1. Certified Hospital Emergency Coordinator (CHEC) Training Program
Exercises

2. Objectives Recognize the standards and requirements for exercises
After completing this lesson, you should be able to:
Recognize the standards and requirements for exercises
Describe the steps in the exercise cycle
Define the different types of exercises
Incorporate lessons learned from exercises into hospital plans

3. Exercise Requirements
Why exercise?
Test the plan’s effectiveness
Test staff’s ability to implement the plan
Test logistics and equipment
Exercises is a critical part of emergency preparedness. Exercises help to test how effective the plan is, whether or not there are gaps in the plan that need to be addressed. Exercises also test how well staff understand the plan, and how well the plan is implemented within the facility. Another important feature of exercises is that they provide opportunities to test equipment to make sure that staff know how to use emergency preparedness equipment (such as decontamination equipment) and to ensure that equipment remains in good working order.

4. Exercise Requirements: Joint Commission
Assess the Plan’s appropriateness, adequacy, and the effectiveness of logistics, human resources, training, policies, procedures, and protocols
Stress limits of the plan to support assessment of preparedness and performance
Exercise design should test the ability to respond to the effects of emergencies on their capabilities to provide care, treatment, and services
The Joint Commission requires that hospitals test its Emergency Operations Plan twice each year, either through exercises or actual events. During the year, hospitals must test surge capacity, self-sufficiency, and their ability to coordinate with community partners.
CMS is also now requiring 2 exercise per year with at least 1 including community partners and be a full scale

5. Exercise Requirements: ASPR
Each budget cycle, ASPR identifies capabilities to focus on, both in planning and exercises. The current Capabilities include:
Medical Surge
Formerly Medical Surge, Volunteer Management, and Fatality Management
Foundation for Health Care and Medical Readiness
Formerly Health Care System Preparedness
Health Care and Medical Response
Formerly 2 capabilities of: Emergency Operations Coordination & Information Sharing
Continuity of Health Care Service Delivery and Recovery
Formerly Health Care System Recovery & Responder Safety and Health
The Assistant Secretary for Preparedness and Response-Hospital Preparedness Program also identifies capabilities for hospitals to focus on. These capabilities vary each year, based on national priorities and threats.

6. HSEEP Homeland Security Exercise and Evaluation Program
Framework for designing, conducting, and evaluating exercises
Agencies who receive emergency preparedness funding must be HSEEP (emergency management, public health, etc) compliant
Recently, the federal government released the Homeland Security Exercise and Evaluation Program, or “HSEEP”. This program provides step-by-step guidance for exercise design, conduct, and evaluation. Resources and toolkits to support HSEEP guidance are also available. Agencies who receive emergency preparedness funding should adopt HSEEP guidance. The State of Georgia offers a three-day course solely focused on HSEEP. This unit will provide an overview of HSEEP guidance in order for hospital emergency coordinators to have some degree of familiarity with the HSEEP process and terminology.

7. Planning Type and Design Conduct Evaluation Improvement Planning
The Exercise Cycle
Planning
Type and Design
Conduct
Evaluation
Improvement Planning
The exercise cycle is composed of five main components: planning, designing, conducting, evaluation, and improvement.
Planning involves identifying what the exercise needs are for the hospital. What hazards are highly ranked on the HVA? Is there new equipment that needs to be tested, or has it been a while since certain elements of the Emergency Operations Plan were tested?
Designing exercises includes choosing which types of exercise are most appropriate, pulling together a planning team, identifying exercise logistical needs (including volunteers), and choosing personnel to help conduct the exercise. Appropriate documentation also needs to be created.
Conducting the exercise is actually running the scenario created by the exercise planning team. It includes those persons who have been charged with evaluating components of the exercises.
The evaluation is perhaps one of the most important, but probably most overlooked components of the exercise cycle. Evaluation not only involves data collection and analysis, but also compiling that data into an after-action report.
Once the after action report has been developed, and areas for improvement have been identified, those areas are pulled out and placed in an improvement plan. The improvement plan lists the areas of improvement, what will be done to improve them, who is in charge of ensuring improvements are carried out, and timelines for achieving these improvements.

