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VISN Comprehensive Emergency Management Program Analysis Capabilities
Description

**VISN Office Comprehensive Emergency Management**

**Program: Pilot Site Visit Assessment**

Department of Veterans Affairs

Veterans Health Administration

Office of Public Health and Environmental Hazards, Emergency Management
Strategic Health Care Group

![vaseal](media/image2.png){width="1.0972222222222223in"
height="1.0972222222222223in"}

**November 6, 2008**

**Table of Contents**

[1 Program Level Capabilities 5](#program-level-capabilities)

[1.1 Systems-Based Approach to the Development, Implementation,
Management, and Maintenance of the Emergency Management Program
6](#systems-based-approach-to-the-development-implementation-management-and-maintenance-of-the-emergency-management-program)

[1.2 Administrative Activities ensure the Emergency Management Program
meets its Mission and Objectives
8](#administrative-activities-ensure-the-emergency-management-program-meets-its-mission-and-objectives)

[1.3 Development, Implementation, Management, and Maintenance of an
Emergency Management Committee Process to support the Emergency
Management Program
10](#development-implementation-management-and-maintenance-of-an-emergency-management-committee-process-to-support-the-emergency-management-program)

[1.4 Incorporation of Comprehensive Preparedness Planning in the VISN's
Coordination Activities in Conjunction with the Individual Facility
Emergency Management Programs.
12](#incorporation-of-comprehensive-preparedness-planning-in-the-visns-coordination-activities-in-conjunction-with-the-individual-facility-emergency-management-programs.)

[1.5 Incorporation of Continuity Planning into the Coordination
Activities of the VISN Office's Emergency Management Program to ensure
Organizational Continuity and Resiliency of Mission Critical Functions,
Processes, and Systems
14](#incorporation-of-continuity-planning-into-the-coordination-activities-of-the-visn-offices-emergency-management-program-to-ensure-organizational-continuity-and-resiliency-of-mission-critical-functions-processes-and-systems)

[1.6 Development, Implementation, Management, and Maintenance of an
Emergency Operations Plan
15](#development-implementation-management-and-maintenance-of-an-emergency-operations-plan)

[1.7 Incorporation of Comprehensive Instructional Activity into the
Preparedness Activities of the VISN's Emergency Management Program
17](#incorporation-of-comprehensive-instructional-activity-into-the-preparedness-activities-of-the-visns-emergency-management-program)

[1.8 Incorporation of a Range of Exercise Types that Test the VISN's
Emergency Management Program
19](#incorporation-of-a-range-of-exercise-types-that-test-the-visns-emergency-management-program)

[1.9 Demonstration of Systems-Based Evaluation of the VISN's overall
Emergency Management Program and its Emergency Operations Plan
21](#demonstration-of-systems-based-evaluation-of-the-visns-overall-emergency-management-program-and-its-emergency-operations-plan)

[1.10 Incorporation of Accepted Improvement Recommendations into the
Emergency Management Program and its Components such that the Process
becomes one of a Learning Organization.
22](#incorporation-of-accepted-improvement-recommendations-into-the-emergency-management-program-and-its-components-such-that-the-process-becomes-one-of-a-learning-organization.)

[2 Incident Management Capabilities
24](#incident-management-capabilities)

[2.1 Initial Incident Actions (e.g., first four hours)
25](#initial-incident-actions-e.g.-first-four-hours)

[2.1.1 Processes and Procedures for Incident Recognition, Activation of
EOP/EOC, and Initial Notification of Staff
25](#processes-and-procedures-for-incident-recognition-activation-of-eopeoc-and-initial-notification-of-staff)

[2.1.2 Mobilization of Critical Staff and Equipment for Incident
Response
27](#mobilization-of-critical-staff-and-equipment-for-incident-response)

[2.1.3 Situational Assessment of Response and Coordination Efforts for
Initial Incident Management and Emergency Operations Center Activation
30](#situational-assessment-of-response-and-coordination-efforts-for-initial-incident-management-and-emergency-operations-center-activation)

[2.2 Management of Extended Operations (e.g., after first four hours)
33](#management-of-extended-operations-e.g.-after-first-four-hours)

[2.2.1 Management of Extended Operations
33](#management-of-extended-operations)

[2.2.2 Public Information Management Services during an Incident
35](#_Toc213733197)

[2.2.3 Management and Acquisition of Resources for Incident Response and
Recovery Operations
37](#management-and-acquisition-of-resources-for-incident-response-and-recovery-operations)

[2.2.4 Processes and Procedures for Demobilization of Personnel and
Equipment
40](#processes-and-procedures-for-demobilization-of-personnel-and-equipment)

[2.2.5 Processes and Procedures for a Return to Readiness of Personnel
and Equipment
41](#processes-and-procedures-for-a-return-to-readiness-of-personnel-and-equipment)

[3 Occupant Safety Capabilities 43](#occupant-safety-capabilities)

[3.1 Evacuation vs. Shelter-In-Place
43](#evacuation-vs.-shelter-in-place)

[3.1.1 Processes and Procedures for Evacuation of Patients', Staff, and
Visitors'
43](#processes-and-procedures-for-evacuation-of-patients-staff-and-visitors)

[3.1.2 Processes and Procedures for Sheltering-in-Place
45](#processes-and-procedures-for-sheltering-in-place)

[3.1.3 Processes and Procedures for Sheltering Family of Critical Staff
47](#processes-and-procedures-for-sheltering-family-of-critical-staff)

[3.2 Perimeter Management of Access/Egress to Facility during an
Incident (e.g., Lock Down)
49](#perimeter-management-of-accessegress-to-facility-during-an-incident-e.g.-lock-down)

[3.3 Processes and Procedures for Managing a Hazardous Substance
Incident
51](#processes-and-procedures-for-managing-a-hazardous-substance-incident)

[3.4 Infection Control 53](#infection-control)

[3.4.1 Biohazard (Infection) Control Surge Services during Emergencies
53](#biohazard-infection-control-surge-services-during-emergencies)

[3.4.2 Selection and Use of Personal Protective Equipment for Incident
Response and Recovery Operations
55](#selection-and-use-of-personal-protective-equipment-for-incident-response-and-recovery-operations)

[3.4.3 Processes and Procedures for Staff and Family Mass Prophylaxis
during an Infectious Outbreak (i.e., Influenza)
58](#processes-and-procedures-for-staff-and-family-mass-prophylaxis-during-an-infectious-outbreak-i.e.-influenza)

[4 Resiliency/Continuity of Operations
59](#resiliencycontinuity-of-operations)

[4.1 Personnel Resiliency 60](#personnel-resiliency)

[4.1.1 Maintaining Authorized Leadership (Leadership Succession)
60](#maintaining-authorized-leadership-leadership-succession)

[4.1.2 Processes and Procedures for Personal Preparedness and Employee
Welfare
61](#processes-and-procedures-for-personal-preparedness-and-employee-welfare)

[4.1.3 Dissemination of Personnel Incident Information to Staff during
an Incident
62](#dissemination-of-personnel-incident-information-to-staff-during-an-incident)

[4.2 Mission Critical Systems Resiliency
64](#mission-critical-systems-resiliency)

[4.2.1 Maintaining Information Technology (IT) and Computing Systems
Resiliency during an Incident
64](#maintaining-information-technology-it-and-computing-systems-resiliency-during-an-incident)

[4.2.2 Maintaining Access to Critical Commodities and Services during
Response and Recovery Operations
66](#maintaining-access-to-critical-commodities-and-services-during-response-and-recovery-operations)

[4.3 Communications 69](#communications)

[4.3.1 Maintenance of Voice and Data Communication through Satellite
Link
69](#maintenance-of-voice-and-data-communication-through-satellite-link)

[4.3.2 Interoperable Communications with External Agencies'
70](#interoperable-communications-with-external-agencies)

[4.3.3 Interoperable Communications with VISN Facilities'
72](#interoperable-communications-with-visn-facilities)

[4.4 Healthcare Systems Resiliency 74](#healthcare-systems-resiliency)

[4.4.1 Management of Primary Care for Special Needs Patients, including
Home-Based Care during Incidents
74](#management-of-primary-care-for-special-needs-patients-including-home-based-care-during-incidents)

[5 Medical Surge 76](#medical-surge)

[5.1 Processes and Procedures for Expansion of Staff for Response and
Recovery Operations
77](#processes-and-procedures-for-expansion-of-staff-for-response-and-recovery-operations)

[5.2 Management of Volunteers Deployment Support (e.g., DEMPS) during
Response and Recovery Operations
79](#management-of-volunteers-deployment-support-e.g.-demps-during-response-and-recovery-operations)

[5.3 Expansion of Evaluation and Treatment Services 81](#_Toc213733229)

[5.3.1 Development, Implementation, Management, and Maintenance of the
VA All-Hazards Emergency Cache
81](#development-implementation-management-and-maintenance-of-the-va-all-hazards-emergency-cache)

[5.3.2 Designated Capability for Expanded Patient Triage, Evaluation and
Treatment during Surge
83](#designated-capability-for-expanded-patient-triage-evaluation-and-treatment-during-surge)

[5.3.3 Processes and Procedures for Control and Coordination of Mass
Fatality Management
86](#processes-and-procedures-for-control-and-coordination-of-mass-fatality-management)

[6 Support to External Requirements
87](#support-to-external-requirements)

[6.1 Provision of Supplemental Health Services to Support the National
Disaster Medical System
88](#provision-of-supplemental-health-services-to-support-the-national-disaster-medical-system)

[6.2 VA/DOD Contingency Hospital System
89](#vadod-contingency-hospital-system)

[6.3 Support Under the National Response Framework (NRF)
90](#support-under-the-national-response-framework-nrf)

[7 Acronym List 93](#acronym-list)

Program Level Capabilities
==========================

Ensuring that Veterans Integrated Service Networks (VISNs) address
issues relative to emergency planning and preparedness is important for
supporting the VISN Leadership's coordination of disaster responses that
involve VISN facilities, particularly Veteran Affairs (VA) Medical
Centers (VAMCs). The following Program-Level capabilities are critical
to VISNs:

-   Systems-Based Approach to the Development, Implementation,
    Management, and Maintenance of the Emergency Management Program
    (EMP)

```{=html}
<!-- -->
```
-   Administrative Activities ensure the Emergency Management Program
    meets its Mission and Objectives

-   Development, Implementation, Management, and Maintenance of an
    Emergency Management Committee (EMC) Process to support the EMP

-   Incorporation of Comprehensive Preparedness Planning in the VISN's
    Coordination Activities in Conjunction with the Individual Facility
    EMPs

-   Incorporation of Continuity Planning into the Coordination
    Activities of the VISN Office's EMP

-   Development, Implementation, Management, and Maintenance of an
    Emergency Operations Plan (EOP)

-   Incorporation of comprehensive instructional activity into the
    Preparedness Activities of the VISN's EMP

-   Incorporation of a Range of Exercise Types that Test the VISN's EMP

-   Demonstration of Systems-Based Evaluation of the VISN's overall EMP
    and its EOP.

