Healthcare Emergency Manager Core Competencies Assignment

Healthcare Emergency Manager Core Competencies Assignment

Appendix C – Healthcare Emergency Management Competencies
Institute for Crisis, Disaster and Risk Management
The George Washington University
33
Appendix C
Healthcare Emergency Management Competencies:
Competency Framework Final Report 1
Joseph A. Barbera, MD, Anthony G. Macintyre, MD, Greg Shaw, DSc,
Valerie Seefried, MPH, Lissa Westerman, RN, Sergio de Cosmo, MS
Institute for Crisis, Disaster, and Risk Management
The George Washington University
October 11, 2007
Introduction
In December 2004, the Veterans Health Administration (VHA) Emergency Management
Strategic Healthcare Group awarded the Institute for Crisis Disaster & Risk Management
(ICDRM) a contract to participate in establishing innovative training and personal
development curricula for the VHA Emergency Management Academy (VHA-EMA).
The objective of the project was to develop a nationally peer-reviewed, National Incident
Management System (NIMS) compliant, competency-based instructional outline and
curriculum content upon which to base education and training courses. The curriculum is
intended to educate VHA personnel for response and recovery in healthcare emergencies
and disasters, to provide a resource for future VHA training programs, and to be placed in
the public domain for use by other healthcare personnel.
The initial phase of the EMA project consisted of developing a competency framework
(competency definition, structure and format, and critical elements) followed by
development of peer-reviewed emergency response and recovery competencies for VHAselected healthcare system job groups. The competencies describe knowledge, skills, and
abilities essential for adequate job performance during the emergency response and
recovery phases of an incident. Peer review was accomplished through a web-based
survey of the proposed competencies, which was distributed to a select, nationwide
sampling of emergency management personnel who were identified as having extensive
experience or advanced expertise in healthcare emergency response. The survey process
was designed to obtain a balanced expert opinion as to whether the project team’s written
competencies were valid, and to assess the appropriate level of proficiency for each
primary competency (i.e., awareness, operations, or expert). The competencies developed
during this initial phase were then used to guide the development of learning objectives
for the instructional curriculum.
1
This report was supported by Department of Veterans Affairs, Veterans Health Administration contract
“Emergency Management Academy Development,” CCN20350A. The report is the work of the authors
and does not represent the views of the Department of Veterans Affairs or any of its employees.
Appendix C – Healthcare Emergency Management Competencies
Institute for Crisis, Disaster and Risk Management
The George Washington University
34
An extensive research effort was conducted to understand the historical use of
competencies, and to establish objective criteria for competency development.
Historical development of competencies
Competency modeling originated in business management research, and has evolved
extensively over the past 25 years as other disciplines began adopting the practice.2
The
original intent of competency development was to enhance the then common “job
analysis” by relating a position’s requisite knowledge, skills and abilities to the overall
objectives of the organization in which the position existed. This approach aligns the
objectives (i.e., desired outputs) of individual jobs with the overall objectives of the
organization, such that organizational objectives are achieved through effective
individual job performance. While this was the original intent of competencies, their
definition varied widely as time progressed. Competency definitions range from
emphasizing underlying characteristics of an employee (e.g., a motive, trait, skill, aspects
of one’s self-image, social role, or a body of knowledge) that produce effective and/or
superior performance 3
to performance characteristics (i.e., how an employee conducted
their job in relation to the organization’s objectives). 4
The application of competencies across the many organizations that use them has also
varied widely. The private sector has commonly employed competencies to define
“superior performers”5
and therefore, as a selection tool for hiring, promotion, and/or
salary enhancement. In other organizations, competencies have been used for job-specific
performance feedback and improvement. Still others have used competencies to guide
future program training and development. Because of this variation in definition and
application, it becomes critically important to address these vagaries at the outset of any
competency development project. This concept was well-described by one competency
research team:
“The first step in the implementation of any competency-based management
framework must be the organizational consensus on how to define ‘competency.’
This agreed upon definition will drive the methodology used to identify and
assess the competencies within the organization.” 6
The GWU-ICDRM project team strongly agreed with this concept, and started the project
by defining how the competencies within this initiative would be applied:
2
Newsome, Shaun, Victor M Catano, and Arla L. Day. Leader Competencies: Proposing a Research
Framework. 2003. available at http://www.cleleadership.ca/paper/leader_competenciesproposing_a_research_framework.pdf
3
Boyatzis, Richard. The Competent Manager: A Model for Effective Performance New York: Wiley, 1982. 4
US Office of Personnel Management. Executive Core Qualifications (ECQ’s), accessed at
http://www.opm.gov/ses/ecq.asp
5
Klein AL. Validity and Reliability for Competency-based Systems: Reducing Litigation Risks.
Compensation Benefits and Review, 28, 31-37, 1996. cited in “Newsome, Shaun, Victor M Catano, and
Arla L. Day. Leader Competencies: Proposing a Research Framework. 2003. 6
Newsome, Shaun, Victor M Catano, and Arla L. Day. Leader Competencies: Proposing a Research
Framework. 2003. available at http://www.cleleadership.ca/paper/leader_competenciesproposing_a_research_framework.pdf
Appendix C – Healthcare Emergency Management Competencies
Institute for Crisis, Disaster and Risk Management
The George Washington University
35
The project competencies are intended to serve as formative tools to guide
healthcare system personnel in developing knowledge, skills and abilities for
effective performance during emergency response and recovery. These
competencies are also intended to serve as a guide for developing preparedness
education and training, and therefore, to serve as a basis for the healthcare
emergency management curriculum. Finally, the competencies may be employed
as a tool for assessing the performance of individual healthcare personnel
performance during emergency response and recovery operations.
Defining a competency framework
Despite an extensive search of published articles related to competencies, the GWUICDRM project team determined that no single authoritative source presented a
consistent competency definition and competency framework to adequately support the
VHA-EMA project needs. A framework was therefore developed, analyzed through pilot
competency development, refined and completed before establishing the individual
emergency response and recovery competencies for this project. The competency
framework was therefore used to impose a strict methodological consistency when
developing and defining all competencies developed in this program. Central to this
framework is the critical importance of competencies being objective and measurable,
internally and externally consistent, and tightly described within the context of the
organization’s specific objectives.
Within this framework, the project team defined a “competency” as a specific knowledge
element, skill, and/or ability that is objective and measurable (i.e., demonstrable) on the
job. It is required for effective performance within the context of a job’s responsibilities,
and leads to achieving the objectives of the organization. Competencies are ideally
qualified by an accompanying proficiency level. 7
The GWU-ICDRM project team recognized the need to adapt the methods for
competency development, since the usual business approach to establishing competencies
is problematic for emergency management. Business management models establish
competencies by observing performance and relating it to individual and organizational
outputs. Because emergencies are rare events, and therefore emergency response and
recovery outputs occur very infrequently, the related competency framework and
definitions for this project are based less upon observed outputs. Instead, the basis is a
healthcare system’s emergency response and recovery objectives, together with the
NIMS-consistent incident command system8
structure and processes mandated for use by
all emergency response organizations in the U.S.9,10
7
GWU Institute for Crisis, Disaster and Risk Management. Emergency Management Glossary of Terms
(October 2007) available at www.gwu.edu/~icdrm/ 8
Fedral Emergency Management Agency. National Incident Management System (NIMS) (March 1, 2004),
available at: http://www.fema.gov/emergency/nims/index.shtm. 9
Bush GW. Homeland Security Presidential Directive (HSPD) -5: Management of Domestic Incidents
(February 28, 2003) accessed at http://www.whitehouse.gov/news/releases/2003/02/20030228-9.html
Appendix C – Healthcare Emergency Management Competencies
Institute for Crisis, Disaster and Risk Management
The George Washington University
36
Response competencies in systems using the Incident Command System (ICS), therefore,
should be based upon the general incident objectives an organization has during incident
response, and upon the organizational structures, processes, and relationships with other
organizations that are used during response rather than those used during everyday
experience. Emergency competencies are commonly developed without this relationship
to a defined response system,11 making it difficult to define how scientific or medical
knowledge is to be implemented in an emergency response. In contrast, the GWUICDRM project team specifically incorporated the NIMS mandate to use ICS by
including reference to the NIMS/Incident Command System structure and processes
throughout the project’s emergency response and recovery project competencies.
Because of the anticipated large number of competencies, the project team also
established a “primary versus supporting competency” hierarchy to categorize the
individual competencies as they were developed. Designating “primary” and
“supporting” competencies helps to maintain a priority in the framework when listing a
large number of individual competencies. Supporting competencies are also a means to
more fully define and clarify the primary competencies.
Preparedness versus response and recovery competencies
Published articles describing emergency management competencies commonly do not
differentiate between preparedness and response competencies, and list them in an
intermixed fashion. 12,13 The GWU-ICDRM project team sought to maintain a separation
between these categories.
Preparedness competencies are commonly based upon everyday organizational
objectives, structure, processes, and relationships to other organizations. Preparedness is
unquestionably important, but for it to be accurate, comprehensive and successful in
establishing an effective emergency response capability, a thorough understanding of the
response system must be established first, and preparedness guided by this. It was
therefore reasoned by the project team that specific competencies for emergency response
should be established and validated first, and then used as the “end state” to guide the
development of valid preparedness competencies.
10 Barbera JA, Macintyre AG, et al. Emergency Management Principles and Practices for Healthcare
Systems, Unit 3, Lesson 3.1.1, accessed at http://www1.va.gov/emshg/page.cfm?pg=122 11 ATPM (Association of Teachers of Preventive Medicine) in collaboration with Center for Health policy,
Columbia University School of Nursing. Emergency Response Clinician Competencies in Initial
Assessment and Management, 2003, accessed at http://www.atpm.org/education/Clinical_Compt.html 12 INCMCE (International Nursing Coalition for Mass Casualty Education). Educational Competencies for
Registered Nurses Responding to Mass Casualty Incidents, 2003. Available at:
http://www.nursing.hs.columbia.edu/institutes-centers/chphsr/hospcomps.pdf 13 ACEP (American College of Emergency Physicians) and the U.S Department of Health & Human
Services, Office of Emergency Preparedness. Developing Objectives, Content, and Competencies for the
Training of Emergency Medical Technicians, Emergency Physicians, and Emergency Nurses to Care for
Casualties Resulting From Nuclear, Biological, or Chemical (NBC) Incidents, Final Report April 23, 2001.
American College of Emergency Physicians, Irving, Texas.
Appendix C – Healthcare Emergency Management Competencies
Institute for Crisis, Disaster and Risk Management
The George Washington University
37
Because of these considerations, the initial project focus was response and recovery
competencies. Emergency management program competencies related to mitigation and
preparedness were developed later for the two job groups that are the initial focus of the
certification project.
Establishing appropriate levels of proficiency
Concurring with other authors that “competency” is not an all-or-none phenomenon, the
GWU-ICDRM project team established “proficiency levels” to address this issue in a
graduated fashion. Proficiency levels delineate the “The degree of understanding of the
subject matter and its practical application through training and performance…” 14 In
emergency management, proficiency indicates the level of mastery of knowledge, skills
and abilities (i.e., competencies) that are demonstrable on the job and lead to the
organization achieving its objectives. Levels of proficiency may therefore also be used to
describe the level of mastery that is the objective of and specific training or education
program. The final proficiency levels defined for this project are presented in Table 1.
Table 1. Definition of the Levels of Proficiency
Awareness
Represents an understanding of the knowledge/skills/abilities
encompassed by the competency, but not to a level of capability to
adequately perform the competency actions within the organization’s
system.
Operations Represents the knowledge/skills/abilities to safely and effectively
perform the assigned tasks and activities, including equipment use as
necessary
Expert Represents operations-level proficiency plus the additional
knowledge/skills/abilities to apply expert judgment to solve problems
and make complex decisions.
As core and job group competencies were developed, the project team qualified each
primary competency with an indicated level of proficiency (awareness, operations,
expert).
14 EMA. Urban Search & Rescue Incident Support Team Training: Student Manual. Module 1, Unit 4,
Page 6: Planning Process Overview. n/a:40. 4/16/2004, accessed at:
http://www.fema.gov/emergency/usr/usrist2.shtm
Appendix C – Healthcare Emergency Management Competencies
Institute for Crisis, Disaster and Risk Management
The George Washington University
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Developing emergency response and recovery competencies
Using the competency framework established in this project, response and recovery
“core” competencies were developed for all personnel within a healthcare system that
may have a role in the emergency response, regardless of their specific emergency
response and recovery function. Additional competencies were then established for three
functionally based job groups within a healthcare. The original designation for these job
groups were (1) healthcare facility leaders, (2) patient care providers, and (3) emergency
management program managers. The titles and definitions evolved with outside input as
the project tasks were accomplished (see Table 2 for final titles and descriptions).
Initial competency identification and development was accomplished through an analysis
of ICS as presented in NIMS, an extensive literature review, and an evaluation of the
VHA system and processes for emergency response. 15 Additionally, the GWU-ICDRM
project team relied upon their extensive emergency management and disaster response
experience, and upon related previous research efforts. 16,17,18
The emergency response and recovery competencies for the initially designated three job
groups were then fully developed, studied through a web-based survey, revised based
upon input and completed. 19
Identification of additional job groups and their associated competencies
Early in the competency development process, it became apparent that there were
additional important healthcare emergency management job groups beyond the three that
were initially described. These groups have distinct response and recovery
responsibilities (and therefore associated competencies) for the healthcare organization’s
resiliency and medical surge. After extensive research during the latest phase of the
project, the additional groups were identified as: Facilities and Engineering Services
(FES), Police and Security Services (PSS), and Clinical Support Services (CSS). Their
descriptions are presented in Table 2. Using the previously defined methodology
(including web-based peer review), the follow-on project allowed for the development of
emergency response and recovery competencies for these remaining job groups.
15 Veterans Health Administration. VHA Emergency Management Program Guidebook, 2005, accessed at:
http://www1.va.gov/emshg/page.cfm?pg=114
16 Barbera, Joseph A and Anthony G. Macintyre. Medical and Health Incident Management System: A
Comprehensive Functional Description for Mass Casualty Medical and Health Incident Management.
Institute for Crisis, Disaster & Risk Management. The George Washington University, Washington DC,
October 2002, accessed at www.gwu.edu/~icdrm/ 17 Barbera, Joseph A and Anthony G. Macintyre. Mass Casualty Handbook: Hospital Emergency
Preparedness and Response, First Edition. Jane’s Information Group, 2003. 18 CNA Corporation. Medical Surge Capacity & Capability: The Management System for Integrating
Medical and Health Resources During large-Scale Emergencies. August 2004, accessed at:
http://www.hhs.gov/ophep/mscc_handbook.html
19 Barbera JA, Macintyre AG, et al. VHA-EMA Emergency Response and Recovery Competencies:
Competency Survey, Analysis, and Report (June 16, 2005), available at www.gwu.edu/~icdrm/
Appendix C – Healthcare Emergency Management Competencies
Institute for Crisis, Disaster and Risk Management
The George Washington University
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Development of preparedness and mitigation (program) competencies for
Emergency Management Program Managers and Healthcare System Leaders
The methodology utilized in this project focused first on the development and validation
of response and recovery competencies as an “end state” for healthcare system personnel
in their emergency management activities. The second phase of the project allowed for
the development of program competencies for Emergency Program Managers and
Healthcare System Leaders, which focused upon preparedness and mitigation activities
necessary to reach this “end state.” These two job groups maintain primary responsibility
for the emergency management program within a healthcare system, and thus have
extensive primary competencies that relate to program development and maintenance
required for successful response to emergencies and disasters.
The program competencies were developed using the earlier methods, with identical
criteria that the competencies be objective and measurable, maintain internal and external
consistency, and be described within the context of an organization’s specific emergency
management program objectives. Program competencies may more closely align with
business management models during day-to-to day operations. Hence, organizational and
individual outputs for these groups can be expected to be more frequent. This concept
was included in the development of the program competencies.
While no formal survey was conducted following the development of these program
competencies, peer review was accomplished by providing draft competencies to experts
for comment. Only minor changes resulted.
The final job group titles and their descriptions are listed below. The competencies
follow.
Table 2. Healthcare System Job Group Definitions
All Personnel
(AP)
All personnel are defined as any healthcare system administrator,
employee, professional staff, licensed independent practitioners or
others with a specified role in the healthcare systems emergency
operations plan (EOP).
Patient Care
Providers
(PCP)
Physicians, physician assistants, registered nurses, licensed practical
nurses, nurses working within expanded roles (CRNA, RNP, and
others), emergency medical technicians, paramedics, and respiratory
therapists and others who provide direct clinical patient care. Not
included are clinical support staff that provide patient care services
under the direct supervision of patient care providers: e.g., nurse’s
aides, procedure technicians, orderlies, and others.
Appendix C – Healthcare Emergency Management Competencies
Healthcare
System Leaders
(HSL)
Hospital and/or healthcare system-wide senior executives (CEO,
COO, CFO), hospital-wide managers, department heads, nursing
executives, chief of the medical staff, and/or senior managers in
large departments or key operating units. It is assumed that
members of this job group, due to their everyday organizational
positions, would be assigned to serve in the command and general
staff positions of an ICS structure during a healthcare system’s
emergency response.