8. Planning
Consider what changes have occurred in the hospital since the last exercise
Use after-action reports to identify objectives
Incorporate HVA into exercise objectives
Reach out to community partners (EMA, public health, LEPCs, etc) to see if exercises can be combined
Exercises should be incorporated into long-term emergency preparedness goals. When thinking about goals and objectives for exercises, consider what has changed in the hospital since the last exercise. Has the hospital received new equipment that has not been tested? Is there a new wing of the hospital? Have staff received training lately? Are there departments with a large percentage of new employees? All of these things should be incorporated into exercise planning.
In addition, when creating an exercise plan, utilize after-action reports and improvement plans from previous exercises to identify elements of the plan that need to be retested. Hazard Vulnerabilities Analyses are also excellent sources for planning exercise objectives.
Once basic objectives have been identified, consider reaching out to community partners who also have exercise requirements, such as emergency management agencies or public health. Combining exercises with community partners not only increases the realism of the exercise, but also helps to save resources.

9. Design: Exercise Types
Discussion-based Exercises
Seminars
Workshops
Tabletops (TTXs)
Games/Simulations
Operations-based Exercises
Drills
Functional (FEs)
Full-Scale (FSEs)
There are two major types of exercises: discussion-based and operations-based. Discussion-based exercises do not involve actually performing any of the response elements.
Seminars are the most basic types of exercises. Seminars provide an overview of new or current plans, resources, strategies, concepts or ideas. If the Emergency Operations Plan has undergone significant revision, a seminar may be held to update staff on the plan.
Workshops achieve specific goals, or build projects. For example, workshops could be utilized to create new policies on decontamination teams.
Tabletop exercises validate plans and procedures by utilizing a hypothetical scenario to drive participant discussion. Players sit around tables, usually either grouped by functional or geographic area, and talk through scenarios. Tabletop exercises can be especially useful to hold prior to conducting operations-based exercises, to identify possible problem areas that can be corrected prior to operations-based exercises. Tabletop exercises can also be used to discuss issues that are not possible, practical, or safe to actually exercise, such as evacuation of critical patients.
Games and simulations are not often used in hospitals, but they are used to explore decision-making processes and examine consequences of those decisions (think of the military).
Operations-based exercises involve actually performing the responses outlined in the EOP to some extent.
Drills focus on testing one specific function of the plan. For example, conducting a call-down is an example of a communications drill. Exercising the decontamination team is another example.
Functional Exercises evaluate capabilities, functions, plans, and staffs of Incident Command Systems. These types of exercises involve personnel reporting to the Hospital Command Center, however, movement of resources and other personnel are simulated. Often, functional exercises incorporate Emergency Operation Centers from different agencies communicating with each other (EMA, public health, hospital, etc).
Full-Scale Exercises validate plans, policies, procedures, and cooperative agreements developed in previous exercises through actual implementation and execution during a simulated scenario. Full-scale exercises include actual mobilization of resources and conduct of operations.

10. Design: Planning Team
Should represent various functions and departments within hospital
May include community partners
Responsible for developing:
exercise objectives
creating exercise documentation
Develop a planning timeline with milestones
Should try to avoid participating in the exercise
The exercise planning team is responsible for organizing the exercise. The team may include representatives from different departments who are playing, and may also include representation from outside agencies. If the hospital is participating in an exercise organized by another agency (EMA, public health, etc) they may be asked to provide representation to the exercise planning team. This representative may also need to organize an internal planning team at the hospital to ensure that objectives are carried out appropriately, according to the complexity of the exercise.
Members of the team create appropriate exercise documentation, and also determine the specific injects of the exercise. Because team members are so involved with all aspects of the exercise, it is wise to try to avoid having team members play in their usual roles during the exercise. Consider utilizing team members in other ways during the exercises.

11. Design: Planning Conferences
Concepts and Objectives Meeting
Initial Planning Conference
Mid-Term Planning Conference
Final Planning Conference
HSEEP incorporates a planning structure that can be utilized to more effectively and completely plan the exercise. Planning conferences are designed to maintain the exercise design process on a timeline.
The Concepts and Objective Meeting is designed to set the goals and objectives for the exercise. The Initial Planning Conference lays the foundation for carrying out the exercise. Responsibilities are assigned to planning team members at this meeting. Specific details about exercise logistics are discussed. The Mid-term planning conference revisits design issues, and addresses any problems in the design process. In more complex exercises, a Master Scenario Events List (MSEL) conference is also conducted to write specific injects for the exercise. The final planning conference addresses any last minute issues and finalize exercise documentation.

