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U.S. Department of Health and Human Services

Performance Measure 19



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

In order to perform its role effectively in an emergency situation, an HCC and its member organizations require timely access to EEI. Just as evacuating facilities must communicate the number of patients identified for evacuation, HCCs and their member organizations must know how many beds are available at receiving facilities in order to match them to incoming patients. This measure gauges how quickly receiving facilities are able to assess and communicate EEI 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
PM19.1 Time in minutes for the last receiving facility to report the total number of beds available to receive patients 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 potential receiving facility reports the number of beds available to receive patients or 90 minutes elapses, whichever is less. If the last receiving facility cannot report the number of beds to receive patients before 90 minutes elapses, the HCC should indicate ‘not complete in 90 minute Phase 1 exercise’.

  • For the last receiving facility: 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.

  • Report the total number of beds available to receive patients: 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. “Appropriate” refers to the clinically appropriate decision that is based on the patient’s specific health care needs. A patient will have a bed identified when there is verbal or written (e.g., email or notation in incident management software) agreement from a receiving facility that it can provide an appropriate destination for the patient. However, there will be no movement of actual patients. The end point of this measure will be achieved when the last potential patient has a bed identified at a receiving facility.

  • 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. 13


13. “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