Emergency
Management
Program
Managers
(EPM)
Personnel primarily responsible for developing, implementing and
maintaining healthcare facility and system-wide emergency
management (EM) programs that include the Emergency Operations
Plan (EOP). System level emergency program managers, above the
level of individual facilities, (such as VHA Area Emergency
Managers or program managers at the level of the VA Emergency
Management Strategic Healthcare Group) are also included in this
job group. It is assumed that the individuals in this job group will
be assigned to a command & general staff ICS position (usually
planning section chief) during response, and so are expected to
possess the response and recovery competencies listed under
Healthcare System Leaders as well. In some healthcare systems, an
EM Program Manager may oversee a more limited position (e.g.
program coordinator) with a narrower range of competencies.
Clinical
Support
Services
(CSS)
Personnel that perform tasks related to the medical care of patients
without direct patient interface (e.g. pharmacists, lab technicians,
etc.) or provide patient services that aren’t primarily medical care
(social services, physical and occupational therapy, pastoral care,
patient educators, and others) or provide patient care services under
the direct supervision of patient care providers (such as nurse’s
aides, procedure technicians, orderlies, transporters).
Police &
Security
Services
(PSS)
Personnel whose day to day job in the healthcare system involves
security and the full range of law enforcement activities. Day-today duties may or may not put these individuals into direct contact
with patients.
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The George Washington University
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Appendix C – Healthcare Emergency Management Competencies
Facilities and
Engineering
Services
(FES)
Personnel whose day to day job involves maintaining the physical
plant and its various systems. Included in this group are facilities
and physical plant personnel, engineers, grounds personnel,
biomedical engineers, food services, communications and IT
personnel. It also usually includes administrative safety positions
below the level of the healthcare system leaders. Day to day duties
rarely put these personnel in direct patient contact.
Institute for Crisis, Disaster and Risk Management
The George Washington University
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Appendix C – Healthcare Emergency Management Competencies
Emergency Response and Recovery Competencies
All Personnel (AP)
All personnel are defined as any healthcare system administrator, employee, professional
staff, licensed independent practitioners or others with a specified role in the healthcare
systems emergency operations plan (EOP).
x AP-R1: Utilize general Incident Command System (ICS) principles during
incident response and recovery.
Recommended proficiency for Primary Competency: operations level
Knowledge
o AP-R1.1: Describe ICS as an emergency response and recovery operating
system and its application to healthcare system incident response and
recovery, management structure, concept of operations, and planning
cycle.
o AP-R1.2: Describe your potential role(s) and responsibilities within the
healthcare system response and recovery in terms of ICS principles.
o AP-R1.3: Describe the ICS-delineated expectations of individual
responders in relation to the healthcare system response and recovery to
include: attendance at briefings, reporting requirements, and use of rolerelated documents such as Operational Checklists (Job Action Sheets).
Skills
o AP-R1.4: Demonstrate an operations level of proficiency in ICS principles
by utilizing appropriate forms, attending indicated meetings, and adhering
to appropriate reporting requirements.
x AP-R2: Recognize situations that suggest indications for full or partial
activation of the healthcare system’s Emergency Operations Plan (EOP), and
report them appropriately and promptly.
Recommended proficiency for Primary Competency: operations level
Knowledge
o AP-R2.1: Describe the general characteristics of emergency situations that
may indicate the need for full or partial EOP activation.
o AP-R2.2: Describe the reporting requirements and methodology for
situations that may require full or partial EOP activation.
Skills
o AP-R2.3: Identify situations within your areas of regular duty that should
be reported for consideration for full or partial activation of the healthcare
system’s EOP.
Institute for Crisis, Disaster and Risk Management
The George Washington University
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Appendix C – Healthcare Emergency Management Competencies
o AP-R2.4: Report situations within your areas of regular duty by following
EOP notification procedures and contacting the appropriate person as
indicated by your specific role and by the situation at hand (e.g., page
operator, supervisor, etc.).
x AP-R3: Participate in healthcare system mobilization to rapidly transition
from day-to-day operations to incident response organization and processes
Recommended proficiency for Primary Competency: operations level
Knowledge
o AP-R3.1: Describe the procedures necessary to receive notification of
EOP activation and to prepare your work area, as indicated, for EOP
response and recovery.
o AP-R3.2: Describe the initial reporting requirements for your expected
role or position.
o AP-R3.3: Describe the location and format of the system EOP.
Skills
o AP-R3.4: Follow your functional areas mobilization plan as outlined in the
EOP to prepare your work area for EOP response and recovery.
o AP-R3.5: Confirm notification receipt and report to the appropriate EOP
position your initial situation, resource status, and any special problems
encountered for your specific role or functional area.
o AP-R3.6: Locate the facility EOP and access portions applicable to your
role and responsibilities.
x AP-R4: Apply the healthcare system’s core mission statement to your actions
during emergency response and recovery.
Recommended proficiency for Primary Competency: operations level
Knowledge
o AP-R4.1: Describe how your emergency operations role and
responsibilities support the healthcare system mission during emergency
response and recovery.
Skills
o AP-R4.2: Demonstrate your understanding of the healthcare system’s
mission during emergency response and recovery by ensuring your actions
continually contribute to 1) continuity of patient care operations, 2) the
safety of patients, families, and staff, 3) the conservation of property, and
4) the healthcare system support to the community to ensure the nation’s
safety.
x AP-R5: Apply the healthcare system code of ethics to your actions during
emergency operations.
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Appendix C – Healthcare Emergency Management Competencies
Recommended proficiency for Primary Competency: operations level
Knowledge
o AP-R5.1: Describe how the healthcare system’s and other codes of ethics
(such as Federal codes of ethics for Federal facilities), as applicable, apply
to your role and responsibilities during emergency response and recovery.
Skills
o AP-R5.2: Demonstrate your understanding of the healthcare system’s and
Federal codes (as applicable) of ethics by applying them to your individual
response actions during emergency response and recovery.
x AP-R6: Execute your personal/family preparedness plans to maximize your
availability to participate in the healthcare system’s emergency response and
recovery.
Recommended proficiency for Primary Competency: expert level
Knowledge
o AP-R6.1: Describe the importance of both a personal and a family
preparedness plan to allow you to perform your healthcare system
emergency response and recovery role.
o AP-R6.2: Describe your responsibility as an employee to maintain a
personal and family preparedness plan.
o AP-R6.3: Describe your responsibility as a supervisor (if applicable) to
promote employee maintenance of a personal and family preparedness
plan.
o AP-R6-4: Identify the personal/family specific requirements and details
that must be addressed in your personal/family preparedness plan that
allow you to perform your healthcare system response role in a potentially
changed work schedule and environment.
Skills
o AP-R6.5: Demonstrate your availability to work in your assigned role
during healthcare system response and recovery by executing your
personal/family preparedness plan.
o AP-R6.6: Demonstrate an expert level of proficiency in personal and
family preparedness planning by executing your personal/family
preparedness plan and meeting your personal and family needs across any
circumstances.
x AP-R7: Respond with your previously prepared and maintained personal
“go-kit” to maximize your ability to perform your assigned role during
healthcare system response and recovery.
Recommended proficiency for Primary Competency: expert level
Knowledge
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Appendix C – Healthcare Emergency Management Competencies
o AP-R7.1: Describe the importance of your personal “go kit” for selfprotection and to allow you to perform your healthcare system response
and recovery role and responsibilities (A “go kit” contains personal
supplies that an employee would need to work their emergency response
and recovery role beyond a usual work shift, potentially not returning
home for 72 hours).
o AP-R7.2: Describe your responsibility as an employee to maintain a
personal “go-kit.”
o AP-R7.3: Describe your responsibility (if applicable) as a supervisor to
promote employee maintenance of a personal “go kit.”
o AP-R7.4: Describe how the EOP components and related policies and
procedures, (evacuation, shelter in place, lock down, etc.) of the healthcare
system Emergency Operations Plans impact your decisions on what should
be included in your personal “go kit.”
o AP-R7.5: Identify your personal situation (physical ability/constraints,
medical needs, personal/family preparedness plan, etc.) and how it impacts
on your decisions on what should be included in your personal “go kit.”
Skills
o APC-7.6: Demonstrate your availability to work in your assigned role and
operational periods during response and recovery through the use of your
personal “go kit.”
x AP-R8: Follow the general response procedures for all personnel in the
Occupant Emergency Procedures (OEP) and assist others (healthcare system
personnel, patients, and visitors) as necessary to accomplish the OEP
directives. [Footnote: More specific response procedures are addressed under
respective job groups.]
Recommended proficiency for Primary Competency: operations level
Knowledge
o AP-R8.1: Describe the component parts of the OEP and your
responsibilities and actions under each.
o AP-R8.2: Describe circumstances that could lead to OEP activation and
your responsibilities during OEP activation.
o AP-R8.3: Describe the reporting procedures for your job position that
would activate the OEP.
Skills
o AP-R8.4: Execute your roles and responsibilities for the facility OEP by
conducting the OEP directives for your job position in evacuation, shelter
in place, or other actions during emergency operations.
x AP-R9: Perform your specific roles and responsibilities as assigned in the
healthcare system’s Emergency Operations Plan (EOP) and the appropriate
Incident Action Plan (IAP) in order to support the system’s objectives.
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Appendix C – Healthcare Emergency Management Competencies
Recommended proficiency for Primary Competency: operations level
Knowledge
o AP-R9.1: Describe the ICS framework as applied specifically to the
healthcare system emergency response and recovery.
o AP-R9.2: Describe your role and responsibility as assigned in the
healthcare system’s EOP.
o AP-R9.3: Describe how potential changes in event parameters may
necessitate changes in the facility IAP objectives and strategies, and hence
changes in your job area’s tactics and assignments (Management by
objectives).
o AE-R9.4: Describe the urgent issues that could potentially require a
change in your job or job area’s response strategies and tactics.
o AP-R9.5: Describe your personal accountability requirements during
emergency response and recovery.
o AP-R9.6: Describe the equipment and technologies for your specific role
and responsibilities within the healthcare facility EOP.
o AP-R9.7: Describe the facility policy applicable to your role for engaging
the media.
Skills
o AP-R9.8: Demonstrate appropriate EOP-designated reactive actions in
response to potential/actual events that have activated the EOP.
o AP-R9.9: Demonstrate your specific role and responsibilities as assigned
in the healthcare facility’s EOP by following your operational checklist
(job action sheet), completing assignments, filling out appropriate forms,
and fulfilling reporting requirements.
o AP-R9.10: Ensure organizational objectives are met by formulating and/or
implementing specific tactics consistent with the objectives and strategies
delineated in the controlling IAP for the current operational period.
o AP-R9.11: Report data to supervisors, as indicated, to contribute to
measuring effectiveness of your EOP functional area and its contributions
to achieving the organization’s designated incident objectives.
o AP-R9.12: Operate all equipment and technologies for your specific role
and responsibilities within the healthcare system’s EOP.
x AP-R10: Follow the Communication Plan and reporting requirements as
outlined in the healthcare system’s EOP and the specific Incident Action
Plan for an emergency event.
Recommended proficiency for Primary Competency: operations level
Knowledge
o AP-R10.1: Describe the policy and methods for communication and
reporting during emergency response and recovery.
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o AP-R10.2: Describe the process for rapidly communicating urgent issues
that could require a change in response strategies or tactics for your job
area, and the appropriate party to receive your communication.
o AP-R10.3: Describe the process for reporting significant hazard or
response impacts that you or your job area encounter to the appropriate
party as indicated by the EOP.
o AP-R10.4: Describe the general content of the communication plan
component of the Incident Action Plan as it relates to your emergency
response and recovery role.
o AP-R10.5: Describe the procedures applicable to your role for interaction
with the media.
Skills
o AP-R10.6: Demonstrate the reporting requirements within your functional
area as delineated in the healthcare system EOP.
o AP-R10.7: Maintain communications with appropriate parties for your
role/functional area despite changing requirements and event parameters.
o AP-R10.8: Demonstrate an understanding of media interactions by
referring requests to appropriate personnel (as applicable), and when
interacting with the media, follow designated interview procedures and
protocols.
x AP-R11: Follow and enforce healthcare system’s safety rules, regulations,
and policies during emergency response and recovery.
Recommended proficiency for Primary Competency: operations level
Knowledge
o AP-R11.1: Describe the healthcare system’s safety rules, regulations, and
policies during emergency response and recovery that maintain personal
safety and a safe work environment.
o AP-R11.2: Describe how to apply the Safety Plan component of the
facility Incident Action Plan.
o AP-R11.3: Describe the safety specific actions and procedures to be
followed when unsafe situations/events are encountered.
o AP-R11.4: Describe incident parameters that may serve as stressors for
response personnel, how stress may be manifested, and appropriate
interventions for your specific role.
Skills
o AP-R11.5: Demonstrate your adherence to and enforcement of healthcare
system safety rules, regulations, and policies during emergency response
and recovery by wearing appropriate PPE, following pre-defined safety
procedures, identifying and addressing unsafe practices, and following the
IAP Safety Plan as briefed by your immediate supervisor.
o AP-R11.6: Recognize and address incident stress for yourself and others in
your functional area by identifying manifestations of stress and, in a
fashion appropriate to your specific role, decreasing the stressors, limiting
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the negative impact of the stressors, or ensuring appropriate assistance in
recovering from negative stressors.
x AP-R12: Follow and enforce police and security measures consistent with the
nature of the incident that has prompted the EOP activation.
Recommended proficiency for Primary Competency: operations level
Knowledge
o AP-R12.1: Describe healthcare system security rules, regulations, and
policies that apply to your assigned role and responsibilities in the EOP.
o AP-R12.2: Describe the security specific actions and procedures to be
followed when a suspicious event or security breach is detected.
Skills
o AP-R12.3: Demonstrate your adherence to and enforcement of security
measures during emergency response and recovery by following security
briefings, instruction from individual security personnel, and badge
procedures.
x AP-R13: Utilize or request (as appropriate) and integrate equipment,
supplies, and personnel for your specific role or functional area during
emergency response and recovery.
Recommended proficiency for Primary Competency: operations level
Knowledge
o AP-R13.1: Describe procedures for requesting equipment, supplies, and
personnel for your functional area and the integration of these resources
during emergency response and recovery.
Skills
o AP-R13.2: Demonstrate your ability to request and integrate additional
resources by following EOP procedures outlined for these activities.
o AP-R13.3: Demonstrate the ability to assess the adequacy of equipment,
supplies and personnel to carry out your job assignments during each
operational period.
x AP-R14: Follow demobilization procedures that facilitate rapid and efficient
incident disengagement and out-processing of individual resources and/or the
overall healthcare organization.
Recommended proficiency for Primary Competency: operations level
Knowledge
o AP-R14.1: Describe demobilization policies and procedures for your work
area, including procedures to “catch up” on regular staffing and other
activities that were suspended or revised during emergency operations.
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o AP-R14.2: Describe the policy and procedures for out-processing of
personnel during demobilization.
o AP-R14.3: Describe the policy and procedures for conducting an initial
Incident Review (commonly known as a “hot wash”) for your work area.
o AP-R14.4: Describe the policy and procedures for documenting and
reporting incident-related issues for inclusion in After Action Report
process, analysis, and corrective measures.
Skills
o AP-R14.5: Demonstrate demobilization procedures for the incident by
following the demobilization plan specific to your functional area.
o AP-R14.6: Prioritize, initiate or participate in delayed activities (relevant
to your position) that were suspended or revised during emergency
response.
o AP-R14.7: Participate in out-processing, to include a performance
evaluation and any indicated physical exam.
o AP-R14.8: Provide input into the Incident Review as appropriate for your
position during emergency response.
x AP-R15: Follow recovery procedures that ensure facility return to baseline
activity.
Recommended proficiency for Primary Competency: operations level
Knowledge
o AP-R15.1: Describe policies and procedures for rehabilitation of
personnel.
o AP-R15.2: Describe policies and procedures for rehabilitation of
equipment (including recertification for use), reordering of supplies
specific to your functional area, and rehabilitating your workspace.
o AP-R15.3: Describe policies and procedures specific to your role and
responsibilities for rehabilitation of the facility.
o AP-R15.4: Describe the policies and procedures for a formal After-Action
Report.
Skills
o AP-R15.5: Demonstrate an understanding of the importance of personnel
rehabilitation activities by participating in personnel rehabilitation as
instructed.
o AP-R15.6: Demonstrate an understanding of facility and equipment
rehabilitation by participating in these procedures to ensure your
functional area readiness for day-to-day activities and future EOP
activations.
o AP-R15.7: Demonstrate an understanding of After Action-Reports by
submitting items in the required format.
Appendix C – Healthcare Emergency Management Competencies
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Emergency Management Program Manager (EPM)
Personnel primarily responsible for developing, implementing and maintaining healthcare
facility and system-wide emergency management (EM) programs that include the
Emergency Operations Plan (EOP). System level emergency program managers, above
the level of individual facilities, (such as VHA Area Emergency Managers or program
managers at the level of the VA Emergency Management Strategic Healthcare Group) are
also included in this job group. It is assumed that the individuals in this job group will
be assigned to a command & general staff ICS position (usually planning section
chief) during response, and so are expected to possess the response and recovery
competencies listed under Healthcare System Leaders as well.
20
x EPM-R1: Recognize circumstances and/or actions, across the program
manager’s jurisdiction if appropriate, that indicate a potential incident and
report the situation to facility leadership and appropriate authorities.