12. Design: Documentation
Discussion-based
Situation Manual (SitMan)
Master Scenario Events List (MSEL) (also for Operations-based exercises)-may be in conjunction with the Midterm Planning Conference
Facilitator Guide
Operations-based
Exercise Plan (ExPlan)
Controller and Evaluator (C/E) Handbook
Player Handout
Exercise Evaluation Guide (EEG)(also for TTXs)
The Situation Manual is the participant handbook for discussion-based exercises, especially TTXs. It provide background information on exercise scope, schedule, and objectives. It also presents the scenario that drives discussions during the exercise.
An Exercise Plan (ExPlan) is used for operations-based exercises, provides an exercise synopsis and is published and distributed to players and observers prior to the start of the exercise. The ExPlan addresses exercise objectives and scope and assigns roles and responsibilities that must be carried out for successful exercise execution. The ExPlan does not contain detailed scenario information.
Controller and Evaluator (C/E) Handbook is a supplement to the ExPlan, and contains detailed information about the scenario and describes the roles and responsibilities of controllers and evaluators. The C/E Handbook, is only distributed to controllers and evaluators.
The Master Scenario Events List (MSEL) is a chronological timeline of expected actions and scripted events (i.e., injects) to be inserted into exercise play by controllers in order to generate or prompt player activity. It ensures necessary events happen so that all exercise objectives are met.
Player handouts are used in operations-based exercises. They provide quick reference material for exercise players related to safety, logistics, schedule, and any other necessary information.
Exercise Evaluation Guides (EEGs) help evaluators collect and interpret relevant exercise observations. EEGs provide evaluators with information on what tasks they should expect to see accomplished or discussed during an exercise, space to record observations, and questions to address after the exercise.

13. Conduct: Exercise Personnel
Facilitators/Controllers
Evaluators
Players
Actors
Simulators
Observers
There are several types of personnel essential to the success of the exercise. Facilitators are used for discussion-based exercises, and controllers are used for operations-based exercises. They are responsible for ensuring that the exercise stays on task, and that participants are addressing the exercise objectives. Facilitators and controllers may also need to alter exercise injects as appropriate to move the exercise along.
Evaluators evaluate and comment on specific functions of the exercise. Evaluators should have some knowledge regarding the subject matter they evaluate. Evaluators should not directly address players.
Players either discuss (in discussions-based) or perform (operations-based) their roles in emergency response.
Actors are volunteers that are generally used to demonstrate victims to create realism.
Simulators perform the role of agencies, individuals, or organizations that are not actually participating in the exercise in order to drive exercise play.
Observers are those who view play for learning purposes. It is important to assign a staff member to the group of observers who is knowledgeable about the actions occurring during the exercise, so that they may describe the actions of the players to the observers.

14. Exercise Conduct C/E Briefing Player Briefing Safety Briefing
Depending on the complexity of the exercise, particularly in operations based exercises, a number of briefing may need to be conducted prior to the start of play to ensure that personnel know their roles, and operate in a safe environment.

15. Exercise Conduct
Ensure that during the exercise, evaluators specifically address:
Communications
Safety and Security
Staff Roles and Responsibilities
Patient Care and Clinical Activities
Utilities Management
Resources and Assets
And include the ASPR Exercise Capabilities
During the exercise, evaluators should pay special attention to these six critical areas of emergency management. This will ensure that evaluation data reflects priorities identified by the Joint Commission.

16. Media Consider inviting media to exercise Specify locations for media
May be beneficial to all parties

17. After-Action Conference
Exercise Evaluation
Hotwash
After-Action Conference
Immediately after the exercise, a hotwash is conducted to capture initial thoughts and reflections on the exercise. In some situations, it is wise to conduct a player hotwash, and then a hotwash with controllers and evaluators.
Once the draft version of the after action report has been completed, an after action conference is held for players, controllers, and evaluators to review the report, as well as draft the improvement plan.

18. Improvement Planning

19. Certified Hospital Emergency Coordinator (CHEC) Training Program
Exercises
Questions?

20. Improvement Plan Matrix