Emergency Management For Healthcare, Volume IV: Staff Education

Emergency Management for Healthcare,
Volume IV
Emergency Management for Healthcare,
Volume IV
Staff Education
Norman Ferrier
Emergency Management for Healthcare, Volume IV: Staff Education
Copyright © Business Expert Press, LLC, 2023.
Cover design by Charlene Kronstedt
Interior design by Exeter Premedia Services Private Ltd., Chennai, India
All rights reserved. No part of this publication may be reproduced,

stored in a retrieval system, or transmitted in any form or by any
means—electronic, mechanical, photocopy, recording, or any other
except for brief quotations, not to exceed 400 words, without the prior
permission of the publisher.
First published in 2022 by

Business Expert Press, LLC
222 East 46th Street, New York, NY 10017
www.businessexpertpress.com
ISBN-13: 978-1-63742-275-5 (paperback)

ISBN-13: 978-1-63742-276-2 (e-book)
Business Expert Press Healthcare Management Collection
First edition: 2022
10 9 8 7 6 5 4 3 2 1
This book is dedicated to my loving wife and most stalwart supporter—
Jennifer Johnson.
Description
This series of books focuses on highly specialized Emergency Management
arrangements for healthcare facilities and organizations. It is designed to
assist any healthcare executive with a body of knowledge which permits a
transition into the application of Emergency Management planning and
procedures for healthcare facilities and organizations.
This series is intended for experienced practitioners of both healthcare
management and Emergency Management and also for students of these
two disciplines.
Keywords
emergency; disaster; mass-casualty event; healthcare; hospital; specialty
facility; triage; Disaster Plan; mass-casualty plan; evacuation plan; staff
training; university program; critical incident; Command and Control;
incident management system; disaster recovery
Contents
Acknowledgments��xi
How to Use This Series��xiii
Introduction�� xv
Chapter 1 Emergency Exercise Design and Staff Education��1

Chapter 2 Maintaining Momentum��47
Chapter 3 Dealing With the Media��65
Chapter 4 Staff Communications��97
Afterword��129
Notes��135
References��139
About the Author��145
Index��147
Acknowledgments
No body of knowledge is ever singular, and no book is ever written in
isolation. The author wishes to thank the following individuals—friends
certainly, but also both colleagues and mentors, for their reviews and cri-
tiquing of material and for their support and guidance in this project:
Eric Dykes, PhD, Professor of Emergency Planning and Disaster Man-

agement (retd.), University of Hertfordshire, Hatfield, UK, and Past Pres-
ident, Institute of Civil Protection and Emergency Management, UK.
Gerald Goldberg, PhD, Professor of Psychology, York University,

Toronto, Canada.
Daniel Klenow, PhD, Professor of Emergency Management, University

of North Dakota, USA.
Margaret Verbeek, CEM, Past President, International Association of

Emergency Managers.
How to Use This Series
This series of books is intended to provide the student of Emergency
Management with a comprehensive introduction to the practice of this
discipline within the specialized context of a healthcare setting. It deals
with the practice of Emergency Management from the “ground up,”
introducing all of the basic concepts and skills, but in the context of
healthcare settings. Healthcare institutions, such as hospitals and specialty
care facilities, by the very nature of their business, operate with variables
which are not normally found in the community at large and, therefore,
require more attention than normally occurs in community emergency
plans. All of the expected subjects will be covered in some degree of detail.
Each chapter will focus on a different aspect of Emergency Management,
always within the specialized context. That is not to say that the content
would not be applicable in other types of Emergency Management; in
fact, the opposite is quite true.
Each chapter contains both theory and practical applications. In
terms of chapter organization, in each case the applicable theory will be
addressed, followed by examples which are, wherever possible, specific to
the healthcare setting. The examples are then followed by the identifica-
tion of location-specific problems and by the development of appropriate
strategies to address and resolve each type of problem identified. Following
each chapter’s conclusion, a series of student projects are recommended,
each with the intent of developing the student’s experience at the appli-
cation of practical skills. These are followed by a series of multiple-choice
questions, intended to provide the student with a knowledge check prior
to moving on to the next chapter. Finally, a list of recommended read-
ings, along with citations, and end notes for the content of each chapter
are included. The author recognizes the fact that we live in an increas-
ingly digital world and that good textbooks are becoming increasingly
expensive and difficult for both students and their learning institutions to
acquire. As a result, wherever possible, instructions have been provided in
each citation for accessing the appropriate reference information source
xiv How to Use This Series
online. Additionally, wherever possible, the recommended reading list

includes instructions to access the entire books digitally.
This series of books is not just intended for a student audience.
Working Emergency Managers in both healthcare settings and in com-
munity and government settings will hopefully find this information
useful and practical. As a result, the author has attempted to include actual
examples of the majority of the document types described in the various
chapters of this book. These are available digitally, on a copy-protected
website, access to which accompanies this book at the time of sale. The
website is formatted to permit the viewing of the documents, but not
the printing of those documents, and without the ability to modify the
documents in any way. As a major labor-saving device, the reader may
purchase a password-protected one-year renewable license, which will
unlock the content of the website, permitting the full customization of
each document to reflect local realities, including specific site locations,
local telephone numbers, and even the logo of the reader’s institution.
In essence, this feature permits the rapid development of a comprehen-
sive Emergency Response Plan, and all of the associated documentation,
for any type of hospital or other healthcare institution. Information on
obtaining such a license is included on the inside leaf of this book.
Introduction
This series of books is intended to teach the skills which have been tra-
ditionally associated with the practice of Emergency Management. This
includes all of the skills involved in the assessment of risk, selection of
Command and Control models, the writing of an Emergency Plan, the
testing of that document by means of various types of Exercises, and the
development of employee education programs which are intended to
strengthen familiarity with the plan. However, no Emergency Plan is a
“blueprint” to guide a community or organization through its successful
response to a disaster. Every disaster is different in multiple ways and is
extremely complex. If we could simply preplan and preprogram every
type of emergency response from start to finish successfully, we would
be in possession of crystal balls, and the need for Emergency Managers
would be minimal.
This series of books differs from other well-written and useful Emer-
gency Management textbooks in two important respects. First, it will deal
exclusively with the practice of Emergency Management as it should occur
specifically within a healthcare setting. Second, it will attempt to intro-
duce the use of contemporary mainstream business planning practices to
the practice of Emergency Management, something with the potential to
build bridges between the Emergency Manager and the senior executive
who has little knowledge or understanding of the subject.
The application of Emergency Management to a healthcare setting
is essential. It can be argued that any healthcare institution is, in fact, a
highly specialized community. It can also be argued that virtually every
type of service or agency found in a normal community has some type of
counterpart within the specialized community of a healthcare setting. It is
also important to remember that the vast majority of a community’s most
vulnerable population will typically be found within some sort of health-
care setting, whether an acute care hospital, a specialty care hospital, or
a long-term care facility. In order to mitigate against such vulnerabilities
and to protect those who possess them, a certain degree of understanding
xvi Introduction
of the clinical context is required. The clinical context is, in the majority
of cases, a substantive source of each individual’s vulnerability. This is
not to say that the Emergency Manager must be an expert clinician, but
they do need to possess an understanding of relevant clinical issues. In
Emergency Management, the best Emergency Manager available cannot
simply be “dropped” into a hospital to work, any more than they can
do so in an oil refinery, a postsecondary institution, a busy international
airport, or any other highly specialized institution.
This series of books will attempt to introduce several new mainstream
business and academic concepts into the practice of Emergency Manage-
ment. These will include formal Project Management, applied research
methodology, root cause analysis, Lean for Healthcare, and Six Sigma.
All of these concepts have a potentially valuable contribution to make to
the effective practice of Emergency Management. Of equal importance is
the fact that for many years the Emergency Manager has been challenged
to affect the types of preparedness and mitigation-driven changes that
are required within the organization or the community. Part of this has
been the challenge of limited resources and competing priorities, but an
equally important aspect of this has been the fact that the Emergency
Manager has typically used a skill set and information generation and
planning processes which were not truly understood by those to whom
they reported and from whom they required project approval.
These mainstream business and academic processes and techniques
are precisely the same ones which are used to train senior executives and
CEOs for their own positions. As a result, the information generated is
less likely to be misunderstood or minimized in its importance, because
it comes from a process which the senior executive knows and uses every
working day. This “de-mystifies” the practice and the process of Emer-
gency Management, giving the Emergency Manager, and Emergency
Management itself, dramatically increased understanding and credibility,
potentially making the Emergency Manager a “key player” and contribu-
tor to the management team of any organization in which they work, and
far more likely to be regarded as an expertise resource.
CHAPTER 1
Emergency Exercise Design

and Staff Education
Introduction
The staff of any healthcare facility cannot be reasonably expected to
perform emergency procedures in any type of emergency or disaster set-
ting without reasonable preparation, in the forms of training and practice.
Emergency situations are not “business as usual,” and situations are likely
to occur in which the standard operating procedures may not be available
or even advisable. Moreover, it is precisely such unusual and emergent
situations which are most likely to be the subject of detailed review after
the fact, in the form of inquests, public inquiries, and civil litigation.
In such circumstances, it is frequently essential for the organization
to be able to demonstrate “due diligence” that the facility had taken every
reasonable measure to ensure that both the facility and its staff were
trained and equipped to cope with the crisis which had occurred. Perfor-
mance to a given set of expectations cannot be assumed in the absence of
appropriate training. If healthcare facility staff are to perform to a specific
standard in a given circumstance, it is only reasonable to expect them to
be trained or otherwise supported to do so; staff will not do what they do
not know.
One of the biggest challenges faced by the Emergency Manager in
any type of healthcare facility is the education and preparation of all staff
to cope with the various types of emergency situations which may occur.
Healthcare facilities are busy places with important work to do, and the
challenges of getting staff who are already busy to focus on yet another
priority are not small. Moreover, the Emergency Manager must also be
aware of the reality that such training cannot and should not distract staff
2 Emergency Management for Healthcare, Volume IV
and other resources away from the essential business of the facility. Finally,
it is often necessary to overcome a resistance by the Senior Management
Team of the organization which, in the absence of a legislative or regula-
tory mandate, is likely to be, “in an environment of intense competition
for limited resources, why should I spend staff time, money, and other
resources on preparing for something which might never occur?” This
chapter will focus on the types of emergency Exercises and staff education
which are possible in a healthcare environment, how to create and con-
duct each, the various strengths and weaknesses of each, and how to create
and operate an effective, dynamic, and ongoing Emergency Management
training and education program within a challenging environment.
Learning Objectives
In this chapter, the student will learn the use of emergency Exercises as
a staff education tool. They will understand the various types of emer-
gency Exercises and the purpose, strengths, and weaknesses of each. The
student will learn how to create, prepare, conduct, and debrief each
type of Exercise and how to use the findings generated to create an
ongoing and dynamic Emergency Response Plan and Emergency Pre-
paredness Program within a healthcare facility. Finally, the student will
understand the documentation requirements for such a program, how
such documentation can be used to support Accreditation processes,
and how it can be used to support a demonstration of due diligence by
the healthcare facility.
Research
With any effort in the creation of emergency Exercises or emergency
preparedness education, credibility must be the bedrock upon which sub-
sequent efforts are built. The staff of healthcare facilities are unique in
that they are arguably among the best-educated populations of workers in
any given society. They are also quite accustomed to functioning in envi-
ronments in which conflicting demands are made upon their time. As a
result, most have learned to be discerning in their response to education
efforts, focusing only on what they find to be credible, interesting, and
Emergency Exercise Design and Staff Education 3
relevant to them personally. They are open to new learning, but, by the
same token, will be unlikely to waste their time on any effort which they
perceive as being “far-fetched,” unlikely, or simply nonsense.
All information, regardless of the method of presentation, must be
authoritative, accurate, and relevant or the audience will simply be lost.
All Exercises must be fact based, or they too will simply be wasted efforts.
The author is reminded of an episode of the old, American television
drama, “E.R.” In the episode, the hospital had decided to conduct an
emergency Exercise with a scenario of an explosion occurring in a mar-
aschino cherry factory. Throughout the episode, the staff progressively
lost more and more credibility…there simply was no maraschino cherry
factory, the “injuries” arriving at the facility were wrong for the scenario
used, and the staff, who also had real patients to deal with, grew increas-
ingly frustrated with the Exercise until the entire effort simply collapsed,
largely due to staff indifference! There is a lesson there for all Emergency
Managers working in healthcare facilities: do your homework, conduct
your research, and do not, under any circumstances, insult the intelli-
gence of the staff you are trying to serve, or your efforts will fail miserably!
Once again, the Emergency Manager is not a specialist, but, rather,
a sophisticated generalist. The Emergency Manager working in a health-
care facility must be an effective researcher. It is necessary to be able to
conduct effective and reproducible research on emergency events and
to understand contemporary theories and methods of adult education.
By achieving these objectives, the Emergency Manager will be able to
develop and operate credible and effective Exercise programs and other
emergency preparedness efforts which are well received by the staff.
Adult Education
A good deal of the practice of Emergency Management involves adult
education. It is essential for the Emergency Manager to understand some
basic theory regarding this subject, as this will assist greatly in the develop
ment of the required staff education programs. Being able to stand up
and recite facts is simply not adult education. Every effort should be a
carefully thought-out and planned event, with a specific set of learning
objectives, a method of delivering these, and an understanding of how
they are likely to be received and processed by the student(s). Moreover,