Recommended proficiency for Primary Competency: expert level
Knowledge
o EPM-R1.1: Describe the conditions across representative hazard types that
indicate a potential incident requiring healthcare system response and
recovery capabilities.
o EPM-R1.2: List the healthcare system leadership positions that should be
notified in the event of a potential incident and describe the formal
notification process.
o EPM-R1.3: List the outside authorities and resources that can be queried
to rapidly obtain information about an evolving event, and describe the
communication methods for this purpose.
Skills
o EPM-R1.4: Identify and obtain information from all non-healthcare
system sources that could indicate the occurrence of an incident and need
for healthcare system response.
o EPM-R1.5: Report the circumstances of the potential incident to the
relevant facility leader(s) and notify outside authorities as appropriate.
x EPM-R2: Provide assistance and guidance to healthcare system Incident
Managers, and other authorities as requested, on the decision to fully or
partially activate Emergency Operations Plans (EOP).
Recommended proficiency for Primary Competency: expert level
Knowledge
20 In some healthcare systems, an EM Program Manager may oversee a more limited position (e.g. program
coordinator) with a narrower range of competencies.
Appendix C – Healthcare Emergency Management Competencies
o EPM-R2.1: Describe the criteria that indicate the need for a partial or full
healthcare system EOP activation.
o EPM-R2.2: Describe the impact of EOP activation (full or partial) upon
day-to-day facility operations.
o EPM-R2.3: Describe the process for healthcare system EOP activation.
Skills
o EPM-R2.4: Assist facility leaders with the decision to activate emergency
medical response plans and procedures by communicating relevant
information about the nature and consequences of an incident and by
explaining the benefits of activating the EOP.
o EPM-R2.5: Provide Incident Managers with a list of all facility personnel
positions with the authority to activate the EOP, as requested, and outline
the methods for activation.
x EPM-R3: Assist in the rapid mobilization of activated healthcare systems to
transition from day-to-day activities to response and recovery operations.
Recommended proficiency for Primary Competency: operations level
Knowledge
o EPM-R3.1: Describe processes and procedures used to mobilize the
healthcare system and/or its individual facilities for emergency response
and recovery.
o EPM-R3.2: List all the external agencies relevant to your position that
should be notified of the healthcare system’s EOP activation and determine
their level of response.
o EPM-R3.3: List all the internal healthcare system resources and facilities
(ICP/EOC and others) that must be mobilized as the EOP is activated.
Skills
o EPM-R3.4: As requested by facility or healthcare system leadership, assist
in facility mobilization by ensuring appropriate external liaisons are
established and ensuring the facility management structure for response is
clearly communicated externally.
o EPM-R3.5: Provide the Healthcare System Incident Manager with
briefings on the mobilization status of healthcare system facilities and/or
internal resources (such as the EOC or the Decontamination Area) as
indicated by the type and scope of the incident activation.
x EPM-R4: Ensure full and proper execution of the appropriate emergency
operations plan (EOP) for your healthcare system or designated healthcare
system facilities during emergency response and recovery.
Recommended proficiency for Primary Competency: expert level
Knowledge
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o EPM-R4.1: Describe the facility-specific as well as the larger, overarching
healthcare system incident management organizational structure and
response roles of all functional areas and key positions and how the
incident management team (IMT) functions in parallel with continued
enterprise management and operations..
o EPM-R4.2: Describe the healthcare enterprise’s organizational
requirements as well as the relevant laws, regulations, policies and
precedents that affect emergency operations and principles of emergency
management.
Skills
o EPM-R4.3: Provide the healthcare system Incident Command Post with an
initial projection of the supplies and resources needed for response and
recovery as requested and as appropriate.
o EPM-R4.4: At the outset of the incident, provide a briefing to the
healthcare system incident manager on the response actions undertaken by
external incident response agencies, or assure this is accomplished by the
healthcare system senior liaison.
o EPM-R4.5: Verify that the healthcare system’s personnel have adopted
incident management roles and responsibilities according to the response
structure and functional roles delineated in the relevant EOPs.
o EPM-R4.6: Verify compliance of EOP response actions with applicable
rules and regulations, and advise the facility Incident Commander as
indicated.
o EPM-R4.7: Provide assistance by monitoring the emergency response
system assessing the adequacy and effectiveness of the incident
management system in place at activated facilities within the healthcare
system, as appropriate for the Program Manager’s jurisdiction.
o EPM-R4.8: Address any apparent deficiencies noted in the incident
management system during response and recovery by notifying the
Incident Commander of the facility within the healthcare system and
recommending solutions.
x EPM-R5: Demonstrate the ability to function as a healthcare system’s Plans
Chief within the ICS structure as indicated by the Emergency Operations
Plan (EOP).
Recommended proficiency for Primary Competency: expert level
Knowledge
o EPM-R5.1: Describe the healthcare system response roles and
responsibilities ascribed to the chief of the Planning Section in the EOP.
o EPM-R5.2: Describe the facility Incident Planning Cycle and the key
components for which the Plans Chief is responsible.
o EPM-R5.3: Describe the methods for functional area reporting and for the
collation, processing, and dissemination of this information.
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o EPM-R5.4: Describe methods for monitoring response and recovery
actions in order to assist the Incident Commander in determining progress
towards achieving the incident objectives.
Skills
o EPM-R5.5: Establish an effective Incident Planning Cycle by defining
operational periods (approved by the system Incident Commander),
coordinating the Planning Cycle timing with non-healthcare system
response agencies, and disseminating the schedule for essential planning
activities (management and planning meetings, operational briefings, and
others).
o EPM-R5.6: Ensure adequate functional area reporting by establishing the
time schedule for reporting and verifying reports are received, to include
situation, resource status, specific tactics utilized, progress accomplished,
and unusual problems encountered; include patient tracking as necessary.
o EPM-R5.7: Include information originating internal and external to the
system in the planning process by monitoring internal and external sources
for information, including the level of response by external organizations,
and considering the information in the planning process.
o EPM-R5.8: Ensure awareness of event parameters within the healthcare
system by providing continual updates to the leader of functional areas and
external agencies as appropriate.
o EPM-R5.9: Provide rapid contingency response by monitoring for sudden
changes in event parameters that necessitate revision of response strategies
and tactics, and disseminate appropriate notification to relevant internal
and external parties.
o EPM-R5.10: Manage orderly and concise planning activities (management
and planning meetings, operational briefings) by limiting distractions,
providing agendas, and ensuring documentation of all relevant information
discussed in the meetings.
x EPM-R6: Perform or assist with the senior healthcare system liaison function
and ensure that relevant response and recovery information is exchanged
with senior healthcare system management levels beyond the immediate
agency executive, if indicated.
Recommended proficiency for Primary Competency: operations level
Knowledge
o EPM-R6.1: Describe the purpose and structure of the enterprise’s
overarching healthcare system administrative hierarchy (such as the
Veterans Integrated Service Network and Headquarters for the VHA) and
its potential role during facility emergency response and recovery.
o EPM-R6.2: Describe essential components of facility planning that should
be disseminated to senior healthcare system management levels.
o EPM-R6.3: Describe any assigned healthcare enterprise responsibilities to
the community, State, or Federal governments or other entities established
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through contracts, statutes or other authorities (for example, the VHADoD Contingency Plan) where the healthcare organization should
establish a formal liaison function.
Skills
o EPM-R6.4: If part of a larger healthcare system (such as a VA Medical
Center within a Veterans Integrated Service Network (VISN)), fulfill the
region-wide emergency operations (response) plan and liaison function if
it is activated.
o EPM-R6.5: Ensure that senior healthcare system officials are receiving
accurate information from the facility (usually through the facility’s
agency executive) by providing the current facility IAP and/or situation
reports in formats that are understandable to them.
o EPM-R6.6: Ensure that the facility Agency Executive and Incident
Manager receive appropriate communications from senior healthcare
system officials above the level of the incident management structure.
o EPM-R6.7: Assure that established responsibilities to the community,
State, or Federal governments or other entities addressed and required
actions communicated to appropriate Agency Executives and Incident
Management Teams.
x EPM-R7: If Program Manager of a larger healthcare system (such as a VA
Medical Center within a Veterans Integrated Service Network (VISN)) with
activated IMTs within individual healthcare facilities within your network,
establish senior liaison with appropriate external healthcare organizations
within the healthcare system in your area, conduct information exchange,
and coordinate incident response strategies and tactics.
Recommended proficiency for Primary Competency: operations level
Knowledge
o EPM-R7.1: List relevant external healthcare organizations that exist within
the emergency response network in your area and methods for contacting
them.
o EPM-R7.2: Describe how the emergency response and recovery actions of
healthcare facilities within your network and in your area impact one
another.
o EPM-R7.3: Describe how healthcare facilities within your network and
external agencies in the same impact area may support one another during
emergency response and recovery.
Skills
o EPM-R7.4: Ensure the IMT contact information for activated IMTs in
your network is disseminated to appropriate external emergency response
agencies.
o EPM-R7.5: Facilitate the process for healthcare facilities within your
network to gain access to appropriate external emergency response
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agencies by establishing liaison or providing contact methods (as
indicated).
o EPM-R7.6: Facilitate coordination of response strategies and tactics by
ensuring regular exchange of Incident Action Plans (or summaries
contained in Situation Reports) between IMTs in your network and the
appropriate external emergency response agencies.
EPM-R7.7: Facilitate the use of mutual aid agreements between facilities
within your network, and with external organizations when indicated.
x EPM-R8: Participate in demobilization processes within the activated
healthcare organization (such as a VHA Medical Center and/or within its
overarching Veterans Integrated Service Network) to disengage resources
from incident response and allow return to normal operations or back to
stand-by status.
Recommended proficiency for Primary Competency: operations level
Knowledge
o EPM-R8.1: Describe both the general objectives of the demobilization
process and the specific management issues associated with
demobilization, rehabilitation of response elements, and preparation to
return to routine professional roles.
Skills
o EPM-R8.2: Assist in the demobilization of the healthcare organization and
its resources by verifying that operational objectives have been met (or are
reassigned to continuing units) and that appropriate internal and external
notification is made regarding demobilization.
o EPM-R8.3: Participate in any initial incident review (commonly known as
a “hot wash”) and assist organizational leadership with ensuring
appropriate procedures are followed for maintaining/preserving
information for the After Action Report process.
o EPM-R8.4: Assist with the debriefing and performance assessments of
response personnel under your supervision, and others as requested by the
organization’s incident manager.
x EPM-R9: Assist, as indicated by assigned position in recovery management,
with healthcare organization recovery to full pre-incident function, including
return to routine facility management and medical care activities.
Recommended proficiency for Primary Competency: operations level
Knowledge
o EPM-R9.1: Describe the incident planning and management processes for
transitioning from response to recovery.
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o EPM-R9.2: Describe the procedures and priorities for returning response
resources and the overall organization to pre-incident operations and
management.
o EPM-R9.3: Describe the process required to re-evaluate the healthcare
organization’s patient population and post-incident patient care activities,
which includes addressing the backlog of regular work.
Skills
o EPM-R9.4: Assist, as requested, with personnel rehabilitation by
providing advice on procedures for addressing physical or psychological
concerns.
o EPM-R9.5: Assist, as requested, with facility and equipment rehabilitation
by establishing priority of recovery activities and identifying additional
resources that may be required.
o EPM-R9.6: Assist, as requested, with addressing backlogs of regular work
by providing advice to facility leaders on surge capacity methods and the
prioritization of backlogged services.
x EPM-R10: Fulfill emergency management program requirements for a
formal incident After-Action Report (AAR) process that captures and
processes recommended changes to achieve organizational learning.
Recommended proficiency for Primary Competency: expert level
Knowledge
o EPM-R10.1: Describe the policies and procedures as well as other
considerations for completing the formal After Action Report on
healthcare system response.
o EPM-R10.2: Describe procedures for capturing information, analysis and
acceptance or recommendations, and implementation of changes to a
healthcare system EOP and overarching emergency management program.
Skills
o EPM-R10.3: Conduct efficient After Action Reports by utilizing incident
response procedures for conducting a meeting and by ensuring After
Action Report items are documented in the required format (i.e., issue,
background, recommended action, responsible party and recommended
timeframe).
o EPM-R10.4: Ensure organizational learning by conducting appropriate
analysis of recommendations, obtaining formal administration approval of
accepted recommendations, and incorporating the recommended changes
into the healthcare system EOP and other components of the emergency
management program.
Appendix C – Healthcare Emergency Management Competencies
Healthcare System Leaders (HSL)
Hospital and/or healthcare system-wide senior executives (CEO, COO, CFO), hospitalwide managers, department heads, nursing executives, chief of the medical staff, and/or
senior managers in large departments or key operating units. It is assumed that members
of this job group, due to their everyday organizational positions, would be assigned to
serve in the command and general staff positions of an ICS structure during a healthcare
system’s emergency response.
x HSL-R1: Identify specific criteria of potential events that require the full or
partial activation of the system’s Emergency Operations Plan (EOP).
Recommended proficiency for Primary Competency: expert level
Knowledge
o HSL-R1.1: Describe the specific characteristics of potential events that
would require EOP full or partial activation.
o HSL-R1.2: Describe the impact of EOP activation (full or partial) upon
day-to-day facility operations.
o HSL-R1.3: Describe potential sources of information that may assist with
incident recognition.
Skills
o HSL-R1.4: Demonstrate understanding of criteria for EOP full or partial
activation by initiating appropriate levels of EOP activation rapidly during
specific events.
o HSL-R1.5: Ensure appropriate decisions are made about EOP activation
by considering the impact of EOP activation (full or partial) upon day-today facility operations including the provision of essential services to
existing patient populations.
o HSL-R1.6: Ensure appropriate information is included in the decision to
activate the EOP (as necessary) by coordinating with facility personnel
who have relevant information or who have expertise relevant to the
incident type.
o HSL-R1.7: Ensure appropriate information from external sources is
considered in the decision to activate the EOP by coordinating with
external agencies that may provide incident-related information.
x HSL-R2: Activate or support activation of the Emergency Operations Plan
(EOP) to manage emergency response.
Recommended proficiency for Primary Competency: operations level
Knowledge
o HSL-R2.1: Describe the EOP activation and notification process.
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o HSL-R2.2: List the types of notification for the facility and specific
functional areas.
o HSL-R2.3: List relevant external agencies that should be notified of the
system’s EOP activation (full or partial); e.g. VHA/VISN administrators,
local public health, local public safety, etc.
o HSL-R2.4: Describe the initial reporting process from the notified
functional areas in order to determine receipt of the notification message
and initial resource availability.
Skills
o HSL-R2.5: Ensure appropriate EOP activation by identifying personnel
with authority to activate the EOP and using the established methods for
activation.
o HSL-R2.6: Ensure awareness of EOP activation by determining and
conducting the appropriate level of notification (update, alert, advisory,
activation) for the system, specific functional areas, and external agencies
as applicable.
o HSL-R2.7: Confirm the activation of functional areas (management,
operations, logistics, plans/information, finance/administration) by
receiving and processing confirmation of notifications.
x HSL-R3: Ensure rapid system mobilization that transitions response
personnel and resources from day-to-day activities to their designated
incident response status.
Recommended proficiency for Primary Competency: operations level
Knowledge
o HSL-R3.1: Describe the management positions responsible for assuring
mobilization of all key resources and personnel in the healthcare system’s
EOP, and the reporting process for determining mobilization status.
o HSL-R3.2: Describe the layout, location of supplies, and set-up of the
facility Incident Command Post (ICP) or alternatively (according to the
organization’s EOP), the healthcare facility’s Emergency Operations
Center (EOC) with a smaller ICP at the site of primary response activity.
Skills
o HSL-R3.3: Confirm the mobilization of functional areas (management,
operations, logistics, plans/information, finance/administration) by
receiving and processing confirmation of mobilization and full readiness
for response.
o HSL-R3.4: Ensure adequate resources and facilities are available for the
healthcare system including assisting with or supervising (as indicated by
leader position) establishment of the Emergency Operations Center (EOC)
and Incident Command Post (ICP) for the organization.
o HSL-R3.5: Review the mobilized command and general staff area of the
ICP or EOC to confirm that those positions can fully operate in their
positions.
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x HSL-R4: Ensure appropriate execution of the healthcare system Occupant
Emergency Procedures (OEP) by assuring appropriate protective actions for
patients, staff and visitors, and for the integrity of the healthcare system.
Recommended proficiency for Primary Competency: operations level
Knowledge
o HSL-R4.1: Describe the decision process for activating the OEP and how
the OEP functions within the Emergency Operations Plan (EOP) for the
organization.
o HSL-R4.2: Describe the accountability processes for staff, patients,
visitors, vital records, and critical equipment and how the overall and final
accountability is confirmed.
o HSL-R4.3: List critical external resources required to support OEP
activation.
Skills
o HSL-R4.4: Make decisions during OEP implementation that reflect the
prioritized system objectives of life safety, incident stabilization, and
protection of mission critical property and operating systems.
o HSL-R4.5: Demonstrate oversight of accountability for staff, patients,
visitors and mission critical systems.
x HSL-R5: Ensure that the system’s incident management is effective, utilizes
Emergency Operations Plan (EOP) procedures and processes, and uses a
pro-active ‘management by objective’ approach.
