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U.S. Department of Health and Human Services

The MSCC Management System

The MSCC Management System describes a system of interdisciplinary coordination that emphasizes responsibility rather than authority. In other words, each public health and medical asset is responsible for managing its own operations, as well as integrating with other response entities in a tiered framework. This allows response assets to coordinate in a defined manner that is more effective than the individual, ad hoc relationships that otherwise occur during a major emergency or disaster.

The six-tier construct (Figure 1-2) depicts the various levels of public health and medical asset management during response to mass casualty and/or mass effect incidents. The tiers range from the individual HCO or other healthcare assets and their integration into a local healthcare coalition, to the coordination of Federal assistance. Each tier must be effectively managed internally in order to coordinate and integrate externally with other tiers.

Figure 1-2. MSCC Management Organization Strategy

Figure 1-2 shows the six-tier construct depicting the various levels of public health and medical asset management during response to mass casualty and/or mass effect incidents.  Tier 1 is the healthcare asset management (emergency management program and emergency operations plan using incident command).  Tier 2 is the healthcare coalition in which multiple HCOs cooperate in information sharing, cooperative planning, and mutual aide).  Tier 3 is the jurisdiction incident management (medical ICS and emergency support, EOC).  Tier 4 is the state response and coordination of intrastate jurisdictions (management coordination and support to jurisdictions).  Tier 5 is the interstate regional coordination (management coordination and mutual support).  Lastly, Tier 6 is the Federal response (support to state and locals).

1.2.1 Management of Individual Healthcare Assets (Tier 1)

Tier 1 includes hospitals, integrated healthcare systems, private physician offices, outpatient clinics, nursing homes and other skilled nursing facilities, and other resources where "point of service" medical care is provided. Emergency Medical Services (EMS) may be included in Tier 1 if called on to provide field-based medical care in an emergency. The goal of Tier 1 is to maximize MSCC within each healthcare asset while ensuring the safety of personnel and other patients, and the integrity of the asset's usual operations. This is best accomplished by optimizing an entity's Emergency Operations Plan (EOP) to effectively manage internal resources and to integrate with external response assets. The MSCC Management System describes key considerations for internal preparedness planning, while focusing primarily on the processes within the EOP that facilitate external integration with the larger response community.

1.2.2 Management of the Healthcare Coalition (Tier 2)

The healthcare coalition organizes individual healthcare assets into a single functional unit. Its goal is to maximize MSCC across the coalition through cooperative planning, information sharing, and management coordination. The coalition ensures that public health and medical assets have the information and data they need at a level of detail that will enable them to optimally provide MSCC. In addition to hospitals, the coalition may include long-term care or alternative treatment facilities, dialysis and other outpatient treatment centers, nursing homes and other skilled nursing facilities, private physician offices, clinics, community health centers and any other healthcare asset that may be brought to bear during major medical response. Its reach may extend beyond the geographic area of the primary responding jurisdiction (Tier 3), especially in rural settings where healthcare assets may be scattered.

Tier 2 strengthens MSCC by creating the ability to move medical resources (e.g., personnel, facilities, equipment, supplies) to sites of greatest need.[4] This is accomplished through mutual aid and cooperative agreements[5] between HCOs. It also provides a platform for unified interface with the jurisdiction's incident management (Tier 3). To be effective, the coalition must establish a planning process that is equal and fair to all participants, giving each the opportunity for input during preparedness planning, response, and recovery.

1.2.3 Jurisdiction Incident Management (Tier 3)

Tier 3 directly integrates HCOs with other response disciplines (e.g., public safety, emergency management) to maximize jurisdictional MSCC. It is the most critical tier for integrating the full range of disciplines that may be needed in a mass casualty and/or mass effect incident. The focus of Tier 3 is to describe how to effectively coordinate and manage diverse disciplines in support of medical system resiliency and medical surge demands. This requires healthcare assets to be recognized as integral members of the responder community and to participate in management, operations, and support activities. In other words, public health and medical disciplines must move from a traditional support role based on an Emergency Support Function (ESF) to part of a unified incident command system. This is especially important during events that are primarily public health and medical in nature, such as infectious disease outbreaks.

1.2.4 Management of State Response and Coordination of Intrastate Jurisdictions (Tier 4)

To address MSCC, Tier 4 describes how State-level actions can support jurisdiction incident management (Tier 3), promote coordination among multiple affected jurisdictions, or assume a primary incident command role. The State management function also serves as the primary interface for requesting Federal assistance. During preparedness planning, State agencies may facilitate arrangements between jurisdictions to coordinate response assets. The use of strategic mutual aid and/or cooperative agreements may standardize the implementation of tactical mutual aid between jurisdictions and promote a cohesive response strategy during a widespread incident.

1.2.5 Interstate Regional Management Coordination (Tier 5)

Tier 5 describes how to maximize interstate coordination to support MSCC. In the past, interstate coordination generally depended on ad hoc arrangements, goodwill at the time of an incident, and other less-than-predictable mechanisms. However, this changed when Congress enacted the Emergency Management Assistance Compact in 1996 (Public Law 104-321). EMAC, as it is commonly known, has now been accepted by all States and U.S. territories, and provides legal authority, financial mechanisms, and operational guidance to establish the ability to request and receive emergency assistance from other States or territories. This tier focuses on how to manage interstate medical and public health assistance and examines how mutual aid, incident management coordination, and information sharing can enhance MSCC.

1.2.6 Federal Support to State, Tribal, and Jurisdiction Management (Tier 6)

The Federal Government maintains public health and medical resources to support State, Tribal, and jurisdictional authorities during a mass casualty and/or mass effect incident. The goal of Tier 6 is to maximize MSCC through the optimal integration and management of Federal public health and medical assets. Activation of Federal public health and medical assistance may occur through implementation of the Robert T. Stafford Disaster Relief and Emergency Assistance Act (424 USC 5121, et seq.) or through independent authority of the Department of Health and Human Services (HHS) to declare a Federal public health emergency or disaster.[6] The National Response Plan (NRP) and National Incident Management System (NIMS) provide operational guidance for Federal action. Tier 6 focuses on key functional concepts that promote integration of the Federal response.


  1. Traditionally, patient needs are matched with available resources by evenly distributing large numbers, or very ill/injured patients, to available facilities. This is logistically difficult because, in a mass casualty and/or mass effect incident, many victims self-refer for medical care (i.e., arrive outside the formal EMS system).
  2. Cooperative agreements provide the same services as mutual aid, but they establish a mechanism for payment for the responding services by the affected jurisdiction. This may also be referred to as "reimbursed" or "compensated" mutual aid (the term "mutual aid" otherwise implies assistance without remuneration).
  3. The authority for the Secretary of HHS to declare a Federal public health emergency or disaster is granted under Section 319 of the U.S. Public Health Service Act.

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  • This page last reviewed: February 14, 2012