particularly in the case of adults, not all learning will necessarily occur in
the classroom nor will it be unidirectional.
Dr. Benjamin Bloom was a leading educational theorist who taught
and conducted research at the University of Chicago and worked from
the 1940s to the 1980s.1 He developed a taxonomy of learning, known
as “Bloom’s Taxonomy,” which, in simplest terms, explored the methods
by which human beings learn different types of information and skills at
different stages of their lives. This work continues to be foundational in
the study of education. The processes are both detailed and complex, and
too detailed for this text; indeed, entire university courses are dedicated
to this single subject. For more detailed reading, Bloom’s work and the
subsequent analysis of it is commended to the Emergency Manager.2
In summary, for the purposes of Emergency Management educa-
tion, adult learners learn best by doing. Moreover, learning which has an
emotional component will be absorbed and retained better than learning
which does not.3 These types of cognitive learning4 represent the foun-
dation upon which the entire use of emergency Exercise play as educa-
tion is built. Any Exercise which is completely credible, practical, and
“hands-on,” and which succeeds in facilitating the emotional “buy-in”
of the participants, will result in learning outcomes, including both the
short-term and long-term retention of both information and developing
skills, which are almost as good as if the participant had taken part in the
actual event, instead of merely an Exercise. They key words, once again,
are factual, credible, practical, and emotional. All Emergency Manage-
ment education efforts should attempt to embrace each of these concepts
as essential to any program.
Setting Priorities
In almost every Emergency Management education program, there are
many projects which could potentially occur. All have the potential to
compete for the attention of the Emergency Manager and for the avail-
ability of staff to receive the training. Moreover, particularly in health-
care, for most Emergency Managers, this area is not their only area of
responsibility; almost all have at least one other major role within the
organization, with Emergency Management activities intended to occupy

half or less of their working day. Many Emergency Managers attempt
to prioritize, using such variable, opinion-based categories as “need to
know,” “nice to know,” and even “maybe someday.” Such systems do not
function in a vacuum, and both decisions and priorities regarding Emer-
gency Management activities are too often driven by political and other
considerations, such as Accreditation, negative press, and public opinion,
instead of legitimate need.
Too often, there is a pressure, particularly when Accreditation is
approaching and an Exercise is mandatory, to “just do something uncom-
plicated and easy,” just to tick off a box on a checklist. This often results
in an Exercise such as a bomb threat, even when the facility’s own Hazard
Identification and Risk Assessment will demonstrate that they are at no
particular risk from this type of event. Similarly, there is a belief that
nothing short of a full-scale Exercise will meet the need, and facilities will
stage such an Exercise when they are nowhere near ready for such a test,
usually with disappointing results. Most Accreditation standards in fact
call for a demonstration of process, not project, and most such efforts do
not really satisfy the intent of the standard in question.
One of the principal reasons for conducting Exercises is to encourage
and develop regular and consistent positive behavior. Skills not practiced
on a daily basis require reinforcement, or there is a good chance of a bad
outcome. Outcome is a matter of both performance and process, and
the purpose of any Exercise is to ensure that those playing key roles do
the “right thing,” do it correctly, and do it consistently. As the following
matrix suggests, there are a variety of potential outcomes to any decision
to act, and we want to encourage the correct outcome to occur as consis-
tently as possible, particularly during a crisis.
Similarly, there is a perception that an Exercise which identifies prob-
lems is a failure and represents potential embarrassment to the organiza-
tion. Such a result can often stop an effective Emergency Management
program in its tracks, as senior managers make “damage control” deci-
sions regarding processes that they do not fully understand. The first thing
that the Emergency Manager in a healthcare facility must make Senior
Leadership understand is that any Exercise which identifies potential
problems is, in fact, a tremendous success. This permits the organization
Wrong Things Right Things
Done Right Done Right
Process – +
Wrong Things Right Things
Done Wrong Done Wrong
Figure 1.1 Performance
to identify and fix one or more serious problems without any human cost,
before they actually occur. Such efforts are intended to drive the Emer-
gency Management program, including education, and the Emergency
Response Plan, making them “evergreen” documents which are subject to
a process of continuous quality improvement.5 Any Exercise which fails
to identify any problems or opportunities for improvement is, in large
measure, a waste of both time and limited resources.
The best tool for driving the need for Emergency Management educa-
tion and Exercise activities is the organization’s Hazard Identification and
Risk Assessment document, described in detail elsewhere in this series.
This will provide the Emergency Manager with a set of priorities which are
driven by reproducible, research-based, and documented risk exposures,
which are ranked by priorities, including probability of actual occur-
rence and likely impacts in a worst-case scenario. Like all other aspects of
the Emergency Management program, this makes the staff Exercise and
education program the product of fact, not speculation. The wise Emer-
gency Manager has the top-ranked 20 percent of scenarios in the HIRA
absolutely committed to memory.
This makes the decision about Exercises more appropriately one of
which type of Exercise to stage, with the priority scenario already iden-
tified by the HIRA document. Moreover, one of the biggest challenges
with full-scale Exercises is that, just as is usually believed, they are large,
complicated, expensive to stage, and disruptive. As a result, they are typ-
ically only staged once, and only those staff who happened to be on duty
at the time of occurrence have any real possibility of gaining direct expe-
rience from it. The vast majority of staff working in healthcare facilities,
sometimes for decades, never experience an Exercise, unless they actively

seek out participation.
Smaller, less complex Exercises, such as case studies, tabletop Exer-
cises, and functional Exercises, are far less expensive and disruptive and, as
a result, may be repeated over and over, until all of the targeted staff mem-
bers have been reached. The correct approach should be one of many,
varied, small Exercises, with the full-scale Exercise coming only when the
Emergency Manager believes that the system requires confirmation.
Types of Exercises
Exercises have been conducted as an integral part Emergency Manage-
ment for a very long time. Like many of the oldest aspects of the practice
of Emergency Management, the use of Exercises for training purposes has
its origins in the military, the source of many of the original Emergency
Managers in municipal and other government settings. The military has
always used various types of Exercises for training purposes, and it has
long been believed that, like most adult learners, military personnel learn
best by doing. The same holds true for healthcare personnel and is already
an essential principle of education for various types of healthcare provid-
ers, up to and including the old adage in the clinical education of physi-
cians of “see one, do one, teach one.”6
There exists a common misconception in healthcare that unless you
have employed a cast of thousands, including the drama club from the
local high school, and disrupted the entire business of the facility for
a day in what a trained Emergency Manager would describe as a full-
scale Exercise, you haven’t really conducted an Exercise. Nothing could
be further from the truth. There are, in fact, an entire range of processes
which, conducted properly, qualify as useful and valuable Exercises,
very few of which meet the usual description of a “real” Exercise. These
include case studies, tabletop Exercises, functional Exercises, and full-
scale Exercises, and each gathers specific information and/or fulfills
a specific purpose in an effective Emergency Management program.7
Each of these will be discussed separately, and in detail in this chapter,
and their place in a comprehensive Emergency Management program
will be examined.
Case Studies
Case study Exercises, conducted properly, constitute an effective, low-
cost, and pain-free method for the staff, usually managers, of any health-
care facility to learn from the problems of others. The process involved is
generally quite simple. In all cases, the Emergency Manager must begin
by determining a set of objectives to be achieved by the Exercise. Such
objectives should be reasonable, practical, and achievable. More than one
objective is fine, but don’t “overdo” the objective list; two or three primary
objectives are appropriate, with a similar number of secondary objectives
listed, if required.
Next, identify the target audience; who will this presentation be
received by? Are they front-line staff ? A particular group, such as the
Emergency Preparedness Committee? Mid-level managers or senior exec-
utives? This is an essential step, as the information needs of each group
will be different. The Emergency Preparedness Committee or Occupa-
tional Health and Safety Committee is more likely to be more receptive
to obtaining all of the information, while other managers and executives
are challenged by many competing demands for their time. The time
demands will also affect the amount of content, with some groups finding
value in a comprehensive and detailed presentation, while others will only
want the “high points”—executive summaries exist for a reason! In some
cases, it may even be prudent to customize the basic presentation, in order
to meet the differing information and time demands of various groups.
As a next step, the Emergency Manager identifies an emergency inci-
dent which has occurred somewhere in the world, ideally affecting a hos-
pital or healthcare facility, and which meets some or all of the Exercise
objectives listed. It may be recent or it may be historical. In some cases, it
may be possible to use a situation which has occurred within the facility
itself, but there are several limitations to this approach. First of all, the
situation to be used must be completely resolved; no ongoing investi-
gation, external review, or potential for litigation should exist. Second,
the privacy of identifiable individuals and the confidentiality of sensitive
information, such as medical records, must be scrupulously protected.
Indeed, if the Emergency Manager intends to exploit such a scenario for
an Exercise, it is almost always best to capture the events accurately, but
to change the locations and times of occurrence, and to change the names
to “protect the innocent.”
The Emergency Manager will then conduct a meticulous and thorough
set of research on the incident in question. To begin with, find that informa-
tion which is readily available within the public domain. This would include
sources such as print or broadcast media reports, most of which are readily
available on the Internet, using search engines such as Google or Bing. The
search can begin with broad terms, such as “hospital + fire” or “nursing
home + earthquake.” Eventually, an appropriate case will be identified, and
the search will become more focused on the specific event. It is often more
effective to use cases which are at least a few months old, as such cases tend
to be followed by media sources, with more and more information being
recovered, as the review of the incident progresses. In some cases, it may be
appropriate to contact the involved facility directly, in order to clarify infor-
mation. While many facilities are reluctant to share much information, the
Emergency Manager probably has a counterpart filling a similar role within
the affected facility, and the collegial approach may provide more coopera-
tion and information sharing than might normally be available.
Once all of the information is gathered, the Emergency Manager can
arrange it in chronological order and begin to prepare a formal presen-
tation on the incident. This can be done using Microsoft PowerPoint or
similar presentation tools. Ensure that all of the facts are included for
reporting, but don’t overload individual slides with information. Keeping
the facts in manageable “chunks” will prevent the audience from becom-
ing overwhelmed, and missing key information.
They say that a picture is “worth a thousand words,” and in many
cases, the media reports will be full of excellent pictures. Add these lib-
erally; and where possible, ensure that you obtain permission from the
media source for their inclusion. Bear in mind that such materials tend to
be copyright protected, although many would argue that once the infor-
mation is published online, it enters the public domain. In the circum-
stances described here, most publishers and media sources will readily
agree to the use of their materials, as a not-for-profit public service, so it
is always better to ask.
Once the presentation content is complete, the Emergency Manager
should review the content and order of presentation both carefully and
critically. Is the information factually accurate? Does it unnecessarily dis-