Recommended proficiency for Primary Competency: expert level
Knowledge
o HSL-R5.1: Describe the functional organization of the healthcare system’s
incident management during emergency response and recovery and how
the activated incident management team (IMT) interacts through the
agency executive with the enterprise’s ongoing management and operating
systems.
o HSL-R5.2: Describe the initial reactive phase of the healthcare system’s
incident response and the important transition to pro-active ‘management
by objectives.’
o HSL-R5.3: Describe the healthcare system’s code of ethics and how it is
considered/applied during incident planning and management decisionmaking procedures during emergency response and recovery.
Skills
o HSL-R5.4: Ensure the healthcare system’s incident management structure
is well delineated by formally assigning facility incident management
positions and providing the organizational structure with assignments
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Appendix C – Healthcare Emergency Management Competencies
(System ICS diagram) to relevant parties both internal and external to the
system.
o HSL-R5.5: Provide pro-active incident management by developing,
analyzing, and revising, as necessary, facility response objectives during
management meetings in the Planning Cycle (management by objectives).
o HSL-R5.6: Ensure that healthcare system response objectives are
efficiently and adequately met by performing continual monitoring of the
system’s incident response system and outcomes.
o HSL-R5.7: Ensure the healthcare system’s code of ethics is applied, as
appropriate, by considering it during response planning and decisionmaking.
o HSL-R5.8: Address limitations of the healthcare system’s EOP capacity
and capability by identifying limitations and developing responseappropriate options to address unmet needs.
x HSL-R6: Manage continuous incident action planning through iterative
planning cycle procedures that provide strategic and general tactical
guidance to healthcare system personnel in order to achieve surge capacity,
surge capability, and organizational resiliency.
Recommended proficiency for Primary Competency: expert level
Knowledge
o HSL-R6.1: Describe the purpose of management meetings, planning
meetings, and operations briefings for emergency response and recovery.
o HSL-R6.2: Describe the key components of the healthcare system’s
response Incident Action Plan and methods of dissemination, both
internally and externally.
o HSL-R6.3: Describe the purpose and the components of long term,
alternative, contingency, and demobilization planning.
Skills
o HSL-R6.4: Ensure the clear delineation of the healthcare system’s
operations cycle by establishing and disseminating the timing of planning
meetings and operational periods.
o HSL-R6.5: Ensure facility objectives are met by supervising the
development, analysis, and revision of facility response strategies and
general tactics.
o HSL-R6.6: Ensure healthcare system personnel safety by identifying,
minimizing, or preventing threats/hazards, and by responding to all real or
potential safety issues for healthcare system response (Safety Plan)
throughout the emergency response and recovery.
o HSL-R6.7: Ensure efficient incident planning, as indicated by your
incident management position, by participating in or conducting structured
planning and management meetings, and operations briefings.
o HSL-R6.8: Ensure appropriate dissemination of incident planning
decisions by documenting and disseminating the healthcare system’s
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Incident Action Plans to relevant persons internal and external to the
facility.
o HSL-R6.9: Demonstrate comprehensive incident planning by performing
or assigning analysis of long term, alternative, contingency, and
demobilization plans during response and recovery.
o HSL-R6.10: Manage efficient exchange of information by participating in
shift change briefings.
x HSL-R7: Manage efficient information processing regarding response
activities
Recommended proficiency for Primary Competency: operations level
Knowledge
o HSL-R7.1: Describe the components and timing of functional area
reporting and how the results can be processed and analyzed to identify
progress or problems in meeting the facility’s incident objectives.
o HSL-R7.2: Describe critical sources of incident information external to the
healthcare system.
o HSL-R7.3: Describe procedures for reporting back to functional areas,
including dissemination of the healthcare system’s Incident Action Plan.
o HSL-R7.4: Describe types of event parameters that would require sudden
changes in response strategies or tactics.
Skills
o HSL-R7.5: Ensure adequate functional area reporting by establishing the
timing of the reporting and verifying that reports include a situation
description, resource status, specific tactics utilized, progress
accomplished, and unusual problems encountered (include patient tracking
as necessary).
o HSL-R7.6: Include information originating external to the healthcare
system in the planning process by monitoring external sources for
information (including the level of response by external organizations) and
considering them in the planning process.
o HSL-R7.7: Ensure awareness of event parameters within the healthcare
system by providing continual updates to the leaders of functional areas
and to external agencies as appropriate.
o HSL-R7.8: Provide early response to contingencies by monitoring sudden
changes in event parameters that necessitate immediate revision of
response strategies and tactics and by disseminating appropriate
notification to relevant parties (internal and external).
x HSL-R8: Provide information on the facility’s emergency response and
recovery activities to patients, patients’ families, facility personnel’s families,
the media, and the general public, as appropriate.
Recommended proficiency for Primary Competency: operations level
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Knowledge
o HSL-R8.1: Describe the methods of delivering information to the media
and the important components of the message.
o HSL-R8.2: Describe procedures used to ensure patients, patients’ families,
and facility personnel’s families are kept apprised of response operations.
o HSL-R8.3: Describe coordination techniques that ensure the facility’s
media message is consistent with other organizations’ messages to the
public.
o HSL-R8.4: Describe HIPAA and its application to emergency response
and recovery as well as other patient confidentiality measures.
Skills
o HSL-R8.5: Ensure the continuous update of relevant parties by providing,
or assigning the task of providing, incident updates and the timing of
subsequent update reports.
o HSL-R8.6: Ensure media messages are appropriate and consistent with
that of other organizations by coordinating with the external community
incident managers and public information personnel.
o HSL-R8.7: Identify public perceptions of the facility’s response and false
information relating to the facility’s response by performing monitoring of
media reports (address falsehoods as indicated).
o HSL-R8.8: Ensure confidentiality of patient information by monitoring
response and recovery actions for adherence to these standards where
applicable.
x HSL-R9: Monitor the response and recovery needs of the facility’s functional
areas, and, if needed, provide support with additional facilities, equipment,
communications, personnel or other assistance.
Recommended proficiency for Primary Competency: operations level
Knowledge
o HSL-R9.1: Describe resource-tracking processes for the facility.
o HSL-R9.2: Describe the resource request processes for functional areas in
the facility to request both internal and external resources.
o HSL-R9.3: List the critical elements of a Communications Plan.
o HSL-R9.4: List potential sources of technical assistance.
o HSL-R9.5: Describe procedures for ensuring the health and well-being of
facility personnel.
o HSL-R9.6: Describe integration methods of outside donated resources
(personnel, equipment, supplies).
Skills
o HSL-R9.7: Demonstrate the ability to anticipate functional area requests
by conducting an adequate incident planning process.
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o HSL-R9.8: Provide logistical support to functional areas, first by
identifying functional area needs and then appropriate resources to meet
those needs.
o HSL-R9.9: Provide communication support to functional areas by
assisting with the development and approval of the facility
Communications Plan, which should document and disseminate contact
methods for relevant parties internal and external to the facility.
o HSL-R9.10: Provide technical assistance to functional areas, as indicated,
by identifying outside subject matter experts or other appropriate
information resources.
o HSL-R9.11: Ensure the health and well-being of facility personnel by
participating in/approving the Medical Plan for the IAP (as indicated by
your management position).
o HSL-R9.12: Assist with the integration of external assistance and supplies,
solicited and unsolicited, by managing them until they are assigned to
specific functional areas.
x HSL-R10: Establish appropriate measures to document, track, or reimburse
financial costs associated with facility response and recovery.
Recommended proficiency for Primary Competency: operations level
Knowledge
o HSL-R10.1: Describe processes for tracking personnel and resources
utilized during response.
o HSL-R10.2: Describe processes for compensating personnel utilized
during response and for claims made by these personnel.
o HSL-R10.3: Describe processes for reimbursement of external assistance
provided during response.
o HSL-R10.4: Describe processes for tracking other costs of response (e.g.
delayed elective procedures, equipment and supplies consumed, etc).
Skills
o HSL-R10.5: Provide for personnel compensation by maintaining lists of
personnel utilized during response and time worked.
o HSL-R10.6: Provide for incident expense claims by ensuring appropriate
documentation is completed and submitted within the required time
periods.
o HSL-R10.7: Provide for equipment and supply reimbursement by tracking
lists of supplies and equipment utilized during response and recovery.
o HSL-R10.8: Provide for compensation of external assistance (contract or
cooperative assistance) by tracking utilization of these resources and
ensuring prompt payment as indicated.
o HSL-R10.9: Provide a summary of response and recovery impact on
facility finances by documenting and analyzing the direct and indirect
costs of EOP activation, including lost revenue.
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x HSL-R11: Manage facility response so that it adheres to appropriate
regulations and standards or seek relief as required.
Recommended proficiency for Primary Competency: operations level
Knowledge
o HSL-R11.1: Describe permissible emergency response and recovery
deviations from the normal standard of medical care provided under
normal facility conditions, and the processes for seeking temporary
suspension or relaxation of regulations during emergencies.
o HSL-R11.2: Describe, in general, the applicable public health laws and
their impact on the facility’s emergency response and recovery.
o HSL-R11.3: Describe the process for verifying the credentials of
healthcare and other professionals, from resources external to the facility,
who offer assistance to the healthcare facility.
o HSL-R11.4: Describe potential liability exposures that could occur for the
facility and its patient care staff during emergency response and recovery.
Skills
o HSL-R11.5: Address appropriate healthcare regulatory issues during
response and recovery by monitoring response activities for regulatory
compliance and correcting deviations or appropriately justifying and
explaining them.
o HSL-R11.6: Request and obtain appropriate regulatory relief by contacting
appropriate authorities and providing explanations of, and justifications
for, the requests.
o HSL-R11.7: Ensure appropriate credentialing and privileging of response
personnel (from internal or external sources) to perform healthcare tasks,
within the facility’s operations, by monitoring personnel activities for
conformance to their specific expertise.
o HSL-R11.8: Provide facility and personnel liability protection by
documenting incident details surrounding occurrences with potential legal
liability.
x HSL-R12: Ensure that the Business Continuity Program considerations are
incorporated into the facility’s Incident Action Planning (IAP) process.
Recommended proficiency for Primary Competency: operations level
Knowledge
o HSL-R12.1: Describe the purpose and importance of a Business
Continuity Program that is fully integrated into the facility EOP.
o HSL-R12.2: Describe the elements and supporting functions of a Business
Continuity Program as outlined in the NFPA 1600 Standard on
Disaster/Emergency Management and Business Continuity Programs,
2004 Edition.
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o HSL-R12.3: Describe how the Business Continuity Program aligns with
overall Incident Command System (ICS) organization and procedures.
Skills
o HSL-R12.4: Include business continuity specific objectives in the Incident
Action Planning process in order to address the recovery, resumption, and
restoration of facility-specific services.
o HSL-R12.5: Use (as appropriate) the Business Continuity support annex
forms and guidance during emergency response and recovery.
x HSL-R13: Assure that incident-specific safety guidance, in the form of an
Incident Safety Plan and/or IAP safety message, is developed by the Safety
Officer position through action planning and appropriately disseminated to
responders.
Recommended proficiency for Primary Competency: operations level
Knowledge
o HSL-R13.1: Describe the importance of empowering the safety office
position to stop or alter incident operations that present immediate safety
risks to responders, staff, patients, visitors or the integrity of the healthcare
system.
Skills
o HSL-R13.2: Provide technical advice and other input into the safety plan
and safety message development as indicated by technical background and
the assigned position in Command and General Staff of the Incident
Management Team (IMT).
x HSL-R14: Ensure rapid and effective demobilization of the healthcare
organization’s response resources, and eventually the emergency response
itself, as the organization transitions to recovery operations.
Recommended proficiency for Primary Competency: operations level
Knowledge
o HSL-R14.1: Describe the management of demobilization and the
important processes that must occur during the demobilization process.
o HSL-R14.2: Describe methods used to formally announce full or partial
demobilization.
o HSL-R14.3: Describe procedures for out-processing of personnel.
o HSL-R14.4: Describe the procedures for conducting an initial incident
review.
Skills
o HSL-R14.5: Guide the orderly demobilization of functional areas by
ensuring that demobilization occurs as soon as the facility and/or resources
are no longer needed for response (i.e. their specific response objectives
have been met or otherwise resolved).
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o HSL-R14.6: Provide clear explanation and notification of demobilization
to relevant parties (internal and external), usually by demonstrating that
response objectives have been met.
o HSL-R14.7: Provide adequate out-processing of response personnel by
ensuring adequate debriefings and assessments of performance as
appropriate.
o HSL-R14.8: Provide for an orderly initial incident review process
(commonly known as a “hot wash”) by utilizing response procedures to
conduct the meeting.
x HSL-R15: Ensure recovery is accomplished to restore the healthcare
organization to baseline operations and to capture important lessons for
organizational improvement.
Recommended proficiency for Primary Competency: operations level
Knowledge
o HSL-R15.1: Describe the overall process for managing the return of the
organization to baseline operations and all activities to regular
management oversight, including addressing the backlog of regular
workload that accumulated during emergency operations.
o HSL-R15.2: List critical equipment, priorities for rehabilitation, and the
methods for re-certifying the equipment for future use.
o HSL-R15.3: Describe the process for facility re-certification (if
applicable).
o HSL-R15.4: Describe the personnel rehabilitation process.
o HSL-R15.5: Describe the After-Action Report process and methods
utilized to keep the process orderly and constructive.
Skills
o HSL-R15.6: Manage the initial recovery operations by employing the
same incident management structure and processes as used for the
emergency response phase, with new objectives, personnel, and
departmental assignments as needed; transition the management of
residual recovery operations to everyday administrative functions as
recovery management is terminated.
o HSL-R15.7: Manage rehabilitation and re-certification for use of
equipment and incident facilities by prioritizing areas for initial attention.
o HSL-R15.8: Provide for personnel rehabilitation by disseminating the
methods for response personnel to address psychological and/or physical
concerns.
o HSL-R15.9: Oversee the After-Action Report process by using facility
procedures and processes that capture response deficiencies and best
practices, and that incorporate accepted changes as EOP and emergency
management program revisions (i.e., organizational learning).
Appendix C – Healthcare Emergency Management Competencies
Patient Care Provider (PCP)
Physicians, physician assistants, registered nurses, licensed practical nurses, nurses
working within expanded roles (CRNA, RNP, and others), emergency medical
technicians, paramedics, and respiratory therapists and others who provide direct clinical
patient care. Not included are clinical support staff that provide patient care services
under the direct supervision of patient care providers: e.g., nurse’s aides, procedure
technicians, orderlies, and others.
x PCP-R1: Recognize situations related to patient care that indicate the need
for full or partial activation of the healthcare system’s Emergency
Operations Plan (EOP), and report them appropriately and promptly.
Recommended proficiency for Primary Competency: operations level
Knowledge
o PCP-R1.1: Describe patient presentation criteria (unusual signs and
symptoms indicative of deliberate illness/injury, indications of potentially
epidemic illness/injury, unexpected rapid patient deterioration, difficult
patient interventions such as decontamination, etc.) that indicate the
possible need for EOP activation.
o PCP-R1.2: Describe patient population profiles and other situation-based
criteria (unusual numbers, very unusual contagiousness and other
indications of increased risk to response personnel or current patients, etc.)
that indicate the possible need for EOP activation.
o PCP-R1.3 Describe resources available to Patient Care Providers in
obtaining additional patient or situational information related to
determining the need for activating the EOP.
o PCP-R1.4: Describe the reporting requirements and the contact methods
when events are recognized that may indicate the need for possible EOP
activation (full or partial).
Skills
o PCP-R1.5: Identify situations within the regular clinical care area that
should be reported for consideration of full or partial activation of the
healthcare facility’s EOP.
o PCP-R1.6: Report situations within the regular clinical care area by
following EOP notification procedures and contacting the appropriate
person (e.g., page operator, supervisor, etc.) as indicated by your specific
role and by the situation at hand.
o PCP-R1.7: Assist decision-makers with incident recognition by
responding rapidly and adequately to their inquiries and requests for
additional pertinent clinical and patient population information.
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x PCP-R2: Participate in the mobilization of the your clinical area to transition
from day-to day operations to the incident response organization and
process.
Recommended proficiency for Primary Competency: operations level
Knowledge
o PCP-R2.1: Describe the procedures necessary to prepare your clinical
area, as indicated, for EOP response and recovery.
Skills
o PCP-R2.2: Ensure maximum patient surge capacity and capability and
organizational resiliency by assisting in the mobilization of your clinical
care area as described in the EOP.
o PCP-R2.3: Establish and implement triage criteria based on actual and
anticipated patient needs, disease parameters, and anticipated resources.
o PCP-R2.4: Establish a decontamination area and other functions that are
inactive during baseline operations, as indicated and per your individual
assignment.
o PCP-R2.5: Provide surge bed capacity for incident victims by
accomplishing rapid disposition of existing patients in the emergency
department, outpatient procedures area, and inpatient units as indicated by
the EOP.
o PCP-R2.6: Conduct actions as described in the EOP that are indicated for
the specific incident parameters, including resource management and
situation reporting.
o PCP-R2.7: Ensure that external notifications (as relevant to your position)
are coordinated through command and general staff
x PCP-R3: Follow the healthcare Occupant Emergency Procedures (OEP) for
your specific clinical care areas by assuring protective actions for patients
and staff and by assisting others as necessary to accomplish the OEP
directives.
Recommended proficiency for Primary Competency: operations level
Knowledge
o PCP-R3.1: Describe the component parts of the OEP and your
responsibilities to protect patients and, as indicated by your position,
maintain accountability for patients, patient care information (charts, etc.)
and clinical staff.
o PCP-R3.2: Describe the methods to be used to maintain patient care
during OEP activity, including during shelter-in-place, evacuation, or
emergency events in the clinical unit.
