discussion remains brief and constructive and who can focus conversation on strengths and areas for improvement while these issues remain fresh in players’ minds. It also provides an opportunity for them to gain clarification on exercise play that was outside of their view. The information gathered during a Hot Wash can be used during the AAR)/ IP process, and exercise-specific suggestions can be used to improve future exercises. Hot Washes also provide opportunities to distribute Participant Feedback Forms, which, when completed by players, can be used to help generate the AAR/IP.

• Controller/Evaluator Debriefing. The C/E Debriefing provides a forum for functional area controllers and evaluators to review the exercise. The exercise planning team leader facilitates this debriefing, which provides each controller and evaluator with an opportunity to provide an overview of the functional area they observed and to discuss both strengths and areas for improvement. During the debriefing, controllers and evaluators complete and submit their EEGs and their Participant Feedback Forms. Debriefing results are captured for inclusion in the AAR/IP.

EVALUATION Evaluation is the cornerstone of exercises and must be considered through all phases of exercise planning—beginning as soon as exercise objectives are identified. Effective evaluation assesses performance against the exercise objectives, documents core capability levels and gaps, and identifies strengths and areas for improvement. Key elements of the HSEEP approach to exercise evaluation include:

• Data Analysis. HSEEP includes an objectives-driven approach to evaluating exercise performance. This approach is grounded in collection and analysis of both quantitative and qualitative data. During exercise play, evaluators collect a range of data—data that evaluators can synthesize and analyze to assess how effectively exercise objectives were met. Effective evaluation involves not merely identifying what issues emerged, but also discovering the root causes of those issues. This root cause analysis enables exercise stakeholders to target how best to address areas for improvement and close capability gaps.




• After Action Report/Improvement Plan. An AAR/IP is used to provide feedback to participating entities on their performance during the exercise. The AAR/IP summarizes exercise events and analyzes performance of the tasks identified as important during the planning process. It also evaluates achievement of the selected exercise objectives and demonstration of the overall capabilities being validated. The IP portion of the AAR/IP includes corrective actions for improvement, along with timelines for their implementation and assignment to responsible parties. To prepare the AAR/IP, exercise evaluators analyze data collected from the hot wash, debrief, Participant Feedback Forms, EEGs, and other sources (e.g., plans, procedures) and compare actual results with the intended outcome. The level of detail in an AAR/IP is based on the exercise type and scope. The conclusions are discussed and validated at an AAC that occurs within several weeks after the exercise is conducted.

IMPROVEMENT PLANNING During improvement planning, corrective actions from the AAR/IP—such as additional training, planning, and/or equipment acquisition—are tracked to completion, ensuring that exercises yield tangible preparedness improvements. A key element of the HSEEP approach to improvement planning includes:

• Improvement Plan. The IP portion of an AAR/IP converts lessons learned from the exercise into concrete, measurable steps that result in improved response capabilities. It specifically details the actions that the participating entity will take to address each recommendation presented in the draft AAR/IP, who or what agency will be responsible for taking the action, and the timeline for completion.

• IP Tracking and the Corrective Action Program. Once recommendations, corrective actions, responsibilities and due dates are clearly identified in the IP, the exercising entity ensures that each corrective action is tracked to completion. Exercising entities review all exercise evaluation feedback and resulting Improvement Plans to assess progress on enhancing preparedness. This analysis and information is incorporated into the capabilities-based planning process because it may identify needs for additional equipment, training, exercises, coordination, plans, and/or procedures that can be validated through future exercises. Continual tracking and implementation should be part of a corrective action program within each participating entity. A corrective action program ensures IPs are living, breathing documents that are continually monitored and implemented, and that they are part of the larger cycle of improving preparedness.




