National Preparedness System Process
This process begins with the identification of threats and hazards. These include: 1) a risk assessment (vulnerability and likelihood of occurrence); 2) determining the desired levels of each core capability (desired outcomes); and 3) an impact estimation of those threats/hazards on the various core capabilities. When taken together with the desired outcome, these assessments establish the capability target.36,37 For example, one desired outcome might be, during the first 72 hours of an incident, conduct operations to recover fatalities. The estimated impact of a theoretical earthquake is 375 fatalities. Therefore, the capability target for fatality management services is, “during the first 72 hours of an incident, conduct operations to recover 375 fatalities.” Estimating the resource requirements for capability targets is based on the existing resource baseline compared to the required levels for the desired outcomes.38 Delivery of such capabilities involves the development of Emergency Operations Plans (EOPs) that are implemented through the Incident Command System (ICS).
Planning Frameworks and Core Capabilities
National and international response frameworks describe the concept of operations for the response to disaster events.39,40 These frameworks have been traditionally organized around functional areas, for example, communications, transportation, public health, and medical services. However, there has been a recent trend in the United States to organize plans/frameworks around “mission areas” (protection, prevention, mitigation, response and recovery), and for each mission area, to identify the capabilities that will be needed. Note that in this conceptual model, preparedness is a component of each mission area and not a separate one. While both the functional and the mission area concepts support an all-hazards approach, capability-based planning enables a closer connection to competency-based education and training.41 Capabilities for emergency management, public health, and healthcare have been designed to address the full spectrum of requirements needed to manage disasters (see Table 2.2).21,23,24,42
Capabilities for Emergency Management (EM), Public Health (PH), and Healthcare
| EM Capabilities | PH Capabilities | Healthcare Capabilities |
|---|---|---|
| Planning | Community Preparedness | Healthcare Preparedness |
| Public Info/Warning | Community Recovery | Healthcare Recovery |
| Operational Coordination | Emergency Operations Coord. | Emergency Operations Coordination |
| Forensics and Attribution | Public Information/Warning | Fatality Management |
| Intel/Info Sharing | Fatality Management | Medical Surge |
| Interdiction/Disruption | Information Sharing | Responder Safety and Health |
| Screening/Detection | Mass Care Services | Volunteer Management |
| Access Control | Medical Countermeasure Dispensing | |
| Cybersecurity | Medical Materiel Management/Distribution | |
| Physical Protection | Medical Surge | |
| Risk Management | Non-Pharmaceutical Interventions | |
| Supply Chain Integrity | Public Health Laboratory Testing | |
| Vulnerability Reduction | Public Health Epidemiological Surveillance | |
| Resilience Assessment | Responder Safety and Health | |
| Hazard Identification | Volunteer Management | |
| Critical Transportation | ||
| Environmental Response | ||
| Fatality Management | ||
| Infrastructure Systems | ||
| Mass Care Services | ||
| Mass Search and Rescue | ||
| Security and Protection | ||
| Operational Communications | ||
| Public and Private Services | ||
| Public Health and Medical | ||
| Situational Assessment | ||
| Economic Recovery | ||
| Health and Social Services | ||
| Housing | ||
| Natural/Cultural Resources |
Capability development is a process involving hazards identification, gap analysis, resource management, education and training, and exercises.43
In 2007, the president of the United States issued a national preparedness directive that called for the establishment of a national preparedness goals and guidelines. The guidelines were designed to: 1) unify federal, state, local, tribal, and territorial preparedness efforts; 2) describe the capability-based and risk-based planning process; 3) establish metrics to measure progress; and 4) create a system to assess the nation’s overall preparedness capability for response to major emergencies.44 Key to the development of national preparedness was the Target Capability List (TCL). These thirty-seven target capabilities were derived from the tasks planners and responders must perform to prevent, protect against, respond to, and recover from the fifteen National Planning Scenarios. These scenarios represent the range, scope, magnitude, and complexity of major incidents that could affect the United States, including terrorism, natural disasters, and other hazards (see Table 2.3).45
National Planning Scenarios (2006)
| Nuclear Detonation – 10-Kiloton Improvised Nuclear Device |
| Biological Attack – Aerosol Anthrax |
| Biological Disease Outbreak – Pandemic Influenza |
| Biological Attack – Plague |
| Chemical Attack – Blister Agent |
| Chemical Attack – Toxic Industrial Chemicals |
| Chemical Attack – Nerve Agent |
| Chemical Attack – Chlorine Tank Explosion |
| Natural Disaster – Major Earthquake |
| Natural Disaster – Major Hurricane |
| Radiological Attack – Radiological Dispersal Devices |
| Explosives Attack – Bombing Using Improvised Explosive Devices |
| Biological Attack – Food Contamination |
| Biological Attack – Foreign Animal Disease (Foot and Mouth Disease) |
| Cyber Attack |
Other countries using the same approach might develop a slightly different set of national planning scenarios based on the threats they face.