close any information which should remain confidential? Is there any
element of information which might be misleading? Is there sufficient
information for the audience to draw appropriate conclusions from,
after viewing it? Most importantly, does the presentation actually meet
the primary and secondary objectives which the Emergency Manager
identified at the beginning of this process? Finally, is it a good presenta-
tion? Is there anything in the presentation which might be misleading
or confusing? Is it accurate, thought-provoking, likely to stimulate dis-
cussion among the audience? Is there, in the opinion of the Emergency
Manager, anything which might be done to improve the quality of the
information provided?
Next, it will be necessary to select a venue for the Exercise and to
obtain permission for its use. The space should be comfortable, well lit,
and adequately ventilated. Ideally it will have a digital projector and
screen or a large monitor for display purposes. These should be readily
visible from all parts of the room. Depending on the size of the room and
the group, a microphone and sound system may also be required. Most
modern healthcare facilities contain both boardrooms and classrooms
which are suitable for such presentations, but all require advance booking
with the individual or group, which is responsible for their operation.
The target group for the presentation will need to be identified and
invited. This can occur in a variety of ways. If this is an established group,
the Senior Management Team or Emergency Preparedness Committee,
for example, it may simply be a case of having your Exercise added to the
agenda of the existing group. In other cases, individual invitations may
be required. This becomes more challenging, since virtually everyone in
a leadership role sees themselves as extremely busy, and it is likely that
attending your Exercise will, in their minds, compete with other priorities
which may be competing for their time and attention.
Tying the Exercise to some other important process, such as satisfying
Accreditation requirements, and finding a “champion” among the exec-
utive leadership of the organization are both strategies which are more
likely to improve attendance. Another fact which will help is the credi-
bility of the Emergency Manager; if the reputation is that such presen-
tations are consistently well researched and interesting, that they yield
valuable information, and that they are well run and respectful of the time
demands of the participants, the presentations are much more likely to
be well attended.
On the day of occurrence, the Emergency Manager should arrive well
in advance of the scheduled start time. Audio-visual systems should all be
turned on and tested, and the room should be inspected for any problems
which are likely to interfere with the presentation. Ensure that any sup-
porting documentation (fact sheets, copies of the presentation, etc.) have
been printed and are available to the participants.
If the Emergency Manager decides to use a written debriefing ques-
tionnaire, these too should be available, although, in the experience of the
author, only about 10 percent of these are ever completed and returned.
Ensure that there is a sign-in sheet or similar process at the door, to ensure
that you can accurately identify who actually attended the Exercise, and
who did not, after the fact.
Start your presentation on time, and also finish it on time. Ensure that
the length of the presentation is appropriate; running too long typically
loses audience members quickly. Speak loudly and clearly, attempting to
hold all discussion until the end of the presentation. Finish the presen-
tation with a brief period for general questions from the audience, prior
to beginning the debriefing, but if a question more properly belongs in
the debriefing discussion, don’t be afraid to redirect it to that point in the
meeting. Don’t forget to thank people for their attendance; their time and
projects are as important as yours!
Begin the debriefing by generally summarizing the major facts of the
incident; then follow this with a series of questions. Could this event
happen in this facility? If this event did happen here, what would be
the problems that we would face? How would these problems affect our
normal business operations? How vulnerable are we? What would be
our strengths in such circumstances? What would we need to do differ-
ently? Do we possess the required resources? Do we need to obtain those
resources, and from where? Do our staff know what to do in these cir-
cumstances? Do our staff require additional training, and of what types?
Can we recover from such an event, and what would be required to do so?
Are there changes which are required in our Emergency Response Plan
and procedures?
Ensure that someone is readily available to take detailed written

notes and to capture as much information as possible. Such a discus-
sion can be a virtual “gold mine” of useful information for the Emer-
gency Manager, while raising consciousness about the potential of the
event and the value of both the Emergency Response Plan and the
Emergency Manager!
Once the Exercise has been completed, thank and release all of the
participants. Summarize all of the feedback provided by the debrief-
ing process, and prepare a formal After-Action Report, summarizing
the Exercise and its results. Create a file with a copy of the agenda, the
Exercise presentation, the debriefing notes, the After-Action Report, and
the attendance sheet. Place this file in long-term storage, where it will be
available for viewing by accreditors as required and where it will be con-
tinually available, if ever required in any type of legal or civil proceedings.
Informally review your actions with respect to the Exercise itself. Did
it go well or poorly, and why? Where there any problems or challenges
that you did not anticipate? Did you achieve your objectives, and if not,
why? What did you learn from this process? What will you do differently
the next time? What are the reasonable “next steps”? Exercises are a learn-
ing process, and they are a learning process for everyone, including the
Emergency Manager! Finally, prepare a summary of the Exercise and the
results, and forward this to the Senior Management Team; there is noth-
ing that will generate support for Emergency Management more than a
demonstration of positive progress.
Tabletop Exercises
Tabletop Exercises are of particular use to the Senior Leadership group
and to the group of predesignated staff and alternates who are expected
to fill Command and Control roles during any type of emergency. These
Exercises essentially set up the facility’s Command Center, and they will
guide the group through the steps required for the actual operation of
the facility and problem solving, during a simulated emergency situation.
This Exercise type also has its origins in the military; think back
to old newsreel footage of the Second World War, with Generals gath-
ered around a sand table moving markers representing actual military
resources. Tabletop Exercises, when created and staged effectively, provide

the participants with a thorough orientation to procedures and a level
of experience gained through actual practice which, short of actual
emergency experience, they could not gain anywhere else.
Such Exercises are primarily about learning management by objec-
tives.8 The experience becomes immersive for the participants, and it pro-
vides actual practice at using a Command and Control model which is
not in everyday use. It also orients the participants to working as a team
and to the special decision making and documentation processes of the
Command Center. It can also help to ensure the consolidation and devel-
opment of trust bonds of a team that may never have worked together
before and which may have never run an actual emergency before. Such
experience can be almost as good as the “real” thing!
As with any other type of Exercise, the first step is for the Emergency
Manager to develop a set of clear objectives. These should be realistic and
achievable, and they should be limited in number to two or three pri-
mary objectives, and a similar number of secondary objectives, if these are
required. With these in place, the Emergency Manager can select a sce-
nario which best meets the objectives selected. There are literally dozens
of possibilities in almost every healthcare setting, ranging from a simple
missing patient, through a bomb threat, severe weather, a fire, the evac-
uation of the facility or a mass-casualty incident, to name but a few. The
selected scenario will become the “framework” within which the balance
of the Exercise script is assembled.
The next step is to conduct formal research on the occurrence of simi-
lar events in other facilities, in order to determine precisely what occurred
in that case and how the problems were actually addressed. There is no
shortage of such information available; following major incidents, almost
all hospitals will share their stories, in an effort to help other facilities
to avoid similar situations. Next, the Emergency Manager should ensure
that they have a thorough and comprehensive knowledge of their own
facility, how things operate, what can actually happen, and what cannot.
If the Emergency Manager is unsure whether a particular event can occur
within a particular facility, the prudent and reasonable approach is to ask
someone who actually knows. With the pre-Exercise research completed,
it is time to actually write the Exercise.
The Exercise will be composed of a series of discreet elements of infor-

mation, called “inputs.” In an effective tabletop Exercise, approximately
one input for every two minutes of Exercise play will be required. This
approach permits the participants a sufficient amount of time for discus-
sion and problem solving, without overwhelming them, and maintains a
“flow” of Exercise play. The Emergency Manager should begin with each
of the primary objectives and should create two or three inputs which will
test that objective in a reasonable way. These will be known as “primary
inputs.” Each should be placed on a single sheet of paper.
To illustrate, if the objective is to test the ability of the Operating
Room to manage a large-scale, unanticipated influx of patients, and the
OR can normally manage 18 cases in a 12-hour period, an input from
the Emergency Department that they currently have 25 patients requir-
ing some level of emergency surgery would be an appropriate test. How
will the Command Center react: will they attempt to redistribute patients
to other facilities or develop other types of improvisation and “work-
arounds”? This is, of course, but a single example, and there are multitudes
of examples throughout a typical facility; it is largely a matter of what
needs to be tested.
Next, the Emergency Manager should create a similar set of inputs to
be used to test the identified secondary objectives of the Exercise. These
might be used to address specific concerns regarding building systems
or secondary functions within the patient management process. To illus-
trate, if a concern has been expressed that one of the emergency power
generators requires replacement, perhaps it should fail during the simu-
lated emergency, with an exploration of the result and its impact on the
facility. There is, once again, no shortage of potential scenarios; in fact,
staff are already aware of these potential problems, probably postponed
due to budget concerns or conflicting demands for resources, and many
will be happy to tell the Emergency Manager all about them.
With the primary and secondary inputs in place, it is time to review
progress for credibility problems. Could the events described in the inputs
actually occur within the framework of the selected scenario? Could they
actually occur within the facility being tested? How likely are these occur-
rences? Would the event actually occur in the manner described in the
inputs, or does it require adjustment? Any Exercise is about persuading
the participants to submerge their disbelief and actually “buy in” to the
scenario. When this occurs, the learning outcomes can be excellent, in
fact, almost as good as if the participants had taken part in the actual
event. On the other hand, if the Emergency Manager presents a scenario,
or an event within a scenario, that all of the participants know cannot
occur, the “buy-in” is lost, and so are the learning outcomes. Credibility
is absolutely essential.
As a next step, the primary and secondary inputs should be arranged
in the correct chronological order. The Emergency Manager can then cre-
ate “filler” inputs, intended to describe the events which logically lead
up the primary and secondary inputs. No event occurs in complete iso-
lation. A fire almost never “magically” appears; there might be a patient
sneaking cigarette in a washroom, a smell of smoke, and the activation of
automated alarms. Fill out the missing information for each primary and
secondary input as it would actually occur within that particular facil-
ity. Exercise participants know the manner in which the facility works,
and this logical flow will assist them in achieving the type of “buy-in”
previously described.
Next, create a “starter” input, one which will set the stage at the begin-
ning of the Exercise. Describe the exact conditions which are present at
the start of the Exercise play. Is it the middle of the night or the middle
of a business day? A weekday or a weekend? What are the outside weather
conditions? What are the current occupancy and staffing? Are there spe-
cific services within the facility which are currently closed or at or near
their capacity? What activities are underway at the start of the Exercise?
The provision of this information helps to establish some ground rules
for the participants; if you haven’t mentioned that there are six surgeons in
the building, they cannot magically appear when the participant decides
that they are required!
Arrange all of the inputs which have been developed into correct
chronological order. Bear in mind that, in normal circumstances, each
event would not be dealt with in isolation, so it is appropriate to mix
the various filler inputs somewhat, in order to create the impression of
a more random flow of events. It is perfectly appropriate for an event to
occur, with the participants wondering why it was included, then move
on to deal with describing something else, and then, four or five inputs
downstream, the reason for the initial input becomes clear, in a demon-
stration of cause and effect! With all of this arranged, the Emergency
Manager has the basic Exercise script in place, and it is appropriate to
move on to the actual delivery of the various inputs.
The method delivery of inputs will be determined to some extent by
the resources which are available. At one end of the spectrum, with min-
imal resources, the Emergency Manager, as the Exercise Controller, can
simply sit at the table with the participants and read each input aloud for
all to hear.
At the other end of the scale, the Emergency Manager may establish
a Control Cell in another room, with individual participants receiving
input “updates” in the form of actual telephone calls or radio transmis-
sions from the “Operating Room” or the “Emergency Department” or
the “Fire Chief ” (all Exercise Controllers). The author has even seen
recorded simulations of newscasts describing outside events, played on
the display screens of the Command Center. All of these things are possi-
ble; it becomes a matter of how elaborate the Emergency Manager wants
the Exercise to be and what type of budget resources is available. It is
often best, however, to start with small and simple Exercises and then
raise the levels of realism as the participants gain experience. They are
there to learn, not to be overwhelmed!
The Emergency Manager will then create an Exercise script, using
the inputs which have been created. This will provide the guidance to
the Chief Exercise Controller to provide the inputs. The content will be
included for each input. Also included will be the timing for delivery,
the method of delivery, and any anticipated responses or outcomes. This
creates a tool which ensures that the Exercise will constantly remain “on
track,” that nothing will be forgotten or omitted, and that the experience
for the participants will remain as realistic as possible. The script also
ensures consistency; one of the advantages of a tabletop Exercise is that its
low cost makes it repeatable, ensuring that all members of the Command
Center team, both primary and backup, can receive the same training and
experience.
The predesignated Command Center, if such a facility exists, is the
ideal place for a tabletop Exercise for the Command team. Although
most are not purpose-built, the assembly of the facility from kit form can
actually provide a useful functional Exercise prior to the commencement