Skills
o PCP-R3.3: Execute your roles and responsibilities in the facility OEP for
protecting patients, patient information and others (as indicated) by
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assisting with evacuating patients, establishing shelter-in-place, or other
actions during OEP operations.
o PCP-R3.4: Ensure continuous patient care by prioritizing and performing
essential clinical interventions during OEP operations.
x PCP-R4: Provide Surge Capacity by managing/treating increased numbers
of patients (compared with day-to-day activities), regardless of etiology.
Recommended proficiency for Primary Competency: operations level
Knowledge
o PCP-R4.1: Describe strategies and tactics appropriate to your clinical area
that provide surge capacity for a significantly increased number of
patients.
o PCP-R4.2: Describe the triage processes necessary to match need with
available resources in your clinical area.
Skills
o PCP-R4.3: Provide patient surge capacity by instituting and adhering to
the EOP measures designated for your clinical area.
o PCP-R4.4: Maximize the ability of patients to help themselves (when
appropriate) by providing clear instructions and by enhancing their ability
to help themselves (e.g., by controlling pain or other interventions).
o PCP-R4.6: Manage or participate in degradation of overall services by
prioritizing critical tasks and activities over less critical ones.
o PCP-R4.7: Perform ongoing triage (matching resources to needs) to
manage patient load by assigning priorities for services including
diagnostic testing, pharmaceutical administration, operative intervention,
blood infusion, and others.
o PCP-R4.8: Provide continuous input into management decision-making by
projecting resource needs for your clinical area as appropriate.
x PCP-R5: Provide Surge Capability by managing/treating all incoming
patients with specialty needs that vary significantly from day-to-day
healthcare system activities.
Recommended proficiency for Primary Competency: operations level
Knowledge
o PCP-R5.1: Describe special etiologies that may tax the facility response,
even with limited numbers of patients.
o PCP-R5.2: Describe the pathophysiology of injuries and illnesses
associated with mass casualties and the indicated interventions for your
clinical discipline.
o PCP-R5.3: Describe threats or hazards posed by these types of patients.
o PCP-R5.4: Describe methods for hazard/threat containment for these types
of patients (as applicable).
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o PCP-R5.5: List resources where technical information may be found that
may assist with caring for patients with these needs.
Skills
o PCP-R5.6: Demonstrate understanding of injury and illness associated
with these specialty-needs patients by providing the appropriate
interventions to minimize further injury/illness and to maximize patient
recovery.
o PCP-R5.7: Provide evidence-based care for these patients by accessing
technical expertise as appropriate.
o PCP-R5.8: Perform special situation procedures per the EOP annexes and
as indicated by event circumstances (e.g., decontamination, isolation, etc.)
o PCP-R5.9: Contain hazards/threats posed by patients (as applicable) by
removing the hazards from the patients, the use of PPE, appropriately
locating patients or other measures.
o PCP-R5.10: Adhere to appropriate chain custody procedures as applicable
to the particular situation at hand.
x PCP-R6: Provide for efficient information processing for your clinical area
through both reporting and receiving information according to established
time schedules.
Recommended proficiency for Primary Competency: operations level
Knowledge
o PCP-R6.1: Describe the types of relevant information that are required for
reporting from your clinical area.
o PCP-R6.2: Describe the format and timing of reporting information from
your clinical area.
o PCP-R6.3: Describe the methods in which your clinical area should
receive incident information during emergency response and recovery.
Skills
o PCP-R6.4: Provide input into the healthcare system’s incident planning
through updates (as requested) on situation (patient care, continued or
recovered function of patient care systems, etc.), resources
(pharmaceuticals, equipment and medical supplies, etc.), special problems
encountered, and tasks completed in your clinical area.
o PCP-R6.5: Ensure tracking of incident patients by providing updates (as
requested) on numbers, types, and locations of patients as well as
interventions required.
o PCP-R6.6: Ensure appropriate designations are used for patient tracking
(‘meets case definition for incident’, ‘suspicious for case definition,’ etc.)
as applicable.
o PCP-R6.7: Provide prompt notification when patient care activities reveal
information that dictates major or sudden changes in response strategies.
o PCP-R6.8: Deliver or participate in briefings conducted for your clinical
area.
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x PCP-R7: Manage the psychological impact on victims, victims’ families, and
staff through both preventative and therapeutic measures.
Recommended proficiency for Primary Competency: operations level
Knowledge
o PCP-R7.1: Describe the potential psychological effects on incident victims
and their families and the indicated interventions for your clinical
discipline.
o PCP-R7.2: List the potential psychological effects on responding
personnel and the indicated interventions for your work area.
o PCP-R7.3: Describe preventative methods that may lessen the
psychological impact on victims, victims’ families, and staff.
Skills
o PCP-R7.4: Provide psychological and emotional support to patients and
their families as indicated by your clinical discipline.
o PCP-R7.5: Provide information on the event, its etiology, and facility
interventions to patients and family members in your clinical area (written
if possible).
o PCP-R7.6: Provide frequent updates on expected interventions for
individual victims to the family members in your clinical area.
o PCP-R7.7: Assist with the identification of specific stressors for staff in
your work area and report them to your supervisor.
o PCP-R7.8: Assist with assigned measures designed to reduce staff stress
during response and recovery (e.g. facilitating information dissemination
amongst staff).
x PCP-R8: Incorporate relevant safety practices and procedures in all incident
operations for your clinical area.
Recommended proficiency for Primary Competency: operations level
Knowledge
o PCP-R8.1: Describe categories of hazards that may pose a risk to clinical
staff during emergency response and recovery.
o PCP-R8.2: Describe interventions for clinical staff and others to reduce the
potential risk created by incident parameters.
Skills
o PCP-R8.3: Participate in or conduct safety briefings (based upon the
incident Safety Plan) during each work cycle.
o PCP-R8.4: Adhere to universal precautions and infection control
procedures (whether day-to-day or specific to the incident) as indicated.
o PCP-R8.5: Adhere to appropriate work cycles for your clinical area.
o PCP-R8.6: Select and use appropriate PPE when applicable.
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Appendix C – Healthcare Emergency Management Competencies
o PCP-R8.7: Provide for safe use of PPE by monitoring those individuals
utilizing PPE.
o PCP-R8.8: Minimize security-safety risk to clinical personnel by
coordinating with facility security personnel.
x PCP-R9: Integrate outside resources into your clinical area as required to
meet response objectives.
Recommended proficiency for Primary Competency: operations level
Knowledge
o PCP-R9.1: Describe procedures for requesting, receiving, briefing,
assigning and supervising clinical personnel from other clinical units or
from other facilities.
o PCP-R9.2: Describe procedures for requesting, receiving, rapid inservicing and using equipment and supplies (especially items that aren’t
normally used in your clinical area).
Skills
o PCP-R9.3: Initiate requests for outside resources by delineating specific
needs in the required format.
o PCP-R9.4: Assist in the integration of personnel from outside your work
area by ensuring they participate in briefings on operations in your area
and monitoring their response actions
o PCP-R9.5: Integrate equipment and supplies from outside your clinical
area by ensuring familiarity with their use and by tracking their use.
o PCP-R9.6: Provide appropriate utilization of technical expertise by
assessing the source and incorporating applicable recommendations.
x PCP-R10: Follow recovery procedures for your clinical area that promote
rapid return of the facility to baseline activity.
Recommended proficiency for Primary Competency: operations level
Knowledge
o PCP-R10.1: Describe policies and procedures for rehabilitation of patient
care and clinical support personnel.
o PCP-R10.2: Describe procedures for reassessing your clinical area’s
patient population and planning for resolving surge needs.
o PCP-R10.3: Describe the responsibilities, specific to your role, for
rehabilitation of your clinical area.
o PCP-R10.4: Describe the policies and procedures for formal After Action
Report of patient care in your clinical area.
Skills
o PCP-R10.5: Demonstrate an understanding of the importance of personnel
rehabilitation activities by participating in personnel rehabilitation as
instructed.
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o PCP-R10.6: Demonstrate an understanding of facility and equipment
rehabilitation by participating in these procedures to ensure functional area
readiness for day-to-day activities and future EOP activations.
o PCP-R10.7: Demonstrate an understanding of After Action Reports by
submitting items in the required format.
Appendix C – Healthcare Emergency Management Competencies
Clinical Support Services (CSS)
Personnel that perform tasks related to the medical care of patients without direct patient
interface (e.g. pharmacists, lab technicians, etc.) or provide patient services that aren’t
primarily medical care (social services, physical and occupational therapy, pastoral care,
patient educators, and others) or provide patient care services under the direct supervision
of patient care providers (such as nurse’s aides, procedure technicians, orderlies,
transporters).
x CSS-R1: Recognize situations related to the support of patient care that
indicate the need for full or partial activation of the healthcare system’s
Emergency Operations Plan (EOP), and report them appropriately and
promptly.
Recommended proficiency for Primary Competency: operations level
Knowledge
o CSS-R1.1: Describe patient presentation data (unusual, signs and
symptoms indicative of deliberate illness/injury, unexpected rapid patient
deterioration, difficult patient interventions such as decontamination, etc.)
that indicate the possible need for EOP activation.
o CSS-R1.2: Describe patient test results and other diagnostic data (positive
blood culture or other infectious disease tests) relevant to your position
that indicate the possible need for EOP activation.
o CSS-R1.3 Describe resources available to Clinical Support Services
Personnel in obtaining additional patient or situational information related
to determining the need for activating the EOP.
o CSS-R1.4: Describe the reporting requirements and the contact methods
when factors are recognized that may indicate the need for possible EOP
activation (full or partial).
Skills
o CSS-R1.5: Identify situations within the Clinical Support Services areas
that should be reported for consideration of full or partial activation of the
healthcare facility’s EOP.
o CSS-R1.6: Report situations within the Clinical Support Services areas by
following EOP notification procedures and contacting the appropriate
person (e.g., page operator, supervisor, etc.) as indicated by your specific
role and by the situation at hand.
o CSS-R1.7: Assist decision-makers with incident recognition by
responding rapidly and adequately to their inquiries and requests for
additional pertinent information (related to patient(s) or otherwise).
x CSS-R2: Participate in the mobilization of your work area to transition from
day-to day operations to incident response organization and process.
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Recommended proficiency for Primary Competency: operations level
Knowledge
o CSS-R2.1: Describe the procedures necessary to prepare your work area,
as indicated, for EOP response and recovery.
Skills
o CSS-R2.2: Ensure maximum patient surge capacity and capability and
organizational resiliency by assisting in the mobilization of your work care
area as described in the EOP.
o CSS-R2.3: Assist with the establishment of triage of patients or the triage
of diagnostic services as indicated by actual or anticipated patient needs,
disease parameters, and expected resource status.
o CSS-R2.4: Assist with the establishment of functions that are inactive
during baseline operations (e.g. command center, alternative treatment
sites) as relevant to your position in the EOP.
o CSS-R2.5: Assist with surge and organizational resiliency by supporting
rapid disposition of existing patients within the healthcare system as
indicated by the EOP.
o CSS-R2.6: Conduct actions as described in the EOP that are indicated for
the specific incident parameters, including resource management and
situation reporting.
o CSS-R2.7: Ensure that external notifications (as relevant to your position)
are coordinated through command and general staff
x CSS-R3: Follow the healthcare Occupant Emergency Procedures (OEP) for
your specific Clinical Support Service work area by assuring protective
actions for patients and staff and by assisting others as necessary to
accomplish the OEP directives.
Recommended proficiency for Primary Competency: operations level
Knowledge
o CSS-R3.1: Describe the component parts of the OEP and your
responsibilities to protect patients and, as indicated by your position,
maintain accountability for patients, patient care information (charts, etc.)
and staff.
o CSS-R3.2: Describe the methods to be used to maintain patient care
during OEP activity, including during shelter-in-place, evacuation, or
emergency events as relevant to your work area.
Skills
o CSS-R3.3: Execute your roles and responsibilities in the facility OEP for
protecting patients, patient information and others (as indicated) by
assisting with evacuating patients and staff, establishing shelter-in-place,
or other actions during OEP operations.
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o CSS-R3.4: Ensure continuous patient care by prioritizing and performing
essential clinical and non-clinical interventions during OEP operations.
x CSS-R4: Provide Surge Capacity by participating in the diagnosis of,
treatment of, or recovery of increased numbers of patients (compared with
day-to-day activities), regardless of etiology.
Recommended proficiency for Primary Competency: operations level
Knowledge
o CSS-R4.1: Describe strategies and tactics appropriate to your work area
that provide surge capacity for a significantly increased number of
patients.
o CSS-R4.2: Describe the triage processes necessary to match need with
available resources in your work area.
Skills
o CSS-R4.3: Provide patient surge capacity by instituting and adhering to
the EOP measures designated for your work area.
o CSS-R4.4: Manage or participate in degradation of overall services by
prioritizing critical tasks and activities over less critical ones (as indicated
for your position).
o CSS-R4.5:As indicated by your position, perform ongoing triage
(matching resources to needs) to manage patient load by assigning
priorities for services including diagnostic testing, pharmaceutical
administration, operative intervention, blood infusion, and others.
o CSS-R4.6: Provide continuous input into management decision-making by
projecting resource needs for your work area as appropriate.
x CSS-R5: Provide Surge Capability by participating in the diagnosis of,
treatment of, or recovery of all incoming patients with specialty needs that
vary significantly from day-to-day healthcare system activities.
Recommended proficiency for Primary Competency: operations level
Knowledge
o CSS-R5.1: Describe special etiologies that may tax the facility response,
even with limited numbers of patients.
o CSS-R5.2: Describe threats or hazards posed by these types of patients.
o CSS-R5.3: Describe methods for hazard/threat containment for these types
of patients (as applicable).
o CSS-R5.4: List resources where technical information may be found that
may assist with caring for patients with these needs.
Skills
o CSS-R5.5: Demonstrate understanding of injury and illness associated
with these specialty-needs patients by assisting with the appropriate
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interventions to minimize further injury/illness and to maximize patient
recovery.
o CSS-R5.6: Perform special situation procedures per the EOP annexes and
as indicated by event circumstances (e.g., decontamination, isolation, etc.)
o CSS-R5.7: Contain hazards/threats posed by patients (as applicable) by
removing the hazards from the patients, the use of PPE, appropriately
locating patients or other measures.
o CSS-R5.8: Adhere to appropriate chain of custody procedures as
applicable to the particular situation at hand.
x CSS-R6: Provide for efficient information processing for your work area
through both reporting and receiving information according to established
time schedules.
Recommended proficiency for Primary Competency: operations level
Knowledge
o CSS-R6.1: Describe the types of relevant information that are required for
reporting from your work area.
o CSS-R6.2: Describe the format and timing of reporting information from
your work area.
o CSS-R6.3: Describe the methods in which your work area should receive
incident information during emergency response and recovery.
Skills
o CSS-R6.4: Provide input into the healthcare system’s incident action
planning by assisting with updates (as requested) on situation (patient care,
continued or recovered function of patient care systems, etc.), resources
(pharmaceuticals, equipment and medical supplies, etc.), special problems
encountered, and tasks completed in your work area.
o CSS-R6.5: Assist with tracking of incident patients (as appropriate) and
clinical resources by providing updates (as requested) on numbers, types,
and locations of patients as well as resources and interventions required.
o CSP-R6.6: Provide prompt, appropriate notification when work activities
reveal information that dictates major or sudden changes in response
strategies.
o CSP-R6.7: Participate in briefings conducted for your work area.
x CSS-R7: Assist in the management of the psychological impact on victims (as
appropriate), victim families (as appropriate), and staff through both
preventative and therapeutic measures.
Recommended proficiency for Primary Competency: operations level
Knowledge
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o CSS-R7.1: Describe the potential psychological effects on incident victims
and their families and the indicated interventions for your discipline (as
appropriate).
o CSS-R7.2: List the potential psychological effects on responding
personnel and the indicated interventions for your work area.
o CSS-R7.3: Describe preventative methods that may lessen the
psychological impact on victims and their families (as appropriate) and on
staff.
Skills
o CSS-R7.4: Provide psychological and emotional support to patients and
their families as indicated by your position and assigned by your
supervisor.
o CSS-R7.5: Provide information on the event, its etiology, and healthcare
system interventions to patients and family members in your work area, as
assigned by your supervisor.
o CSS-R7.6: Assist with the identification of specific stressors for staff in
your work area and report them to your supervisor.
o CSS-R7.7: Assist with assigned measures designed to reduce staff stress
during response and recovery (e.g. facilitating information dissemination
amongst staff).
x CSS-R8: Incorporate relevant safety practices and procedures in all of your
activities as relevant to your work area.
Recommended proficiency for Primary Competency: operations level
Knowledge
o CSS-R8.1: Describe categories of hazards that may pose a risk to staff
during emergency response and recovery.
o CSS-R8.2: Describe interventions for Clinical Support Staff and others to
reduce the potential risk created by incident parameters.