RESOURCES Los Angeles County EMS Agency: http://ems.dhs.lacounty.gov/ California Department of Public Health; Statewide Medical and Health Exercise Program: http://www.californiamedicalhealthexercise.com California Hospital Association; Emergency Preparedness: www.calhospitalprepare.org Emergency Management Institute: http://training.fema.gov Federal Emergency Management Agency: http://www.fema.gov Homeland Security Exercise Evaluation Program: https://hseep.dhs.gov Center for HICS Education and Training; Hospital Incident Command System: www.hicscenter.org Lessons Learned Information System: https://www.llis.dhs.gov NIMS Integration Center: http://www.fema.gov/emergency/nims U.S. Department of Homeland Security: www.dhs.gov




APPENDIX A: JOINT COMMISSION STANDARDS Elements of performance under The Joint Commission standards may be demonstrated during the tabletop and/or functional exercise, dependent on level of exercise participation. Hospital planners should review the most current publications from The Joint Commission to look for opportunities to demonstrate additional performance elements. The following standards can be found in the Emergency Management, Environment of Care and Life Safety Chapters. Emergency Management (EM) A partial list of EM Standards as identified in The Joint Commission Chapter follows: EM 02.02.01 As part of its Emergency Operations Plan, the healthcare facility/hospital prepared for how it will communicate during emergencies. ELEMENTS OF PERFORMANCE FOR EM.02.02.01 The Emergency Operations Plan describes the following:

• How staff will be notified that emergency response procedures have been initiated.

• How the hospital will communicate information and instructions to its staff and Licensed Independent Practitioners during an emergency.

• How the hospital will notify external authorities that emergency response measures have been initiated.

• How the hospital will communicate with external authorities during an emergency.

• How the hospital will communicate with patients and their families, including how it will notify families when patients are relocated to alternate care sites.

• How the hospital will communicate with the community or the media during an emergency.

• How the hospital will communicate with purveyors of essential supplies, services and equipment during an emergency.

• How the hospital will communicate with other healthcare facilities in its contiguous geographic area regarding the essential elements of their respective command structures.

• How the hospital will communicate with other healthcare facilities in its contiguous geographic area regarding the essential elements of their respective command centers.

• How the hospital will communicate with other healthcare facilities in its contiguous geographic area regarding the resources and assets that can be shared in an emergency response.




• 14. The hospital establishes backup systems and technologies for the communication activities identified in EM 02.02.01, Elements of Performance 1-9.

EM.02.02.03 As part of its Emergency Operations Plan, the organization/hospital prepares for how it will manage resources and assets during an emergency. ELEMENTS OF PERFORMANCE FOR EM.02.02.03 The Emergency Operations Plan describes the following:

• How the hospital will obtain and replenish medications and related supplies that will be required throughout the response and recovery phases of an emergency, including access to and distribution of caches that may be stockpiled by the hospital, its affiliates, or local, state or federal sources.

• How the hospital will obtain and replenish medical supplies that will be required throughout the response and recovery phases of an emergency, including personal protective equipment where required.

• How the hospital will obtain and replenish non-medical supplies that will be required throughout the response and recovery phases of an emergency.

• How the hospital will share resources and assets with other healthcare facilities within the community if necessary.

• How the hospital will share resources and assets with other healthcare facilities outside the community, if necessary, in the event of a regional or prolonged disaster.

• How the hospital will monitor quantities of its resources and assets during an emergency.

• The hospital’s arrangements for transporting some or all patients, their medications, supplies, and equipment and staff to an alternative care site when the environment cannot support care, treatment and services.

EM.02.02.05 As part of its Emergency Operations Plan, the organization/hospital prepares for how it will manage security and safety during an emergency ELEMENTS OF PERFORMANCE FOR EM.02.02.05 The Emergency Operations Plan describes the following:

• The hospital’s arrangements for internal security and safety. • The roles that community security agencies (for example, police,

sheriff, National Guard) will have in the event of an emergency. • How the hospital will control entrance into and out of the healthcare

facility during an emergency.