The national preparedness directive was reaffirmed in March 2011 as a presidential policy directive, with the purpose to strengthen the security and resilience of the United States through an integrated, nationwide capability-based approach.46 The TCL was revised to a set of “core capabilities” that address the five mission areas that define homeland security and emergency management program activity: prevention, protection, mitigation, response, and recovery (see Table 2.4).21
Core Capabilities for the Five Mission Areas
| Prevention | Protection | Mitigation | Response | Recovery |
|---|---|---|---|---|
| Planning Public Information and Warning Operational Coordination | ||||
| Forensics and Attribution Intelligence and Information Sharing Interdiction and Disruption Screening, Search, and Detection | Access Control and Identity Verification Cybersecurity Intelligence and Information Sharing Interdiction and Disruption Physical Protective Measures Risk Management for Protection Programs and Activities Screening, Search, and Detection Supply Chain Integrity and Security | Community Resilience Long-term Vulnerability Reduction Risk and Disaster Resilience Assessment Threats and Hazard Identification | Critical Transportation Environmental Response/Health and Safety Fatality Management Services Infrastructure Systems Mass Care Services Mass Search and Rescue Operations On-scene Security and Protection Operational Communications Public and Private Services and Resources Public Health and Medical Services Situational Assessment | Economic Recovery Health and Social Services Housing Infrastructure Systems Natural and Cultural Resources |
While the five mission areas may seem to be a departure from the classic “mitigation, preparedness, response and recovery” orientation, they represent greater unity in the United States between emergency management, law enforcement, public health, business continuity, and social services communities.
Planning frameworks were developed for each of these five mission areas. The purpose of the frameworks is to clarify roles, responsibilities, and a coordinating structure between federal, state, local, tribal and private sector organizations. Disaster health (public health and medical services) is one of fifteen functional areas included in the National Response Framework and is identified as the eighth Emergency Support Function (ESF 8) (see Table 2.5).40
Emergency Support Functions
| Transportation |
| Communications |
| Public Works and Engineering |
| Firefighting |
| Information and Planning |
| Mass Care Services |
| Logistics |
| Public Health and Medical Services |
| Urban Search and Rescue |
| Oil and Hazardous Materials |
| Agriculture and Natural Resources |
| Energy |
| Public Safety and Security |
| Long-term Community Recovery |
| External Affairs |
Within this framework, ESF 8 coordinates the assistance to an actual or potential public health and medical disaster or incident. It provides the core capabilities of public health and medical services, fatality management services, mass care services, critical transportation, public information and warning, environmental response/health and safety, and public and private services and resources.40
National Incident Management System
The National Incident Management System (NIMS), the subject of HSPD 5 (2003), is a comprehensive structure used to organize the response to emergencies in the United States and as such is the principal vehicle for implementing the capabilities developed through the preparedness process described in the previous section.47 The current system has its roots in the National Inter-agency Incident Management System, created by the National Wildland Fire Coordinating Group in the early 1980s due to the need to better coordinate the efforts of federal, state, and local wildland firefighting agencies in Southern California.48 NIMS consists of the three main components: command and management (ICS); communications and information management; and resource management. The ICS organizational structure consists of command and general staff positions with additional units filling out the structure. The particular organizational structure needed to manage any particular incident at any point in time is driven by a management-by-objectives process called incident action planning. Inter-agency involvement is achieved through structures for unified command and multi-agency coordination. Efforts to prepare individuals to serve in ICS positions has been led by the wildland firefighting community and include the development of a position qualifications system; position-specific procedures or task books; a standardized, competency-based curriculum; and a certification system.49,50 The Department of Homeland Security (DHS) and FEMA are working to replicate the system structure in support of NIMS.