of the tabletop. This adds substantially to the realism of the Exercise and
also to the learning which is made available to the team.
The Emergency Manager may also choose to use a large classroom,
particularly if more than one team is to be trained simultaneously. In this
setup, each team will cluster around a single large table; if the ICS, IMS,
or HECCS model is in use, this will mean up to nine individuals around a
single table, with each of the Key Roles, plus a Scribe. This configuration
is useful if primary and backup teams are to be trained together.
The table should be arranged just as it would be in the Command
Center, with all of the required documents readily available to the par-
ticipants. Adult learners typically learn best by doing, and so, rather than
have participants describe what they would do upon receiving each input,
have them actually do it! They can actually start the Incident Log, record
resource requests, and so on. In some cases, trainers use a laminated ver-
sion of the facility floor plan or a property map as a central reference point
in the center of the table. This can provide participants with a physical
connection to the information being provided in each input. By laminat-
ing the floor plan or map, the participant can actually mark the tool up
for planning purposes, using a dry-erase marker. Seating should be com-
fortable, and lighting should be adequate. The room should be adequately
ventilated, and the usual comfort amenities should be present.
In many cases, the information inputs will simply be read aloud by
the Exercise Controller. This permits the Exercise Controller to directly
monitor the results of each input delivery, which may help to direct the
learning in the debriefing which will follow the actual Exercise. However,
if the team is being trained in an actual Command Center, a unique
opportunity exists for a tremendously increased level of realism for the
participants. A control cell9 is a separate room, located somewhere near
the Command Center, equipped with telephones, a computer, a fax
machine, and possibly, a two-way radio. In this room, subordinate Exer-
cise Controllers, under the direction of the Chief Controller, will deliver
the inputs to participants as dictated by the Exercise script, using the
previously mentioned communications devices. To illustrate, if the team
has not yet ordered the establishment of a Family Information Center in
the facility, Security may report, by two-way radio, that there are upset
family members creating a disruption in the Emergency Department. The

team may receive a telephone call from the Fire Department or Police
Department or a fax containing instructions from the Public Health
Department. In this manner, for the participants, information will appear
to be flowing in an extremely realistic manner.
Immediately following the conclusion of the Exercise script, the
team or teams will be debriefed. Two types of debriefing are possible.
These include an informal debriefing, conducted immediately follow-
ing the conclusion of the Exercise, while the participants are still under
Exercise stress, often called a “hot-wash” debriefing, or a more formal
debriefing, conducted some time later or even by questionnaire. It is the
experience of the author that the most useful of these is the “hot-wash”
type of event. A debriefing can be an intimidating and even, in some
organizations, a political event. Participants, while still under Exercise
stress, are much more likely to speak frankly. They will tell you about
things that went wrong, which would never occur following sober, second
thought! In more formal debriefings, participants are likely to be much
more measured and cautious in their responses, even with an assurance
that the contents of the debriefing will remain confidential. With ques-
tionnaires, their principal value is that those who take the time to com-
plete and return them will include not only problems identified, but also
solutions and suggestions for improvement. The problem with question-
naires is that, typically, under 20 percent of the completed questionnaires
will ever be returned to the Emergency Manager.
It is also useful to debrief all of the Exercise Controllers separately as a
group. This will provide useful information on observations at individual
locations during the Exercise, information which might not have been
readily apparent to the Emergency Manager. This is also useful from a
quality improvement perspective for the Exercise itself. Did unexpected
deviations from the Exercise script or even outright Exercise errors occur?
How were they corrected? What can be done to prevent their recurrence?
Were there ways in which the Exercise itself could be improved? This type
of debriefing not only improves and strengthens each Exercise script, but
also helps to build the experience and the level of collaboration among
the members of the team staging the Exercise. In this manner, the Emer-
gency Manager can not only teach and train the Command Center Team,
but will also develop an experience pool among those helping to stage the
Exercise, perhaps even leading to an enhanced Emergency Preparedness
Committee for the facility.
Functional Exercises
Functional Exercises may be used to develop or refresh mechanical skills
which are performed only infrequently, but which may be essential during
the facility’s response to an emergency. The purpose of functional Exer-
cises is to discreetly test those individual elements of the response which
are essential to success, but seldom practiced. They help to train the staff
and can also provide the Emergency Manager with essential information
required for the growth and continuous improvement of the Emergency
Response Plan. What follows are a few examples of functional Exercises;
in reality, any emergency-related procedure can be tested, and the list is
limited only by the imagination of the Emergency Manager.
Testing Emergency Staff Recall
If off-duty staff were to be required at the facility in order to cope with

an emergency, how would they be recalled? Does the facility actually have
adequate recall information or a system for doing so? How up to date is
the information? How effective is the recall system? These are all questions
which typically haunt many Emergency Managers operating in healthcare
facilities. This information is crucial, because without adequate staff, the
best Emergency Response Plan in the world will not work! Such systems
need to be tested, and this needs to occur on a regular basis.
For decades, hospitals have relied upon an old tool called a telephone
fan-out list to recall staff during a crisis. There are several flaws with this
approach. In the first place, for healthcare facilities in an urban setting,
telephone fan-out lists which are not scrupulously maintained and tested
(at minimum every six months) will go out of date by approximately
20 percent, per year! Staff come and go, and they change positions. Staff
move and change telephone numbers. The Personnel Department or the
Supervisor may be notified by staff members of these changes, as per pol-
icy, but somehow this information never quite finds its way from the
personnel file to the emergency telephone fan-out list. The result is a list
full of people who no longer work there, don’t have the same telephone
number that is listed, or have completely different responsibilities and is
missing people who have joined the organization, but for whom you have
no method of contact!
Such fan-out lists are typically an “all or nothing” tool. The list either
calls the entire staff to work or they get no one. Such lists typically use a
“tree”-type configuration. Those activating the list call the Supervisor or
manager of every service and notify them. They, in turn, are expected to
call all of their staff and ask them to report for work, and then report their
results back to those who originated the call-out. If a Supervisor or man-
ager cannot be reached, there is a potential that none of their subordinates
will be contacted either. There is also a possibility that the required staff
telephone list will inadvertently be left at work. In either case, the poten-
tial exists for entire services and departments within a facility to remain
“dark” during a call-out.10 The other distinct possibility is that you will
succeed in calling out three times as many people as you actually require
or people for whom you have no work!
Also problematic in this process are the changes in technology which
have occurred over the past several decades. These include the widespread
use of mobile telephones and tablet devices. They also include features
such as “Caller ID,” and the fact the people are increasingly mobile and
often have a vacation property in addition to their principal residence.
The result is that many people no longer have a single telephone number;
they may have several, all of which are active, and any of which they
might be at when you require them in an emergency. If you need to reach
them, you may need to call all of those numbers! When fan-out lists
were created, telephones were static devices; you were either near them,
or you were unavailable. This is now seldom the case, although the recall
methodology has only rarely changed to adjust for this. Envision a mass-
casualty incident at a hospital; staff recall has been activated. Three ER
nurses, all off-duty, are sitting at a planned dinner outing in a restaurant
which is less than a mile from the hospital. All have mobile telephones,
but because the fan-out procedure is calling only their home telephone
number, three urgently needed resources are unavailable for recall. This is
also true of the stereotypical doctors on the golf course, and so on.
More troubling is the problem of Caller ID. As working in healthcare

becomes more and more demanding, staff members are opting out of
recalls. In many facilities, staff are asked to work more overtime hours,
instead of hiring additional staff. The economic reasons for this are obvi-
ous and understandable, but it reaches a point where staff members may
have worked all of the overtime that they want, and thus begin using
the Caller ID feature on their telephone to simply screen incoming calls.
When they see the facility’s number on the Caller ID, they simply do not
answer the telephone, and another resource is lost. In any case, without
regular and systematic testing of the system, such problems as described
here will be neither identified nor corrected until a crisis actually occurs!!!
Without someone, or a group of people, periodically sitting down and
actually calling every number on the list and documenting the results,
then following up on the failures to connect, the Emergency Manager will
never have a staff call-out tool upon which any confidence can be placed.
Assembly of the Command Center
In the vast majority of healthcare facilities, the facility Command