EM 02.02.09 As part of its Emergency Operations Plan, the hospital prepares for how it will manage utilities during an emergency. ELEMENTS OF PERFORMANCE FOR EM 02.02.09 The Emergency Operations Plan describes the following:

• As part of its Emergency Operations Plan, the hospital identifies alternative means of providing the following: electricity.

• As part of its Emergency Operations Plan, the hospital identifies alternatives means for providing the following: water needed for consumption and essential care services.

• As part of its Emergency Operations Plan, the hospital identifies alternatives means for providing the following: water needed for equipment and sanitary services.

• As part of its Emergency Operations Plan, the hospital identifies alternatives means for providing the following: fuel required for building operations, generators, and essential transport services that the hospital would typically provide.

• EP6: As part of its Emergency Operations Plan, the hospital identifies alternatives means for providing the following: Medical gases/vacuum systems.

• As part of its Emergency Operations Plan, the hospital identifies alternatives means for providing the following: utility systems that the hospital defines as essential (for example, vertical and horizontal transport, heating and cooling systems and steam for sterilization).

• The hospital implements the components of its Emergency Operations Plan that require advance preparation to provide for utilities during an emergency.

EM.02.02.11 As part of its Emergency Operations Plan, the organization/hospital prepares for how it will manage patients during emergencies. ELEMENTS OF PERFORMANCE FOR EM.02.02.11 The Emergency Operations Plan describes the following:

• How the hospital will manage a potential increase in demand for clinical services for vulnerable populations serves by the hospital, such as patients who are pediatric, geriatric, disabled or have serious chronic conditions or addictions.

• How the hospital will manage mortuary services. EM.03.01.03 The organization/hospital evaluates the effectiveness of its Emergency Operations Plan. ELEMENTS OF PERFORMANCE FOR EM.03.01.03 The Emergency Operations Plan describes the following:

• As an emergency response exercise, the hospital activated its EOP twice a year at each site included in the plan.




• For each site of the hospital that offers emergency services or is a community-designated disaster receiving station, at least one of the hospital’s two emergency response exercises includes an influx of simulated patients.

• For each site of the hospital that offers emergency services or is a community-designated disaster receiving station, at least one of the hospital’s two emergency response exercises includes an escalating event in which the local community is unable to support the hospital.

• For each site of the hospital with a defined role in its community’s response plan, at least one of the two exercises includes participation in the community-wide exercise.

• Emergency response exercises incorporate likely disaster scenarios that allow the hospital to evaluate its handling of communications, resources and assets, security, staff, utilities and patients.

• The hospital designates an individual(s) whose sole responsibility during emergency exercises is to monitor performance and document opportunities for improvement.

• During the emergency response exercises, the hospital monitors the effectiveness of internal communication and the effectiveness of communication with outside entities such as local government leadership, police, fire, public health officials and other healthcare facilities.

• During emergency response exercises, the hospital monitors resource mobilization and asset allocation, including equipment, supplies, personal protective equipment and transportation.

• During emergency response exercises, the hospital monitors its management of the following: safety and security.

• During emergency response exercises, the hospital monitors the following: staff roles and responsibilities.

• The evaluation all emergency response exercises and all response to actual emergencies includes the identification of deficiencies and opportunities for improvement. This evaluation is documented.

Environment of Care (EC) A partial list of EC Standards as identified in The Joint Commission Chapter follows: EC 02.05.01 The hospital manages risks associated with its utility systems ELEMENTS OF PERFORMANCE FOR 02.05.01

• The hospital maps the distribution of its utility systems • The hospital labels utility system controls to facilitate partial or

complete emergency shutdowns.




• The hospital has written procedures for responding to utility systems disruptions.

• The hospital procedures address shutting off the malfunctioning system and notifying staff in affected areas.

• The hospital’s procedures address performing emergency clinical interventions during utility system disruptions.

• The hospital responds to utility system disruptions as described in its procedures.

