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U.S. Department of Health and Human Services


Background on the MSCC Handbook

The 9/11 terrorist attacks and the anthrax mailings in October 2001 focused significant attention on mass casualty response systems in the United States. Analyses of these incidents revealed deficiencies in many important preparedness areas that adversely affected the medical and public health response. It was apparent that many preparedness actions (pharmaceutical stockpiling, training to care for contaminated victims, etc.) were occurring in narrow stovepipes created by traditional healthcare disciplines and delivery systems.

In 2003, the U.S. Department of Health and Human Services (HHS) funded a study to describe an operational management structure for medical and public health emergency response. At the request of HHS, this initiative was designed to expand on guidance contained in the Medical and Health Incident Management (MaHIM) System[1] MaHIM described a functional organization to prepare for and respond to mass casualty incidents. While MaHIM focused at the local jurisdiction and regional levels, the 2003 study extended similar guidance to healthcare organizations and proposed methods for improved coordination across all levels of a healthcare emergency response.

CNA conducted the 2003 study in collaboration with the MaHIM System researchers at The George Washington University. They applied established principles of the Incident Command System (ICS) and incorporated input from a multidisciplinary panel of subject matter experts. The resultant Medical Surge Capacity and Capability (MSCC) Handbook was published in August 2004. A revised edition was published in 2007 to describe changes that had occurred in the Federal public health and medical response following Hurricane Katrina and to clarify concepts from the National Incident Management System (NIMS).[2] The revised version also placed greater emphasis on effective response to hazards that impact healthcare organizations themselves (e.g., continuity of operations).

The MSCC Handbook described a six-tier model for organizing healthcare response to emergencies or disasters. The tiers demonstrate the integration of responding healthcare resources through a response management system that extends from individual healthcare organizations (Tier 1) through local jurisdiction (Tier 3), State, including sub-State regions (Tier 4), inter-State regions (Tier 5), and Federal (Tier 6) levels of response. The second tier – known as the Healthcare Coalition – was briefly described as a group of individual healthcare organizations in a specified geographic area that have partnered to respond to emergencies or disasters in a coordinated manner. During an incident, the Coalition’s response organization helps enhance the collective surge capacity and capability of its members by facilitating information sharing, resource support, and response coordination. The Coalition’s response organization functions as a supporting entity (similar to a Multiagency Coordination System) rather than as a command and control or Area Command organization.

Since its release, the MSCC Handbook has been widely read and used. Its overarching concepts and management strategy for healthcare system emergency response became the basis of guidance for HHS’ Hospital Preparedness Program (HPP) in 2006.[3] HPP awardees are expected to work within the MSCC framework to ensure integration of the healthcare system response from the local through the State level.[4]

Why the Healthcare Coalition Focus?

Following the adoption of MSCC concepts into HPP guidance, HPP personnel received feedback from participating healthcare organizations and local jurisdictions revealing difficulties with implementing the Healthcare Coalition (Tier 2) construct. The lack of published, well described models for establishing the required relationships, authorities, and responsibilities for a Healthcare Coalition contributed to the implementation challenges.

Despite these challenges, there is evidence that efforts are underway across the U.S. to develop Healthcare Coalitions.[5] This is very encouraging and many locales have developed, or are in the process of developing, some form of a Healthcare Coalition. Much of this development has focused on building “preparedness organizations,” as defined by NIMS.[6] This work is important for establishing relationships and conducting preparedness planning. However, it is only a preliminary step to operational readiness for healthcare organizations to coordinate effectively during incident response. The desired goal for Healthcare Coalition development should be a “response organization”[7] that can provide effective actions in a no-notice, sudden onset incident under the most adverse conditions.

Project Goal and Objectives

The goal of this project is to provide guidance to healthcare planners on how to develop and implement cost-effective, sustainable, and response-oriented Healthcare Coalitions in rural, suburban, and urban areas of the U.S. and its territories. The following objectives were delineated for this handbook:

  1. Present a System Description (including an organizational chart) and Concept of Operations for a Healthcare Coalition response organization.
  2. Provide an operational understanding for how the Healthcare Coalition can promote optimal medical surge capacity and capability, as well as healthcare organization resiliency, in the face of overwhelming casualties and/or direct hazard impact.[8]
  3. Define the essential elements of situational awareness for the Healthcare Coalition during emergency medical and public health response. This includes real-time information collection, processing, and dissemination to support informed and coordinated decision-making for the healthcare response.
  4. Describe the Healthcare Coalition’s potential role in supporting mutual aid and other resource sharing arrangements between healthcare organizations (Tier 1). The Healthcare Coalition may also facilitate resource acquisition from local jurisdictional authorities (Tier 3) or other sources. Efficiency is promoted by establishing consistent methods for requesting and offering assistance when medical needs extend beyond the capacity and capability of Coalition member organizations.
  5. Provide guidance on how to coordinate response objectives and strategy among Healthcare Coalition members and integrate the Healthcare Coalition into other MSCC response tiers.

