8.1 Implementation Strategies The concepts described in the MSCC Management System present an overall strategy for defining cohesive management and operational relationships for the diverse and often disparate entities that collaborate to provide MSCC. The MSCC Management System does not require an all-or-nothing approach; it may be partially implemented or fully implemented, but in a stepwise fashion over time. It is meant to complement ongoing initiatives that establish individual components of MSCC, such as identifying pools of qualified personnel, pharmaceutical and equipment caches, plans for medication-dispensing stations, plans for alternative care sites, and enhancements to laboratory capabilities. In addition, the MSCC Management System can serve as a comparison tool when assessing and revising current programs and plans, as a tool for planning and evaluating exercises, or even as a metric for conducting incident after-action review and analysis. The concepts described in this handbook should be incorporated with existing assets and processes to limit the amount of new infrastructure that must be developed. Therefore, implementation efforts should focus first on evaluating established Emergency Management Programs (EMPs) and Emergency Operations Plans (EOPs) within individual tiers. If systems already in place meet the objectives of the MSCC Management System but operate differently than presented here, they most likely do not require change. If deficits are detected, this document could suggest where revisions to the system (rather than replacement) might enable the system to integrate more effectively into the overall response. 8.1.1 Management of Individual Healthcare Assets (Tier 1) The Centers for Medicare and Medicaid Services (CMS), State survey agencies, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and other accrediting agencies require all HCOs (hospitals, integrated healthcare systems, nursing homes or other skilled nursing facilities, hospices, etc.) to have individual EOPs.[1] As stated in Chapter 2, excellent models already exist that describe how HCOs can organize internally to respond to extreme events. Tier 1 focuses on the internal HCO processes that enhance external integration with other HCOs (Tier 2) and with jurisdictional assets (Tier 3). Persons reviewing existing HCO EOPs or developing new ones should consider the following major issues in applying MSCC concepts to their facility: - Management of the HCO response: Review the qualifications and training of personnel expected to lead HCO efforts during a major response. These personnel must understand the full range of internal resources available during response and how to organize and manage the HCO effort to maximize integration with external assets. In addition, the HCO EOP should outline the steps necessary to institute a proactive management model, driven by action planning, during the early stages of response. This promotes internal HCO organization and information exchange with other entities.
- Information management: Establish quick, reliable, and redundant methods for sharing incident information. This will help link HCOs with other acute-care medical assets (Tier 2) and with the larger jurisdiction response (Tier 3). It is important not only to establish the modes of communication that will be used, but also to identify the type of information required for a coordinated response. Examinations of HCO procedures for obtaining and conveying incident information should be reviewed to determine:
- What internal linkages are necessary to ensure that initial survey data and ongoing incident information can be rapidly provided to internal HCO operations? Establishing a method for frequent situation assessments and, resource status reports across the range of assets within the HCO is invaluable for incident management.
- What mechanisms can be instituted to track patients internally during incidents of sudden surge, so that it can be quickly determined which patients are, or definitely are not, receiving care at the facility?
- What external linkages need to be made to facilitate information exchange with other medical assets, both in terms of providing data and soliciting information during a crisis?
- What types of information are appropriate to share externally during response and, therefore, can be formatted into an HCO incident action plan?
To the maximum extent possible, these efforts should be standardized across jurisdictional HCOs through Tier 2 mechanisms. Smaller entities that provide hands-on care in the community (community health centers, neighborhood outpatient clinics, nursing homes or other skilled nursing facilities, private physician offices, etc.) should not be neglected in preparedness efforts. Presenting methods for participation (as described in Chapter 2) to individual practitioners and smaller HCOs may greatly enhance their participation in major response efforts. 8.1.2 Management of the Healthcare Coalition (Tier 2) HCOs are increasingly engaged in joint-planning efforts, particularly as they participate in Federally-funded bioterrorism preparedness initiatives.[2] Moreover, many localities already have established operational interaction between HCOs to monitor emergency department and critical care capacity, ambulance diversion, and other everyday situations. These activities provide an ideal opportunity for HCOs to come together to discuss and plan for coordinating major medical response. Key issues to consider when implementing Tier 2 concepts include: - Is there an organizational structure in place that allows HCOs to collaborate in a non-competitive environment? This organizational structure may be a local hospital association, local medical society, or local/regional EMS council.