Skills
o CSS-R8.3: Participate in or conduct safety briefings (based upon the
incident Safety Plan) during each work cycle.
o CSS-R8.4: Adhere to universal precautions and infection control
procedures (whether day-to-day or specific to the incident) as well as other
relevant workplace safety practices as indicated.
o CSS-R8.5: Adhere to appropriate work cycles for your clinical services
support area.
o CSS-R8.6: Select and use appropriate PPE when applicable.
o CSS-R8.7: Provide for safe use of PPE by monitoring co-workers utilizing
PPE.
o CSS-R8.8: Minimize security-safety risk to clinical services support
personnel by coordinating with healthcare system police and security
personnel.
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x CSS-R9: Assist in the integration of outside resources into your work area as
required to meet response objectives.
Recommended proficiency for Primary Competency: operations level
Knowledge
o CSS-R9.1: Describe general procedures for requesting, receiving, briefing,
assigning and supervising personnel from other departments or from other
healthcare systems assigned to your work area.
o CSS-R9.2: Describe procedures for requesting, receiving, rapid inservicing and using equipment and supplies (especially items that aren’t
normally used in your work area).
Skills
o CSS-R9.3: Initiate or assist in the process of requesting outside resources
by delineating specific needs in the required format.
o CSS-R9.4: Assist in the integration of personnel from outside your work
area by ensuring they participate in briefings on operations in your area
and monitoring their response actions
o CSS-R9.5: Integrate equipment and supplies from outside your work area
by ensuring familiarity with their use and by tracking their use.
x CSS-R10: Follow recovery procedures for your clinical area that promote
rapid return of the healthcare system to baseline activity.
Recommended proficiency for Primary Competency: operations level
Knowledge
o CSS-R10.1: Describe policies and procedures for rehabilitation of clinical
services support personnel.
o CSS-R10.2: Describe procedures for reassessing your work area’s patient
population and planning for resolving surge needs (as appropriate).
o CSS-R10.3: Describe the responsibilities, specific to your role, for
rehabilitation of your work area.
o CSS-R10.4: Describe the policies and procedures for formal After Action
Report participation relevant to your work area.
Skills
o CSS-R10.5: Participate in personnel rehabilitation as appropriate and as
instructed.
o CSS-R10.6: Participate in healthcare system, facility, and equipment
rehabilitation as relevant to your work area to ensure functional area
preparation for day-to-day activities and future EOP activations.
o CSS-R10.7: Participate in the After Action Report process by submitting
items in the required format and participating in indicated meetings.
Appendix C – Healthcare Emergency Management Competencies
Police & Security Services (PSS)
Personnel whose day to day job in the healthcare system involves security and the full
range of law enforcement activities. Day-to-day duties may or may not put these
individuals into direct contact with patients.
x PSS-R1: Recognize situations related to the security of the healthcare system
that indicate the need for full or partial activation of the healthcare system’s
Emergency Operations Plan (EOP), and report them appropriately and
promptly.
Recommended proficiency for Primary Competency: operations level
Knowledge
o PSS-R1.1: Describe patient, visitor, or staff actions or characteristics that
indicate the possible need for EOP activation.
o PSC-R1.2: Describe types of information received from external agencies
or entities relevant to Police and Security Services that indicate the
possible need for EOP activation.
o PSS-R1.3: Describe resources available to Police and Security Services
Personnel in obtaining additional situational information related to
determining the need for activating the EOP.
o PSS-R1.4: Describe the reporting requirements and the contact methods
when factors are recognized that may indicate the need for possible EOP
activation (full or partial).
Skills
o PSS-R1.5: Identify Police and Security situations that should be reported
for consideration of full or partial activation of the healthcare facility’s
EOP.
o PSS-R1.6: Report Police and Security situations within your work area by
following EOP notification procedures and contacting the appropriate
person (e.g., page operator, supervisor, etc.) as indicated by your specific
role and by the situation at hand.
o PSS-R1.7: Assist decision-makers with incident recognition by responding
rapidly and adequately to their inquiries and requests for additional
pertinent information (related to patient(s) or otherwise).
x PSS-R2: Participate in the mobilization of the healthcare system Police and
Security Services to transition from day-to day operations to incident
response organization and process.
Recommended proficiency for Primary Competency: operations level
Knowledge
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o PSS-R2.1: Describe the procedures necessary to prepare the healthcare
system for EOP response and recovery as related to Police and Security
Services.
Skills
o PSS-R2.2: Ensure maximum patient surge capacity and capability and
organizational resiliency by assisting in the mobilization of the healthcare
system as described in the appropriate functional or incident specific
annex to the EOP.
o PSS-R2.3: Participate in the mobilization of assets to secure the facility
from internal or external threats.
o PSS-R2.4: Assist with the establishment of functions that are inactive
during baseline operations (e.g. command center, alternative treatment
sites) as relevant to your position in the EOP.
o PSC-R2.5: Conduct actions as described in the EOP that are indicated for
the specific incident parameters, including resource management and
situation reporting.
o PSS-R2.6: Ensure that external notifications (as relevant to your position)
are coordinated through command and general staff
x PSS-R3: Follow the healthcare Occupant Emergency Procedures (OEP) for
Police and Security Services by assuring protective actions for patients and
staff and by assisting others as necessary to accomplish the OEP directives.
Recommended proficiency for Primary Competency: operations level
Knowledge
o PSS-R3.1: Describe the component parts of the OEP and your
responsibilities to protect patients, visitors, and staff through direct control
of hazards and by shielding and/or directing staff, patients and visitors to
safety.
o PSS-R3.2: Describe the methods to be used to maintain patient, visitor,
and staff safety and accountability during OEP activity, including during
shelter-in-place, evacuation, or emergency events.
Skills
o PSS-R3.3: Execute your roles and responsibilities in the facility OEP for
protecting patients, visitors, and staff by assisting with evacuation,
establishing shelter-in-place, or other actions during OEP operations.
x PSS-R4: Manage or participate in the restriction or facilitation of movement
of personnel, visitors, patients, vehicles, and specific resources regardless of
actual or impending hazards.
Recommended proficiency for Primary Competency: operations level
Knowledge
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o PSS-R4.1: Describe strategies and tactics used to restrict or facilitate the
movement of patients, visitors, staff, vehicles, or specific resources as
appropriate to specific hazards.
o PSS-R4.2: Describe structural and other physical barriers that can be
utilized in your specific healthcare system to restrict or facilitate the
movement of patients, visitors, staff, vehicles, or specific resources.
o PSS-R4.3: Describe methodologies for diminishing psychological impacts
and addressing behavioral reactions of individuals encountered while
fulfilling your Police and Security duties.
Skills
o PSS-R4.4: Participate in the healthcare system security operations by
instituting and adhering to the EOP activities for your work area.
o PSS-R4.5: Utilize physical and structural systems appropriate for your
specific healthcare system to restrict or facilitate the movement of patients,
visitors, staff, vehicles, or specific resources.
o PSS-R4.6: Utilize specific interpersonal methods to address the
psychological impact on staff, patients and visitors that PSS interacts with
while fulfilling EOP duties.
x PSS-R5: Manage or participate in investigative, preventive, protective, and
apprehension activities related to EOP activation for the healthcare system.
Recommended proficiency for Primary Competency: operations level
Knowledge
o PSS-R5.1: Describe special hazards that may warrant investigative
activities as related to hospital Police and Security Services.
o PSS-R5.2: Describe investigative procedures to be utilized during EOP
activation as related to threats posed.
o PSS-R5.3: Describe methods for hazard/threat containment for these types
of situations (as applicable).
o PSS-R5.4: List resources where technical information may be found that
may assist with containing these hazards/threats.
Skills
o PSS-R5.5: Initiate and participate in investigation, protection, prevention,
apprehension, and chain of custody procedures used for any special
hazards that pose a threat to healthcare system operations.
o PSS-R5.6: Perform special situation procedures per the EOP annexes and
as indicated by event circumstances (e.g., initiating chain of custody
procedures as appropriate, etc.)
o PSS-R5.7: Contain hazards/threats through removal, protection, isolation,
or neutralization (as appropriate).
x PSS-R6: Provide for efficient information processing for Police and Security
Services through both reporting and receiving information according to
established time schedules.
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Recommended proficiency for Primary Competency: operations level
Knowledge
o PSS-R6.1: Describe the types of relevant information that are required for
reporting from Police and Security Services.
o PSS-R6.2: Describe the format and timing of reporting information from
your work area.
o PSS-R6.3: Describe the methods in which your work area should receive
incident information during emergency response and recovery.
Skills
o PSS-R6.4: Provide input into the healthcare system’s incident action
planning by assisting with updates (as requested) on the situation (security,
crowds, police actions and investigations), PSS resources, special
problems encountered, and tasks completed in your work area.
o PSS-R6.5: Assist with tracking of incident patients (as appropriate) and
resources by providing updates (as requested).
o PSS-R6.6: Provide prompt, appropriate notification when work activities
reveal information that dictates major or sudden changes in response
strategies.
o PSS-R6.7: Participate in briefings conducted for your work area.
x PSS-R7: Incorporate relevant safety practices and procedures in all of your
activities as relevant to your work area.
Recommended proficiency for Primary Competency: operations level
Knowledge
o PSS-R7.1: Describe categories of hazards that may pose a risk to Police
and Security Services staff during emergency response and recovery.
o PSS-R7.2: Describe interventions for Police and Security staff and others
to reduce the potential risk created by incident parameters.
Skills
o PSS-R7.3: Participate in or conduct safety briefings (based upon the
incident Safety Plan) during each work cycle.
o PSS-R7.4: Adhere to universal precautions and infection control
procedures (whether day-to-day or specific to the incident) as well as other
relevant workplace safety practices as indicated.
o PSS-R7.5: Adhere to appropriate work cycles for your work area.
o PSS-R7.6: Select and use appropriate PPE when applicable.
o PSS-R7.7: Provide for safe use of PPE by monitoring co-workers utilizing
PPE.
x PSS-8: Assist in the integration of outside resources into Police and Security
Service work areas as required to meet response objectives.
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Recommended proficiency for Primary Competency: operations level
Knowledge
o PSS-R8.1: Describe general procedures for requesting, receiving, briefing,
assigning and supervising personnel from other departments or from other
external agencies assigned to Police and Security, including how police
powers are addressed for assisting police personnel.
o PSS-R8.2: Describe procedures for requesting, receiving, rapid inservicing and using equipment and supplies (especially items that aren’t
normally used in Police and Security Services).
Skills
o PSS-R8.3: Initiate or assist in the process of requesting outside resources
by delineating specific needs in the required format.
o PSS-R8.4: Assist in the integration of personnel from outside your work
area by ensuring they participate in briefings on operations in your area
and monitoring their response actions.
o PSS-R8.5: Integrate equipment and supplies from outside your work area
by ensuring familiarity with their use and by tracking their use.
x PSS-R9: Follow recovery procedures for Police and Security Services that
promote rapid return of the healthcare system to baseline activity.
Recommended proficiency for Primary Competency: operations level
Knowledge
o PSS-R9.1: Describe policies and procedures for rehabilitation of Police
and Security personnel. .
o PSS-R9.2: Describe the responsibilities, specific to your role, for
rehabilitation of your work area.
o PSS-R9.3: Describe the policies and procedures for formal After Action
Report participation relevant to police and security services.
Skills
o PSS-R9.4: Participate in personnel rehabilitation as appropriate and as
instructed.
o PSS-R9.5: Participate in healthcare system, facility, and equipment
rehabilitation as relevant to your work area to ensure functional area
preparation for day-to-day activities and future EOP activations.
o PSS-R9.6: Participate in the After Action Report process by submitting
items in the required format and participating in indicated meetings.
Appendix C – Healthcare Emergency Management Competencies
Facilities and Engineering Services (FES)
Personnel whose day to day job involves maintaining the physical plant and its various
systems. Included in this group are facilities and physical plant personnel, engineers,
grounds personnel, biomedical engineers, food services, communications and IT
personnel. It also usually includes administrative safety positions below the level of the
healthcare system leaders. Day to day duties rarely put these personnel in direct patient
contact.
x FES-R1: Recognize situations related to the physical plant or engineering
infrastructure of the healthcare system that indicate the need for full or
partial activation of the healthcare system’s Emergency Operations Plan
(EOP), and report them appropriately and promptly.
Recommended proficiency for Primary Competency: operations level
Knowledge
o FES-R1.1: Describe physical plant or engineering infrastructure
characteristics, relevant to your position, that indicate the possible need for
EOP activation.
o FES-R1.2: Describe types of information received from external agencies
or entities relevant to Facilities and Engineering Services that indicate the
possible need for EOP activation.
o FES-R1.3: Describe resources available to Facility and Engineering
Services Personnel in obtaining additional situational information related
to determining the need for activating the EOP.
o FES-R1.4: Describe the reporting requirements and the contact methods
when factors are recognized that may indicate the need for possible EOP
activation (full or partial).
Skills
o FES-R1.5: Identify Facilities and Engineering situations within your
regular day-to-day role that should be reported for consideration of full or
partial activation of the healthcare facility’s EOP.
o FES-R1.6: Report Facilities and Engineering situations within your work
area by following EOP notification procedures and contacting the
appropriate person (e.g., page operator, supervisor, etc.) as indicated by
your specific role and by the situation at hand.
o FES-R1.7: Assist decision-makers with incident recognition by responding
rapidly and adequately to their inquiries and requests for additional
pertinent information (related to patient(s) or otherwise).
x FES-R2: Participate in the mobilization of the healthcare system Facility and
Engineering Services to transition from day-to day operations to incident
response organization and process.
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Recommended proficiency for Primary Competency: operations level
Knowledge
o FES-R2.1: Describe the procedures necessary to prepare the healthcare
system for EOP response and recovery as related to Facility and
Engineering Services.
Skills
o FES-R2.2: Ensure maximum patient surge capacity and capability and
organizational resiliency by assisting in the mobilization of the healthcare
system as described in the appropriate functional or incident specific
annex to the EOP.
o FES-R2.3: Participate in the mobilization of assets to secure the facility
from internal or external threats.
o FES-R2.4: Assist with the establishment of functions that are inactive
during baseline operations (e.g. command center, alternative treatment
sites) as relevant to your position in the EOP.
o FES-R2.5: Conduct actions as described in the EOP that are indicated for
the specific incident parameters, including resource management and
situation reporting.
o FES-R2.6: Ensure that external notifications (as relevant to your position)
are coordinated through command and general staff
x FES-R3: Follow the healthcare Occupant Emergency Procedures (OEP) by
assuring engineering and infrastructure controls are appropriately activated
or de-activated and by assisting others as necessary to accomplish the OEP
directives.
Recommended proficiency for Primary Competency: operations level
Knowledge
o FES-R3.1: Describe the component parts of the OEP and your
responsibilities to activate or de-activate engineering and infrastructure
controls.
o FES-R3.2: Describe the methods to be used to maintain patient, visitor,
and staff safety and accountability during OEP activity, including during
shelter-in-place, evacuation, or emergency events.
Skills
o FES-R3.3: Execute your roles and responsibilities in the facility OEP for
activating or de-activating engineering and infrastructure controls to assist
with evacuation, establishing shelter-in-place, or other actions during OEP
operations.
x FES-R4: Manage or participate in the implementation of facility and
engineering back-up systems and the repair of active systems relevant to
actual or impending hazard impact.
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Recommended proficiency for Primary Competency: operations level
Knowledge
o FES-R4.1: List critical facility and engineering systems for your specific
healthcare system.
o FES-R4.2: Describe processes and procedures to implement and maintain
back up systems for your specific healthcare system.
o FES-R4.3: Describe processes and procedures to expedite repairs to
mission critical systems for your healthcare system.
Skills
o FES-R4.3: Utilize EOP processes and procedures to implement facility
and engineering back up systems for your healthcare system.
o FES-R4.4: Prioritize and expedite the repair of mission critical facility
and engineering systems for your healthcare system.
x FES-R5: Manage or participate in hazard containment (as appropriate) for
your healthcare system.
Recommended proficiency for Primary Competency: operations level
Knowledge
o FES-R5.1: Describe special hazards that may warrant containment
activities as related to hospital Facilities and Engineering Services.
o FES-R5.2: Describe methods for hazard/threat containment for these types
of situations (as applicable).
o FES-R5.3: List resources where technical information may be found that
may assist with containing these hazards/threats.
Skills
o FES-R5.4: Initiate and participate in containment procedures used for any
special hazards that pose a threat to healthcare system operations.
o FES-R5.5: Perform special situation procedures per the EOP annexes and
as indicated by event circumstances (e.g., isolation of specific facility
areas, etc.)
o FES-R5.6: Contain hazards/threats through removal, protection, isolation,
or neutralization (as appropriate).
x FES-R6: Provide for efficient information processing for Facilities and
Engineering Services through both reporting and receiving information
according to established time schedules.
Recommended proficiency for Primary Competency: operations level
Knowledge
o FES-R6.1: Describe the types of relevant information that are required for
reporting from Facilities and Engineering Services.
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o FES-R6.2: Describe the format and timing of reporting information from
your work area.
o FES-R6.3: Describe the methods in which your work area should receive
incident information during emergency response and recovery.
Skills
o FES-R6.4: Provide input into the healthcare system’s incident action
planning by assisting with updates (as requested) on situation (facilities
impact resolution, functionality of mission critical operating systems, etc.),
resources, special problems encountered, and tasks completed in your
work area.
o FES-R6.5: Assist with tracking of resources by providing updates (as
requested).
o FES-R6.6: Provide prompt, appropriate notification when work activities
reveal information that dictates major or sudden changes in response
strategies.
o FES-R6.7: Participate in briefings conducted for your work area.
x FES-R7: Incorporate relevant safety practices and procedures in all of your
activities as relevant to your work area.