Center is not a purpose-built resource. Such tools tend to exist only in
a very small number of very large and resource-rich facilities which can
afford the space and resources required. Most often, the facility Com-
mand Center will be a boardroom or a classroom which is converted to
Figure 1.2 The assembly and testing of the Command Center is

essential to preparedness
this use when required, usually from equipment which is stored in the
room under lock and key or on carts which are securely stored elsewhere.
In such cases, workstations, resources, and equipment for individual
members of the Command team will require assembly and testing. These
will even include a telephone network, a computer network with all of
the required peripherals; all of this equipment is typically multiuse, due
to economic considerations. This assembly needs to occur quickly and
correctly, even in the middle of the night!11
The vast majority of Command Center staff will not be computer
or telephone system experts, nor will they immediately understand the
mechanics of converting the workspace. Many of these individuals will
rarely even know where the equipment which they are using comes from
or how to get it. It is a simple truth that the person in charge of the Com-
mand Center is almost never the same person who knows how to change
the toner cartridge on the printer! That does not mean that they are not
the most likely person to have to perform these functions in the middle
of a crisis at 2 a.m.! These individuals will require training, and refresher
training, and the problems of assembling the Command Center at short
notice will need to be identified and addressed.
As previously stated, “adult learners learn best by doing,” and so, the
best way of achieving all of these objectives is to simply bring everyone
together periodically (every six months is recommended) and have them
actually assemble the Command Center from kit form, and then put it
away when they are done. This will permit the identification and res-
olution of any problems before the crisis actually occurs. Such testing
can actually even be incorporated into a tabletop Exercise for Command
Center staff; after all, this is what is likely to happen in a real emergency,
and so, contributes directly to the realism of the experience.
Tactical Exercise Without Troops (TEWT)
There is a list of facilities which do not exist on a daily basis within most
healthcare facilities, but which are likely to be required during any major
emergency. These include a designated space in which off-duty staff will
report, be briefed, and be assigned to duties as required. This space is also
where staff will return for reassignment, when their existing assignment
concludes and where all staff timekeeping will occur. Almost no staff
member is likely to end up working in their unit of origin during a crisis.
The staff staging area, staffed by Administration, Human Resources, and
Payroll staff, fills such a function, and the facility will fall under the juris-
diction of the logistics function, in most Command and Control models.
Also included is a space in which the members of the media can be
placed and provided with information, usually called a Media Center.
They are sequestered in this location and permitted to do their jobs,
without disrupting the business of the organization or violating patient
privacy. It is here that media conferences and interviews will be conducted
and media releases and background information will be available. Such
facilities are typically staffed by corporate communications or a similar
function, supported by Security, and they fall under the jurisdiction of
the public information function in most Command and Control models.
Also required is an area in which the families of victims can be seques-
tered, away from public scrutiny, to await news on their loved ones. It is
from this family information center that the identification of unidenti-
fied victims is likely to occur. Here both good news and bad news will
be delivered by individuals with experience at this special skill. Family
reunification can also occur at this location. Such facilities are typically
staffed by Social Services, Pastoral Care, and hospital volunteers and fall
under the jurisdiction of the planning function in most Command and
Control models.
Other areas which may be required include areas for the triage of
incoming patients, temporary treatment areas to prevent the overwhelm-
ing of the ER, temporary treatment areas, including improvised critical
care expansion spaces, and spaces for the specific use of decontaminating
any patients exposed to hazardous or radioactive materials. This list is by
no means comprehensive; there are probably many temporary facilities
required, but these are the most common.
The Tactical Exercise Without Troops (TEWT) has its origins in the
military, where typically before a war-game Exercise, military officers
would gather together, walking across the “battlefield” and identifying
locations for fixed facilities, and the resources and supply chains required
to support them.12 A similar function is possible within any health-
care facility, with the Emergency Manager, and, ideally, the Emergency
Preparedness Committee, walking through the facility and identifying

both primary and backup locations for the placement of all temporary
disaster resources, identifying the “owners” of these locations, and secur-
ing permission for their use and instructions for how to access them,
including outside of normal business hours. The resources required for
each type of facility are then identified and sourced, and the supply chains
to support them are formalized. Once all of this is in place, these resources
may be formally incorporated into the facility’s Emergency Response
Plan. It is useful to repeat this Exercise at least annually, as healthcare
facilities tend to grow organically, and a space which seemed “perfect”
during the last TEWT Exercise may have radically changed, due to the
legitimate needs of its daily occupants.
Assembly of Decontamination Equipment
In modern society, every hospital should have some provision in place for
the safe decontamination of patients who have been exposed to radio-
active or other hazardous materials. While the facility may not be in a
war zone, or in an area perceived as being particularly susceptible to ter-
rorist activity, it should always be borne in mind that, in most of the
developed world, one heavy truck in 10 and virtually all freight trains are
carrying some form of hazardous materials. As a result, the possibility of
receiving contaminated patients is real, and has real potential for totally
disrupting the operations of the facility. As a result, every acute care hos-
pital should have a plan and resources for conducting decontamination
of incoming patients.
Any assumption that all patients will be decontaminated prior to
transport or that the local fire service will arrive to perform decontam-
ination for the hospital is likely to be largely false hope; many patients
arrive by means other than EMS, with little or no decontamination, and
the vast majority of fire services, with the exception of very large ones,
often have little or no equipment or training in decontamination proce-
dures. Each healthcare facility will need to make its own arrangements
for decontamination, either through training and equipping their own
staff or by “contracting out” to a commercial service provider, if one is
available.13 The lowest cost option is usually the training and equipment
of the facility’s own staff. In the United States, the Federal Emergency
Management Agency actually provides online and in-person courses for
the training of healthcare staff to manage contaminated patients.
Such skills will typically be used on a relatively infrequent basis. As
a result, those staff assigned to the various decontamination roles will
benefit greatly from a period Exercise in which they assemble the decon-
tamination area from a kit, “don and doff” personal protective equip-
ment, and “decontaminate” on or several “patients,” suffering from a
variety of exposures. The ability to assemble equipment, dress safely, and
begin decontamination quickly and effectively is essential to success, and
it may even ensure that the facility does not have to close its doors due to
potential hazardous material contamination.
Triage is a formal process for sorting patients according to clinical
severity, in order to provide appropriate levels and order of access to lim-
ited clinical resources.14 This usually occurs in most daily Emergency
Department operations, but assumes greatly increased importance in any
major emergency. Whereas on a daily basis, it is a relatively slow process,
with patients assessed one at a time by a single nurse determining the
order of access to the Emergency Department, in a mass-casualty situa-
tion it is more likely to be algorithm based, conducted by several nurses,
attempting to “sieve” and redirect large numbers of patients arriving
simultaneously, either to the Emergency Department or, for the less seri-
ous cases, to alternate treatment areas. Moreover, subsequent retriage may
Figure 1.3 Triage Exercises practice: an essential skill

be required, in order to provide order of access to diagnostic resources,

operating theaters, in-patient beds, and even critical care beds.
In such a state of potential confusion, the safe and effective triage of
incoming patients can become elevated to almost an art form. While most
Emergency Departments have no shortage of nurses who can perform daily
triage, this more elevated form of triage requires its own special spaces,
additional training, and repeated practice, in order to sharpen assessment
skills and ensure that, when actually needed, all efforts are performed
correctly, with all patients receiving appropriate care, quickly, safely, and
efficiently. Regular opportunities to practice these skills, in the form of
simple, low-cost, functional Exercises are essential to achieving these
objectives, and such opportunities should be provided to predesignated
staff members on at least a semiannual basis.
Evacuation of the Facility
One of the greatest challenges ever to face any healthcare facility is likely
to be the safe and effective evacuation of its patients, staff, and visitors.
This can occur through a variety of circumstances and may require a rapid
removal, such as with a fire, or may be a more controlled response, such
as with a prolonged utility failure. While it can be argued that the popu-
lations of healthcare facilities are typically the most vulnerable population
Figure 1.4 In evacuation Exercises, much can be learned from

moving a single, simulated sample patient
within any community, there has, historically, been surprisingly little

activity at actual evacuation.
In a research conducted in Canada in 2000, for example, it became
apparent that the vast majority of acute care hospitals of all sizes and
locations had completely unrealistic expectations of how long it would
actually take staff to evacuate the facility. This is not particularly surpris-
ing, since the majority had never even attempted to evacuate, even as
an Exercise;15 in fact, less than one-third of the acute care hospitals in
the entire country had ever tested their ability to evacuate, and only
8 percent had tested their ability to receive evacuees from another
healthcare facility. Such results are not exclusive to Canada, and are, in
fact, much more common than we would wish to believe. An increase in
interest by Accreditation bodies, and by legislators, is slowly changing this
reality in most countries.
The most common reasons cited for a lack of evacuation practice were
the safety of both patients and staff and the disruption of daily business.
In fact, these arguments have some validity; it is unsafe to begin moving
actual patients for the purpose of an Exercise, and it would be unfor-
giveable if a patient or staff member were actually injured during train-
ing. That being said, it is quite possible to generate a great deal of useful
information about the evacuation of the facility without putting a single
patient or staff member at risk. The challenge is to develop the informa-
tion without actually evacuating.
The patients normally housed within a typical healthcare facility can
be differentiated by three common factors: clinical acuity, degree of mobil-
ity, and degree of supervision required. It is entirely possible to develop
an evacuation “benchmarking” Exercise, using these characteristics. The
Emergency Manager has the potential to simulate a high-range and low-
range patient for each of these three characteristics, with a handful of
additional simulations for other patient types with special needs, includ-
ing incubators, bariatric patients, and perhaps, intensive care patients.
These patients can then be placed in the most distant and inaccessible
location of the facility, and then moved, one at a time, to the designated
point of egress. In each case, the amount of time required and the amount
of staff resources required to perform the movement would be recorded.
Each simulated patient would be moved through the process twice, the
first time, using elevators to simulate a nonurgent, controlled evacuation,

and the second, with no elevators used, simulating a “flight to safety”
scenario, such as a major fire.
Simultaneously, a telephone poll could be conducted, asking neigh-
boring facilities how many of the sending facility’s patients could be
accommodated, if a real evacuation were occurring. The facility would
also poll potential transportation providers, such as Emergency Medi-
cal Services, private ambulance companies, private patient transportation
services, and bus companies, in order to determine how many of each
type of vehicle would be available at that moment and what the esti-
mated time would be for a round trip to and from each potential receiv-
ing facility. Most facilities estimate time of evacuation to the “front lawn”
of the facility; this represents a much more comprehensive picture of what
evacuation would look like, were it to actually occur.
By placing these patients in the furthest and most inaccessible loca-
tion in the facility, the timings generated represent an absolutely “worst
case” scenario. By then conducting a census of the entire facility, using the
characteristic classifications used in the Exercise, a much more realistic
picture is generated of how much time and resources would be required
to successfully evacuate the facility in both types of scenarios. They also
represent a benchmark, by which future evacuation tests may be mea-
sured, permitting the Emergency Manager to monitor progress and to
adjust for and justify the acquisition of resources to address any identified
shortfalls. Such a process is extremely useful and should occur regularly,
probably on an annual basis.
Full-Scale Exercises
Full-scale Exercises have been widely believed by many to be the only
“real” type of Exercise, and this belief has resulted in a good deal of the
general resistance by healthcare administrators to many proposals to con-
duct an Exercise in a healthcare facility. Many administrators believe that
such Exercises are complicated, expensive, occupy a great deal of staff
time, and have the potential to interfere with the core business of the
facility or the organization. In the case of full-scale Exercises, most of
these beliefs are somewhat accurate, at least for this type of Exercise.
The full-scale Exercise involves the use of dozens, perhaps, in some