EC02.05.03 The hospital has a reliable emergency electrical power source. ELEMENTS OF PERFORMANCE FOR 02.05.03

• The hospital provides emergency power for the following: alarm systems, as required by the Life Safety Code.4

• The hospital provides emergency power for the following: Exit route and exit sign illumination as required by the Life Safety Code.

• The hospital provides emergency power for the following: emergency communication systems, as required by the Life Safety Code.

• The hospital provides emergency power for the following: Elevators (at least for non-ambulatory patients).

• The hospital provides emergency power for the following: equipment that could cause patient harm when it fails, including life-support systems; blood, bone and tissue storage systems; medical air compressors; and medical and surgical vacuum systems.

• The hospital provides emergency power for the following: areas in which loss of power could result in patient harm, including operating rooms, recovery rooms, obstetrical delivery rooms, nurseries, and urgent care areas.

• The hospital maps the distribution of its utility systems • The hospital has written procedures for responding to utility systems

disruptions. • The hospital's procedures address shutting off the malfunctioning

systems and notifying staff in affected area. • The hospital responds to utility system disruptions as described in its

procedures.

4 For guidance in establishing a reliable emergency power system, see NFPA 99, 1999 edition (Section 12-3.3)




Life Safety (LS) A partial list of LS Standards as identified in The Joint Commission Chapter follows: LS.01.02.01 The hospital protects occupants during periods when the Life Safety Code is not met or during periods of construction. ELEMENTS OF PERFORMANCE FOR LS.01.02.01

• The hospital notifies the fire department (or other emergency response group) and initiates a fire watch when a fire alarm or sprinkler system is out of service more than 4 hours in a 24-hour period in an occupied building. Notification and fire watch times are documented (refer to NFPA 101-2000:9.6.1.8 and 9.7.6.1).

• The hospital has a written interim life safety measure (ILSM) policy that covers situations when Life Safety Code deficiencies cannot be immediately corrected or during periods of construction. The policy includes criteria for evaluating when and to what extent the hospital follows special measures to compensate for increased life safety risk.

• When the hospital identifies Life Safety Code deficiencies that cannot be immediately corrected or during periods of construction, the hospital does the following: Provides additional firefighting equipment. The need for this equipment is based on criteria in the hospital’s ILSM policy.

• When the hospital identifies Life Safety Code deficiencies that cannot be immediately corrected or during periods of construction, the hospital does the following: Provides additional training to those who work in the hospital on the use of firefighting equipment. The need for additional training is based on criteria in the hospital’s ILSM policy.




APPENDIX B: LONG TERM CARE GUIDANCE The following is a partial list of references that long term care organizations may find useful to incorporate into their exercise planning.

• The Emergency Operation Plan must provide for sources of emergency utilities and supplies, including gas, water, food, and essential medial supportive material. [CCR T22 subsection 72551 (b)(1), subsection 76563 (b)(1), subsection 76928 (b)(1), subsection 73549 (b)(1)]

• Recommendations from the American Red Cross, the Federal Emergency Management Agency and the Center for Communicable Diseases state that individuals should plan to be self-sufficient for a minimum of 72 hours in the event of a wide spread disaster. Health facilities' external disaster plans should include provisions to independently mange the essential health, safety, and personal needs of the individuals in their care during an emergency. These provisions include:

- Enough food and water for residents of the facility, and for the staff who will be required to stay and care for them. You also need to plan food and water for individuals you have agreed to shelter such as staff's family members or other facility or community members.

- Systems and supplies for the use of alternative water sources including the purification of water if potable water is lost, and a method to transport water from its source to the resident care areas [CFR subsection 483.70 (h)91)].