-   Incorporation of Accepted Improvement Recommendations into the EMP
    and its Components such that the Process becomes one of a Learning
    Organization

The following sections describe these Program-Level capabilities
including their rationale and measurement.

Systems-Based Approach to the Development, Implementation, Management, and Maintenance of the Emergency Management Program 
--------------------------------------------------------------------------------------------------------------------------

**Description:** To demonstrate this capability the VISN implements a
systems approach for coordinating its activities with individual VAMCs.

**Rationale:** A systems approach to coordinating VISN activities during
a disaster with the individual VISN facilities ensures that facilities
will have the support needed from VISN leadership and eliminate
duplication of effort. In addition, this approach will enhance
standardization across facilities within the Veterans Health
Administration (VHA).

**Measurement**:

-   **Review VISN EMP plan, EOP, and COOP plans**

-   **Review of any VISN Executive Leadership Council (ELC) and EMC
    discussions or actions**

-   **Review of any facility site visits or reports concerning emergency
    preparedness**

-   Assess any annual reviews and exercise activities

-   **Interview with the VISN Director and/or Deputy Director, VISN
    Chief of Operations (COO), Emergency Manager**

-   **Interview with the lead person for emergency management for the
    VISN, to be noted as VISN Emergency Program Coordinator (EPC)**

Framework for Capability Description

+-------------------------+-------------------------------------------+
| Capability Element      | Assessment components                     |
+=========================+===========================================+
| Policy/Organization     | -   Emergency management is an organized  |
|                         |     > program with consistent strategy    |
|                         |     > and integration of all components   |
|                         |     > into the organization's             |
|                         |     > administration and operations.      |
+-------------------------+-------------------------------------------+
| Resources               |                                           |
+-------------------------+-------------------------------------------+
| > Supplies              | -   N/A                                   |
+-------------------------+-------------------------------------------+
| > Facilities/Equipment  | -   N/A                                   |
+-------------------------+-------------------------------------------+
| > Personnel             | -   Staff use the VHA Emergency           |
|                         |     > Management Guidebook to develop and |
|                         |     > update the program.                 |
|                         |                                           |
|                         | -   VISN staff assigned to preparedness   |
|                         |     > activities should use the Incident  |
|                         |     > Command System (ICS) for developing |
|                         |     > the EOP and the associated Standard |
|                         |     > Operating Procedures (SOPs).        |
|                         |                                           |
|                         | -   Lists of contractors and points of    |
|                         |     > contact (POC) for activation of     |
|                         |     > sharing agreements are developed    |
|                         |     > and located at the EOC.             |
+-------------------------+-------------------------------------------+
| Process                 | > Each VISN will have varying examples of |
|                         | > how they coordinate EMP activities with |
|                         | > VISN facilities. Documentation can      |
|                         | > include VISN policies, VISN EMC         |
|                         | > Charter, ELC minutes and any other ELC  |
|                         | > activities.                             |
|                         |                                           |
|                         | -   Process to develop an emergency       |
|                         |     > management plan that identifies the |
|                         |     > development, maintenance,           |
|                         |     > evaluation, and VISN oversight      |
|                         |     > responsibilities (this process      |
|                         |     > should parallel the "9-Step"        |
|                         |     > process in the VHA Guidebook.       |
|                         |                                           |
|                         | -   Process to identify how the VISN      |
|                         |     > conducts incident management        |
|                         |     > activities with VHA entities and    |
|                         |     > external response partners          |
|                         |                                           |
|                         | -   Process for the use of ICS positions  |
|                         |     > that is consistent with January 17, |
|                         |     > 2007 VHA memo                       |
|                         |                                           |
|                         | -   Process for Incident Action Planning  |
|                         |                                           |
|                         | -   Process to delineate the interactions |
|                         |     > with State emergency management,    |
|                         |     > public health and medical agencies  |
+-------------------------+-------------------------------------------+
| Education/Training      | -   Staff is trained to coordinate VISN   |
|                         |     > Emergency Operations Center (EOC)   |
|                         |     > activities with individual          |
|                         |     > facilities including use of the ICS |
|                         |     > system.                             |
+-------------------------+-------------------------------------------+
| Exercise                | -   Exercises are clearly tied to         |
|                         |     > evaluation of specific elements of  |
|                         |     > the EMP.                            |
+-------------------------+-------------------------------------------+
| Evaluation              | -   The EMP is evaluated at least         |
|                         |     > annually and findings are           |
|                         |     > documented in reports to the EMC.   |
+-------------------------+-------------------------------------------+
| Organizational Learning | -   Improvements to the overall EMP       |
|                         |     > structure are made to the program   |
|                         |     > based on both an annual review and  |
|                         |     > After Action Reports (AARs) of      |
|                         |     > exercises and incidents.            |
+-------------------------+-------------------------------------------+

**Questions**:

VISN Oversight:

1.  What is the role of the VISN in supporting the VISN facilities in
    the event of emergencies, i.e., describe the VISN's "Concept of
    Operations (CONOPS)" for managing disasters within the VISN?

2.  Describe the development process of the VISN's overall EMP and any
    supporting policies.

3.  Does the EMC serve as a governing body for the EMP?

4.  Has the VISN prioritized emergency responses based on the VISN
    Office and VISN facilities' Hazard Vulnerability Analysis (HVA)?

5.  Have performance objectives for program management been developed
    for VISN Office and VISN facilities in order to evaluate the
    program?

6.  What has been the involvement of the VISN ELC (or equivalent) in the
    overall VISN EMP?

VISN Office EMP:

7.  How has the VISN used the EMP Guidebook in the development of the
    program and the actual VISN Office EOP?

8.  Has the VISN Office established a strategic goal with supporting
    objectives for the development of the EMP?

Administrative Activities ensure the Emergency Management Program meets its Mission and Objectives
--------------------------------------------------------------------------------------------------

**Description:** To demonstrate this capability the VISN implements and
employs a spectrum of administrative actions to ensure the EMP meets its
missions and objectives.

**Rationale:** Management involvement and commitment are essential to
ensure a successful program. Management needs to commit the necessary
resources to conduct activities essential to the EMP.

**Measurement**:

-   **Review of annual work plan, EMP budget, Service Support
    Agreements**

-   **Review of EMP objectives**

-   **Review of any VISN EMP policies**

-   **Interviews with the Deputy Network Director (DND), COO, and VISN
    EPC**

Framework for Capability Description

+-------------------------+-------------------------------------------+
| Capability Element      | Assessment components                     |
+=========================+===========================================+
| Policy/Organization     | -   The EMP is supported as an essential  |
|                         |     > element of the VISN support of VISN |
|                         |     > facilities.                         |
+-------------------------+-------------------------------------------+
| Resources               |                                           |
+-------------------------+-------------------------------------------+
| > Supplies              | -   Allocation of funding is sufficient   |
|                         |     > to accomplish the annual objectives |
|                         |     > for obtaining necessary supplies.   |
+-------------------------+-------------------------------------------+
| > Facilities/Equipment  | -   Adequate funding is available to      |
|                         |     > obtain facilities and equipment     |
|                         |     > needed specifically for the EMP.    |
+-------------------------+-------------------------------------------+
| > Personnel             | -   VISN ensures that individual VAMCs    |
|                         |     > have properly staffed the emergency |
|                         |     > management function.                |
|                         |                                           |
|                         | -   VISN has appointed a staff member to  |
|                         |     > oversee the full integration of the |
|                         |     > National Incident Management System |
|                         |     > (NIMS) into the VISNs EMP.          |
+-------------------------+-------------------------------------------+
| Process                 | -   VISN leadership actively participates |
|                         |     > in EMC meetings.                    |
|                         |                                           |
|                         | -   The work plan details the budgeting,  |
|                         |     > staffing, and administrative roles  |
|                         |     > of the EMP.                         |
|                         |                                           |
|                         | -   VISN leadership is briefed at least   |
|                         |     > annually on status of readiness of  |
|                         |     > facility.                           |
+-------------------------+-------------------------------------------+
| Education/Training      | -   VISN has allocated resources to       |
|                         |     > accomplish the training needs of    |
|                         |     > the EMP at the VISN level.          |
+-------------------------+-------------------------------------------+
| Exercise                | -   VISN defines the scope of the         |
|                         |     > exercise program and provides       |
|                         |     > funding to accomplish it.           |
+-------------------------+-------------------------------------------+
| Evaluation              | -   VISN conducts an annual program       |
|                         |     > review to assess administrative     |
|                         |     > efficiency and effectiveness in     |
|                         |     > supporting the EMP.                 |
|                         |                                           |
|                         | -   VISN leadership receives periodic     |
|                         |     > briefings from both VISN EPC staff, |
|                         |     > Emergency Management Strategic      |
|                         |     > Healthcare Group (EMSHG), and Area  |
|                         |     > Emergency Manager (AEM).            |
+-------------------------+-------------------------------------------+
| Organizational Learning | -   VISN incorporates identified          |
|                         |     > improvements into its               |
|                         |     > administrative activities.          |
|                         |                                           |
|                         | -   VISN implements changes as indicated  |
|                         |     > to adhere to all pertinent          |
|                         |     > standards and regulations.          |
+-------------------------+-------------------------------------------+

**Questions**:

VISN Oversight:

1.  Has the VISN evaluated the effectiveness of facility EMPs in order
    to better coordinate VISN activities with the facilities in an
    emergency?

2.  Has the VISN funded high priority EMP needs that are best managed at
    the VISN level?

3.  How are VISN EMP needs, particularly those requiring significant
    Non-Recurring Maintenance (NRM) or Minor Construction dollars for
    hazard mitigation, incorporated into resource planning?

