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U.S. Department of Health and Human Services

4.2 Healthcare Coalition Integration with Jurisdictional Command (Tier 3)

      The Healthcare Coalition is effective only when it is closely coordinated with the relevant Jurisdictional Agency(s) (Tier 3) in its geographical area.[4] This coordination is imperative during response even if the issues faced by the Coalition can be resolved internally among the various Tier 1 healthcare assets.

      4.2.1 Response Strategies Supporting Coalition Integration with Jurisdictional Authorities

      Potential response strategies for the Healthcare Coalition in relation to jurisdictional authorities include:

      • Promote a common operating picture (situational awareness) between Coalition member organizations and the community response[5]
      • Supplement, but not supplant, the ability of the Jurisdictional Agency to execute its incident management responsibilities (i.e., support the interests of the Jurisdiction in relation to relevant healthcare organization response activities)
      • Facilitate the delivery of external support by the Jurisdictional Agency to Healthcare Coalition member organizations.

      The Healthcare Coalition’s activities benefit jurisdictional authorities (Tier 3) by providing an efficient conduit for the jurisdiction’s authorities to disseminate guidance, acquire information, and coordinate activities between public health and the private healthcare sector.

      Promote a common operating picture between healthcare organizations (Tier 1) and the community response (Tier 3)

      The information processing function of the HCRT may be critical in helping the Jurisdictional Agency establish a common operating picture for the community response. Much of the data that a Coalition collects and disseminates is useful to Jurisdictional Agencies. Similar to activities listed in 4.1.1, the Coalition might select the following strategies:

      • Collect, compile, and report situation updates and other data from Coalition members to the relevant Jurisdiction Agency(s) to enhance situational awareness. Reported data can include how the hazard has impacted Coalition member organizations.
      • Facilitate the tracking of incident patients treated by Coalition organizations to maintain accountability for patients and facilitate family reunification efforts by Jurisdictional Agencies.
      • Collect, compile, and report elements of Coalition members’ response strategies, which may vary across organizations. This could help shape recommendations given by the jurisdiction.
      • Provide an outlet for recommendations from the Jurisdictional Agency(s) to Coalition members (e.g., treatment protocols).

      Supplementing, not supplanting, jurisdictional incident command

      Many of the Healthcare Coalition’s information processing activities can assist the overall management of the incident by the relevant Jurisdictional Agency(s) if the products are appropriately disseminated to these agencies. Exhibit 4-1 provides one example.

      Exhibit 4-1. Assistance with rapid epidemiological investigation

      Public health authorities often have the difficult task of developing an accurate and complete epidemiological picture of an incident. This may require them to rapidly collect data and information from many disparate sources.[6] The ability of the HCRT to acquire, aggregate, and transmit epidemiological data from its member organizations can markedly assist with this task and be mutually beneficial.

      It is important that the Healthcare Coalition is not perceived as competing with or intruding on the incident management responsibilities of jurisdictional authorities (Tier 3). The Healthcare Coalition should make every effort to prevent this perception by ensuring the following:

      • Timely notification to jurisdictional authorities (Tier 3). The Notification Center Technician or Duty Officer may be the first to receive a report that a potential incident is occurring. There must be a reporting mechanism in place to rapidly notify jurisdictional authorities (Tier 3).
      • Participation in Incident Action Planning conducted by the relevant Jurisdictional Agency(s). The response of the HCRT and Coalition member organizations should be consistent with the overarching response objectives, strategy, and tactics of the Jurisdictional Agency. This coordination may require, at the request of the Jurisdictional Agency, the participation of the HCRT or select personnel from Coalition member organizations in local Incident Action Planning activities. HCRT personnel should be available to participate in planning meetings or operations briefings with the Jurisdictional Agency.
      • Availability of medical and other advice to the Jurisdictional Agency. Even if not participating in the Jurisdictional Agency’s Incident Action Planning, the HCRT may be asked to provide expert advice related to medical issues. This could include identifying subject matter experts from Coalition members to provide advice to jurisdictional authorities on issues such as protective measures and other safety issues for responders encountering an unusual infectious agent.
      • Adjusting to the strengths and weaknesses of the Jurisdictional Agency. Some Healthcare Coalitions may reside in areas with robust public health and medical resources in the public sector. This does not obviate the need for the Healthcare Coalition; it merely reshapes its operational focus. For example, a jurisdiction may already have an efficient process to collect response data from local healthcare organizations. The HCRT might still enhance response coordination between Coalition members by providing a forum for direct information exchange. Alternatively, if few public health and medical resources reside in the local public sector, the Healthcare Coalition, through the HCRT, may develop more robust processes to support the public sector’s incident management responsibilities. This should be defined in collaboration with local public agencies during preparedness activities.