Recommended proficiency for Primary Competency: operations level
Knowledge
o FES-R7.1: Describe categories of hazards that may pose a risk to facilities
and engineering staff during emergency response and recovery.
o FES-R7.2: Describe interventions for facilities and engineering staff and
others to reduce the potential risk created by incident parameters.
Skills
o FES-R7.3: Participate in or conduct safety briefings (based upon the
Incident Safety Plan) during each work cycle.
o FES-R7.4: Adhere to universal precautions and infection control
procedures (whether day-to-day or specific to the incident) as well as other
relevant workplace safety practices as indicated.
o FES-R7.5: Adhere to appropriate work cycles for your work area.
o FES-R7.6: Select and use appropriate PPE when applicable.
o FES-R7.7: Provide for safe use of PPE by monitoring co-workers utilizing
PPE.
x FES-R8: Assist in the integration of outside resources into Facilities and
Engineering work areas as required to meet response objectives.
Recommended proficiency for Primary Competency: operations level
Knowledge
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o FES-R8.1: Describe general procedures for requesting, receiving, briefing,
assigning and supervising personnel from other departments or from other
external agencies assigned to Facilities and Engineering.
o FES-R8.2: Describe procedures for requesting, receiving, rapid inservicing and using equipment and supplies (especially items that aren’t
normally used in Facilities and Engineering Services).
Skills
o FES-R8.3: Initiate or assist in the process of requesting outside resources
by delineating specific needs in the required format.
o FES-R8.4: Assist in the integration of personnel from outside your work
area by ensuring they participate in briefings on operations in your area
and monitoring their response actions
o FES-R8.5: Integrate equipment and supplies from outside your work area
by ensuring familiarity with their use and by tracking their use.
x FES-R9: Follow recovery procedures for Facilities and Engineering that
promote rapid return of the healthcare system to baseline activity.
Recommended proficiency for Primary Competency: operations level
Knowledge
o FES-R9.1: Describe policies and procedures for rehabilitation of Facility
and Engineering personnel. .
o FES-R9.2: Describe the responsibilities, specific to your role, for
rehabilitation of the physical plant and mission critical systems relevant to
Facility and Engineering Services.
o FES-R9.3: Describe the policies and procedures for formal After Action
Report participation relevant to Facilities and Engineering.
Skills
o FES-R9.4: Participate in personnel rehabilitation as appropriate and as
instructed.
o FES-R9.5: Participate in healthcare system, facility, and equipment
rehabilitation as relevant to your work area to ensure functional area
preparation for day-to-day activities and future EOP activations.
o FES-R9.6: Participate in the After Action Report process by submitting
items in the required format and participating in indicated meetings.
Appendix C – Healthcare Emergency Management Competencies
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Emergency Management Program Competencies21
The “program competencies” address the Emergency Management (EM) phases of
mitigation and preparedness, and the post-incident/post-exercise activities that
accomplish evaluation and organizational learning objectives. Together with the
emergency response and recovery competencies, they provide a comprehensive set of
performance metrics for each job group within the emergency management program
(EMP) for healthcare systems.
Emergency Management Program Manager (EPM) Job Group
Personnel primarily responsible for developing, implementing and maintaining
healthcare facility and system-wide emergency management (EM) programs that include
the Emergency Operations Plan (EOP). System level emergency program managers,
above the level of individual facilities, (such as VHA Area Emergency Managers or
program managers at the level of the VA Emergency Management Strategic Healthcare
Group) are also included in this job group. It is assumed that the individuals in this job
group will be assigned to a command & general staff ICS position (usually planning
section chief) during response, and so are expected to possess the response and
recovery competencies listed under Healthcare System Leaders as well.
22
x EPM-P1: Apply a ‘systems-based approach’ to the development,
implementation, management, and maintenance of the Emergency
Management Program (EMP).
Recommended proficiency for Primary Competency: expert level
Knowledge
o EPM-P1.1: Describe the meaning of (definition) and importance of the
following terms in the context of healthcare organization emergency
management: Goal (mission), objective, strategy, and tactic.
o EPM-P1.2: List the sequential steps of a systems-based approach to
program development
o EPM-P1.3: Describe why and how system assumptions are developed and
how they are utilized during mitigation, preparedness, response, and
recovery.
Skills
21 These program competencies, when added to the VHA All Personnel Competencies and the emergency
response and recovery competencies for the specific job group, complete the comprehensive set of EMP
competencies for each specified job group.
22 In some healthcare systems, an EM Program Manager may oversee a more limited position (e.g. program
coordinator) with a narrower range of competencies.
Appendix C – Healthcare Emergency Management Competencies
o EPM-P1.4: Develop or oversee the development and maintenance of a
clear mission statement for the healthcare organization EMP.
o EPM-P1.5: Apply common managerial strategies that incorporate the
healthcare organization’s mission statement, code of ethics, and core
values into the EMP.
o EPM-P1.6: Apply the sequential steps of a systems approach to
establishing and conducting all relevant EMP activities (For example, the
VHA uses their nine-step implementation process for establishing the
EMP).
o EPM-P1.7: Develop or oversee the development of systems assumptions
for all relevant EMP activities.
x EPM-P2: Apply foundational Emergency Management concepts as they
relate to healthcare organizations.
Recommended proficiency for Primary Competency: operations level
Knowledge
o EPM-P2.1: Describe the principles of Comprehensive Emergency
Management (CEM) as articulated in the 1978 National Governors’
Association report.
o EPM-P2.2: Explain the 13 steps and the emphasis placed on Hazard
Vulnerability Analysis (HVA) and mitigation in the FEMA report
Integrated Emergency Management Systems (IEMS), 1983.
o EPM-P2.3: List and explain the 11 elements of Continuity of Operations
as documented in Federal Preparedness Circular 65 (FEMA, June 2004).
o EPM-P2.4: Describe the origins, purpose, and framework of the National
Incident Management System (NIMS) including variances from
traditional Incident Command System principles.
o EPM-P2.5: Describe the framework, processes, and procedures for
Federal government response as outlined in the National Response Plan
(NRP).
o EPM-P2.6: Describe the components of the four phases of
Comprehensive Emergency Management (Mitigation, Preparedness,
Response and Recovery), and how additional “aspects” can be
incorporated as presented in NFPA 1600 (2007).
o EPM-P2.7: Describe the difference between Emergency Management and
Homeland Security.
o EPM-P2.8: List major findings applicable to healthcare organizations of
disaster sociology research into emergency preparedness and response.
Skills
o EPM-P2.9: Demonstrate that foundational Emergency Management
principles and major findings applicable to healthcare organizations from
disaster sociology research are incorporated into all components of the
EMP.
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Appendix C – Healthcare Emergency Management Competencies
x EPM-P3: Perform administrative tasks/jobs that permit the Emergency
Management Program (EMP) to meet its overall mission and objectives.
Recommended proficiency for Primary Competency: operations level
Knowledge
o EPM-P3.1: Describe the term ‘strategic administrative planning’ as it
relates to the EMP.
o EPM-P3.2: Describe the relationship of the EMP to the overall healthcare
organization including processes for how the EMP integrates within the
overall administrative structure and functions.
o EPM-P3.3: List relevant regulations and policies (and their origins) for
the EMP. For JCAHO regulations, list specific components applicable to
the EMP.
o EPM-P3.4: List the strategies and tactics necessary for building support to
and maintaining awareness of the EMP (both external and internal to the
healthcare organization).
o EPM-P3.5: Describe the different financial implications of a well run
EMP for a healthcare organization (across all four phases of EM).
o EPM-P3.6: Describe different legal implications for the EMP of a
healthcare organization.
o EPM-P3.7: Identify relevant authorities external to the healthcare
organization and their important relationship to the EMP.
Skills
o EPM-P3.8: Develop an annual work plan for the EMP that includes an
annual program review.
o EPM-P3.9: Maintain required reporting relationship with relevant
healthcare organization authorities that support the EMP.
o EPM-P3.10: Conduct and/or oversee specific activities to meet regulatory
and funding requirements relevant to the EMP (including evaluative
activities required by JCAHO).
o EPM-P3.11: Conduct and/or oversee specific activities to build support
and maintain awareness of the EMP both internal and external to the
healthcare organization.
o EPM-P3.12: Maintain and/or oversee generally accepted accounting
practices for all four phases of CEM within the EMP.
o EPM-P3.13: Incorporate legal considerations into EMP activities to
reduce the potential exposure to litigation.
x EPM-P4: Develop, implement, manage, and maintain an Emergency
Management Committee (EMC) process to support the Emergency
Management Program (EMP).
Recommended proficiency for Primary Competency: expert level
Knowledge
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Appendix C – Healthcare Emergency Management Competencies
o EPM-P4.1: Describe the difference between preparedness organizations
and response organizations.
o EPM-P4.2: List relevant representatives that should take part in the EMC
for a healthcare organization.
o EPM-P4.3: Describe general competencies that EMC participants from
within the healthcare organization should possess.
o EPM-P4.4: Describe the necessary processes for the EMC to successfully
operate.
o EPM-P4.5: Describe processes for effective meeting management.
Skills
o EPM-P4.6: Maintain adequate representation on the EMC, including
appropriate representatives from organizations external to the healthcare
organization.
o EPM-P4.7: Establish and supervise EMC sub-committees, plus ad hoc
and standing task groups beyond formal EMC membership as indicated, to
assure adequate representation and expertise in developing and conducting
EM program activities (mitigation, preparedness, organizational learning).
o EPM-P4.8: Maintain and/or supervise the maintenance of adequate
knowledge and skills of internal representatives to the EMC and its task
groups.
o EPM-P4.9: Develop and maintain or oversee the development and
maintenance of document control activities for the EMC.
o EPM-P4.10: Implement and maintain processes to ensure effective
meeting management.
x EPM-P5: Develop, implement, and maintain a Hazard Vulnerability
Analysis (HVA) process as the foundation for conducting the Emergency
Management Program (EMP).
Recommended proficiency for Primary Competency: expert level
Knowledge
o EPM-P5.1: Define the terms hazard, vulnerability, risk, and risk
management in the context of healthcare organizations and requirements.
o EPM-P5.2: Describe the purpose, context, and timing of the HVA process
within a healthcare organization’s EMP.
o EPM-P5.3: Describe unique characteristics of healthcare organizations
that contribute to their overall vulnerability.
o EPM-P5.4: List representative external agencies and organizations that
should be considered for inclusion in a healthcare organization’s HVA
process.
o EPM –P5.5: List internal and external stakeholders that should be
considered for inclusion in a healthcare organization’s HVA process.
o EPM-P5.6: List different methods for identifying potential hazards to the
healthcare organization.
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Appendix C – Healthcare Emergency Management Competencies
o EPM-P5.7: Describe the process of analyzing the risk (probability and
vulnerability) created by each identified hazard, including a standardized
deconstruction of each hazard vulnerability.
o EPM-P5.8: Describe the process of grouping and prioritizing
vulnerabilities to provide potential EMP risk interventions.
o EPM-P5.9: Describe various ways in which HVA findings may be applied
as a basis for planning and evaluating the EMP activities.
Skills
o EPM-P5.10: Oversee or individually develop, implement, and maintain
an HVA process that is continually performed throughout the life cycle of
the EMP.
o EPM-P5.11: Incorporate relevant stakeholders (personnel and agencies)
into the HVA process, both from internal and external to the healthcare
organization.
o EPM-P5.12: Ensure the HVA process is able to identify all possible
hazard types that could significantly impact the healthcare organization.
o EPM-P5.13: Develop, implement, and maintain a consistent methodology
for analyzing the risk for identified hazards in the HVA process.
o EPM-P5.14: Develop, implement, and maintain a consistent process for
grouping and prioritizing vulnerabilities in the HVA process.
o EPM-P5.15: Develop, implement, and maintain a consistent process for
incorporating HVA findings into the EMP.
x EPM-P6: Incorporate comprehensive mitigation planning into the
healthcare organization’s Emergency Management Program (EMP).
Recommended proficiency for Primary Competency: expert level
Knowledge
o EPM-P6.1: Describe the distinction between HVA planning and
mitigation planning.
o EPM-P6.2: List different types of mitigation activities relevant to
healthcare organizations.
o EPM-P6.3: Describe the context and timing of mitigation planning for
healthcare organizations.
o EPM-P6.4: Describe different strategies for managing and conducting
healthcare organization mitigation planning.
o EPM-P6.5: Explain the process of establishing cost-benefit ratios for each
potential mitigation action.
o EPM-P6.6: Describe the outline of a mitigation plan for healthcare
organizations.
Skills
o EPM-P6.7: Oversee or individually maintain mitigation planning
activities throughout the life cycle of the EMP.
o EPM-P6.8: Oversee or individually maintain integrated mitigation efforts
that include appropriate external parties and that avoid unnecessary
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Appendix C – Healthcare Emergency Management Competencies
overlap with the efforts of other sectors (such as Safety) in the healthcare
organization.
o EPM-P6.9: Ensure that the mitigation planning for the healthcare
organization addresses both long-term as well as short term strategies and
cover structural and non-structural mitigation interventions.
o EPM-P6.10: Develop, implement, manage, and maintain a process for
prioritizing mitigation activities consistent with risk and funding
parameters.
o EPM-P6.11: Develop and maintain a consistent template for mitigation
planning.
x EPM-P7: Incorporate comprehensive preparedness planning into the
healthcare organization’s Emergency Management Program (EMP).
Recommended proficiency for Primary Competency: expert level
Knowledge
o EPM-P7.1: Describe the context and essential elements of preparedness
planning for a healthcare organization.
o EPM-P7.2: List components of a comprehensive healthcare organization
Emergency Operations Plan (EOP) based upon national standards such as
the National Response Plan and FEMA State and Local Guide (SLG 101).
o EPM-P7.3: Describe how the healthcare organization EOP should be
utilized across the phases of Comprehensive Emergency Management.
o EPM-P7.4: Describe the four primary tasks in resource management as
presented in the National Incident Management System (NIMS) and the
categories of preparedness resource management tasks for a healthcare
organization.
o EPM-P7.5: List the essential components of a mutual aid instrument and
differentiate from a cooperative agreement.
o EPM-P7.6: Describe the relevance of and methodologies for
incorporating input from external agencies into healthcare organization
preparedness planning.
o EPM-P7.7: Outline the core components of a healthcare organization
preparedness plan.
o EPM-P7.8: Describe the importance of and the methods for assuring
coordinated response with other local and regional healthcare
organizations.
o EPM-P7.9: Describe the components of personal and family preparedness
for healthcare organization personnel.
Skills
o EPM-P7.10: Maintain as a core focus for the EMP the development,
implementation, and maintenance of the healthcare organization EOP,
including all annexes and appendices and service-level planning.
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Appendix C – Healthcare Emergency Management Competencies
o EPM-P7.11: Oversee the development of the healthcare organization EOP
that is functionally based and establishes all-hazards processes for
response and recovery.
o EPM-P7.12: Use the HVA to determine issues that should be specifically
addressed in the EOP, and apply HVA findings in developing appropriate
Support and/or Incident Specific Annexes for the EOP, and in establishing
specific operating procedures across the EOP.
o EPM-P7.13: Supervise and assist, through the EMC, task groups to
produce organization-level and service-level planning in the functional,
incident-specific, and support annex(es), service-levcel plans, and other
relevant program-specific plans for the organization.
o EPM-P7.14: Provide continuous preparedness resource management
oversight to the EMP that includes concepts such as competency
certifications, resource descriptions and requirements, resource
acquisition, accountability, finance, and resource maintenance.
o EPM-P7.15: Participate in the development and maintenance of a
response platform for sharing incident notification and incident
information with other local and regional healthcare organizations during
incident response, as well as coordinating response objectives and
strategies and resource requests.
o EPM-P7.16: Oversee the development of tactical mutual aid instruments
and cooperative agreements with external entities that are consistent with
relevant strategic mutual aid instruments.
o EPM-P7.17: Develop and implement a consistent template for
preparedness planning.
o EPM-P7.18: Oversee the implementation and maintenance of personal
and family preparedness planning for the healthcare organization’s
personnel.
o EPM-P7.19: Develop and maintain an appropriate personal and family
preparedness plan (see AP-R7 for further detail).
x EPM-P8: Incorporate continuity planning into the activities of the
healthcare organization’s Emergency Management Program (EMP) to
ensure organizational continuity and resiliency of mission critical functions,
processes and systems.
Recommended proficiency for Primary Competency: expert level
Knowledge
o EPM-P8.1: Describe the relationship of continuity planning to the
healthcare organization HVA process and the four phases of
Comprehensive Emergency Management.
o EPM-P8.2: Identify priority functions, processes and systems relevant to
continuity planning for healthcare organizations.
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Appendix C – Healthcare Emergency Management Competencies
o EPM-P8.3: Describe the concept of leadership succession and delegation
of authority as it relates to healthcare organizations, and explain its
importance.
o EPM-P8.4: Describe how mission critical continuity planning
considerations may be cross-walked to incorporate interventions into a
well written healthcare organization Emergency Operations Plan (EOP).