4.  What are the current high priority EMP and hazard mitigation funding
    needs?

5.  Is there a VISN EPC?

6.  What are the primary duties of the VISN EPC?

7.  What is the relationship with the VAMC EPCs?

8.  Please describe your service support agreement with your AEMs and
    its effectiveness.

9.  Please describe your relationship to EMSHG in the VHACO.

Development, Implementation, Management, and Maintenance of an Emergency Management Committee Process to support the Emergency Management Program 
-------------------------------------------------------------------------------------------------------------------------------------------------

**Description:** To demonstrate this capability the VISN must have an
EMC that provides governance and oversight to the EMP. This will provide
essential support for VISN EMP coordination and individual facilities
EMP activities.

**Rationale:** A VISN EMC, or its equivalent, is essential to ensure the
design, implementation, management, and review of VISN EMP coordination
activities.

**Measurement**:

-   **Review of EOP**

-   **Review of EMC (committee structure and membership, schedule and
    minutes, outputs, and annual review)**

-   **Interview with DND and/or COO and VISN EPC**

-   **Interview with Chair, VISN EMC**

Framework for Capability Description

+-------------------------+-------------------------------------------+
| Capability Element      | Assessment components                     |
+=========================+===========================================+
| Policy/Organization     | -   There is a fully chartered VISN EMC.  |
|                         |     > There is an equivalent VISN         |
|                         |     > committee or periodic meeting of    |
|                         |     > individuals that assess and act on  |
|                         |     > VISN EMP coordination capabilities  |
|                         |     > and individual facility             |
|                         |     > preparedness.                       |
|                         |                                           |
|                         | ```{=html}                                |
|                         | <!-- -->                                  |
|                         | ```                                       |
|                         | -   The EMC or its equivalent is          |
|                         |     > organized to adequately address all |
|                         |     > components of a VISN EMP.           |
+-------------------------+-------------------------------------------+
| Resources               |                                           |
+-------------------------+-------------------------------------------+
| > Supplies              | -   N/A                                   |
+-------------------------+-------------------------------------------+
| > Facilities/Equipment  | -   The EMC or equivalent has acquired    |
|                         |     > appropriate meeting space and the   |
|                         |     > critical equipment and facilities   |
|                         |     > needed to support its management of |
|                         |     > the EMP.                            |
+-------------------------+-------------------------------------------+
| > Personnel             | -   VISN EMC members represent a cross    |
|                         |     > section of the VISN and provide the |
|                         |     > diverse perspectives and expertise  |
|                         |     > necessary to support the EMP        |
|                         |     > activities of VISN facilities.      |
|                         |                                           |
|                         | -   Adequate personnel are assigned to    |
|                         |     > support the EMC administrative      |
|                         |     > activities.                         |
+-------------------------+-------------------------------------------+
| Process                 | -   The EMC meets regularly and keeps     |
|                         |     > meaningful minutes of the meetings. |
|                         |                                           |
|                         | -   The committee generates strategic and |
|                         |     > work plans and other outputs that   |
|                         |     > move the EMP forward.               |
|                         |                                           |
|                         | -   Subcommittees are assigned as needed. |
|                         |                                           |
|                         | -   VISN specific high priority emergency |
|                         |     > management plans or activities are  |
|                         |     > approved by the EMC and reviewed    |
|                         |     > annually.                           |
+-------------------------+-------------------------------------------+
| Education/Training      | -   EMC members are trained in their role |
|                         |     > and responsibilities on the         |
|                         |     > committee.                          |
+-------------------------+-------------------------------------------+
| Exercise                | -   The EMC is involved in VISN-level     |
|                         |     > exercises and, on occasion,         |
|                         |     > facility exercises.                 |
+-------------------------+-------------------------------------------+
| Evaluation              | -   The EMC\'s annual program review      |
|                         |     > includes an assessment of the       |
|                         |     > effectiveness and efficiency of the |
|                         |     > EMC activities, including whether   |
|                         |     > the EMC achieved its program goals  |
|                         |     > (and reflected in the minutes or    |
|                         |     > the annual review report).          |
+-------------------------+-------------------------------------------+
| Organizational Learning | -   The EMC demonstrates that the EMC     |
|                         |     > function and the EMP are            |
|                         |     > continually improved and updated    |
|                         |     > based upon evaluation findings.     |
|                         |     > Accepted/implemented actions are    |
|                         |     > documented in the minutes.          |
+-------------------------+-------------------------------------------+

**Questions**:

VISN Office EMP:

1.  How does the EMC function as the EMP governing body for VISN
    facility EMPs and VISN Office emergency preparedness?

2.  Does the EMC function as the governing body for EMP activities
    specific to VISN staff preparedness?

3.  Does the VISN conduct a HVA?

4.  How often is the HVA updated?

5.  Has the EMC reviewed the HVA conducted for the VISN Office?

6.  Please describe how the VISN EMC functions, i.e., Chair, meeting
    frequency, posting of minutes, reviews of AARs from the VISN or
    facilities, action tracking, roles of VISN Office staff and facility
    staff serving on the EMC and committee reporting structure.

7.  What, if any, staff support does the VISN EMC have?

8.  Does the VISN EMC review the results of the VISN facility HVA for
    action at the VISN level, including developing potential resource
    requests?

9.  What is the relationships between the VISN EMC and AEM? Is the AEM a
    member of the EMC?

10. Please describe how the EMC develops its annual goals and
    objectives.

11. How does the EMC use these goals to develop an annual work plan?

12. How is the EMC involved in developing training plans and VISN
    emergency exercises?

13. Please describe other EMC driven initiatives.

14. Does the EMC perform an annual evaluation and how does the EMC
    report its plans, recommendations and results of evaluations to the
    VISN ELC?

15. How does the VISN EMC interact with the facility EMCs?

Incorporation of Comprehensive Preparedness Planning in the VISN's Coordination Activities in Conjunction with the Individual Facility Emergency Management Programs. 
---------------------------------------------------------------------------------------------------------------------------------------------------------------------

**Description:** To demonstrate this capability the VISN must engage in
comprehensive emergency management planning to prepare for those events
most likely to occur as specified in the HVA. Additionally, this
capability demonstrates the ability of the VISN to coordinate its
efforts with the individual VAMCs.

**Rationale:** Strategic planning is important to identifying program
goals, objectives, and priorities for improving preparedness at the VISN
and facility levels. Tactical planning is important to identifying and
conducting the tasks that achieve the strategic preparedness objectives.

**Measurement**:

-   Review of EOP, HVA and any other VISN policies regarding emergency
    management planning

-   **Review of callback rosters and procedures**

-   **Review of VISN communication capabilities with VISN facilities**

-   Review of any ELC level discussions

-   Review of any facility site visits or reports concerning emergency
    preparedness

-   Review of any construction projects instituted by the VISN in
    support of emergency management planning

-   Review of preparedness training program documentation

-   Interview with the DND or COO, VISN EPC, Safety, Chief Logistics

Framework for Capability Description

+-------------------------+-------------------------------------------+
| Capability Element      | Assessment components                     |
+=========================+===========================================+
| Policy/Organization     | -   The VISN develops an overall VISN     |
|                         |     > approach to comprehensive           |
|                         |     > preparedness planning based upon    |
|                         |     > the HVA, identified deficiencies,   |
|                         |     > reports from facilities and EMP     |
|                         |     > maintenance requirements.           |
+-------------------------+-------------------------------------------+
| Resources               |                                           |
+-------------------------+-------------------------------------------+
| > Supplies              | -   Supplies necessary for preparedness   |
|                         |     > planning and executing the          |
|                         |     > preparedness plan (see process) are |
|                         |     > adequately available.               |
+-------------------------+-------------------------------------------+
| > Facilities/Equipment  | -   Facilities and equipment for          |
|                         |     > conducting the range of             |
|                         |     > preparedness activities (see        |
|                         |     > process) are available.             |
+-------------------------+-------------------------------------------+
| > Personnel             | -   Preparedness activities are staffed   |
|                         |     > by adequate numbers of qualified    |
|                         |     > staff.                              |
+-------------------------+-------------------------------------------+
| Process                 | -   The preparedness plan addresses:      |
|                         |                                           |
|                         | ```{=html}                                |
|                         | <!-- -->                                  |
|                         | ```                                       |
|                         | -   Facility HVA and associated external  |
|                         |     HVAs (i.e., State and community)      |
|                         |                                           |
|                         | -   EOP documents - developing and        |
|                         |     revising the EOP and all supporting   |
|                         |     documents and guidance                |
|                         |                                           |
|                         | ```{=html}                                |
|                         | <!-- -->                                  |
|                         | ```                                       |
|                         | -   Resource management -- acquiring,     |
|                         |     organizing, and maintaining in a      |
|                         |     ready state, the necessary personnel, |
|                         |     facilities, supplies and equipment to |
|                         |     effectively execute the EOP           |
|                         |                                           |
|                         | ```{=html}                                |
|                         | <!-- -->                                  |
|                         | ```                                       |
|                         | -   Instruction -- education and training |
|                         |     on the EOP for all relevant personnel |
|                         |                                           |
|                         | ```{=html}                                |
|                         | <!-- -->                                  |
|                         | ```                                       |
|                         | -   Exercise and evaluation               |
|                         |                                           |
|                         | -   Organizational learning --            |
|                         |     implementing evaluation findings to   |
|                         |     improve the emergency response and    |
|                         |     recovery capability and capacity.     |
|                         |                                           |
|                         | ```{=html}                                |
|                         | <!-- -->                                  |
|                         | ```                                       |
|                         | -   VISN implements NIMS-prescribed ICS   |
|                         |     > for preplanned events               |
+-------------------------+-------------------------------------------+
| Education/Training      | -   The Emergency Manager and other key   |
|                         |     > preparedness staff are trained to   |
|                         |     > develop and execute emergency       |
|                         |     > management preparedness plans.      |
+-------------------------+-------------------------------------------+
| Exercise                | -   Callback rosters are exercised        |
|                         |     > quarterly.                          |
+-------------------------+-------------------------------------------+
| Evaluation              | -   VISN conduct's an annual assessment   |
|                         |     > of its emergency preparedness plan  |
|                         |     > and its coordination activities to  |
|                         |     > determine successes and identify    |
|                         |     > areas for improvement.              |
+-------------------------+-------------------------------------------+
| Organizational Learning | -   Findings from the annual evaluation   |
|                         |     > of emergency planning activities    |
|                         |     > are incorporated into the follow-on |
|                         |     > preparedness plan to improve        |
|                         |     > preparedness levels.                |
+-------------------------+-------------------------------------------+

**Questions**:

VISN Oversight:

1.  Describe any VISN-wide emergency preparedness planning activities.

2.  Have there been discussions at the ELC level regarding facility
    preparedness?

3.  Discuss any VISN level acquisitions in support of facility EMPs such
    as commodities, construction or services?

Incorporation of Continuity Planning into the Coordination Activities of the VISN Office's Emergency Management Program to ensure Organizational Continuity and Resiliency of Mission Critical Functions, Processes, and Systems
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

**Description:** To demonstrate this capability the VISN must ensure
organizational continuity and resiliency of mission critical functions,
processes, and systems through continuity planning.