APPENDIX C: NATIONAL INCIDENT MANAGEMENT SYSTEM IMPLEMENTATION OBJECTIVES FOR HEALTHCARE In 2008, the Incident Management Systems Division of the federal Department of Homeland Security grouped the implementation objectives for healthcare facilities into sections:

• Adoption • Preparedness: Planning • Preparedness: Training and Exercises • Communications and Information Management • Command and Management

In July of 2012, the NIMS compliance elements for healthcare will again be revised, decreasing the number of elements from 14 to 11. In preparation for the November functional exercise, the applicable objectives based on this revision are identified below. 5 Objective 7: Promote and integrate as appropriate NIMS concepts and principles (i.e., the Incident Command System) into all healthcare organization-related training and exercises. Objective 8: Promote and ensure that hospital processes, equipment, communication and data interoperability facilitates the collection and distribution of consistent and accurate information with local and state partners during an incident or event. Objective 9: Apply common and consistent terminology as promoted in NIMS, including the establishment of plain language communications standards. Objective 10: Manage all emergency incidents, exercises and preplanned (recurring/special) events with consistent application of Incident Command System organizational structures, doctrine, processes and procedures.

5 DHHS, Office of the Assistant Secretary for Preparedness & Response. Letter to Hospital Preparedness Awardees from David Marcozzi – NIMS Implementation Guidance for the National Hospital Preparedness Program’s (HPP) FY12 Funding Opportunity Announcements (FOA). December 9, 2011.




Objective 11: Adopt the principle of Public Information, facilitated by the use of the Joint Information System and Joint Information Center ensuring that Public Information procedures and processes gather, verify, coordinate and disseminate information during an incident or event.




APPENDIX D: EXERCISE EVALUATION AND IMPROVEMENT PLANNING The 2012 Statewide Medical and Health Functional Exercise follows the principles of exercise design and execution as outlined in Homeland Security Exercise and Evaluation Program. Refer to EXPLAN for core capabilities and objectives by agency/jurisdiction. Each Target Capability6 is developed into an Exercise Evaluation Guide. Within each of the Target Capabilities are associated activities and tasks that gauge successful outcomes. Using the Exercise Evaluation Guides NOTE: THE Exercise Evaluation Guides ACCOMPANYING THE GUIDEBOOK ARE

TO BE USED FOR THE FUNCTIONAL EXERCISE The purpose of the Homeland Security Exercise and Evaluation Program is to provide common exercise policy and program guidance that constitutes a national standard for exercises. Exercise Evaluation Guides assist in evaluation of the performance of the tasks, activities, and capabilities necessary for exercise evaluation and improvement plans, and corrective actions, by providing evaluators with consistent standards and guidelines for observation, data collection, analysis, and report writing. Exercise Evaluation Guides are the primary reference to ensure all jurisdictions/organizations evaluate exercises against the same measurable baseline. This method of evaluation helps to identify significant gaps in preparedness capabilities across the nation, and also serves as a tool to develop a stronger and more consistent After Action Report and Improvement Plan. Exercise Evaluation Guides provide exercise evaluators with a manageable tool with which they can collect data during an exercise, in a format allowing the easy transfer of information to the After Action Report/Improvement Plan. The Exercise Evaluation Guides can be customized with organization/jurisdiction specific tasks and performance measures that may be added to the list of Tasks and Performance Measures to be exercised. Please refer to the following website for more information on Homeland Security Exercise training, tools, and samples: https://hseep.dhs.gov/.

6 Based on 2012 HSEEP revisions, EEGs have not currently been developed for the core capabilities so Target Capabilities are reference here