cases, hundreds, of people. Performed properly, they will involve corps
of simulated patients, often community volunteers, members of service
clubs, or students. These will require some degree of casualty makeup and
programming as to their signs, symptoms, and expected behaviors. The
Exercise will also require a large group of staff members, in addition to
those who are currently on duty caring for the actual patients of the hos-
pital. Most of these will be on overtime pay, since the staff who are already
on duty cannot be taken away from the real patients for an Exercise.
The Emergency Manager needs to educate the administrator to the fact
that there are many useful and cost-effective options for Exercises and
that the proper place for the full-scale Exercise in an effective healthcare
Emergency Management program occurs only occasionally, and then
only for confirmation.
A full-scale Exercise will require less storytelling, and only a mini-
mal number of inputs, usually only to start and finish the Exercise. In a
full-scale Exercise conducted in a healthcare setting, the patients them-
selves become the inputs. These patients will need to be decontaminated
if necessary, assessed and triaged, assigned to the appropriate treatment
area, registered, recorded the initial assessment and history, diagnosed
and treated, assigned to diagnostic/treatment resources, and then moved
through the system to a point which is predetermined by the Emergency
Manager when the Exercise is created. As each patient reaches the point
of conclusion, the Exercise is over for that patient. When there are no
more patients to be processed through the system, the Exercise concludes.
The Exercise itself can involve any variety of scenarios, with an intent
of testing specific aspects of the emergency response mechanism. It may be
conducted in isolation, or it may be a part of a larger Exercise conducted
by one of the emergency services or the community in which the facility
is located. To illustrate, the community elects to conduct their annual
emergency response Exercise with a scenario of a school bus accident or
a plane crash. As the Exercise progresses, the “patients” are located, extri-
cated, triaged, and treated at the scene. They are finally transported from
the incident site according to triage priority, and, as they begin to arrive
at the local hospital, that aspect of the Exercise begins. The emergency
services will have their own objectives to accomplish in their portion of
the Exercise, while the healthcare facility will have a separate, but equally
important series of objectives and processes to test. Both organizations
cooperate, and both draw the benefits that they need from the process.
Similarly, when acting alone, the healthcare facility will probably simply
imagine an incident, such as the bus or plane crash, and the Exercise will
begin as the “patients” begin to arrive at their doorstep.
Such Exercises are elaborate and complex, and most good ones require
literally months of planning. An appropriate first step, as with any type
of Exercise, is the setting of objectives and the determination of precisely
how these objectives will be met, along with a definition of precisely what
series of steps constitutes a pass or fail for each objective. Next, a scenario
should be chosen and researched, in detail, in order to ensure the accuracy
of its presentation. The time of occurrence and day of occurrence are also
important, as these will, to some extent, determine the amount of impact
on the real treatment resources of the facility; conducting the Exercise
on a Sunday morning will impact less real patients, but will require the
payment of more overtime to staff. Conducting the same Exercise on a
Wednesday morning means more staff will be in the facility, but will also
likely pose significant interference in the treatment of real patients.
Ideally, the facility’s Emergency Response Plan should be activated
twice in each calendar year, at minimum. It is not mandatory that every
Exercise feature a mass-casualty incident scenario; any type of emergency
event may be chosen, and all should be tested periodically. It should be
noted here that any Exercise is intended as a substitute for real learning
experiences. In most Accreditation standards, this fact is recognized. In
the Joint Commission Standards,16 for example, any facility which has
a real major emergency event within a calendar year may substitute this
for a required emergency Exercise, providing that it has been debriefed,
documented, studied, and used to drive improvements to the Emergency
Response Plan.
The development of such an Exercise is a massive effort, and doing so
requires a team to support the Emergency Manager. The best Emergency
Manager in the world cannot possibly create, develop, stage, debrief, and
report a good full-scale Exercise alone. An Exercise Planning Committee
will need to be created. In a healthcare setting, this should include a rep-
resentative from every department which will be affected by the Exercise.
The Emergency Manager may also wish to include representatives from

local emergency services and/or the municipal Emergency Manager, in
an advisory capacity. Choose the Committee Members carefully; this will
be a months-long commitment, at least on a part-time basis, and a sig-
nificant amount of additional work from everyone involved. Common
sense and an understanding of human behavior indicate that the Emer-
gency Manager is likely to get more effort and more useful result out of a
Committee Member who actually wants to be there.
As previously stated, Project Management skills are a useful tool in
the development of any Exercise, and this is particularly true in the case
of a full-scale Exercise. Most Exercises of this type begin preparation six
months to a year in advance of their actual occurrence. They require
a long list of individual projects, which can be treated as steps to the
completion of a much larger project. Some of these projects will be inde-
pendent, but many will be intrinsically connected to other projects and
cannot begin until these are completed. To illustrate, a group assigned
to begin the design of an “accident” area cannot begin to do so until
the area has been selected, permission obtained for its use, the type of
accident determined, the use of the “school bus” obtained, and so on.
The entire Exercise can and should be the subject of a formal project
plan, created by the Emergency Manager. Each subordinate step must be
identified, the interdependencies of the steps determined (e.g., we can’t
obtain casualty makeup until the list of injured “patients” is developed),
and timelines identified.
These subprojects need to be placed in chronological order and must
follow a logical flow. Some projects will be more essential than others to
the successful development and staging of the Exercise, and the Emer-
gency Manager will benefit from the plotting of all of these measures
on a linear chart for tracking and control purposes. There are several
approaches to this charting which will work, including Gantt charts17
and “fishbone” diagrams,18 also known as “Ishikawa” or “cause and
effect” diagrams, the use of which can be learned in the most basic of
Project Management training. Once all Exercise development measures
and subprojects have been plotted, and the interdependencies identified,
the Emergency Manager should be able to identify a “critical path” to
project completion.
Another useful approach is to employ the use of step-by-step

“checklists,” as per the “standardized work”19 approach of both Lean
Healthcare and Six Sigma, for both subordinate projects and the main
project, and a method of providing consistent work and reporting,
and for measurement of progress, for use by the Emergency Manager
and all subordinate Committee Members who are assigned projects.
Subprojects can then be assigned to individuals or groups, along with
completion dates, according to priorities for completion and availabil-
ity of appropriate resources and skill sets, timelines for completion set,
and then the project and each subproject or step can be dynamically
monitored for completion.
To illustrate, one work group might be assigned to identify and obtain
the use of physical areas required in order to stage the Exercise. Each of
these will require identification of each separate location, determining
“ownership” of the space, negotiating conditions for its use, obtaining
permission for its use, determining the resource requirements for the
intended use, and sourcing these. Finally, the spaces selected will need
to be presented to those in another group who will be planning actual
Exercise play and need to know what resources they have at their disposal,
a process which cannot begin in earnest until the areas are identified. In
this case, the specific areas required, which will vary according to the scale
and type of Exercise being planned, might include, but are not necessarily
limited to:
Exercise Area
Accident Area
Triage Area
Treatment Area(s)
Debriefing Area
Changing/Clean-Up Area for “Patients”
Male
Female
Casualty Makeup Area
Exercise Control Area
Exercise Briefing/Debriefing Area
Observation Area
Each of these will need to be negotiated for and obtained individually,

usually well in advance of the actual date that the Exercise is to be staged.
Another framework element which can and should also be used for
Exercise planning is one which is already quite familiar to the Emergency
Manager, the facility’s Command and Control model. Just as it is used to
manage an emergency, remember that the resolution of the emergency is
also a project and that the same skills areas and division of responsibilities
will prove useful. To illustrate, while the example used is not exhaustive,
in a facility which uses ICS, IMS, HECCS, or HEICS, the Incident Man-
ager/project manager would be the Emergency Manager, with separate
groups developing:
Safety (site, participants, actual patients, emergency procedures)

Liaison (with senior management and outside agencies, thank-you
letters)
Public Information (staff updates, media management)
Operations (Exercise Control Group)
Planning (Exercise script development, controller/observer briefing,
debriefing)
Logistics (human resources, sites, materials management, support
resources)
Finance (budget, cost to date, etc.)
By managing the development and staging of the full-scale Exercise in

this manner, the control of an exceedingly large project can be maintained
and the project itself can be completed successfully.
As with all Exercises, the completed Exercise will require the debrief-
ing of all participants (including the simulated patients), Exercise Con-
trollers, Committee Members, and observers, in order to identify all of
the problems identified and other successes of the Exercise, as well as any
problems in script development and Exercise play. This should include
both the “hot-wash” approach previously described, with copious notes
being taken, and the use of debriefing questionnaires. The group size in
a full-scale Exercise is far too large to ensure the accurate capture of the
critical performance information needed by the Emergency Manager in
any other way.
At the completion of the Exercise, a clean-up team will be required

to restore each location used for Exercise purposes to its original condi-
tion. A similar team will also be required to clean and restore those other
resources borrowed for Exercise purposes to their original condition.
Once these measures are completed, the resources and physical spaces
will be returned to their original “owners,” in at least as good a condition
as they were received in. The Emergency Manager should make a point
of sending a personal “thank-you” note to each of these individuals; a
Department Head who feels that their efforts are appreciated and valued
is far more likely to provide cooperation for future Exercise efforts! Sim-
ilar “thank-you” letters should be provided to the affected Department
Heads, all Exercise participants, and Committee Members (and to their
normal Supervisors), and to any municipal or emergency services which
participated in the project.
Finally, the Emergency Manager will collate the findings of the de
briefings and will use these to create a formal After Exercise Report. This
report will be provided to the senior management of the organization
and will outline the scenario nature of the Exercise, what was tested (and
what was not), the strengths and weaknesses identified, opportunities for
improvement, and next steps. The report should also acknowledge and
thank all of the Committee Members. This report should be provided
to all members of the Senior Management Team, with the Emergency
Manager prepared to answer any questions which may arise from this
review. A copy should also remain on file to support any future Accredi-
tation submissions or any need indicated by the facility’s Legal and Risk
Management Departments.
Exercise Control
On the day of occurrence, the Exercise will be run by a group called the
Exercise Control Group. This group consists of a Chief Exercise Con-
troller, who coordinates the overall running of the Exercise and assigns
tasks to subordinates, based upon the Exercise script, and subordinate
Exercise Controllers, who will perform tasks which manage the “flow”
of the Exercise. Each of these individuals should be readily identifiable,
usually by means of colored vests or tabards, and each should ideally be
in two-way radio contact with the Chief Controller and their colleagues
on a private frequency (not audible to participants) throughout the Exer-
cise. Also often present at any Exercise are a group of observers, often
from other facilities or outside agencies, and these should also be readily
identifiable by means of a different colored vest or tabard, or some other
visual marker.
Participants should be briefed in advance of the start of the Exercise
regarding the “rules” of Exercise play, what is permitted, and what is not.
They should understand the boundaries of the Exercise area, what is sim-
ulated, and what is real. They should also be informed on how to identify
Exercise Controllers and observers and should be informed that they may
refer to an Exercise Controller if they have a problem, but that for the
purpose of the Exercise, the observers should be regarded as “invisible.”
Exercise Safety
Safety is of paramount importance during any Exercise. There is never a rea-
sonable excuse for any Exercise participant, staff member, or volunteer to
become injured during Exercise play. As a result, the Exercise Safety Officer
and any subordinate staff should be charged with carefully preinspecting
every element of space being used for the Exercise, in order to identify and
remedy any potential safety hazards which may be present. During actual
Exercise play, this group should be patrolling the entire Exercise site, with
a clearly understood mandate that they have the authority to immediately
halt Exercise play at any time when a potential hazard is identified.
There is also a well-understood potential for confusion to occur with
so much simulation ongoing. A clear procedure is required for the sep-
arating of simulated problems from real ones, and this process must be
included in all pre-Exercise briefings, in order to ensure that everyone
on the site has a clear understanding of procedures. A method of rapidly
identifying a real event or problem is the use of the phrase “no duff”
prior to any communication which involves a real emergency event. To
illustrate, a participant approaches the Exercise Controller and says “No
duff…this lady has fallen and broken her ankle,” with the Exercise Con-
troller instantly understanding that this is a real emergency and arranging
the appropriate response to the incident.
A similar problem can also potentially occur with non-“face-to-face”

