Performance Measure 20

Goal or Target

SPPR will establish a baseline based on performance data collected in initial fiscal years, which will be used to set programmatic targets and goals for subsequent years. As the CST exercise (Phase 1) concludes at 90 minutes, each HCC’s goal is to complete the exercise within 90 minutes.

Operational Intent

Once appropriate beds are identified by receiving facilities, the HCC and its member organizations will identify the appropriate modes of transport to receiving facilities (based on patient care needs). This PM assesses demonstrated ability to meet patient transportation needs.

Data Reporting

Each HCC should report the following data in the CAT. During the specified time period for end-of-year reporting, recipients should enter this information on behalf of each HCC into the end-of-year performance measure module in PERFORMS. SPPR will calculate percentages.

Definitions and Interpretation

• Evacuating patients: Evacuating facilities are instructed to identify all inpatients in each facility (regardless of location or admission status) and to find appropriate destinations and transportation for each patient using whatever communication mechanisms would be used during a real evacuation. However, there will be no movement of actual patients.


• Acceptance for transfer to another facility that has a mode of appropriate transport identified: A patient will be considered accepted for transfer when: 1) there is verbal or written (e.g., email or notation in incident management software) agreement from another facility that it can provide an appropriate destination for the patient; and, 2) the exercise participants have identified appropriate modes of transport that could move patients to their new locations. “Appropriate” refers to the clinically appropriate decision that is based on the patient’s specific health care needs.


• CST: The CST tests a coalition’s ability to work in a coordinated way using their own systems and plans to find appropriate destinations for patients by using a simulated evacuation of inpatient facilities (that collectively represent at least 20 percent of a coalition’s staffed acute care bed capacity). The CST is designed to help HCCs identify gaps in their surge planning through a no- or low-notice exercise. The exercise’s foundation comes from a real-world health care system disaster challenge—the evacuation of a hospital or other patient care facility. Further, the test incorporates lessons learned from pilot tests with HCCs in South Dakota, Texas, Michigan, and Wyoming, which contributed significantly to the tool’s development. The test is available and free for all to use in their health care disaster preparedness and planning. The CST and related materials are available online.


• AAR/IP: An AAR/IP is used to provide feedback to participating entities on their performance during an 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, timelines for implementation of corrective actions, and assignment to responsible parties. AAR/IPs should follow HSEEP principles, and HPP will provide an optional template for future use.¹⁴

^14.“Phase 4: After Action Report and Improvement Planning.” City and County of San Francisco Department of Emergency Management. http://sfdem.org/phase-4-after-action-report-and-improvement-planning-0. Accessed 6 Aug. 2020.

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