Evaluators should familiarize themselves with the Exercise Evaluation Guides, including the list of activities and tasks. During an exercise, each guide is intended as a viewing guide, pointing evaluators in the direction of specific actions in order to assist in their evaluation focus and to support root-cause analysis and after action report development. While observing, the Evaluator is expected to: RECORD THE COMPLETION OF TASKS ON THE EXERCISE EVALUATION GUIDE For each task, Evaluators should check the box corresponding to the exercise participants' actions. Was the task "fully completed," "partially completed," "not completed," or "not applicable"? Most importantly, supplemental notes should be included to support the level of task completion identified. Each task line includes space to record the time at which a particular task was completed. The checked boxes and timekeeping functions of the Exercise Evaluation Guide format do not produce a report card or score sheet, but provides an objective record of task completion and support post-exercise analysis. RECORD THE DEMONSTRATION OF PERFORMANCE MEASURES ON THE EXERCISE EVALUATION GUIDE ITSELF Performance measures are associated with many tasks and provide the Evaluator the ability to record quantitative, observable indicators of performance. Each performance measure is followed by a target indicator as well as a location to input the actual, observed figure. For example, the Medical Surge Target Capability lists Activity 3: Increase Bed Surge Capacity. The associated task is: maximize utilization of available beds. The Evaluator can record observations on the actions taken to maximize utilization of available beds. RECORD SUPPLEMENTAL NOTES ON EXERCISE EVENTS AND OBSERVATIONS While the Exercise Evaluation Guides contain an extensive list of activities and tasks designed to help guide Evaluators' observations, it is also necessary for evaluators to record supplemental notes during exercise play. Notes might include observations on areas of strength and areas needing improvement area, times for completed actions and exercise events. Supplemental notes may also include initial analyses of root-causes for problems and recommendations for improvement. DEVELOP AFTER ACTION REPORT/IMPROVEMENT PLAN To maximize lessons learned from the experience, the evaluation materials should be used to draft an exercise After Action Report. Much of the information provided in the Exercise Evaluation Guide Analysis Sheets will directly feed into the After Action Report.




Completing the Analysis Sheet The following structure is used to complete the Analysis Sheet:

• Capability 1: Insert name of Target Capability (i.e., Communication, Intelligence and Information Sharing and Dissemination or Medical Surge.)

For example: Capability 1: Emergency Operations Center Management

Activity 1.1: Identify the activity from the Exercise Evaluation Guide that is being observed.

For example: Activity 1.3: Activate Command Center

Observation 1.1: First label as “Strength” or an “Area for Improvement.” A strength is an observed action, behavior, procedure, and/or practice that is worthy of recognition and special notice. Areas for improvement are those areas in which the Evaluator observed that a necessary task was not performed or that a task was performed with notable problems. Following this heading, insert a short, complete sentence that describes the general observation.

For example: Strength

References: List relevant plans, policies, procedures, laws, and/or regulations, or sections of these plans, policies, procedures, laws, and/or regulations and Exercise Objective to which the observation relates. Include the name of the task and the applicable plans, policies, procedures, laws, and/or regulations, and one to two sentences describing their relation to the task.

For example: References: St. Elsewhere Emergency Operations Plan Objective 2. Activate the Hospital Command Center

Analysis: Include a description of the behavior or actions at the core of the observation, as well as a brief description of what happened and the positive and/or negative consequence(s) of the action or behavior. If an action was performed successfully, include any relevant innovative approaches utilized by the exercise participants. If an action was not performed successfully, the root causes contributing to the shortcoming must be identified.

For example: The Hospital Command Center was activated within fifteen minutes of notification from the local health department of a disruption in the public water system.




Recommendations: Insert recommendations to address identified areas for improvement, based on the judgment and experience of the evaluation team. If the observation was identified as strength, without corresponding recommendations, insert “none.”

For example: Recommendations: None




LOS ANGELES COUNTY BOARD OF SUPERVISORS

Gloria Molina FIRST DISTRICT

Mark Ridley Thomas

SECOND DISTRICT

Zev Yaroslavsky THIRD DISTRICT

Don Knabe

FOURTH DISTRICT

Michael D. Antonovich FIFTH DISTRICT

LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES

Mitchell H. Katz

Director

LOS ANGELES COUNTY EMERGENCY MEDICAL SERVICES AGENCY

Cathy Chidester

Director

William Koenig Medical Director

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