To adequately provide MSCC, individual HCOs must have a comprehensive EMP that addresses mitigation, preparedness, response, and recovery activities for major public health and medical incidents. A valid hazard vulnerability analysis (HVA)[5] forms the cornerstone of the EMP. The HVA is conducted by HCOs to define and prioritize a strategy for mitigation preparedness, response, and recovery based on the perceived risk (i.e., likelihood of hazard occurrence and vulnerability to the hazard impact) posed by potential hazards to HCO.
The primary objective of an HVA is to identify hazards and the vulnerability (i.e., susceptibility) to hazard impacts, and to prioritize EMP initiatives. Many models and guides are available to develop an HVA, but the critical components may be accomplished through the following steps:
- Hazard identification. Identify and list, by type, all hazards that could affect the location or asset of interest, and the relative likelihood of each hazard's occurrence ("threat").
- Vulnerability determination. For each hazard, develop an assessment of both the community and the response system's susceptibility to the hazard impact. For MSCC, this includes:
- The community vulnerability in terms of potential post-impact health and medical needs of the population
- The medical response system's vulnerability to each hazard (both the vulnerability of the system's baseline operations and its ability to surge).
- Analysis of the vulnerabilities. Use a systems-based approach to:
- Break down each hazard vulnerability into its key components
- Identify components that are common across multiple hazards
- Identify issues that create extremely high-stakes weaknesses
- Compare relative cost-benefit ratios between the many possible mitigation and preparedness interventions.
While no HVA instrument can provide precise stratification of hazard threat and vulnerability for an asset or community, the HVA exercise should provide a basis for developing priorities among the many options that can reduce risk and enhance preparedness. From the HVA findings, the HCO can prioritize initiatives for mitigation and preparedness, and develop plans to address the identified vulnerabilities during response and recovery. If approached in this fashion, the HVA has maximum applicability to an EMP. In addition to guiding internal HCO mitigation and preparedness, the HVA activities can foster relationships with other local HCOs (Tier 2), with jurisdictional authorities (Tier 3), and with non-health-related organizations by highlighting common threats facing them.
Universities and other educational facilities may find it beneficial to address some aspects of preparedness planning in partnership with a nearby HCO. Because the threats they face may be similar, each should understand the other's vulnerability in order to effectively plan. For example, the HCO should have a sense of the number of students and staff that might be affected by identified hazards, and the university should know the patient-receiving capacity of the HCO so that it can plan for additional resources if necessary. This relationship can extend to the preparedness phase, with each organization's strengths offered to help address the other's vulnerabilities. The university may provide housing and temporary staging facilities for HCO evacuation, whereas the HCO's patient tracking and family assistance mechanisms may be used to rapidly inform the university of the location and status of students transported there for care (which addresses a significant area of university vulnerability in meeting parental expectations).
Senior executives at HCOs have ultimate responsibility for the development, implementation, and maintenance of their institution's EMP, and often appoint an emergency management coordinator to perform EMP activities.[6] In addition, an EMP committee composed of senior-level representatives from major departments within an HCO is usually established to review all EMP-related work and to provide expert input into the development of the HCO's EOP. The following are brief descriptions of key activities in the four phases of the EMP that promote integration with the larger response community.
2.2.1 Mitigation
Mitigation is the process of planning for and implementing measures to prevent the occurrence of potential hazards. It also includes actions undertaken to minimize the impact of a hazard should one occur. It is advantageous to collaborate with other HCOs and with non-medical responders when identifying mitigation activities, as this (1) may help uncover hazards and vulnerabilities that the individual HCO might not otherwise consider and (2) allows for sharing of best practices or other solutions. Examples of mitigation activities include the following:
- Designing and constructing HCOs to avoid or minimize potential hazards (e.g., build electrical systems above ground level in flood- prone areas)
- Confining internal hazards, such as hazardous materials, in safe and secure areas to prevent their release during an internal event (e.g., a fire)
- Developing redundancy in hospital operating systems to ensure backup capability during an emergency. Backup systems should be evaluated for their vulnerability to hazards, particularly those most likely to affect primary systems (e.g., backup generators should be located above ground level in flood prone areas)
- Protecting communication systems (both internal and external) and computer infrastructure from accidental or deliberate disruption
- Establishing programs for testing, inspection, and preventive maintenance of backup systems and facility safety features.
2.2.2 Preparedness
Preparedness activities are undertaken to build capacity and capability within an HCO so that it can meet potential patient and staff needs that arise after a hazard impact. Preparedness centers on having an effective EOP in place that:
- Describes a well-defined management structure for emergency response
- Assigns important roles and responsibilities to the HCO incident management team and general staff during response
- Provides mechanisms to facilitate interfacility cooperation and integration into the community response (e.g., development of standardized data collection and information sharing protocols)
- Describes processes for requesting and receiving mutual aid, or for providing support to other HCOs whose operational thresholds have been exceeded
- Establishes mechanisms to conduct and evaluate semi-annual emergency response exercises.
Regular meetings of the EMP committee should be conducted as part of preparedness activities, and there should be an annual evaluation (and revision, if necessary) of the EOP. In addition, preparedness includes all training and drills, to impart knowledge and skills, plus exercises that are performed to stress and evaluate the HCO EOP. These activities are best performed in conjunction with other HCOs (Tier 2) or the jurisdiction (Tier 3) to enhance their integration.
2.2.3 Response
Response actions address a specific hazard impact that has occurred (or an impending impact, such as a hurricane or tornado) and are guided by the HCO EOP. The primary goals of response actions are to:
- Prevent or limit the extent of a hazard impact on HCO staff, patients, and operations (e.g., proper isolation/quarantine measures)
- Maximize patient and population resistance to a hazard after exposure (e.g., administration of appropriate vaccination or medication prophylaxis)
- Promote healing of incident victims and the general population from a hazard impact (e.g., provision of definitive care, rehabilitation and mental health services).
While these response goals (i.e., control objectives[7]) should be universal to all HCOs during response, operational period objectives, strategies, and tactics to achieve these goals may vary. It is important to coordinate response strategies among HCOs (or at least clearly communicate preferred strategies to individual HCOs) through a collective response planning process (Tier 2).
2.2.4 Recovery
The activities of the recovery phase seek to return response personnel and the HCO to normal operations (or to a defined "new normal") as quickly as possible. Recovery efforts should include a thorough evaluation of how the response system performed under stress, making note of specific strengths, weaknesses, and strategies to improve the HCO's ability to respond to future emergencies and disasters. Other important recovery activities include the following:
- Accounting accurately for all costs incurred by the HCO as a result of a response, and applying for financial remuneration for those costs
- Attending to acute and long-term physical and mental health effects incurred by HCO staff during response (e.g., providing counseling services)
- Replacing or servicing equipment and supplies used during response
- Evaluating, cleaning, and/or repairing damage to the facility.
Recovery activities should be coordinated with other tiers. Moreover, it is critical that each HCO report to the designated jurisdictional (Tier 3) incident management authority when its recovery is complete and the facility has returned to normal operations.
- For a detailed discussion of the HVA for healthcare systems, see Emergency Management Principles and Practices for Healthcare Systems: Unit 1, Lessons 1.3.3 and 1.3.2.
- J. A. Barbera and A. G. Macintyre. Jane's Mass Casualty Handbook: Hospital. Surrey, UK: Jane's Information Group, Ltd., 2003.
- "Control objectives" is the NIMS term for overall incident response goals and are not limited to any single operational period (thus distinguishing them from operational period objectives).
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