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U.S. Department of Health and Human Services

Performance Measure 17

Goal or Target

SPPR will establish a baseline based on performance data collected in initial fiscal years, which will be used to set programmatic targets and goals for subsequent years. As the CST exercise (Phase 1) concludes at 90 minutes, each HCC’s goal is to complete the exercise within 90 minutes.

Operational Intent

The CST assesses the preparedness and response performance of HCCs and member organizations across a number of critical functions. While an HCC may have completed foundational aspects of community preparedness (i.e., response plans), exercises test an HCC’s ability to perform critical functions in an emergency scenario. One of these functions is to identify the total number of patients in an evacuating facility so that receiving facilities may prepare to receive them. This measure determines how quickly evacuating facilities are able to assess and communicate essential patient counts across the HCC.

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
PM17.1 Time, in minutes, for the last evacuating facility to report the total number of patients identified as able to be evacuated after start of 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:________

Time: ________(min)

Definitions and Interpretation

  • Time [in minutes]: Measured from the start of Phase 1 of the CST and ending when the last evacuating facility reports the patient count to be evacuated or 90 minutes elapses, whichever is less. If the last evacuating facility cannot report the patient count before 90 minutes elapses, the HCC should indicate ‘not complete in 90 minute Phase 1 exercise’.

  • Evacuating facilities: A trusted insider creates a list of patient care facilities (e.g., acute care hospitals, skilled nursing facilities) that could play the role of evacuating facilities during the exercise. The list should identify backup facilities as well, in case some decline to participate when called, as well as include information on bed and patient count, which might help the assessment team select evacuating facilities. The assessment team (led by the LEAD assessor) will use facility information provided by the trusted insider to identify a facility (or set of facilities) whose evacuation would adequately stress the coalition. Assessors should seek to identify inpatient facilities whose collective evacuation would surge the coalition to 20 percent above staffed acute care bed capacity. The LEAD Excel tool from the CST provides a table for organizing this information.

  • Report the total number of patients identified as able to be evacuated: Evacuating facilities should plan to evacuate all of their patients. Evacuating facilities are instructed to take a current patient count; however, there will be no movement of actual patients. The end point of this measure will be achieved when the last evacuating facility reports their patient count.

  • 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. 11

11.Phase 4: After Action Report and Improvement Planning.” City and County of San Francisco Department of Emergency Management. Accessed 6 Aug. 2020.

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  • This page last reviewed: November 05, 2020