NIMS resource typing includes efforts to organize resources using consistent terminology and organizational structures, and an overarching management process that helps ensure accountability and safety. Resource typing is a process of defining and categorizing, by capability, the various resources that are requested, deployed and used in incidents. Resource typing definitions are used to establish a common language and define the minimum capabilities of equipment and teams of personnel.51 The Emergency Management Assistance Compact (http://www.emacweb.org/index.php/mutualaidresources/mission-ready-packages/get-started), an organization serving the interests of state emergency management agencies, has developed several public health and medical mission-ready packages created under the NIMS principles.
Incident Management Systems for Public Health and Medical Services
While the use of ICS had been part of firefighting efforts since the 1980s, the use of ICS in the emergency management, public health, and medical communities was slower to evolve. In 2002, a key document was developed that introduced both the ICS structure and management process. It did so in the form of a planning tool for communities to use in developing a comprehensive approach to address the various requirements created by mass casualty incidents.52 It was the foundation for the current system description and concept of operations for the delivery of disaster public health and medical services used by the U.S. Department of Health and Human Services. This current tool organizes the department’s preparedness and response activities and grant funding opportunities for states (see Table 2.6).53
Operational System Structure for Public Health and Medical Services
| Tier 1 | Individual Healthcare Asset |
| Tier 2 | Healthcare Coalition |
| Tier 3 | Jurisdiction |
| Tier 4 | State/Intra-State |
| Tier 5 | Inter-State/Regional |
| Tier 6 | Federal Support to State, Tribal, and Jurisdiction |
The Hospital Incident Command System expands on the Tier 1 level shown in this table.54
Key to successful implementation of an incident management system during an event is the strength of the linkages between the various professional disciplines and organizations that would work together in that response. These participants include: hospital personnel; representatives from the healthcare coalition; public health officials; EMS personnel; fire service personnel; law enforcement officers; emergency management personnel; state-level emergency managers; and other organizations that may become involved such as the American Red Cross, Salvation Army, and the local medical society.
Homeland Security Exercise and Evaluation Program
Validating the baseline capability performance levels would occur through exercises developed using a process similar to the Homeland Security Exercise Evaluation Program (HSEEP). This program provides a structured exercise design and evaluation process that leads to an After Action Report and Improvement Plan (IP). Capability performance is evaluated utilizing standardized Exercise Evaluation Guides (see Table 2.7) that are used by subject matter expert observers to identify strengths and weaknesses. In producing the IP, weaknesses are analyzed to determine what changes are needed to organizational structures, plans and procedures, management processes, equipment and supplies, resources and funding, and training that sustain existing performance and build additional capability. This information is organized into a multi-year work plan that would include review and revision to the various components of the preparedness system.55,56
DHS, Target Capability List, Exercise Evaluation Guide, Medical Surge
| Capability – Medical Surge |
| Activity 1: Pre-event Mitigation and Preparedness |
| Tasks: |
| Conduct Hazard Vulnerability Analysis. |
| Define incident management structure and methodology. |
| Establish a bed tracking system. |
| Develop protocols for increasing internal surge capacity. |
| Determine medical surge assistance requirements. |
| Develop plans for providing external surge capacity. |
| Activity 2: Incident Management |
| Tasks: |
| Activate the healthcare organization’s EOP. |
| Conduct incident action planning. |
| Disseminate key components of incident action plan. |
| Provide emergency operations support to incident management. |
| Activity 3: Increase Bed Surge Capacity |
| Tasks: |
| Implement bed surge capacity plans, procedures, and protocols. |
| Maximize utilization of available beds. |
| Forward transport less acutely ill patients. |
| Provide medical surge capacity in alternate care facilities. |
| Activity 4: Medical Surge Staffing Procedure |
| Tasks: |
| Recall clinical staff in support of medical surge capacity. |
| Augment clinical staffing. |
| Augment non-clinical staffing. |
| Activity 5: Decontamination |
| Task: |
| Provide mass decontamination capabilities, if necessary. |
| Activity 6: Receive, Evaluate and Treat Surge Casualties |
| Tasks: |
| Establish initial reception and triage site. |
| Provide medical equipment and supplies. |
| Initiate patient tracking. |
| Execute medical mutual aid agreements. |
| Activate procedures for altered nursing and medical care standards. |
| Activity 7: Provide Surge Capacity for Behavioral Health Issues |
| Tasks: |
| Institute strategy to address behavioral health issues. |
| Provide behavioral health support. |
| Provide family support services. |
| Activity 8: Demobilize |
| Tasks: |
| Coordinate decision to demobilize with incident management. |
| Provide a staff debriefing. |
| Reconstitute medical supply equipment inventory. |
Conceptual Basis for Linking Disaster Requirements, Organizational Capabilities, and Individual Competencies
A series of workshops in the United States conducted for the Federal Education and Training Interagency Group (FETIG) in 2010–2011 sought to establish a conceptual basis for the relationship between disaster requirements, national policy, strategy, and planning frameworks (see Figure 2.2).57
Framework for Developing Workforce Competencies for Public Health and Medical Disciplines.
