Exercises

The After Action Report (AAR) captures observations of an exercise and makes recommendations for post-exercise improvements. The AAR then is used to develop Improvement Plans (IP). HSEEP AAR examples can be found on the HSEEP website.

The Joint Commission requires a hospital designee whose sole responsibility during emergency response exercises is to monitor performance and document opportunities for improvement in EM.03.01.03 and specifies that all emergency response exercises include the identification of deficiencies and opportunities for improvement. Developing an AAR meets the criteria.
 

The Homeland Security Exercise and Evaluation Program (HSEEP) is a capabilities and performance-based exercise program which provides a standardized policy, methodology, and terminology for exercise design, development, conduct, evaluation, and improvement planning. Using HSEEP helps ensures that exercise programs conform to established best practices, and helps provide unity and consistency of effort for exercises at the hospital level and for all levels of government. 

Hospitals are required by The Joint Commission to monitor performance and evaluate each exercise or actual event using a multidisciplinary process that involves licensed independent practitioners. During an exercise, individuals are to be designated to observe performance and document opportunities for improvement. That evaluation process is to result in:

• Documented identification of deficiencies and opportunities for improvement
• Documented assignment and monitoring of improvement activities, including the hospital team/committee responsible for emergency management
• Modification of the hospital Emergency Operations Plan or supporting policies and procedures based on the evaluation; if modifications require substantive resources and cannot be accomplished by the next exercise, interim measures should be implemented
• Incorporation of modified or interim measures in subsequent emergency response exercises.
  The hospital should maintain clear and timely documentation of each step in after action evaluation, improvement planning and monitoring, resulting modifications to Plans policies and procedures, and exercising of modifications or areas identified for improvement.

Hospital Preparedness Program (HPP) participating hospitals are required to participate in community-wide after action evaluation and improvement planning meetings and to submit an exercise summary report form to the Local HPP Entity following each community-wide exercise in which the hospital participates.

The Incident Action Plan contains objectives reflecting the overall incident strategy and specific tactical actions and supporting information for the next operational period. The hospital’s IAP is generally comprised of:

• Form 201: Incident Briefing
• Form202: Incident Objectives
• Form 203: Organizational Assignments
• Form 261: Incident Action Plan Safety Analysis

The IAP may also have a number of other forms as attachments such as Traffic Plans, Branch Assignments, etc.

Objective 12 of NIMS Implementations Objectives for Healthcare states Incident Command System (ICS) implemenation must include the consistent application of incident action planning. Therefore, anytime HICS is implemented in a drill or exercise, the development of IAPs are required.
 

The hospital’s Hazard Vulnerability Analysis (HVA) assists exercise planners in identifying threats facing the facility. The facility’s HVA provides a list of top scenarios to base future drills and exercises on. Additionally, past after action reports and improvement plans provide previously identified areas for improvement that can be tested.

Communitywide discussions and planning with local and regional emergency preparedness committees take into account the Multi-Year Training and Exercise Plan, which includes specific capabilities and objectives that could also be evaluated in future exercises. The identified objectives help address general exercise program goals, provide a framework for scenario development, guide development of individual organizational objectives, and supply evaluation criteria.

Additionally, The Joint Commission lists specific activities and observations to be monitored in exercises in EM.03.01.03 that can be used in future exercises.
 

The initial steps to planning an exercise include identifying:
• Exercise purpose
• Proposed exercise scenario, capabilities, tasks, and objectives
• Available exercise resources
• Proposed exercise location, date, and duration
• Exercise planning team and exercise participants

An exercise Interim Planning Meeting can establish:

• The exercise planning schedule
• Clearly defined, obtainable, and measurable exercise capabilities, tasks, and objectives
• Identified exercise scenario variables (e.g., threat scenario, scope of hazard, venue, conditions)

Additional information and tools for exercise planning and assistance can be found at the Homeland Security Exercise and Evaluation Program Website.
 

According to the Homeland Security Exercise Evaluation Program (HSEEP) there are seven types of exercises, each of which is either discussion-based or operations-based.

Discussion-based exercises familiarize participants with current plans, policies, agreements and procedures, or may be used to develop new plans, policies, agreements, and procedures. Types of discussion-based exercises include:

Seminar: A seminar is an informal discussion, designed to orient participants to new or updated plans, policies, or procedures (e.g., a seminar to review a new Evacuation Standard Operating Procedure)
Workshop: A workshop resembles a seminar, but is employed to build specific products, such as a draft plan or policy (e.g., a Training and Exercise Plan Workshop is used to develop a Multi-year Training and Exercise Plan) 
Tabletop Exercise (TTX): A tabletop exercise involves key personnel discussing simulated scenarios in an informal setting. TTXs can be used to assess plans, policies, and procedures
Games: A game is a simulation of operations that often involves two or more teams, usually in a competitive environment, using rules, data, and procedure designed to depict an actual or assumed real-life situation

Operations-based Exercises validate plans, policies, agreements and procedures, clarify roles and responsibilities, and identify resource gaps in an operational environment. Types of operations-based Exercises include: 
Drill: A drill is a coordinated, supervised activity usually employed to test a single, specific operation or function within a single entity (e.g., a fire department conducts a decontamination drill). 
Functional Exercise (FE): A functional exercise examines and/or validates the coordination, command, and control between various multi-agency coordination centers (e.g., emergency operation center, joint field office, etc.). A functional exercise does not involve any "boots on the ground" (i.e., first responders or emergency officials responding to an incident in real time).                                                                   Full-Scale Exercises (FSE): A full-scale exercise is a multi-agency, multi-jurisdictional, multi-discipline exercise involving functional (e.g., joint field office, emergency operation centers, etc.) and "boots on the ground" response (e.g., firefighters decontaminating mock victims).
 

There are different requirements for the various accrediting bodies and grant requirements. For example, the Hospital Preparedness Program grant may require participation in the Annual Statewide Medical Health Exercise.

The National Incident Management System (NIMS) Compliance for Healthcare Objective 7 states that NIMS concepts and principles are promoted into all organization-related training and exercises.
 

The Joint Commission in EM03.01.03 outlines requirements for hospitals in this area. The hospital must activete it’s Emergency Operations Plan twice a year and at least one of them must include an escalating event in which the local community is unable to support the event, and at least one includes participation in a communitywide exercise.

The California Code of Regulations 70741 (d) states the disaster plan shall be rehearsed at least twice a year. 70743 (c) requires fire and internal disaster drills shall be held at least quarterly for each shift of hospital personnel and under varied conditions.

NFPA 5.14 requires the entity shall evaluate program plans, procedures, and capabilities through periodic reviews, testing, and exercises