**Rationale:** Continuity planning provides a structured method to help
ensure the resiliency of mission critical functions and should be an
integral component of the VISN's EMP.

**Measurement**:

-   **Review of EOP and VISN Continuity Plan**

-   **Review of HVA and SOPs**

-   **Review of documentation of exercises that test business continuity
    planning**

-   **Review of any ELC level discussions and actions**

-   **Examination of VISN EOC and alternate EOC site**

-   **Interview with the DND, VISN EPC, VISN COO, and VISN Chief
    Logistics Officer (CLO)**

Framework for Capability Description

+-------------------------+-------------------------------------------+
| Capability Element      | Assessment components                     |
+=========================+===========================================+
| Policy/Organization     | -   The VISN incorporates Continuity of   |
|                         |     > Operations (COOP) planning across   |
|                         |     > all activities in its EMP.          |
+-------------------------+-------------------------------------------+
| Resources               |                                           |
+-------------------------+-------------------------------------------+
| > Supplies              | -   N/A                                   |
+-------------------------+-------------------------------------------+
| > Facilities/Equipment  | -   A VISN EOC, equipment (particularly   |
|                         |     > communications equipment), and      |
|                         |     > supplies have been identified for   |
|                         |     > activating and sustaining COOP.     |
|                         |                                           |
|                         | -   The VISN has a well-defined system of |
|                         |     > reaching key staff in the event of  |
|                         |     > a callback.                         |
+-------------------------+-------------------------------------------+
| > Personnel             | -   Key Staff have been identified as     |
|                         |     > essential to ensure COOP. This      |
|                         |     > includes well-defined reporting     |
|                         |     > relationships and line of           |
|                         |     > succession.                         |
+-------------------------+-------------------------------------------+
| Process                 | -   The EOP includes specific guidance    |
|                         |     > for incorporating continuity        |
|                         |     > planning and actions across all     |
|                         |     > aspects of the EOP. This includes   |
|                         |     > lines of succession in addition to  |
|                         |     > action guidance to maintain         |
|                         |     > business operations in support of   |
|                         |     > facility healthcare operations.     |
|                         |                                           |
|                         | -   Operating Units at the VISN are       |
|                         |     > defined and have assigned staff to  |
|                         |     > conduct continuity planning for     |
|                         |     > mission critical systems assigned   |
|                         |     > to their unit.                      |
+-------------------------+-------------------------------------------+
| Education/Training      | -   Staff engaged in continuity planning  |
|                         |     > have been trained on how to         |
|                         |     > accomplish this responsibility.     |
+-------------------------+-------------------------------------------+
| Exercise                | -   COOP is tested as part of an EOC      |
|                         |     > exercise.                           |
+-------------------------+-------------------------------------------+
| Evaluation              | -   Facility conducts an annual           |
|                         |     > assessment of the continuity        |
|                         |     > planning activities to determine    |
|                         |     > successes and identify areas for    |
|                         |     > improvement.                        |
+-------------------------+-------------------------------------------+
| Organizational Learning | -   Findings from the annual evaluation   |
|                         |     > and AARs are incorporated into      |
|                         |     > appropriate documents to improve    |
|                         |     > continuity planning.                |
+-------------------------+-------------------------------------------+

**Questions**:

VISN Office EMP:

1.  Please describe your business resiliency and COOP plan as indicated
    in your VISN office EOP.

2.  How have you tested your ability to maintain business operations in
    the event of a disaster?

3.  Do you have emergency power support? If so, how is proper testing
    assured?

4.  Briefly describe your callback process and are you planning to
    operate on a 24x7 basis during an emergency?

5.  Please describe any additional aspects of your COOP plan such as
    support of staff during prolonged activation of your EOC,
    interactions with your supporting VA facility, etc.

Development, Implementation, Management, and Maintenance of an Emergency Operations Plan
----------------------------------------------------------------------------------------

**Description:** To demonstrate this capability the VISN must develop a
comprehensive EOP, based upon the HVA. The EOP must be reviewed and
updated annually by the EMC.

**Rationale:** The EOP provides a structured method to help ensure the
resiliency of the VISN and is the central document of an EMP.

**Measurement**:

-   **Document review of any VISN policies and actions in support of
    emergency operations**

-   **Review of EOP including SOPs**

-   **Interview with the DND, VISN EPC and VISN COO**

Framework for Capability Description

+-------------------------+-------------------------------------------+
| Capability Element      | Assessment components                     |
+=========================+===========================================+
| Policy/Organization     | -   A VISN EOP incorporates all phases of |
|                         |     > emergency management of the EMP     |
|                         |     > into a single plan.                 |
+-------------------------+-------------------------------------------+
| Resources               |                                           |
+-------------------------+-------------------------------------------+
| > Supplies              | -   Necessary supplies to operate the EOC |
+-------------------------+-------------------------------------------+
| > Facilities/Equipment  | -   The EOP including SOPs are available  |
|                         |     > for review during normal operations |
|                         |     > and accessible to members of the    |
|                         |     > EOC.                                |
+-------------------------+-------------------------------------------+
| > Personnel             | -   Staff have been assigned to develop   |
|                         |     > the EOP and conduct execution of    |
|                         |     > the EOP.                            |
+-------------------------+-------------------------------------------+
| Process                 | -   The EOP includes specific guidance    |
|                         |     > for incorporating continuity        |
|                         |     > planning and actions across all     |
|                         |     > aspects of the EOP. This includes   |
|                         |     > lines of succession in addition to  |
|                         |     > action guidance to maintain both    |
|                         |     > business and facility coordination  |
|                         |     > operations.                         |
|                         |                                           |
|                         | -   Operating Units at the VISN are       |
|                         |     > defined and have assigned staff to  |
|                         |     > conduct continuity planning for     |
|                         |     > mission critical systems assigned   |
|                         |     > to their unit.                      |
|                         |                                           |
|                         | -   The EOP defines VISN oversight of     |
|                         |     > VAMCs during incidents.             |
+-------------------------+-------------------------------------------+
| Education/Training      | -   Staff engaged in developing the EOP   |
|                         |     > have been trained on how to         |
|                         |     > accomplish this responsibility.     |
+-------------------------+-------------------------------------------+
| Exercise                | -   The EOP is tested as part of every    |
|                         |     > exercise.                           |
+-------------------------+-------------------------------------------+
| Evaluation              | -   The VISN conducts an annual           |
|                         |     > assessment of the EOP to determine  |
|                         |     > successes and identify areas for    |
|                         |     > improvement.                        |
+-------------------------+-------------------------------------------+
| Organizational Learning | -   Findings from the annual evaluation   |
|                         |     > and AARs are incorporated into the  |
|                         |     > EMP and EOP documents to improve    |
|                         |     > continuity planning and actions for |
|                         |     > the facility.                       |
+-------------------------+-------------------------------------------+

**Questions**:

VISN Office EMP:

1.  Do you have a written EOP? Briefly describe its operation.

2.  Is your EOP based on your HVA?

3.  Is a copy of the EOP located in the EOC?

4.  How often is the EOP updated?

5.  Who reviews the EOP?

6.  How is the EOP communicated to all VISN staff?

Incorporation of Comprehensive Instructional Activity into the Preparedness Activities of the VISN's Emergency Management Program 
---------------------------------------------------------------------------------------------------------------------------------

**Description:** To demonstrate this capability the VISN must conduct
instructional activities that include education and training programs
that support the EMP.

**Rationale** Training key personnel in preparedness activities and the
principles of the ICS are essential components of the VISN's EMP.

**Measurement**:

-   **Review training needs assessment, training schedule, and training
    records**

-   **Interviews with DND/COO and EPC**

Framework for Capability Description

+-------------------------+-------------------------------------------+
| Capability Element      | Assessment components                     |
+=========================+===========================================+
| Policy/Organization     | -   The VISN ensures that response        |
|                         |     > personnel are trained to an         |
|                         |     > appropriate level of proficiency    |
|                         |     > for their emergency response        |
|                         |     > assignments including the operation |
|                         |     > of emergency communications         |
|                         |     > equipment.                          |
+-------------------------+-------------------------------------------+
| Resources               |                                           |
+-------------------------+-------------------------------------------+
| > Supplies              | -   N/A                                   |
+-------------------------+-------------------------------------------+
| > Facilities/Equipment  | -   Adequate facilities and equipment are |
|                         |     > identified to support the education |
|                         |     > and training activities.            |
+-------------------------+-------------------------------------------+
| > Personnel             | -   The VISN uses qualified instructors.  |
|                         |                                           |
|                         | -   The target number and type of         |
|                         |     > personnel are educated/trained in   |
|                         |     > the planned courses.                |
+-------------------------+-------------------------------------------+
| Process                 | -   EMC conducts a needs assessment for   |
|                         |     > preparedness training.              |
|                         |                                           |
|                         | -   EMC members or VISN leadership help   |
|                         |     > define the priorities for training  |
|                         |     > at the VISN level, based upon       |
|                         |     > annual reviews, AARs from           |
|                         |     > exercises, actual experiences and   |
|                         |     > facility identified VISN            |
|                         |     > coordination requirements.          |
|                         |                                           |
|                         | -   Personnel assigned to preparedness    |
|                         |     > activities should have an annual    |
|                         |     > instructional plan complete with    |
|                         |     > course names and dates.             |
|                         |                                           |
|                         | -   Training records are maintained as    |
|                         |     > part of the VISN's continuing       |
|                         |     > education program for all           |
|                         |     > employees.                          |
|                         |                                           |
|                         | -   "Just-in-Time" training should be     |
|                         |     > developed for appropriate areas of  |
|                         |     > emergency response.                 |
+-------------------------+-------------------------------------------+
| Education/Training      | -   Designated staff have completed       |
|                         |     > required Incident Command courses   |
|                         |     > and relevant instructor             |
|                         |     > (train-the-trainer) courses.        |
+-------------------------+-------------------------------------------+
| Exercise                | -   N/A                                   |
+-------------------------+-------------------------------------------+
| Evaluation              | -   VISN conducts an annual assessment of |
|                         |     > the training program to determine   |
|                         |     > successes and document lessons      |
|                         |     > learned.                            |
|                         |                                           |
|                         | -   Participant evaluation materials      |
|                         |     > should be administered for each     |
|                         |     > instructional activity.             |
|                         |                                           |
|                         | -   Participant evaluations should be     |
|                         |     > collected, aggregated and analyzed  |
|                         |     > for areas of potential improvement. |
+-------------------------+-------------------------------------------+
| Organizational Learning | -   Findings from the annual evaluation,  |
|                         |     > participant evaluations, and AARs   |
|                         |     > for exercises and incidents should  |
|                         |     > be used to improve the              |
|                         |     > instructional program.              |
+-------------------------+-------------------------------------------+