Skills
o EPM-P8.5: Oversee the incorporation of continuity planning principles
into the healthcare organization’s HVA process and the four phases of the
EMP.
o EPM-P8.6: Develop and maintain a consistent methodology for the
prioritization of processes and systems for the purposes of continuity
planning.
o EPM-P8.7: Oversee or develop a process for leadership succession and
delegation of authority as it relates to the healthcare organization.
o EPM-P8.8: Oversee the development of a Continuity of Operations plan
(or functional annex if appropriate), and otherwise ensure the
incorporation of continuity planning into the healthcare facility EOP and
service-level plans.
x EPM-P9: Incorporate comprehensive instructional activity into the
preparedness activities of the healthcare organization Emergency
Management Program (EMP).
Recommended proficiency for Primary Competency: expert level
Knowledge
o EPM-P9.1: Define and describe the purpose of the three main types of
instructional activity (education, training, drills).
o EPM-P9.2: Describe the role and application of competencies and
respective levels of proficiency in relation to the healthcare organization’s
EMP.
o EPM-P9.3: Relate the competencies used for a healthcare organization’s
EMP to the “job/task analysis” or position descriptions necessary for
emergency response and recovery.
o EPM-P9.4: Lists different mandates that delineate legal, regulatory, or
accreditation standards applicable to emergency response and recovery
position descriptions and the component competencies.
o EPM-P9.5: Describe the phases and iterative components of Instructional
System Development (ISD) in relation to the healthcare organization’s
EMP.
o EPM-P9.6: Explain the advantages and disadvantages of developing
instructional activities internally to the healthcare organization as
contrasted with contracting outside vendors or other external sources for
this service.
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Appendix C – Healthcare Emergency Management Competencies
o EPM-P9.7: Define and describe the difference between certifications and
qualifications.
Skills
o EPM-P9.8: Oversee the development and maintenance of a competency
framework for the healthcare organization’s EMP.
o EPM-P9.9: Oversee the development of competencies and levels of
proficiency for functional groups and individual response and recovery
positions for the healthcare organization’s EMP.
o EPM-P9.10: Utilize the ISD process for the analysis, design,
development, implementation, and evaluation of instructional activities
related to the healthcare organization’s EMP.
o EPM-P9.11: Oversee the development and maintenance of a system for
recording position certifications and qualifications.
x EPM-P10: Incorporate a range of exercise types into the healthcare
organizations Emergency Management Program (EMP).
Recommended proficiency for Primary Competency: expert level
Knowledge
o EPM-P10.1: Define and describe the different types of exercises that may
be employed by a healthcare organization’s EMP and explain the purpose
of each exercise type.
o EPM-P10.2: Describe the JCAHO standards relevant to a healthcare
organization’s EMP exercise program.
o EPM-P10.3: Describe the application of the Instructional System
Development (ISD) process to exercise analysis, design, development,
implementation and evaluation.
o EPM-P10.4: List essential personnel, processes, and other preparations
necessary for a healthcare organization exercise.
o EPM-P10.5: Describe essential considerations for managing a healthcare
organization’s exercise, including the emphasis on exercise safety.
o EPM-P10.6: Describe exercise planning and other relevant processes that
make exercise an evaluative tool for the healthcare organization’s EMP
Skills
o EPM-P10.7: Oversee the appropriate utilization of the different types of
exercises for the healthcare organization’s EMP.
o EPM-P10.8: Ensure adherence to JCAHO requirements regarding the
healthcare organization’s exercises.
o EPM-P10.9: Utilize the ISD process for the development and conduct of
healthcare organization exercises.
o EPM-P10.10: Oversee the development and maintenance of a consistent
methodology during exercise preparation.
o EPM-P10.11: Oversee the development and maintenance of a consistent
methodology for the conduct of exercises, including the use of ICS
principles where applicable.
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Appendix C – Healthcare Emergency Management Competencies
o EPM-P10.12: Oversee the development of evaluative tools and processes
for all exercises.
x EPM-P11: Demonstrate systems-based evaluation of the healthcare
organization’s overall Emergency Management Program (EMP) and its
Emergency Operations Plan (EOP).
Recommended proficiency for Primary Competency: expert level
Knowledge
o EPM-P11.1: Describe the context, purpose and timing of program
evaluations in relation to the healthcare organization’s EMP.
o EPM-P11.2: Describe the differences between summative and formative
evaluations and their application to the healthcare organization’s EMP.
o EPM-P11.3: Describe the different categories of performance measures
(and metrics) and their applicability to the healthcare organization’s EMP.
o EPM-P11.4: Describe methodologies for the selection of performance
measures most appropriate to the healthcare organization’s EMP,
including evaluation methods for use during exercises.
o EPM-P11.5: Describe various methods for collecting evaluation
information for the healthcare organization’s EMP.
o EPM-P11.6: Describe the different steps of “Performance-based
Programmatic Evaluation.”
o EPM-P11.7: Describe the role, purpose, and methods for conducting the
After Action Report (AAR) process in a healthcare organization’s EMP
system evaluation.
Skills
o EPM-P11.8: Apply both formative and summative evaluations to the
healthcare organization EMP.
o EPM-P11.9: Utilize different performance measures (inputs, processes,
outputs, and outcomes) in an appropriate manner to maximize the
effectiveness of the EMP evaluation.
o EPM-P11.10: Oversee the implementation of the different steps of
‘Performance based Programmatic Evaluation’ in relation to the
healthcare organization EMP.
o EPM-P11.11: Develop and maintain a consistent methodology for
conducting an After Action Report process.
x EPM-P12: Demonstrate incorporation of accepted improvement
recommendations into the EMP and its components such that the process
becomes one of a learning organization.
Recommended proficiency for Primary Competency: expert level
Knowledge
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Appendix C – Healthcare Emergency Management Competencies
o EPM-P12.1: Describe the relevance of organizational learning to the EMP
and how this systems-based approach to improvement may be applied to
mitigation, preparedness, response, and recovery
o EPM-P12.2: List methods for capturing, cataloguing, prioritizing, and
incorporating issues discovered during the AAR process.
Skills
o EPM-P12.3: Develop and maintain a consistent methodology for
capturing, cataloguing, prioritizing, and incorporating issues discovered
during the AAR process.
o EPM-P12.4: Apply the principles of organizational learning to all
relevant EMP activities.
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Appendix C – Healthcare Emergency Management Competencies
Healthcare System Leaders (HSL) Job Group
Hospital and/or healthcare system-wide senior executives (CEO, COO, CFO), hospitalwide managers, department heads, nursing executives, chief of the medical staff, and/or
senior managers in large departments or key operating units. It is assumed that members
of this job group, due to their everyday organizational positions, would be assigned to
serve in the command and general staff positions of an ICS structure during a healthcare
system’s emergency response.
x HSL-P1: Apply foundational Emergency Management concepts as they
relate to healthcare organizations.
Recommended proficiency for Primary Competency: awareness level
Knowledge
o HSL-P1.1: Describe the origins, purpose, and framework of the National
Incident Management System (NIMS) including variances from
traditional Incident Command System principles.
o HSL-P1.2: Describe the framework, processes, and procedures for
Federal government response as outlined in the National Response Plan
(NRP).
o HSL-P1.3: Describe the components of the four phases of Comprehensive
Emergency Management (Mitigation, Preparedness, Response and
Recovery), and how additional “aspects” can be incorporated as presented
in NFPA 1600 (2007).
o HSL-P1.4: Describe the difference between Emergency Management and
Homeland Security.
o HSL-P1.5: List major findings applicable to healthcare organizations of
disaster sociology research into emergency preparedness and response.
Skills
o HSL-P1.6: Demonstrate that foundational Emergency Management
principles and major findings applicable to healthcare organizations from
disaster sociology research are incorporated into all of your work products
related to the EMP.
x HSL-P2: Provide leadership and administrative support to and participate
in the Emergency Management Program (EMP) in order for it to meet its
overall mission and objectives.
Recommended proficiency for Primary Competency: operations level
Knowledge
o HSL-P2.1: Describe the relationship of the EMP to the overall healthcare
organization including processes for how the EMP integrates within the
overall administrative structure and functions.
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o HSL-P2.2: List relevant JCAHO regulations and specific components
applicable to the EMP.
o HSL-P2.3: List the strategies and tactics (appropriate to your position)
necessary for building support to and maintaining awareness of the EMP
(both external and internal to the healthcare organization).
o HSL-P2.4: Describe the different financial implications of a well run
EMP for a healthcare organization (across all four phases of EM).
o HSL-P2.5: Describe different legal implications for the EMP of a
healthcare organization.
o HSL-P2.6: Describe the necessary processes for the Emergency
Management Committee (EMC) to successfully operate.
o HSL-P2.7: Describe the responsibility of HSLs to develop and maintain
their service level readiness at all times.
o HSL-P2.8: List the necessary knowledge and skills for your participation
in the EMC.
Skills
o HSL-P2.9: Conduct and/or oversee specific activities to meet JCAHO
requirements or other regulatory and funding requirements as directed by
the Emergency Program Manager.
o HSL-P2.10: Conduct and/or oversee specific activities to build support
and maintain awareness of the EMP both internal and external to the
healthcare organization relevant to your position.
o HSL-P2.11: Maintain and/or oversee generally accepted accounting
practices for all four phases of CEM within the EMP.
o HSL-P2.12: Incorporate legal considerations into EMP activities to
reduce the potential exposure to litigation.
o HSL-P2.13: Maintain adequate representation on the EMC.
o HSL-P2.14: Maintain adequate knowledge and skills required for
participation in the EMC, if assigned to the EMC.
o HSL-P2.15: Utilize established document control activities for all work
products generated for the EMC, if assigned to the EMC.
x HSL-P3: Participate in the Hazard Vulnerability Analysis (HVA) process as
the foundation for conducting the Emergency Management Program
(EMP).23
Recommended proficiency for Primary Competency: operations level
Knowledge
o HSL-P3.1: Define the terms hazard, vulnerability, risk, and risk
management in the context of healthcare organizations and requirements.
o HSL-P3.2: Describe the purpose, context, and timing of the HVA process
within a healthcare organization’s EMP.
23 In the context of these competencies, “participate” indicates that an individual makes substantive
contributions to the activities, procedures, or processes in question and as applicable to their regular
position.
Appendix C – Healthcare Emergency Management Competencies
o HSL-P3.3: Describe unique characteristics of healthcare organizations
that contribute to their overall vulnerability.
o HSL-P3.4: List different methods for identifying potential hazards to the
healthcare organization.
o HSL-P3.5: Describe various ways in which HVA findings may be applied
as a basis for planning and evaluating the EMP activities.
Skills
o HSL-P3.6: Provide input relevant to your position into the HVA process
that is continually performed throughout the life cycle of the EMP.
o HSL-P3.7: Assist with the process for incorporating HVA findings into
the EMP, as indicated by your specific position.
x HSL-P4: Participate in comprehensive mitigation planning to support the
healthcare organization’s Emergency Management Program (EMP). 2
Recommended proficiency for Primary Competency: operations level
Knowledge
o HSL-P4.1: List different types of mitigation activities relevant to
healthcare organizations.
o HSL-P4.2: Describe the context and timing of mitigation planning for
healthcare organizations.
o HSL-P4.3: Explain the process of establishing cost-benefit ratios for each
potential mitigation action.
Skills
o HSL-P4.4: Provide appropriate input (per your position) into mitigation
planning activities throughout the life cycle of the EMP.
o HSL-P4.5: Manage specific mitigation planning activities, as assigned,
through completion and report appropriately on their status to the
Emergency Management Committee (EMC).
o HSL-P4.6: Incorporate risk and funding parameters into mitigation
activities relevant to your position.
o HSL-P4.7: Apply HVA findings to business decision making as
appropriate to your position.
x HSL-P5: Support and participate in comprehensive preparedness planning
through the healthcare organization’s Emergency Management Program
(EMP).
2
Recommended proficiency for Primary Competency: operations level
Knowledge
o HSL-P5.1: Describe the context and essential elements of preparedness
planning for a healthcare organization.
Institute for Crisis, Disaster and Risk Management
The George Washington University
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Appendix C – Healthcare Emergency Management Competencies
o HSL-P5.2: List components of a comprehensive healthcare organization
Emergency Operations Plan (EOP) based upon national standards such as
the National Response Plan and FEMA State and Local Guide (SLG 101).
o HSL-P5.3: Describe how the healthcare organization EOP should be
utilized across the phases of Comprehensive Emergency Management.
o HSL-P5.4: Describe the four primary tasks in resource management as
presented in the National Incident Management System (NIMS) and relate
how these are applicable to your duties within the EMP.
o HSL-P5.5: List the essential components of a mutual aid instrument and
differentiate from a cooperative agreement.
o HSL-P5.6: Identify priority functions, processes and systems relevant to
continuity planning for healthcare organizations.
o HSL-P5.7: Describe the components of personal and family preparedness
for healthcare organization personnel.
Skills
o HSL-P5.8: Provide input relevant to your position into the development,
implementation, and maintenance of the healthcare organization EOP.
o HSL P5.9: As appropriate, supervise and/or or participate in task groups
or subcommittees formed to support the EMC.
o HSL P5.10: Manage or participate in service level planning relevant to
your position.
o HSL-P5.11: Provide continuous preparedness resource management
oversight to portions of the EMP relevant to your position.
o HSL-P5.12: Participate with HSL peers from other local and regional
healthcare organizations in setting policy and supporting a response
platform for sharing information and coordinating response objectives and
strategies during incident response.
o HSL-P5.13: Manage and complete tactical mutual aid and cooperative
agreement assignments with external entities and report back to the
Emergency Management Committee (EMC) as appropriate.
o HSL-P5.14: Demonstrate integration of Business Continuity and
Emergency Management principles across all EMP activities.
o HSL-P5.15: Oversee the implementation and maintenance of personal
and family preparedness planning for healthcare organization personnel
you are responsible for during day to day activities.
o HSL-P5.16: Develop and maintain an appropriate personal and family
preparedness plan (see AP-R7 for further detail).
x HSL-P6: Utilize and assist in the conduct of appropriate preparedness
activities (e.g. instruction and exercises) that implement the Emergency
Operations Plan (EOP) for the healthcare organization Emergency
Management Program (EMP).
Recommended proficiency for Primary Competency: operational level
Knowledge
Institute for Crisis, Disaster and Risk Management
The George Washington University
104
Appendix C – Healthcare Emergency Management Competencies
o HSL-P6.1: Define and describe the purpose of the three main types of
instructional activity (education, training, drills).
o HSL-P6.2: Define and describe the different types of exercises that may
be employed by a healthcare organization’s EMP.
o HSL-P6.3: Describe the role and application of competencies and
respective levels of proficiency in relation to the healthcare organization’s
EMP.
o HSL-P6.4: Define and describe the difference between certifications and
qualifications.
o HSL-P6.5: Describe the phases and iterative components of Instructional
System Development (ISD) (analysis, design, development,
implementation and evaluation) in relation to the healthcare organization
instructional and exercise activities.
o HSL-P6.6: Explain the advantages and disadvantages of developing and
conducting instructional and exercise activities internally to the healthcare
organization as contrasted with contracting outside vendors or other
external sources for this service.
o HSL-P6.7: List essential personnel, processes, and other preparations
necessary for a healthcare organization exercise.
o HSL-P6.8: Describe essential considerations for managing a healthcare
organization’s exercise, including the emphasis on exercise safety.
o HSL-P6.9: Describe exercise planning and other relevant processes that
make exercises an evaluative tool for the healthcare organization’s EMP.
Skills
o HSL-P6.10: Provide input as appropriate to your position into the
competency framework for the healthcare organization’s EMP.
o HSL-P6.11: Provide input, as appropriate to your position, into the
development and maintenance of a system for recording position
certifications and qualifications.
o HSL-P6.12: Utilize the ISD process for the analysis, design,
development, implementation, and evaluation of instructional and exercise
activities related to the healthcare organization’s EMP.
o HSL-P6.13: Utilize ICS principles (as appropriate) in the development
and conduct of healthcare organization exercises.
o HSL-P6.14: As appropriate to your position, participate in the
development of evaluative tools and processes for all exercises.
x HSL-P7: Participate in the systems-based evaluation of the healthcare
organization’s overall Emergency Management Program (EMP), including
its Emergency Operations Plan (EOP), and assist in the incorporation of
recommended/accepted changes.2
Recommended proficiency for Primary Competency: operations level
Knowledge
Institute for Crisis, Disaster and Risk Management
The George Washington University
105
Appendix C – Healthcare Emergency Management Competencies
Institute for Crisis, Disaster and Risk Management
The George Washington University
106
o HSL-P7.1: Describe the context, purpose and timing of program
evaluations in relation to the healthcare organization’s EMP.
o HSL-P7.2: Describe various methods for collecting evaluation
information for the healthcare organization’s EMP.
o HSL-P7.3: Describe the role, purpose, and methods for conducting the

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After Action Report (AAR) process in a healthcare organization’s EMP
system evaluation.
o HSL-P7.4: Describe the relevance of organizational learning to the EMP
and how this systems-based approach to improvement may be applied to
mitigation, preparedness, response, and recovery
Skills
o HSL-P7.5: As appropriate to your position, participate in EMP evaluative
activities throughout all phases of the program (mitigation, preparedness,
response, and recovery).
o HSL-P7.6: Participate in the development and maintenance of a
consistent methodology for conducting an After Action Report process.
o HSL-P7.7: Participate in the development and maintenance of a
consistent methodology for capturing, cataloguing, prioritizing, and
incorporating issues discovered during the AAR process.