- Are mechanisms available that allow HCO managers to interact with one another in time of need, as well as during day-to-day operations? Current processes and systems should be reviewed for their ability to support this interaction. Hospital communication centers established for private patient transport, or as EMS command centers for a jurisdiction, may be expanded or adapted to fulfill this requirement.
- Have communication and information management processes been standardized among Tier 2 coalition members, including formats for recording data? Consideration should be given not only to technology needs, but also to the methods that will be used to facilitate consensus decision-making.
- Do existing tactical mutual aid arrangements among HCOs clearly establish the processes for requesting, receiving, and managing mutual aid support? An initial assessment may be needed to inventory and evaluate support mechanisms that already exist, and to determine how to prioritize new efforts to maximize MSCC. Consideration of such issues as staff credentialing, liability coverage, worker compensation, and reimbursement mechanisms is critical.
8.1.3 Jurisdiction Incident Management (Tier 3) Implementation of MSCC concepts at the jurisdictional level should follow a process in which representatives of various response disciplines (including public health and acute-care medicine) assemble to examine how to improve the delivery of public health and medical care during extreme events. The process should examine specific questions, such as: - How will the various response entities notify one another of an impending or occurring event?
- What critical information should be included in the initial notification messages?
- How will response entities establish jurisdictional incident management for the wide range of events that may potentially result in human casualties?
- How will response entities organize and interact with one another during a response, and how will the input of individual agencies be given to the lead management agency?
- How will representatives of the medical community (traditionally private sector) provide input into the unified command or UC (e.g., through a designated position in a unified command team, a senior advisory role, or some other mechanism)?
- What critical information should be shared among response entities? How will needs be addressed, while including such private-sector entities as hospitals and clinician offices?
- What type of support from the jurisdiction's non-medical entities may be needed to enhance the ability of public health and medical assets to provide MSCC?
- What critical demobilization issues are there for HCOs?
- How can representatives of the healthcare community be included in after-action analyses?
Initiatives undertaken to address these questions should use currently available assets and processes to enhance operational relationships. For example, most jurisdictions have 911 emergency communication centers (ECCs) for everyday emergency services. The ECC may be adapted to perform the notification and early planning function for the jurisdiction's (Tier 3) EOP until this can be established at the Incident Command Post (ICP). In addition, the ECC and its paging/messaging services can provide initial notification to on-call representatives of the UC and be used for the early teleconference that initiates unified incident planning. Examinations of the jurisdictional (Tier 3) response system should focus on identifying processes that promote unified incident command. Below is a series of basic steps that can be followed to incorporate UC processes into the jurisdictional EOP. In addition, each response entity should be assessed for its ability to integrate into the system. Assets that do not reach a threshold of desired management capability (e.g., effective incident information processing, incident planning, and informed decision-making) should be prioritized for improvement through jurisdiction EMP actions. The following is a general guide for establishing unified incident command techniques in the jurisdiction's EOP. - Review the jurisdiction's hazard vulnerability analysis (HVA) to identify key management needs for all identified hazards.
- Identify agencies that repeatedly are included in the list of key management needs and designate these agencies as standard participants in UC.
- Identify other organizations that might be called on for management input during specific incidents (e.g., public school system for a foodborne outbreak in a school cafeteria). A decision support tool should be established to determine which agencies should be included as UC participants for specific events.
- Identify the lead agency for each type of hazard (recognizing that the lead may shift by response stage and by incident issue).
- Define how the UC will come together during response, whether physically or via remote teleconference.
- Define how transition of lead authority in the UC will occur as indicated during a response.
- Define the incident planning capability for the UC (who will plan and how). This position is the Planning Section Chief and conducts management and planning meetings, operations briefings, and situation updates.
- Define the site where the ICP will be located, if it is not defined by a hazard scene.
- Define how the site and capability for UC will be established if the ICP is scene-defined. For example, if the designated lead agency in the UC has a command vehicle, this may become the ICP during field response.
- Define the process for action planning in the UC. What critical information will be required from both public and private sectors, and what time frames (i.e., planning cycles and operational periods) periods could potentially be used?
- Define how information management functions will be integrated between the various response entities in a jurisdiction.