**Questions**:

VISN Oversight

1.  Has there been EMP training provided VISN-wide?

2.  Has there been a VISN-wide training assessment?

3.  Have VISN facilities requested certain types of training based on
    AARs from exercises or actual events?

VISN Office EMP:

4.  Has there been a training process to support the overall VISN EMP?

5.  Describe what types of training have been provided to VISN staff
    regarding all facets of the EMP, particularly roles when the EOC is
    activated.

6.  Has there been an assessment of training needs and effectiveness?

7.  Have training decisions been based on AARs from exercises or actual
    events?

8.  Has there been any training provided to the ELC?

9.  What are some of the items that individuals request to increase
    training effectiveness?

Incorporation of a Range of Exercise Types that Test the VISN's Emergency Management Program 
--------------------------------------------------------------------------------------------

**Description:** To demonstrate this capability the VISN must develop
and manage an exercise program for evaluating critical aspects of the
EMP as driven by the HVA.

**Rationale:** Evaluative Drills, Tabletops, Functional Exercises and
Full-Scale Exercises are essential to ensuring that emergency management
activities are functional when needed during an actual emergency.

**Measurement**:

-   **Review of Exercise Schedule**

-   **Review of Exercise AARs**

-   **Interview with VISN EPC or DND/COO**

Framework for Capability Description

+-------------------------+-------------------------------------------+
| Capability Element      | Assessment components                     |
+=========================+===========================================+
| Policy/Organization     | -   The VISN uses the full range of       |
|                         |     > exercises to evaluate the EMP,      |
|                         |     > coordination with facility EOC      |
|                         |     > operations and all mission critical |
|                         |     > aspects of emergency response and   |
|                         |     > recovery.                           |
+-------------------------+-------------------------------------------+
| Resources               |                                           |
+-------------------------+-------------------------------------------+
| > Supplies              | -   Any supplies needed for exercises are |
|                         |     > pre-determined and available during |
|                         |     > the conduct of exercises.           |
+-------------------------+-------------------------------------------+
| > Facilities/Equipment  | -   Any facilities and/or equipment,      |
|                         |     > particularly communications         |
|                         |     > equipment, are identified and       |
|                         |     > tested during the conduct of        |
|                         |     > exercises.                          |
+-------------------------+-------------------------------------------+
| > Personnel             | -   A qualified exercise program manager  |
|                         |     > is assigned to oversee the exercise |
|                         |     > initiative.                         |
|                         |                                           |
|                         | -   The exercise planning team should be  |
|                         |     > multi-disciplinary and staffed from |
|                         |     > EMC personnel.                      |
|                         |                                           |
|                         | -   Adequate personnel to staff the       |
|                         |     > exercise control team (including a  |
|                         |     > Safety Officer and staff to manage  |
|                         |     > the volunteer victims) and the      |
|                         |     > exercise evaluation team.           |
+-------------------------+-------------------------------------------+
| Process                 | -   VISNs should develop and conduct at   |
|                         |     > least one Full-Scale exercise per   |
|                         |     > year.                               |
|                         |                                           |
|                         | -   Exercises are designed with formal    |
|                         |     > objectives, an evaluation plan, and |
|                         |     > methods to assure a safe exercise   |
|                         |     > operation.                          |
|                         |                                           |
|                         | -   Exercise objectives are clear,        |
|                         |     > measurable and achievable and       |
|                         |     > reflect VISN disaster priorities    |
|                         |     > based on the HVA, and an evaluation |
|                         |     > of recent AAR findings and          |
|                         |     > organizational improvements.        |
|                         |                                           |
|                         | -   The exercise cycle evaluates all      |
|                         |     > aspects of emergency response and   |
|                         |     > recovery (from incident recognition |
|                         |     > and mobilization process through    |
|                         |     > demobilization, recovery and return |
|                         |     > to readiness).                      |
|                         |                                           |
|                         | -   VISN develops a process to monitor    |
|                         |     > and evaluate exercises across the   |
|                         |     > VISN                                |
|                         |                                           |
|                         | -   Adoption and incorporation of an      |
|                         |     > all-hazards ICS into the VISNs      |
|                         |     > exercise program                    |
+-------------------------+-------------------------------------------+
| Education/Training      | -   The exercise program manager is       |
|                         |     > trained in how to design, supervise |
|                         |     > and manage exercises at the         |
|                         |     > facility.                           |
|                         |                                           |
|                         | -   Controllers, exercise evaluators, and |
|                         |     > others that will support exercises  |
|                         |     > are trained.                        |
+-------------------------+-------------------------------------------+
| Exercise                | -   Exercise program incorporates         |
|                         |     > Evaluative Drills, Tabletops,       |
|                         |     > Functional and Full-Scale           |
|                         |     > Exercises.                          |
|                         |                                           |
|                         | -   Some exercises are conducted with     |
|                         |     > State, Federal and community        |
|                         |     > partners.                           |
+-------------------------+-------------------------------------------+
| Evaluation              | -   The VISN conducts an organized AAR    |
|                         |     > for all incidents and exercises and |
|                         |     > captures promising practices and    |
|                         |     > needs for improvement in a format   |
|                         |     > that promotes organizational        |
|                         |     > learning.                           |
|                         |                                           |
|                         | -   The performance in designing,         |
|                         |     > developing, and conducting the      |
|                         |     > exercise, including conducting      |
|                         |     > exercise evaluation team            |
|                         |     > activities, is reviewed and         |
|                         |     > analyzed.                           |
+-------------------------+-------------------------------------------+
| Organizational Learning | -   AAR findings are incorporated as      |
|                         |     > objective improvements into the EOP |
|                         |     > and supporting documents,           |
|                         |     > preparedness and mitigation         |
|                         |     > planning as appropriate to achieve  |
|                         |     > organizational improvement.         |
|                         |                                           |
|                         | -   Findings from the performance         |
|                         |     > evaluation of the exercise planning |
|                         |     > and execution are incorporated into |
|                         |     > the exercise planning team process. |
+-------------------------+-------------------------------------------+

**Questions**:

VISN Oversight:

1.  Describe the variety of exercises that have been conducted
    VISN-wide?

2.  Have there been any exercises conducted solely at the VISN Office
    level?

3.  Are there AARs from exercises?

4.  How have the AARs been used, particularly in the areas of resource
    or training recommendations?

Demonstration of Systems-Based Evaluation of the VISN's overall Emergency Management Program and its Emergency Operations Plan 
------------------------------------------------------------------------------------------------------------------------------

**Description:** To demonstrate this capability the VISN must conduct an
annual evaluation of the EMP.

**Rationale:** Annual evaluations are essential to ensuring that
emergency management activities are functional when needed during an
actual emergency.

**Measurement**:

-   **Review of annual program reviews**

-   **Review of AARs from exercises and incidents**

-   **Review of any pertinent ELC activities**

-   **Interview with VISN EPC. DND and COO**

-   **Interview with the EMC**

Framework for Capability Description

+-------------------------+-------------------------------------------+
| Capability Element      | Assessment components                     |
+=========================+===========================================+
| Policy/Organization     | -   The VISN conducts an annual           |
|                         |     > systems-based EMP evaluation to     |
|                         |     > identify opportunities for          |
|                         |     > improvement in the EMP and the      |
|                         |     > VISN's plans for emergency response |
|                         |     > and recovery.                       |
+-------------------------+-------------------------------------------+
| Resources               |                                           |
+-------------------------+-------------------------------------------+
| > Supplies              | -   N/A                                   |
+-------------------------+-------------------------------------------+
| > Facilities/Equipment  | -   Indicated tools to conduct the        |
|                         |     > program assessment                  |
+-------------------------+-------------------------------------------+
| > Personnel             | -   Adequate staffing for the program     |
|                         |     > review                              |
+-------------------------+-------------------------------------------+
| Process                 | -   There are defined methods and         |
|                         |     > procedures for conducting EMP       |
|                         |     > reviews and capturing objective     |
|                         |     > information.                        |
|                         |                                           |
|                         | -   Process involves an annual evaluation |
|                         |     > of the program                      |
|                         |                                           |
|                         | -   AARs from exercises and incidents are |
|                         |     > a component in the review process   |
+-------------------------+-------------------------------------------+
| Education/Training      | -   Staff assigned to conduct program     |
|                         |     > reviews of the VISN's EMP are       |
|                         |     > trained in a consistent manner.     |
+-------------------------+-------------------------------------------+
| Exercise                | -   AARs are conducted after exercises    |
|                         |     > and incidents and the reports are   |
|                         |     > analyzed to identify EMP            |
|                         |     > opportunities for improvement.      |
+-------------------------+-------------------------------------------+
| Evaluation              | -   EMC/ELC receives an overall annual    |
|                         |     > evaluation of the EMP.              |
|                         |                                           |
|                         | -   This review also includes             |
|                         |     > recommendations for follow-up from  |
|                         |     > lessons learned.                    |
+-------------------------+-------------------------------------------+
| Organizational Learning | -   Annual program objectives incorporate |
|                         |     > recommendations and progress on     |
|                         |     > needed corrective actions.          |
+-------------------------+-------------------------------------------+

**Questions**:

VISN Oversight:

1.  Do you conduct periodic VISN-wide program evaluations?

2.  What types of VISN EMP assessments have been conducted?

3.  Describe the evaluation objectives, frequency, follow-up and results
    communication to the VISN staff, leadership, EMC and ELC.