communications. For this reason, any telephone or radio communica-
tions between participants should be prefaced by either the phrase “no
duff” described in the preceding paragraph or by the phrase “This is an
Exercise message.” Ideally, steps are already taken in advance to ensure
that the Exercise participants are making any radio or telephone calls to
an Exercise Control Cell, and not the main switchboard of the facility or
to the local emergency services. Dummy numbers to call must be pro-
vided to participants, if this is an essential element of the Exercise. An
accidental real emergency services or hospital code team response to a
simulated situation will not win the Emergency Manager, or the facility,
any friends in the emergency services!
Emergency services dispatch centers should be provided with noti-
fication that the Exercise is ongoing, and with a number at which to
contact the Chief Controller, should they receive an emergency call to the
Exercise site. Bear in mind that the accidental call may not be generated
by the participants. In this increasingly communicative age, it is entirely
possible for a passer-by to come upon the Exercise scene with no real
awareness of what is actually happening, and call emergency services,
believing that they are actually helping! In all cases, the emergency com-
munications loop must be closed to prevent accidental responses.
Managing Exercises
All types of Exercises have their place in the effective Emergency Manage-
ment program of a healthcare facility. Each has the potential to generate
positive outcomes for both the facility and the Emergency Manager, but
only if they are organized, well run, and credible, and if they generate real
results. There is nothing that will destroy an Emergency Management
program more effectively than poor organization, sloppy timelines, and
ineffective results. The good news is that if the Emergency Manager is
organized and skilled, the former results are much more likely than the
latter results. The key to achieving this outcome is good organization.
Like most aspects of Emergency Management, the creation, staging,
debriefing, and information “harvesting” of any Exercise is, in fact, a proj-
ect. As such, the principles and practices of Project Management20 do
apply, and can, in almost all circumstances, provide an extremely useful

process for the creation and staging of an Exercise. Taking the time to
create a formal project plan for each Exercise will ensure that discreet
steps to the development, staging, debriefing, and reporting of the Exer-
cise are identified in advance, that responsibility for each is assigned, that
timelines are adhered to, and that progress to completion is monitored.
This measure can also ensure that that resource wastage is minimal, that
confusion is eliminated, and that work is completed on time; in other
words, the project is organized. The larger and more complex the Exercise,
the more likely it is to benefit from the Project Management process,
although its use on even small Exercises provides good organization to
the Emergency Manager and further develops the skill set and experi-
ence of the Emergency Manager with the Project Management process.
Every Emergency Manager, in every healthcare facility, can benefit from
formal training in Project Management. Indeed, so much of Emergency
Management is, in fact, project based, that it could be argued that formal
certification in the Project Management process should be an essential
part of the training of every Emergency Manager.
Staff Education Strategies

One of the greatest challenges facing the Emergency Manager in a health-
care setting is that of teaching and training staff. While emergency pre-
paredness is undoubtedly important, in a healthcare setting most issues are,
and there tends to be a relatively intense competition for limited resources
by a variety of projects and services at any given time. Moreover, staff are,
themselves, a precious resource, with an essential primary function. The
greatest single cost in healthcare is staffing, and every staff member who
can be there is required on a daily basis at the bedside. Taking them away
for training, however essential, takes them away from the patient, requires
their replacement, and increases operating costs which are already consid-
erable. Therefore, the provision of emergency preparedness education by
the Emergency Manager must be a carefully thought-out strategy which
always respects the needs of the core business of the organization.
When dealing with teaching any type of crisis management strate-
gies to adult learners, there is a distinct hierarchy of decision making,
which can be readily exploited by the education efforts of the Emergency

Manager, in order to achieve the desired outcomes. In a crisis, if a staff
member has been trained to perform in a particular manner and to
take specific steps, that is what is most likely to occur. In the absence of
such training, the staff member can function almost as well with a set
of written instructions which are readily available at all times, are clear
and unequivocal, and are easy to understand. It is only when advance
training and clear instructions are both absent that people who are in
a crisis attempt to access solutions based upon previous experiences, in
Emergency Management called “freelancing,” and this is when the real
problems in emergency response begin. If at all possible, Emergency
Management programs in healthcare facilities should focus on the first or
second options, and avoid the third option at all costs.
As a result, it is appropriate to ensure that those with the greatest need
receive actual “hands-on” training. These would include senior decision
makers, but also those on the Command and Control team, who will
actually operate the facility Command Center, and, to a lesser extent,
front-line management staff. More comprehensive “hands-on” training
is also required by those who will perform specialist functions within the
facility, including specified triage nurses, members of the decontamina-
tion team, and members of the specialized Clinical Acuity/Special needs
Evacuation (CASE) team.
For the balance of staff in a healthcare facility, a well-written and
clear Emergency Response Plan is arguably just as effective, and certainly
more cost-effective, when compared to more comprehensive training. By
employing the techniques described elsewhere of this series, it is possible
for the Emergency Manager to create a series of annexes to the Emergency
Response Plan which are, in fact, step-by-step instruction sheets in the
form of checklists, which provide a “standardized work” response, as per
Six Sigma, to a variety of commonly encountered emergency situations.
When written in clear, unequivocal language, the employee can see at a
glance exactly what they are expected to do, and not some generalized,
ambivalent statement about what they “may” do. It then becomes a mat-
ter of conducting reasonable and appropriate awareness programs, which
will encourage all employees to access these checklists at a universally
standard location, which they can commit to memory and rely upon.
The result of this approach is an Emergency Management program

which is not only cost-effective, but also focuses training resources on
those who are actually likely to require them, while providing clear and
concise instructions to all other staff. In this manner, every staff member
does what they are expected to do or can be held accountable for devi-
ation. Freelancing is avoided, and a culture of preparedness is actually
developed and enhanced within the facility. Staff can focus upon core
business, while reassured that if anything goes wrong, appropriate mea-
sures and usable instructions are in place.
Awareness Campaigns
With a creative approach, the Emergency Manager can raise the subject
of emergency preparedness on the “radar” of individual staff members,
often without drawing them away from the bedside. Such programs have
some costs associated with them, but these are typically relatively minor,
and often, one-time expenses for the facility or the organization. Some
may involve a commitment of some time or effort by the employee,
but many simply exist quietly in the background, raising awareness and
even educating, without distracting the employee from the core business
unnecessarily.
Name Tags
(Note: Access the image of the Emergency Color Code chart, located
at: www.nygh.on.ca/patients-and-visitors/visitor-information/health-
and-safety/emergency-codes and obtain permission for its use. Caption:
“Good graphic art can be used to create name tags, mouse pads, and
screen savers to support awareness programs.”)
Healthcare settings are typically filled with vulnerable people, and as
a result, virtually every employee is issued with and required to wear a
photo identification card, issued by the employer. One highly successful
program which has been used by some Emergency Managers is to provide
a “reminder list” of all of the facility’s emergency codes on the reverse of
photo identification card or on a second card which is attached to the
same clip. In this manner, the employee has a constant reminder of all of
the relevant emergency codes on their person at all times. They are more
likely to glance at it from time to time, and, when a code is announced,
they have an immediate reference source on their person, if they are
unsure. The one challenge with this type of approach is an unfortunate
tendency of staff to leave their photo identification in their lockers. This
can also be a challenge in other respects; in a staff recall during any high
security event, staff will be asked to show their ID before being permitted
to enter the building, and they cannot show what is sitting securely in
their lockers! This is a widely reported problem, and it is apparently par-
ticularly problematic among the physician population.
Screen Savers/Mouse Pads

Many printing and promotional companies can custom-print promo-
tional items such as mouse pads or coffee cups with just about anything
that someone might require. These are extremely inexpensive, particu-
larly when ordered in quantity. The mouse pad which normally displays
advertising can just as easily be created with a color-coded list of all of the
emergency codes which are used in the facility. While staff are unlikely
to open and review the Emergency Response Plan binder unless needed,
even when it is sitting right in front of them, such a mouse pad will be
used more or less continuously and will serve as a constant reminder of
the information.
Similarly, it is a relatively easy matter to use the facility’s computer
network to raise staff awareness. The simplest approach to this is for the
Emergency Manager to speak to the facility’s information technology sup-
port staff and simply have a screen saver created which will display the
same color-coded list of emergency codes on each computer screen at times
when the computer is not being used by a staff member. Apart from a small
amount of time by one staff member, the cost of this awareness program is
nil. This idea has also been widely accepted in healthcare facilities.
Intranet-Based Learning
While it may not be feasible to take absolutely every staff member into
the classroom for more formal learning sessions, this does not necessarily
preclude staff education. A successful collaboration by the Emergency
Manager with both staff educators and information technology can lead
to a very successful online learning program, to be accessed at the com-
puter workstation in the nursing station when staff have a few minutes
to spare. Such education programs are already in use for a variety of pur-
poses in many healthcare facilities, and it is a relatively simple matter to
adapt these in order to provide emergency preparedness information pro-
vided by the Emergency Manager. In such cases, the Emergency Manager
provides the information, the staff educator provides the presentation
and learning strategy, and information technology provides the “know
how” to put it all on the screen in front of the employee. In many cases,
these education efforts by employees can actually be identified and the
information accessed and learning activities can be recorded.
“Code of the Month”

Some Emergency Managers have found the concept of focusing on a sin-
gle emergency code each month to be well received by staff members.
This approach focuses, as the name suggests, on a single type of emer-
gency for each one-month period. Any aspect of that type of emergency
may be considered for presentation. Such approaches are often multime-
dia in nature, with a combination of printed information packages left at
work stations for staff to read, information on bulletin boards, and short
seminars and presentations, such as “lunch and learn” sessions, for those
who are interested. Any emergency Exercise being conducted during that
month will be directly related to the “code of the month,” and similar
tie-ins with online education efforts can occur. Run properly, the facility
should be able to demonstrate a review and education effort for each of
their emergency codes, occurring on a given Accreditation Review cycle.
Getting Staff Interest

The key to success in such programs is getting staff interested in the sub-
ject and keeping them that way. Staff typically have a lot on their minds,
and your information will have to compete with everything else that
is going on in the organization and in their lives. To achieve this, the
Emergency Manager must be able to develop and maintain staff interest,
through creative approaches. Simply dropping a “bland” fact sheet for a
particular code at each work station will probably result in it being simply
ignored by the majority of staff. An interesting, well-written newsletter or
blog may be seen completely differently. It is essential to make the infor-
mation contained personally relevant and to ensure that it is presented in
an interesting fashion. This can provide a variety of challenges, but it is
worth the effort.
Personal Family Emergency Plans

Another issue that can raise the issue of emergency preparedness in the
consciousness of staff members is to motivate self-interest. Consider the
issue of personal family emergency plans for employees. While such plans
should be widespread throughout the community, this is rarely the case.
That being said, there are no shortage of do-it-yourself “kits,” created by
a wide number of Emergency Management authorities around the world,
and generally available for free. While the facility Emergency Response
Plan may be “just one more thing to remember,” the idea of a free, after-
work seminar on how to create a family emergency plan might just pique
the interest of employees, particularly if it is well publicized in advance!
Such an effort may raise employee awareness of the issue, and it may make
them more receptive to other types of emergency preparedness education
efforts. As an added benefit, any employee who already knows that his or
her family is planned and provided for during any type of emergency is
much more likely to be available for emergency recall, if required.
Conclusion
In any healthcare facility, the Emergency Response Plan cannot remain
simply a dust-covered document which languishes on shelf somewhere,
being dragged out only occasionally and usually around the time of the
Accreditation review. Such a plan can and must become a dynamic, “ever-
green” document, and a tool which staff trust and which they rely upon
to manage any crisis effectively. For this to occur, staff require effective
and ongoing training, which is both current and directly relevant to their
working environment and realities. It must, like the organization and staff
which it supports, be subject to an ongoing process of continuous testing,
evaluation, problem solving, and improvement. The emergency Exercise

and staff education processes which have been outlined in this chapter
can assist the Emergency Manager in any healthcare facility to make
significant progress toward these objectives and can help to ensure that,
whatever the crisis, the organization will respond to it quickly, calmly,
effectively, and correctly, regardless of the circumstances. The community
served by every such facility expects and deserves nothing less.
Student Projects
Student Project #1
Create a PowerPoint presentation of 30 minutes duration, on some aspect

of the evacuation of a healthcare facility—your own, if possible. Prepare
an accompanying document which supports in detail each point made in
the PowerPoint presentation and condense this to a set of useable lecture
notes. Ensure that major points are accurate and factual and are appropri-
ately cited and referenced, in order to demonstrate that the appropriate
research has occurred.
Student Project #2
Create a tabletop Exercise script for an Exercise of 60 minutes duration,

on some type of emergency scenario, which has actually occurred some-
where in the world within the past 10 years. Prepare an accompanying
document which supports in detail each input in the Exercise, its type,
expected response, and reason for occurrence. Each of the inputs should
represent some element of actual occurrence in the original event or
demonstrate a deficiency which must be identified. Ensure that major
points are accurate and factual and are appropriately cited and referenced,
in order to demonstrate that the appropriate research has occurred.
Test Your Knowledge