Project Scope

Rather than provide prescriptive guidance on how to develop and maintain a Healthcare Coalition, the intent of this handbook is to describe the common elements of an effective Healthcare Coalition that may be applied in any locale. The handbook is intended to help medical and public health planners integrate these elements when they establish or revise a local and/or regional Healthcare Coalition. This handbook is also intended to:

  • Serve as a companion to the 2007 MSCC Handbook.
  • Demonstrate the importance of the Healthcare Coalition in addressing healthcare system resiliency and medical surge.
  • Describe the internal mechanisms required to develop, implement, and maintain a Healthcare Coalition response organization.
  • Describe the external mechanisms required to integrate the Healthcare Coalition with other MSCC response tiers.
  • Ensure consistency with NIMS concepts and terminology.
  • Highlight the benefits of a NIMS-consistent Multiagency Coordination System (MAC System) that is composed of participating healthcare organizations.

This handbook does not offer detailed guidance on the development and implementation of an individual healthcare organization’s Emergency Management Program (EMP) or Emergency Operations Plan (EOP). Discussion at the healthcare organization level (Tier 1) is limited to the elements necessary for an organization to effectively participate in a Healthcare Coalition.

This handbook also does not provide extensive guidance on how to develop and implement a Public Health Department or jurisdiction-wide EOP. Discussion at the jurisdiction level (MSCC Tier 3) is limited to the interface with the Tier 2 Healthcare Coalition. It is important to emphasize that Healthcare Coalition activities during incident response do not supplant or subvert the authority of public officials acting as the incident command or area command authority for the overall incident. Rather, the Healthcare Coalition supports the response by enhancing the integration and performance of responding healthcare organizations.

Important Point of Clarification:

The authors of this handbook recognize that some jurisdictions have established organizational structures for emergency preparedness and response that incorporate elements of MSCC Tiers 1, 2, and 3. This approach is perfectly valid as long as the critical Tier 2 response issues presented in this handbook are addressed. It is important to note, however, that these multi-tier organizational structures almost always incorporate an element of command and control of medical and public health assets during response. In contrast, Tier 2 Healthcare Coalitions, as defined in this handbook, do not have command and control authorities and provide only support to healthcare organizations (Tier 1) and jurisdictional authorities (Tier 3). While Healthcare Coalitions must coordinate and integrate closely with governmental agencies, they are not composed of organizations with statutory command authority.

It is beyond the scope of this handbook to describe the full range of emergency response models that incorporate public sector organizations that conduct command and control or area command. This handbook focuses on the key MSCC Tier 2 issues and the organizational structure, processes, and procedures that address these issues through a Tier 2 Healthcare Coalition. The reader may find utility in adopting the tenets proposed in this handbook regardless of the organizational structures used in their home jurisdiction(s).

Organization of This Handbook

Chapter 1 describes the need for the Healthcare Coalition and presents an overview of the concepts on which the Healthcare Coalition is based. The handbook then presents the Healthcare Coalition as a response organization that supports local and regional medical response and promotes healthcare system resiliency.

Chapters 2 and 3 present a System Description and a Concept of Operations for the Healthcare Coalition response organization. The end state of the Healthcare Coalition is presented upfront because the authors believe it is important to fully understand the desired response functionality of the Healthcare Coalition before undertaking initial Coalition development and implementation activities.

Chapter 4 discusses how the Tier 2 Healthcare Coalition response organization integrates with other MSCC tiers, and offers strategies to promote integration. Chapters 5-7 then focus on the preparedness and mitigation issues in establishing and sustaining a response-oriented Healthcare Coalition.

  1. Barbera JA, Macintyre AG. Medical and Health Incident Management System: A Comprehensive Functional System Description for Mass Casualty Medical Incident Management (December 2002); Available at:
  2. The revised edition of the MSCC Handbook is currently available at:
  3. The HPP was formerly known as the National Bioterrorism Hospital Preparedness Program (NBHPP). In 2007, the NBHPP moved from the Health Resources and Services Administration (HRSA) to the Office of the Assistant Secretary for Preparedness and Response at HHS as a result of the Pandemic and All-Hazards Preparedness Act (Public Law 109-147).
  4. U.S. Department of Health and Human Services, FY09 Hospital Preparedness Program Funding Opportunity Announcement.
  5. Maldin B, Lam C, Franco C, et al., Regional Approaches to Hospital Preparedness. Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science, Volume 5, (2007).
  6. The NIMS definition of a “preparedness organization” is provided in Appendix B.
  7. NIMS describes the “ICS organization” for emergency response and distinguishes it from the preparedness organization. Since the Coalition is not the “command” authority during a major incident, the term “response organization” is used to avoid confusion.
  8. In this handbook, healthcare system resiliency refers to the ability of healthcare organizations to survive a hazard impact and rapidly recover compromised services. This ensures that a reliable platform is available to address medical surge needs and minimize any interruption of routine healthcare service delivery.

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  • This page last reviewed: February 14, 2012