Skip Ribbon Commands
Skip to main content
Skip over global navigation links
U.S. Department of Health and Human Services

Performance Measure 24


Percent of HCC core member organizations with at least one executive participating in the after action review of the Hospital Surge Test


Goal or Target

In the initial fiscal years, SPPR will establish a baseline based on the participation of HCC core member organizations’ executives in the after action review of the HST; this will be used to set targets and goals for subsequent years.


Operational Intent

Participation of member organizations’ executives demonstrates an HCC’s ability to perform its role as a convener. Executive-level participation in the after action review phase of the HST increases the likelihood that HCC member organizations can act on lessons learned, improving preparedness and response capabilities for their communities. This indicator provides insight into the extent to which HCC core member organizations’ executives are engaged in the lessons learned event of the required surge exercise (to enable systematic learning).


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.


Data Point Data Entity Data Source Response
PM24.1 Total HCC core member organizations with at least one executive participating in the After Action Review of the HST (sum of PM24.2 to PM24.5)HCCSum of PM24.2 to PM24.5

​HCC Name:

# ______ (organizations)

PM24.2 Number of acute care hospitals with at least one executive participating in the After Action Review of the HSTHCC​Attendance log for the after action review of the HST

HCC Name:________

# ________ (acute care hospitals)

PM24.3 Number of EMS with at least one executive participating in the After Action Review of the HSTHCC​Attendance log for the after action review of the HST

HCC Name:________

# ________ (EMS)

PM24.4 Number of emergency management agencies with at least one executive participating in the After Action Review of the HSTHCC​Attendance log for the after action review of the HST

HCC Name:________

# ________ (emergency management agencies)

PM24.5 Number of public health agencies with at least one executive participating in the After Action Review of the HSTHCC​Attendance log for the after action review of the HST

HCC Name:________

# ________ (public health agencies)



Definitions and Interpretation

  • Executive: An executive is a decision-maker for his/her respective organization and should have decision-making power that includes, but is not limited to, allocating or reallocating resources, changing staffing roles and responsibilities, and modifying business processes in his/her organization. Typical titles of executives with decision-making power include: Chief Executive Officer, Chief Operating Officer, Chief Medical Officer, Chief Clinical Officer, Chief Nursing Officer, State and/or Local Director of Public Health, Director of Emergency Management, Administrator on Duty, or Chief of EMS, among others.

  • Participating: A member organization or executive is considered to be participating if they are physically or remotely connected to the after action review in real time.

  • After Action Review: An after action review concludes the exercise and consists of an assessment of strengths and weaknesses and corrective action planning. This phase should be conducted within 30 days of the exercise of the HST.

  • HST: The HST is a user-friendly peer assessment designed to identify gaps in a hospital’s preparedness and help assess its ability to respond to a mass casualty event. The exercise is a low- to no-notice exercise and incorporates the real-life considerations of health care delivery in acute care settings. The exercise is intended for use by hospital emergency managers, hospital administrators, and clinical staff to assess and improve their hospital’s surge plans. Hospitals need to exercise their preparedness for a mass casualty incident regularly. This exercise can help hospital emergency managers make recurring table top exercises a reality by providing a fully-developed table top exercise that can be used at their facilities.


<< Previous: Section 5 --------- Top of Page --------- Next: Performance Measure 25 >>

  • This page last reviewed: November 05, 2020