Take your time. Read each question carefully and select the most
correct answer for each. The correct answers appear at the end of the sec-
tion. If you score less than 80 percent (8 correct answers), you should
reread this chapter.
1. When contemporary healthcare Accreditation processes review a facil-

ity’s Emergency Management program, they are generally seeking:
(a) An Emergency Response Plan which has been reviewed recently

(b) Comprehensive staff knowledge of the subject
(c) An ongoing and dynamic process, and not simply a project
(d) Both (a) and (b)
2. Any emergency Exercise which demonstrates failures in the emer-

gency response process should be viewed as:
(a) A failure by the Emergency Manager

(b) A failure by the facility or organization
(c) A failure of the Emergency Response Plan
(d) A success, as it has revealed opportunities for improvement
3. A case study Exercise may be used by the Emergency Manager to:
(a) Identify local issues requiring resolution

(b) Review discreet elements of the Emergency Response Plan
(c) Test the ability of the Command Center team to work together
(d) Perform a comprehensive test of the Emergency Response Plan
for confirmation
4. A tabletop Exercise may be used by the Emergency Manager to:

for confirmation
5. A functional Exercise may be used by the Emergency Manager to:

for confirmation
6. A full-scale Exercise may be used by the Emergency Manager to:

for confirmation
7. For any Emergency Management education effort to be as effective

as possible, wherever possible, information should be provided in a
manner which is:
(a) Factual, credible, practical, and emotional

(b) Exciting, dynamic, and creative
(c) Calm, rational, and polite
(d) Both (b) and (c)
8. When developing any type of emergency Exercise for a healthcare

facility, its research, creation, staging, and debriefing should be con-
sidered to be:
(a) The sole responsibility of the Emergency Manager

(b) A project, and subject to the principles of Project Management
(c) Only necessary as part of the Accreditation process
(d) Both (a) and (c)
9. An Exercise Control Cell may be described as a location in which:
(a) The planning of the Exercise occurs

(b) The Exercise will be debriefed, upon completion
(c) Exercise inputs are delivered to participants by technological
means
10. In any healthcare facility, emergency Exercises and other staff educa-
tion efforts in Emergency Management should be conducted:
(a) In detail for those with specific roles during any emergency
(b) Only when absolutely mandatory, because staff are busy
(c) As awareness campaigns for staff with no specific role to play
Answers
1. (c) 2. (d) 3. (a) 4. (c) 5. (b)

6. (d) 7. (a) 8. (b) 9. (c) 10. (d)
Additional Reading
The author recommends the following exceptionally good titles as supple-
mental readings, which will help to enhance the student’s knowledge of
those topics covered in this chapter:
Gershon, M. 2015. How to Use Bloom’s Taxonomy in the Classroom: The Complete
Guide. Create Space Independent Publishing Platform. ISBN: 1517432014,
978-1517432010.
McClincy, W.D. 2011. Instructional Methods for Public Safety. Sudbury, MS:
Jones and Bartlett Learning. ISBN: 13-978076377608-4, 10-076377608-4.
McCreight, R. 2011. An Introduction to Emergency Exercise Design and Evaluation.
Lanham, MD: Scarecrow Press. ISBN: 978-1605907598, 978-1605907604.
Reilly, M.J. and D. Markenson, (eds.). 2011. Health Care Emergency Management:
Principles and Practice. Lanham, MD: Jones and Bartlett. ISBN: 13-978076
3755133, 10-0763755133.
Wysocki, R.K. 2013. Effective Project Management: Traditional, Agile, Extreme,
(7th ed.), p. 4. Indianapolis, IN: Wiley & Sons. ISBN: 978-1118729168,
978-111874210.
Index
accreditation, 2, 5, 10, 27, 30, 34, 41, emergency

42, 48, 49, 53, 54, 56, 58, 59 communications, 102–104
adult education, 3–4 instructions, 111–113
agreements, 51–52 plan, 42, 52, 132
awareness, 110–111 staff recall, 19–21
campaigns, 39 Emergency Media Plan, 83, 87–90
Emergency Preparedness Committee,
back channel telephone numbers, 8, 10, 19
122–123 Emergency Response Plan, 55–58,
background material, 90 81–84, 86–90, 99, 102, 103,
backup systems, 99, 116 110, 113–115
Bloom, B., 4 exercises
control, 16–18, 34–35
Caller ID, 20, 21, 108 full-scale, 28–34, 53, 54
Clinical Acuity/Special needs functional, 19–28
Evacuation (CASE) team, 38 managing, 36–37
code of the month, 41 safety, 35–36
Command and Control, 12, 13, 23, scheduling, 52–55
33, 38, 80, 81, 91, 111 tabletop, 12–19, 22, 43, 53, 54
Command Center, 12–14, 16–18, types of, 7
21–22, 38, 53, 54, 67, 81, 87,
97, 100, 103, 104, 113–119, Family Information Center, 17, 23
122, 131 fan-out lists, 107–108
communications Federal Emergency Management
emergency, 102–104 Agency, 25
internal, 98–100 full-scale exercises, 28–34, 53, 54
normal, 100–102 functional exercises, 19–28
tips for, 112
two-way, 113–114 Hazard Identification and Risk
upward and external, 118–123 Assessment (HIRA), 49–51
confidentiality, 83 healthcare
conventional pagers, 107 facility, 19, 24, 26–28, 38, 47, 48,
91, 101, 103, 104, 120–123
deadlines, 65, 77, 78, 92 settings, 30, 37, 39, 50, 54, 56, 66,
decontamination, 24–26, 38, 53 79, 83, 88, 99, 113, 120, 121
Dickens, C., 68 hospital, 19, 48–53, 66, 72, 80,
disaster, 66, 76, 83, 85, 88, 90, 91, 105–110
99–100
due diligence, 1, 2, 97, 98, 112, 123, incident management system, 54, 111
130 individual interviews, 87
148 Index
information exchange, 121–122 Public Information Officer, 66, 67,

information requests, 116–118 80–82, 85–87, 89, 91
internal communications, 98–100
intranet-based learning, 40–41 radio, 17, 36, 68–72, 77, 78, 109
resource requests, 118
Joint Commission Standards, 30 risk, 48–49
McLuhan M., 69, 70, 75 screen savers/mouse pads, 40

mass-casualty Senior Management Team, 2, 10, 12,
incident, 13, 30, 79 34, 54, 115, 118, 119, 132
situation, 25 site tours, 88
media Situation Report, 111, 114–116, 120
conferences, 86–87 smart phones, 109
considerations, 76–80 social media, 79–80
democratization of, 74 soundbites, 77
history of, 67–75 staff alerting process, 104
management, 80–82 staff education strategies, 37–39
planning considerations, 82–90 staff interest, 41–42
pools, 89 staff training, 118
print, 76–77
releases, 86 tabletop exercises, 12–19, 22, 43, 53,
role of, 75–76 54
Media Center, 84–85 Tactical Exercise Without Troops
Millennial generation, 71, 72, 74, 79 (TEWT), 22–24
myocardial infarction, 121–122 television, 68–74, 78, 83, 88, 89, 121
Temple University Health System,
name tags, 39–40 105
normal communications, 100–102 triage, 23, 25, 26, 29, 38, 79
notification technologies, 109–110 two-way communications,
113–114
outside agencies/governments,
120–121 upward and external communications,
overhead paging, 104–107 118–123
PIO operation, 85 Vietnam War, 70

potential barriers, 110
press release, 86 Wells, H. G., 69
print media, 76–77 Wells, O., 69

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All rights reserved. No part of this publication may be reproduced,

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Business Expert Press Healthcare Management Collection

First edition: 2022

Chapter 1 Emergency Exercise Design and Staff Education���������������1

Eric Dykes, PhD, Professor of Emergency Planning and Disaster Man-

Gerald Goldberg, PhD, Professor of Psychology, York University,

Daniel Klenow, PhD, Professor of Emergency Management, University

Margaret Verbeek, CEM, Past President, International Association of

online. Additionally, wherever possible, the recommended reading list

Emergency Exercise Design

they are likely to be received and processed by the student(s). Moreover,

organization, with Emergency Management activities intended to occupy

Wrong Things Right Things

Done Right Done Right

Wrong Things Right Things

Done Wrong Done Wrong

Figure 1.1 Performance

sometimes for decades, never experience an Exercise, unless they actively

critically. Is the information factually accurate? Does it unnecessarily dis-

Ensure that someone is readily available to take detailed written

resources. Tabletop Exercises, when created and staged effectively, provide

The Exercise will be composed of a series of discreet elements of infor-

actually provide a useful functional Exercise prior to the commencement

family members creating a disruption in the Emergency Department. The

Testing Emergency Staff Recall

If off-duty staff were to be required at the facility in order to cope with

More troubling is the problem of Caller ID. As working in healthcare

Assembly of the Command Center

In the vast majority of healthcare facilities, the facility Command

Figure 1.2 The assembly and testing of the Command Center is

Tactical Exercise Without Troops (TEWT)

Preparedness Committee, walking through the facility and identifying

Assembly of Decontamination Equipment

Figure 1.3 Triage Exercises practice: an essential skill

be required, in order to provide order of access to diagnostic resources,

Evacuation of the Facility

Figure 1.4 In evacuation Exercises, much can be learned from

within any community, there has, historically, been surprisingly little

first time, using elevators to simulate a nonurgent, controlled evacuation,

The full-scale Exercise involves the use of dozens, perhaps, in some

The Emergency Manager may also wish to include representatives from

Another useful approach is to employ the use of step-by-step

Each of these will need to be negotiated for and obtained individually,

Safety (site, participants, actual patients, emergency procedures)

By managing the development and staging of the full-scale Exercise in

At the completion of the Exercise, a clean-up team will be required

A similar problem can also potentially occur with non-“face-to-face”

apply, and can, in almost all circumstances, provide an extremely useful

Staff Education Strategies

which can be readily exploited by the education efforts of the Emergency

The result of this approach is an Emergency Management program

Screen Savers/Mouse Pads

“Code of the Month”

Getting Staff Interest

Personal Family Emergency Plans

evaluation, problem solving, and improvement. The emergency Exercise

Create a PowerPoint presentation of 30 minutes duration, on some aspect

Chapter 1 Emergency Exercise Design and Staff Education��1