4.  Do you review the annual assessments of the VAMCs EMP and do you
    monitor the performance improvement activities conducted yearly as
    required by The Joint Commission (TJC)?

VISN Office EMP:

5.  Do you conduct periodic program evaluations of the VISN Office EMP?

6.  Has the EMP been evaluated?

Incorporation of Accepted Improvement Recommendations into the Emergency Management Program and its Components such that the Process becomes one of a Learning Organization.
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------

**Description:** To demonstrate this capability the VISN must
incorporate a performance improvement process that results in
organizational learning.

**Rationale:** A program to ensure organizational learning is essential
for an effective VISN EMP and consistent with VHA precepts.

**Measurement**:

-   **Review of EMC minutes**

-   **Review of annual work plan**

-   **Review of Exercise AARs**

-   **Interview with VISN EPC**

Framework for Capability Description

+-------------------------+-------------------------------------------+
| Capability Element      | Assessment components                     |
+=========================+===========================================+
| Policy/Organization     | -   The VISN has an approach for          |
|                         |     accepting EMP improvements so that    |
|                         |     the process results in organizational |
|                         |     learning.                             |
+-------------------------+-------------------------------------------+
| Resources               |                                           |
+-------------------------+-------------------------------------------+
| > Supplies              | -   N/A                                   |
+-------------------------+-------------------------------------------+
| > Facilities/Equipment  | -   N/A                                   |
+-------------------------+-------------------------------------------+
| > Personnel             | -   The EMC or equivalent identifies an   |
|                         |     adequate number of qualified          |
|                         |     personnel to manage the               |
|                         |     organizational learning (corrective   |
|                         |     action) process.                      |
+-------------------------+-------------------------------------------+
| Process                 | -   Methods are defined for considering   |
|                         |     > proposed improvements (from the     |
|                         |     > AARs and program reviews) and       |
|                         |     > determining if and how they will be |
|                         |     > incorporated into the EMP and       |
|                         |     > relevant components such as the EOP |
|                         |     > and for training.                   |
|                         |                                           |
|                         | -   Methods exist for actually            |
|                         |     > incorporating improvements and      |
|                         |     > corrective actions into the VISN's  |
|                         |     > EMP.                                |
|                         |                                           |
|                         | -   A method for tracking and reporting   |
|                         |     > accepted improvements over time is  |
|                         |     > demonstrated, with fully            |
|                         |     > incorporated improvements flagged   |
|                         |     > for future evaluation during        |
|                         |     > exercises and program reviews.      |
|                         |                                           |
|                         | -   The VISN revises and updates plans    |
|                         |     > and Standard Operating Procedures   |
|                         |     > to incorporate the NIMS and the     |
|                         |     > National Response Framework (NRF).  |
|                         |                                           |
|                         | -   Recommendations for improvements are  |
|                         |     > based on AARs and conducted by the  |
|                         |     > EMC                                 |
+-------------------------+-------------------------------------------+
| Education/Training      | -   Staff assigned to implement           |
|                         |     > recommendations from program        |
|                         |     > evaluations and after action items  |
|                         |     > from exercises or actual incidents  |
|                         |     > are trained in a consistent manner. |
+-------------------------+-------------------------------------------+
| Exercise                | -   NA                                    |
+-------------------------+-------------------------------------------+
| Evaluation              | -   The process for ensuring              |
|                         |     > organizational learning is          |
|                         |     > evaluated annually as part of the   |
|                         |     > annual EMP review.                  |
+-------------------------+-------------------------------------------+
| Organizational Learning | -   Updates/improvements are made to the  |
|                         |     > organizational learning process     |
|                         |     > based upon the annual review and    |
|                         |     > other relevant inputs (such as      |
|                         |     > revised guidance in the VHA EMP     |
|                         |     > Guidebook).                         |
+-------------------------+-------------------------------------------+

**Questions**:

VISN Oversight:

1.  How is VISN leadership given opportunities to participate in the
    overall program VISN-wide?

2.  How are AARs from previous events in the VISN used to develop hazard
    mitigation projects?

3.  How are future goals and objectives for the EMP VISN-wide developed?

VISN Office EMP:

4.  Describe how evaluation recommendations, AARs and lessons learned
    are incorporated into EMP process improvements.

5.  How is VISN leadership given opportunities to participate in
    developing program improvements of the VISN Office EMP?

6.  How are future goals and objectives for the VISN Office level
    programs developed?

Incident Management Capabilities
================================

To manage all incidents regardless of scope and coordinate activities
with individual VAMCs, the VISN must have effective and documented
incident management capabilities. The following incident management
capabilities are critical to a VISN's ability to support the Department
of Veterans Affairs (VA) facilities:

-   Initial Incident Actions (e.g., First Four Hours)

-   Management of Extended Operations

-   Evacuation vs. Shelter-in-Place

-   Perimeter Security Management of Access/Egress to Facility during an
    Incident (e.g., Lock Down)

-   Processes and Procedures for Managing a Hazardous Substance Incident

-   Infection Control

-   Personnel Resiliency

-   Mission Critical Systems Resiliency

-   Communications

-   Health Care Systems Resiliency

-   Processes and Procedures for Expansion of Staff for Response and
    Recovery Operations

-   Management of Volunteers Deployment Support (DEMPS) during Response
    and Recovery Operations

-   Expansion of Evaluation and Treatment Services

-   Provision of Supplemental Health Services to Support the National
    Disaster Medical System (NDMS)

-   VA/DOD Contingency Hospital System

-   Support Under the NRF

The following sections will describe these incident management
capabilities, including their rationale and measurement.

Initial Incident Actions (e.g., first four hours)
-------------------------------------------------

### Processes and Procedures for Incident Recognition, Activation of EOP/EOC, and Initial Notification of Staff 

**Description:** To demonstrate this capability the VISN must recognize
circumstances that indicate a potential incident and require a scalable
response.

**Rationale:** An essential ingredient of the response and recovery
phases of an emergency is being able to rapidly and efficiently activate
the EOP/EOC. A rapid activation speeds response and recovery and
enhances the ability of the VISN to support facilities affected by any
form of disaster.

**Measurement**:

-   Review SOPs for staff roles/responsibilities for baseline
    monitoring, notification procedures and activation of EOP

-   Interviews with VISN Director

-   Interviews with DND, VISN EPC and VISN COO

-   Scenario-based discussions

Framework for Capability Description

+-------------------------+-------------------------------------------+
| Capability Element      | Assessment components                     |
+=========================+===========================================+
| Policy/Organization     | -   The VISN demonstrates an effective    |
|                         |     > process for recognizing             |
|                         |     > circumstances within the program's  |
|                         |     > jurisdiction that indicate a        |
|                         |     > potential incident (e.g., incident  |
|                         |     > recognition and the need to         |
|                         |     > activate the EOP/EOC), rapidly      |
|                         |     > notify personnel and report the     |
|                         |     > situation to VISN leadership and    |
|                         |     > appropriate authorities.            |
|                         |                                           |
|                         | ```{=html}                                |
|                         | <!-- -->                                  |
|                         | ```                                       |
|                         | -   Designation of a VISN EOC             |
+-------------------------+-------------------------------------------+
| Resources               |                                           |
+-------------------------+-------------------------------------------+
| > Supplies              | -   N/A                                   |
+-------------------------+-------------------------------------------+
| > Facilities/Equipment  | -   POC for EOP activation has            |
|                         |     > communication equipment at all      |
|                         |     > times (24/7/365).                   |
|                         |                                           |
|                         | -   Adequate communications equipment to  |
|                         |     > rapidly provide notification of EOP |
|                         |     > activation, level of activation and |
|                         |     > immediate instructions per template |
|                         |                                           |
|                         | -   Equipment to receive confirmation of  |
|                         |     > message receipt and report of       |
|                         |     > response status                     |
+-------------------------+-------------------------------------------+
| > Personnel             | -   Designated person(s) identified for   |
|                         |     > baseline monitoring                 |
|                         |                                           |
|                         | -   POC identified to receive initial     |
|                         |     > reports and make decision to        |
|                         |     > activate the EOP/EOC                |
|                         |                                           |
|                         | -   POC is identified to begin callback   |
|                         |     > procedures to notify critical       |
|                         |     > staff.                              |
+-------------------------+-------------------------------------------+
| Process                 | -   Personnel have developed an incident  |
|                         |     > reporting procedure consistent with |
|                         |     > VHA guidance.                       |
|                         |                                           |
|                         | -   There is a written plan identifying   |
|                         |     > how the EOP/EOC will be activated   |
|                         |     > that is consistent with the ICS.    |
|                         |                                           |
|                         | -   A process is described for rapidly    |
|                         |     > convening VISN leadership to        |
|                         |     > determine whether activation is     |
|                         |     > indicated.                          |
|                         |                                           |
|                         | -   A process is described for developing |
|                         |     > the notification message(s) from    |
|                         |     > templates, sending messages,        |
|                         |     > receiving confirmation of message   |
|                         |     > receipt and aggregating reports of  |
|                         |     > response status from notified       |
|                         |     > parties.                            |
+-------------------------+-------------------------------------------+
| Education/Training      | -   Key members responsible for           |
|                         |     > activating the EOP/EOC are trained  |
|                         |     > in their roles in activation,       |
|                         |     > determining the activation level,   |
|                         |     > and notification.                   |
+-------------------------+-------------------------------------------+
| Exercise                | -   Incident recognition, activation and  |
|                         |     > notification are exercised.         |
+-------------------------+-------------------------------------------+
| Evaluation              | -   AARs from exercises and incidents are |
|                         |     > evaluated annually by the EMC.      |
+-------------------------+-------------------------------------------+
| Organizational Learning | -   Lessons learned from incidents and    |
|                         |     > exercises are incorporated into the |
|                         |     > EMP.                                |
+-------------------------+-------------------------------------------+

**Questions**:

VISN Office EMP:

1.  What are your initial actions?

2.  Will you be activating the VISN EOC?

3.  When is the EOC normally activated?

4.  Who authorizes activation and how quickly can this be accomplished?

5.  Are their plans for after hours activation?

6.  Who else in the VISN will be contacted?

7.  How is VA Central Office (VACO) notified?

8.  Will the ICS system be employed?

9.  What is the immediate role of PAO?

10. Describe the likely interaction between the VISN EPC and the EPC(s)
    at the affected facility or facilities?

**Tabletop Observations**

Based on scenario presented, staff selects an appropriate course of
action based on a written procedure to alert and/or advise certain
positions within an acceptable time frame. The notifications message
should provide for closing the loop.