      Facilitating support from Jurisdictional Agencies to Coalition partners and from the Coalition to the jurisdictional response

      When resource support is requested through mutual aid within the Healthcare Coalition, the relevant Jurisdictional Agency(s) managing the overall response should be informed. The Coalition can also facilitate the provision of support from Jurisdictional Agencies to healthcare organizations by facilitating equitable assistance based on actual need. Jurisdictional Agencies may provide the following types of assistance to Coalition members during incident response:

      • Medical equipment and supplies
      • Medical personnel (including solicited volunteers)
      • Facilities (e.g., public facilities to address surge capacity)
      • Assistance with infrastructure support, such as utilities
      • Requesting, from appropriate authorities, modification of day-to-day healthcare regulations to fit the needs of the specific incident (e.g., temporarily modifying the permissible number of licensed beds in a residential healthcare facility)
      • Emergency funding for unusual services (e.g., decontamination) or an unusual level of service delivery (e.g., increasing staffing for a mass demonstration or other type of planned event)
      • Police augmentation of healthcare organization security departments and traffic control
      • Strategic and tactical guidance to healthcare organizations on such issues as victim evaluation or treatment (e.g., conveying new protocols for assessing patient exposure as additional risk information is obtained from a chemical release site)
      • Morgue resources and guidance for mass fatality incidents.

      4.2.2 The Emergency Response Relationship between Tier 2 and Tier 3

      It is critically important that the HCRT coordinates closely with all relevant Jurisdictional Agency(s) (Tier 3) during incident response to exchange information and facilitate requests for and receipt of external assistance. This requires examining the jurisdiction’s organizational structure and Concept of Operations for incident response to determine the most effective interface with the HCRT. It is important to recognize that there are different potential “lead agencies” for the jurisdiction depending on the type of incident. In some situations, the appropriate relationship between the Coalition and Jurisdictional Agency is an interface with an Emergency Support Function 8 (ESF 8, Public Health and Medical) position in the jurisdiction’s EOC. ESF 8 is often operated under the authority of the local Public Health department.

      Alternatively, the HCRT’s primary interface may be directly with a Department Operations Center (DOC).[7] Local and State Public Health departments use DOCs to manage their emergency response. Other examples of DOCs that could be relevant to a Healthcare Coalition include those established by Fire, EMS, and Law Enforcement. In many situations, EOCs and DOCs will not be activated and the Coalition may be required to interface directly with the jurisdiction’s incident command authority (i.e., IMT), which may be located at or near the incident site.

      Important Point of Clarification

      Some States may be configured by sub-State regions without a local agency to support Tiers 1 and 2. In these cases, the State may request that the Healthcare Coalition interface directly at the Tier 4 level with a regional Department or Agency Operations Center that is managed by a State agency.

      As described in Chapter 2, the Coalition may exist as an integrated response organization that combines elements of Tiers 1, 2, and 3. This configuration is considered a Tier 3 response organization under the MSCC Tiers, but it may incorporate many of the Tier 2 activities that are described in this handbook. Typically, these models are more expansive and include elements of command and control or area command. In these models, it is important to preserve the capability of the Coalition to conduct actions on its own (e.g., initiate internal teleconferences with healthcare organizations) or to address specific response issues internally (e.g., consensus decisions on allocation of specific resources across the Healthcare Coalition).

      The Healthcare Coalition should establish a flexible response interface with the relevant Jurisdictional Agency(s) that is consistent with the reporting line and authority structure of the jurisdiction’s EOP. In many locales, a formal position has been established for a healthcare representative in the jurisdiction’s EOC (often at the ESF 8 desk), who reports to the Public Health authority leading ESF 8. This function may be filled by a representative of the Healthcare Coalition as the HCRT liaison. In some areas of the U.S., a regional EOC performs this function collectively for several local jurisdictions and the Coalition liaison could be collocated with that entity. It may also be helpful to have a similar liaison position staffed at the Incident Command Post to coordinate directly with the primary IMT for the incident.

      Standard operating procedures (SOPs) may be established for the HCRT to enhance coordination with the Jurisdictional Agency (Tier 3). Any activation of the Coalition’s EOP, request for assistance, or other significant occurrence must be rapidly communicated to the appropriate Jurisdictional Agency(s). This will allow the local authorities to monitor the situation, address their legal responsibilities, and anticipate resource needs by Coalition member organizations.

      As previously noted, the geographical area of a Healthcare Coalition may extend beyond the boundaries of a single local government. When this occurs, the Healthcare Coalition must effectively interface with each local government in which Coalition member organizations reside, through the relevant Jurisdictional Agency(s).


      1. As noted in Chapter 1, the term “Jurisdictional Agency” in NIMS refers to the agency having jurisdiction and responsibility for a specific geographical area or a mandated function. Usually, this is a local, State, Tribal, or Federal government agency that has direct authority for emergency response and recovery (NIMS, December 18, 2008).
      2. Similar to strategies for integrating with member organizations, this is predicted to be one of the more common activities for any Healthcare Coalition.
      3. 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: http://www.gwu.edu/~icdrm/.
      4. According to NIMS, “Governmental departments (or agencies, bureaus, etc.) or private organizations may also have operations centers (referred to here as Department Operations Centers, or DOCs) that serve as the interface between the ongoing operations of that organization and the emergency operations it is supporting. The DOC may directly support the incident and receive information relative to its operations.”

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      • This page last reviewed: February 14, 2012