- Define the demobilization requirements for UC, including whether agencies can decrease their participation in UC as objectives are met (and, if so, how this will be accomplished).
- Define methodology, participants, and responsibilities for conducting after-action analyses.
8.1.4 Management of State Response and Coordination of Intrastate Jurisdictions (Tier 4) A starting point for implementing State level MSCC is to establish the management processes that would occur if the State were to assume primary incident command responsibility. Preparedness activities should examine how State public health and medical assets would be incorporated into UC, and how State managers would interact with jurisdictional (Tier 3) response entities. The State must examine critical information requirements to coordinate intrastate jurisdictions: - What type of information and/or data will be important for the State to obtain from jurisdictional incident management (Tier 3)?
- How will this information/data be obtained from jurisdictions, and how will it be collated and analyzed at the State level?
- Have standardized formats for reporting incident information/data (including situation assessments and resource status reports) been developed and provided to jurisdictional management?
- Are procedures in place, and does the infrastructure capability exist, to facilitate rapid dissemination of aggregate information/ data back to local jurisdictions?
Other important implementation tasks include conducting an inventory and assessment of existing tactical mutual aid arrangements. These plans should be reviewed to determine possible ways to address the medical (e.g., licensure, liability) and financial (e.g., lack of guaranteed reimbursement) barriers for private HCOs that provide mutual aid services. State level incident management systems that do not incorporate the private medical sector should consider adopting a healthcare coalition (Tier 2) function to address the concerns of HCOs. Recognizing medical and health assets (Tier 1) as crucial players in public safety emergency response may promote their participation in an incident command system. It may also promote an understanding by State officials of the specific requirements of medical and health assets. 8.1.5 Interstate Regional Management Coordination (Tier 5) Activities to improve interstate regional management coordination should focus on expanding current initiatives to better address MSCC in the private health and medical sector. Processes should specify key information requirements, explain how data will be shared between States, and identify key points of contact at the State level and their counterparts in neighboring States. The organization of State incident command (Tier 4) should be shared between partner States to enhance coordination of management activities, such as the exchange of incident action plans and support plans. Examinations of strategic, or "master," mutual aid guidelines should ensure that key "top-line" issues for medical and public health entities have been addressed. Important issues include licensing, liability coverage, and worker's compensation for out-of-State healthcare personnel, as well as reimbursement mechanisms for medical and public health assets. Tactical mutual aid agreements may provide the specific methods for requesting, receiving, and managing interstate mutual aid, transporting and distributing assets, and demobilizing public health and medical resources. Preparedness activities should examine Emergency Management Assistance Compact (EMAC) legislation and regulations to ensure that public health and medical requirements for MSCC are adequately addressed. 8.1.6 Federal Support to State, Tribal, and Jurisdiction Management (Tier 6) Because of significant changes in the Federal response system following 9/11 and, more recently, Hurricane Katrina, State emergency planners should review and understand the Federal response capability, how Federal public health and medical assistance may be obtained, and under what authority it may be activated. The State and jurisdictional EMP should determine what their own response capabilities are (i.e., what can the system handle, and what can it definitely not handle), and identify what types of information will be critical in demonstrating the need for Federal assistance. Before an emergency or disaster occurs, State and local response systems must identify the criteria they will use to determine that their system has reached capacity and that additional support, through mutual aid or Federal assistance, is necessary. States and local jurisdictions should also have operational plans (within their EOP) describing how Federal resources (personnel, supplies, equipment, or facilities) will be integrated into the State and local response effort. Among other issues, it is important to consider: - Where will Federal public health and medical assets be staged upon arrival?
- To whom will Federal personnel report for tactical direction?
- How will State emergency management (usually located at the State EOC) interact with HHS Regional Emergency Coordinators (RECs) and accommodate the Incident Response Coordination Team (IRCT), (see Chapter 7) and other deployed liaisons?
- What management processes will direct the distribution of Federal resources, such as Strategic National Stockpile (SNS) medications, vaccines, and supplies?
- Are guidelines in place specifying who has priority access to limited vaccines, personnel, or supplies, and how this will be communicated to the general public?
- Have plans for demobilization addressed the demobilization of Federal public health and medical assets?
- In past guidance, JCAHO referred to emergency operations plans as "emergency management plans."
- Information on the Hospital Preparedness Program (HPP).
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