### Mobilization of Critical Staff and Equipment for Incident Response 

**Description:** To demonstrate this capability the VISN must be able to
rapidly callback and/or mobilize critical staff.

**Rationale:** Emergencies can occur with or without warning, as such,
when a disaster does occur, VISNs may need to mobilize quickly. To do
this, VISNs must plan to identify the assets and key positions necessary
to manage the situation or coordinate with the affected VISN facilities.

**Measurement**:

-   **Review of EOP for situation assessment and mobilization of key
    Incident Management Team (IMT) staff**

-   **Tour of VISN EOC**

-   **Interview with VISN EPC**

-   **Tabletop Exercise**

Framework for Capability Description

+-------------------------+-------------------------------------------+
| Capability Element      | Assessment components                     |
+=========================+===========================================+
| Policy/Organization     | -   The VISN has established effective    |
|                         |     > mechanisms to rapidly mobilize      |
|                         |     > essential personnel and equipment,  |
|                         |     > particularly communications         |
|                         |     > equipment, to manage the situation  |
|                         |     > or coordinate activities with the   |
|                         |     > affected VISN facilities.           |
+-------------------------+-------------------------------------------+
| Resources               |                                           |
+-------------------------+-------------------------------------------+
| > Supplies              | -   Supplies needed for mobilization      |
+-------------------------+-------------------------------------------+
| > Facilities/Equipment  | -   Storage facilities for equipment and  |
|                         |     > supplies                            |
+-------------------------+-------------------------------------------+
| > Personnel             | -   The VISN has identified qualified and |
|                         |     > trained personnel to manage         |
|                         |     > mobilization and coordinate         |
|                         |     > activities.                         |
|                         |                                           |
|                         | -   Designation of EOC Commander is       |
|                         |     > clear.                              |
+-------------------------+-------------------------------------------+
| Process                 | -   Supplies, equipment and temporary     |
|                         |     > facilities to be mobilized should   |
|                         |     > be readily available for response   |
|                         |     > and recovery to allow rapid         |
|                         |     > mobilization.                       |
|                         |                                           |
|                         | -   A process is delineated for the       |
|                         |     > preparation and expansion of space  |
|                         |                                           |
|                         | -   The EOC facility is pre-identified    |
|                         |     > and equipped with emergency power,  |
|                         |     > back-up communications, facsimile   |
|                         |     > (fax) machines, printers, laptops,  |
|                         |     > and other essential equipment       |
|                         |     > (e.g., satellite phone) and         |
|                         |     > services sufficient to operate      |
|                         |     > throughout the duration of the      |
|                         |     > emergency.                          |
|                         |                                           |
|                         | -   There are written procedures          |
|                         |     > including job descriptions for key  |
|                         |     > EOC personnel.                      |
|                         |                                           |
|                         | -   The EOC has battery powered lighting  |
|                         |     > in case of generator failure.       |
|                         |                                           |
|                         | -   Laptops are operational within a few  |
|                         |     > minutes of EOC activation.          |
|                         |                                           |
|                         | -   There are written procedures for      |
|                         |     > identifying alternative sites for   |
|                         |     > the EOC.                            |
|                         |                                           |
|                         | -   VISN has a callback roster for the    |
|                         |     > IMT.                                |
|                         |                                           |
|                         | -   Staff callback rosters are            |
|                         |     > maintained.                         |
|                         |                                           |
|                         | -   Staff establish phone bank messaging  |
|                         |     > capability and coordinate message   |
|                         |     > alerts with local media.            |
|                         |                                           |
|                         | -   VISN has job action sheets for IMT.   |
+-------------------------+-------------------------------------------+
| Education/Training      | -   Members of the IMT are trained with   |
|                         |     > respect to their role in mobilizing |
|                         |     > the response actions upon incident  |
|                         |     > notification.                       |
+-------------------------+-------------------------------------------+
| Exercise                | -   Callback rosters are tested at least  |
|                         |     > quarterly.                          |
|                         |                                           |
|                         | -   There is an exercise component that   |
|                         |     > practices bringing some key staff   |
|                         |     > back to the VISN EOC during regular |
|                         |     > exercises.                          |
+-------------------------+-------------------------------------------+
| Evaluation              | -   Mobilization is evaluated through     |
|                         |     > AARs from exercises and drills.     |
+-------------------------+-------------------------------------------+
| Organizational Learning | -   Findings from the AARs are            |
|                         |     > incorporated as improvements into   |
|                         |     > the mobilization process.           |
+-------------------------+-------------------------------------------+

**Questions**:

VISN Oversight:

1.  How and when is Incident Command transferred from a facility to a
    VISN?

VISN Office EMP:

2.  Who is the Incident Commander?

3.  Who would be summoned to the EOC?

4.  Will there be use of a virtual EOC (i.e., VISN and any other
    facility staff calling in)?

5.  Does everyone in the VISN have a roster to assist in calls to key
    staff?

6.  Are VISN staff aware of your HR policies regarding callback of staff
    and over-time, etc?

7.  How will all this be managed after normal business hours?

8.  Are staff aware of facility-level reporting requirements to the VISN
    (in the case of facility EOC activation) and VISN level reporting
    requirements, as outlined in the VHA Handbook 0320, Incident
    Management System (IMS) Operational Procedures?

9.  Discuss the flow of the reporting from the facilities to the VISNs
    to VACO (including the VHA Joint Operations Center \[JOC\] Duty
    Officer).

10. Please identify who, at the VISN Office, fills the Command and
    General Staff positions and how do they support the Incident
    Commander and meet the requirements of their assigned roles?

**Tabletop Observations:**

1.  EOC is activated in a timely manner through central alert system and
    > EOC staff are assigned to key positions via the Incident
    > Commander. A situation assessment is completed, Job Action Sheets
    > are briefed as needed, and the Operational Period is defined.

2.  The Incident Commander assigned to the IMT conducts and situation
    > assessment, communicates situation to appropriate staff,
    > designates Operational Periods, assigns staff to General Staff
    > positions, and defines immediate priorities consistent with
    > objectives. The Incident Commander is also responsible for
    > attending Situation, Management, Planning, and Operations
    > meetings/briefings.

3.  The Safety Officer is responsible for monitoring all aspects of
    > safety (i.e., personnel, facility and environmental) during
    > response and recovery efforts and implementing counter measures to
    > correct unsafe working conditions. The Safety Officer attends the
    > Situation, Management, Planning, and Operations
    > meetings/briefings.

4.  The Public Information Officer (PIO) is responsible for developing
    > and disseminating information to the media and/or other external
    > agencies about the incident. PIO is further responsible for
    > establishing a Joint Information Center, and attending the
    > Situation, Management, Planning, and Operations
    > meetings/briefings.

5.  The Liaison Officer is responsible for coordinating efforts and
    > communication between assisting agencies during response and
    > recovery efforts. The Liaison Officer compiles POCs for assisting
    > agencies including lines of communication (i.e., phone, fax,
    > email), responds to inquires and monitors situation for
    > inter-agency communications. The Liaison Officer attends the
    > Situation, Management, Planning, and Operations
    > meetings/briefings.

6.  The Operations Section Chief is responsible for defining the
    > tactical responses, strategies, and potential resources needed for
    > response and recovery efforts. The Operations Section Chief
    > attends the Situation, Management, Planning, and Operations
    > meetings/briefings.

7.  The Planning Section Chief collects, documents, evaluates, and
    > disseminates information pertaining to the incident to Command and
    > General staff (other staff as designated). The Planning Section
    > Chief is also responsible for the development of the Incident
    > Action Plan (with support from Command and Section Chiefs)

8.  The Logistics Section Chief is responsible for the support and
    > services of the incident; managing (i.e., communication,
    > transportation, food, sleeping arrangements).

9.  The Finance Officer is responsible for all financial aspects of the
    > incident from response through recovery, including time reporting,
    > compensation and claims, procurement of resources, and incident
    > cost accounting.

10. Staff in the EOC are able to identify response activities that will
    > organize, coordinate and mobilize essential resources such as
    > responders, equipment, supplies, and transportation.

11. Staff are capable of determining the need to expand or collapse the
    > ICS structure depending on the severity of the incident.

12. Incident Command staff utilize multiple methods to mobilize key
    > staff to the incident and are capable of external communications
    > to notify appropriate authorities (e.g., fire, police, Emergency
    > Medical Services, and media).

13. Appropriate staging areas are identified and managed to handle the
    > influx of personnel, equipment and supplies.

### Situational Assessment of Response and Coordination Efforts for Initial Incident Management and Emergency Operations Center Activation

**Description:** To demonstrate this capability the facility must be
able to identify the need to rapidly activate their EOC.

**Rationale:** All emergencies pose significant and unique challenges to
the VISN. For effective response and recovery the VISN must utilize the
EOC as the central point for Command, Control, Coordination and
Communication.

**Measurement**:

-   **Review of EOP**

-   **Tour of VISN EOC**

-   **Interview with VISN EPC and DND/COO**

-   Presence of inventory of critical resources (communication
    equipment, computers, etc.)

