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U.S. Department of Health and Human Services

Performance Measure 16


Percent of patients at the evacuating facilities that are identified as able to be: a) discharged safely to home or b) evacuated to receiving facilities during Phase 1: Table Top Exercise with Functional Elements and Facilitated Discussion of the Coalition Surge Test


Goal or Target

SPPR will establish a baseline based on performance data collected in initial fiscal years, which will be used to set targets and goals for subsequent years.


Operational Intent

Under a real-world evacuation, it is critical that facilities assess each patient’s care needs and determine the most appropriate approach to ensure his/her care and well-being. This indicator will assess HCC member organizations’ ability to identify current inpatient needs and decompress. An HCC demonstrates the ability to identify patients able to be evacuated or safely discharged through the successful completion of the CST or real-world evacuation of at least 20 percent of the coalition’s staffed acute care beds. In the exercise, evacuating facilities are instructed to take a current patient count and to work (using whatever communication mechanisms it would during a real evacuation) to find appropriate destinations for each patient.


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. All patients at the evacuating facilities shall be represented in one of the data points below.


Data Point Data Entity Data Source Response
PM16.1 Number of patients at evacuating facilities identified as being able to be discharged safely to home during a Coalition Surge Test (or real-world evacuation of at least 20 percent of the coalition’s total staffed acute care beds)HCCCST (or AAR/IP)

HCC Name:________

#_______(Patients)

PM16.2 Number of patients at evacuating facilities identified as being able to be evacuated to receiving facilities during a Coalition Surge Test (or real-world evacuation of at least 20 percent of the coalition’s total staffed acute care beds)HCC​CST (or AAR/IP)

HCC Name:________

#_______(Patients)

PM16.3 Total patients at all evacuating facilities at the beginning of the Coalition Surge Test (or real-world evacuation of at least 20 percent of the coalition’s total staffed acute care beds)HCC​CST (or AAR/IP)

HCC Name:________

#_______(Patients)

PM16.4 Total number of staffed acute care beds in the coalitionHCC​State licensing data

HCC Name:________

#_______(Beds)



Definitions and Interpretation

  • Evacuated or discharged safely: Patients should be categorized by two levels of acuity (based on patient’s clinical status) during the exercise: 1) able to be safely discharged to home or 2) able to be evacuated to receiving facilities.

  • Home or receiving facilities: For the purposes of the CST, no patients will actually be moved. However, the evacuating facilities, in coordination with their HCC, should identify patients that can be safely discharged or who will need to be evacuated to receiving facilities. Home is the patient’s usual and regular living arrangement, such as a single-family house, apartment, group home, barracks, dorm, or other institutional housing. Receiving facilities are all facilities that are able to receive patients. The LEAD Excel tool from the CST provides a table for organizing this information.

  • Total patients at evacuating facilities: The total number of patients at all evacuating facilities participating in Phase 1 of the CST, to include all inpatients in each facility regardless of location or admission status.

  • Total number of staffed acute care beds in the coalition: HCCs are expected to determine the approximate total number of staffed acute care beds across the coalition in order to identify the evacuating facilities for a CST. The evacuating facilities should collectively represent at least 20 percent of the HCC’s total number of staffed acute care beds in order to adequately stress the coalition.

  • 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. 10



10.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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  • This page last reviewed: November 05, 2020