In this diagram, competencies are related to capabilities through the term “domains.” The domain is the overall category from which the competency is derived. For example, if the competency domain is surge management, then it includes four capabilities: fatality management, mass care, medical surge, and volunteer management. By definition, competencies describe employee behavior that supports effective and efficient organizational performance.58
Establishing Core Content
Competency Development
Course development has moved from traditional, content-focused training, such as training clinicians on smallpox, anthrax, and radiation illness to role-specific, outcome-based courses that teach individual students what is expected of them in preparedness and in response.58 This is the basis for competency-based education and training models. Most definitions of the term “competency” include reference to the grouping of knowledge, skills, abilities, and behaviors demonstrated by employees that support the successful attainment of the organization’s mission, vision, and values.15,59 Calhoun et al. identified progressive levels of development for the affective and cognitive domains (“domain” as used here refers to the affective, cognitive, and psychomotor areas defined in Blooms’s Taxonomy of Educational Objectives) to produce a common framework on which to base curriculum development. Proficiencies (novice to expert) are examples of development stages of the psychomotor domain.58
Competency development in disaster health over the past decade includes notable works by: 1) the American College of Emergency Physicians; 2) the University of Michigan; 3) the Johns Hopkins University; 4) the Council on Linkages between Academia and Public Health Practice; 5) the Federal Emergency Management Agency and the National Wildland Fire Coordinating Group; 6) Schultz and Koenig; 7) the George Washington University; and 8) the American Medical Association.49,58,60–68 Currently, there is a consensus-based set of core competencies for disaster health (see Table 2.8). There are now many examples of disaster-related competencies that have been developed for healthcare workers.69 A hierarchy was created to provide a method for aligning and stratifying the many models (see Figure 2.3).
Disaster Health Core Competencies
| 1.0 | Maintain personal and family preparedness for disasters and public health emergencies. |
| 2.0 | Demonstrate knowledge of one’s expected role(s) in organizational and community response plans activated during a disaster or public health emergency. |
| 3.0 | Maintain situational awareness of actual/potential health hazards during a disaster or public health emergency. |
| 4.0 | Communicate effectively with others in a disaster or public health emergency. |
| 5.0 | Use personal safety measures in a disaster or public health emergency. |
| 6.0 | Demonstrate knowledge of surge capacity assets, consistent with one’s role in organizational, agency, and/or community response plans. |
| 7.0 | Demonstrate knowledge of principles and practices for the clinical management of all ages and populations affected by disasters and public health emergencies, in accordance with professional scope of practice. |
| 8.0 | Demonstrate knowledge of public health principles and practices for the management of all ages and populations affected by disasters and public health emergencies. |
| 9.0 | Demonstrate knowledge of ethical principles to protect the health and safety of all ages, populations, and communities affected by a disaster or public health emergency. |
| 10.0 | Demonstrate knowledge of legal principles to protect the health and safety of all ages, populations, and communities affected by a disaster or public health emergency. |
| 11.0 | Demonstrate knowledge of considerations for recovery of all ages, populations, and communities affected by a disaster or public health emergency. |