-   **Tabletop Exercise**

Framework for Capability Description

+-------------------------+-------------------------------------------+
| Capability Element      | Assessment components                     |
+=========================+===========================================+
| Policy/Organization     | -   The VISN provides actionable guidance |
|                         |     > through its EOP for initial         |
|                         |     > incident management.                |
+-------------------------+-------------------------------------------+
| Resources               |                                           |
+-------------------------+-------------------------------------------+
| > Supplies              | -   Appropriate EOP forms, guidance and   |
|                         |     > other documents and supplies per    |
|                         |     > the EOP including ICS Position      |
|                         |     > Descriptions and Job Action Sheets  |
|                         |     > are available for the IMT.          |
+-------------------------+-------------------------------------------+
| > Facilities/Equipment  | -   The EOC is configured for effective   |
|                         |     > operation of the IMT.               |
|                         |                                           |
|                         | -   EOC is equipped with appropriate      |
|                         |     > computers, communications,          |
|                         |     > printers, television and other      |
|                         |     > equipment to support incident       |
|                         |     > action planning and management      |
|                         |     > decisions.                          |
+-------------------------+-------------------------------------------+
| > Personnel             | -   Personnel have been identified to     |
|                         |     > fill ICS Command and General staff  |
|                         |     > positions during incidents and      |
|                         |     > exercises.                          |
+-------------------------+-------------------------------------------+
| Process                 | -   VISN staff conduct a resource status  |
|                         |     > and risk assessment at the outset   |
|                         |     > of any emergency.                   |
|                         |                                           |
|                         | -   Actionable guidance for key IMT       |
|                         |     > positions to contribute to the      |
|                         |     > resource status and risk assessment |
|                         |     > and determine initial actions.      |
|                         |                                           |
|                         | -   At the outset of the incident,        |
|                         |     > incident situation and initial      |
|                         |     > actions are recorded (e.g., ICS     |
|                         |     > 201).                               |
|                         |                                           |
|                         | -   Personnel have access to the EOP for  |
|                         |     > priority hazards including the      |
|                         |     > identification of pre-determined    |
|                         |     > initial Incident Command            |
|                         |     > organizations for specific hazard   |
|                         |     > incidents.                          |
|                         |                                           |
|                         | -   The EOP provides guidance for initial |
|                         |     > critical actions to ensure the      |
|                         |     > appropriate personnel are assigned  |
|                         |     > to necessary duties for emergency   |
|                         |     > response and recovery operations.   |
|                         |                                           |
|                         | -   The IMT is staffed with appropriately |
|                         |     > qualified and trained personnel     |
|                         |     > according to the scalable guidance  |
|                         |     > in the EOP.                         |
+-------------------------+-------------------------------------------+
| Education/Training      | -   IMT personnel are trained to the      |
|                         |     > operations level on their position  |
|                         |     > roles and responsibilities.         |
|                         |                                           |
|                         | -   Personnel assigned to conducting      |
|                         |     > hazard risk assessments are trained |
|                         |     > commensurate with their role in     |
|                         |     > developing the risk assessments and |
|                         |     > managing the EOC.                   |
+-------------------------+-------------------------------------------+
| Exercise                | -   The exercises conducted by the VISN   |
|                         |     > incorporate the resource status and |
|                         |     > situation within the exercise       |
|                         |     > scenario.                           |
+-------------------------+-------------------------------------------+
| Evaluation              | -   AARs due to activation of the EOC     |
|                         |     > during exercises/drills and actual  |
|                         |     > emergencies are evaluated after     |
|                         |     > each incident.                      |
+-------------------------+-------------------------------------------+
| Organizational Learning | -   Lessons learned from AARs are         |
|                         |     > incorporated into the EOC SOP and   |
|                         |     > facility EMP, including training    |
|                         |     > requirements and recommended        |
|                         |     > resource enhancements.              |
+-------------------------+-------------------------------------------+

**Questions**:

VISN Oversight:

1.  How does the VISN assure that VISN facilities have plans in place to
    communicate with patients and their families during emergencies,
    including notification when patients are relocated to alternative
    care sites?

VISN Office EMP:

2.  How are staff assigned for Command and General Staff position roles
    for EOC operations and trained in those roles?

3.  Briefly discuss your EOC and how it is supported with Information
    Technology (IT) equipment, communications equipment and utilities
    (this will be covered in depth during EOC scenario).

4.  Who in the VISN has Government Emergency Telecommunications Service
    (GETS) cards?

5.  What are the provisions for the loss of power in the VISN Office
    and/or the VISN EOC?

6.  What are the provisions for the loss of normal telephones, cell
    phones and computer networks? Do you have access to satellite
    computer communications including video tele-conferencing? Do you
    have access to radio and/or amateur radio communications?

7.  Are VISN staff aware how to communicate via BlackBerry® pin-to-pin?

8.  Is there a back-up EOC site? If yes, where is it located?

9.  How will the VISN EOC interact with the facility EOC involved with
    managing the crisis?

**Tabletop Observations**

1.  Staff understand EOC activation procedures.

2.  EOC is activated in a timely manner through central alert system and
    > EOC staff are assigned to key staff positions via the Incident
    > Commander. A risk analysis is completed and job action sheets are
    > briefed as needed.

3.  Players in the EOC are able to identify response activities that
    > will organize, coordinate or mobilize essential resources such as
    > responders, equipment, supplies, and transportation.

4.  EOC activation involves the implementation of a resource list that
    > identifies necessary components to establish a fully functional
    > EOC (e.g., space, alternative space if needed, equipment,
    > supplies, staffing, security, safety, and communication
    > capabilities).

5.  Appropriate staging areas are identified and managed to handle an
    > influx of personnel, equipment and supplies.

6.  Space is adequate to allow for group meetings and separate
    > functional group meetings. Displays are adequate and include TV
    > and slides. Write/erase boards are available.

Management of Extended Operations (e.g., after first four hours)
----------------------------------------------------------------

### Management of Extended Operations 

**Description:** To demonstrate this capability the VISN must have a
process for conducting extended operations beyond the initial reactive
phase.

**Rationale:** Several emergencies will require extended operations to
meet the changing needs and demands of response, coordination and
recovery activities. The VISN should have a well-developed plan that
uses a Management by Objectives (MBOs) approach or similar methodology.

**Measurement**:

-   **Review of Incident Action Planning processes and forms**

-   **Review of plans to staff for extended operations**

-   Presence of inventory of critical resources

-   **Interview with VISN EPC and DND/COO**

Framework for Capability Description

+-------------------------+-------------------------------------------+
| Capability Element      | Assessment components                     |
+=========================+===========================================+
| Policy/Organization     | -   The VISN demonstrates the ability to  |
|                         |     > effectively manage incident         |
|                         |     > operations beyond the initial       |
|                         |     > reactive phase using the incident   |
|                         |     > action planning process to provide  |
|                         |     > proactive management of the VISN    |
|                         |     > emergency response.                 |
+-------------------------+-------------------------------------------+
| Resources               |                                           |
+-------------------------+-------------------------------------------+
| > Supplies              | -   Relevant incident action planning     |
|                         |     > forms and guidance from the EOP     |
+-------------------------+-------------------------------------------+
| > Facilities/Equipment  | -   Meeting facilities, communication and |
|                         |     > other equipment for supporting the  |
|                         |     > Incident Action Plan (IAP)          |
+-------------------------+-------------------------------------------+
| > Personnel             | -   Qualified and trained personnel to    |
|                         |     > staff the EOC.                      |
+-------------------------+-------------------------------------------+
| Process                 | -   The EOC is fully staffed (i.e.,       |
|                         |     > Incident Commander, Liaison         |
|                         |     > Officer, Planning Officer, Finance  |
|                         |     > Officer, Operations Officer)        |
|                         |                                           |
|                         | -   Staff assigned to the EOC and IMTs    |
|                         |     > employ incident action planning     |
|                         |     > procedures, including:              |
|                         |                                           |
|                         |     -   Situation status reports          |
|                         |                                           |
|                         |     -   Resource status reports           |
|                         |                                           |
|                         |     -   IAP and supporting plans          |
|                         |                                           |
|                         |     -   Processes and procedures for      |
|                         |         briefing the IAP to response      |
|                         |         leaders across the VAMC and       |
|                         |         relevant outside agencies from    |
|                         |         initial incident response through |
|                         |         demobilization                    |
|                         |                                           |
|                         | -   Operational periods and a related     |
|                         |     > planning cycle (with action panning |
|                         |     > meetings) are established           |
|                         |                                           |
|                         | -   Staff establishes operational period  |
|                         |     > objectives to drive response and    |
|                         |     > recovery efforts.                   |
|                         |                                           |
|                         | -   Staff rotation schedules determined   |
|                         |     > by the nature of the scope of       |
|                         |     > response and recovery activities    |
|                         |     > are defined including work          |
|                         |     > schedules, eating and sleeping      |
|                         |     > arrangements                        |
+-------------------------+-------------------------------------------+
| Education/Training      | -   Staff are trained to manage incident  |
|                         |     > operations.                         |
+-------------------------+-------------------------------------------+
| Exercise                | -   Management of extended incident       |
|                         |     > operations is practiced during      |
|                         |     > exercises including incident action |
|                         |     > planning and long range planning.   |
+-------------------------+-------------------------------------------+
| Evaluation              | -   AARs from exercises/drills and actual |
|                         |     > emergencies are evaluated after     |
|                         |     > each incident.                      |
+-------------------------+-------------------------------------------+
| Organizational Learning | -   AARs are incorporated into the EMP to |
|                         |     > improve operations beyond the first |
|                         |     > operational period, and include     |
|                         |     > training, and IAP                   |
+-------------------------+-------------------------------------------+

**Questions**:

VISN Office EMP:

1.  Are there instances when you expect to operate the EOC for extended
    periods, such as through the night?

2.  If so, what are the provisions for staff support?

3.  Are there defined plans for staff rotation?

4.  Please describe any VISN Human Resource (HR) policies regarding VISN
    Office staff on extended duty.

5.  During extended operations, how do the Command and General Staff
    continue to support the planning cycle within each operational
    period?

### Public Information Management Services during an Incident 

**Description**: To demonstrate this capability the VISN must be able to
communicate with internal and external stakeholders.

**Rationale**: Each VISN should have in place and documented the names
and pertinent information for local media resources and local agencies
as well as a process for identifying individuals authorized to release
information.

**Measurement**:

-   Review of media relations plan

-   Review of prescripted messages based on HVA priority hazards

-   Review of documents pertaining to PIO coordination with external
    > agencies and State Joint Information Center

-   Review of AARs from exercises and incidents involving media
    > relations

-   Tour of media briefing area

-   Interview with VISN Public Affairs Officer (PAO)

-   Scenario-based discussion

Framework for Capability Description

+-------------------------+-------------------------------------------+
| Capability Element      | Assessment components                     |
+=========================+===========================================+
| Policy/organization     | -   The VISN demonstrates effective       |
|                         |     > management of messages to the media |
|                         |     > related to the incident and         |
|                         |     > response.                           |
+-------------------------+-------------------------------------------+
| Resources               |                                           |
+-------------------------+-------------------------------------------+
| > Supplies              | -   Relevant forms, templates and other   |
|                         |     > EOP materials providing actionable  |
|                         |     > guidance for managing the public    |
|                         |     > information function.               |
+-------------------------+-------------------------------------------+
| > Facilities/Equipment  | -   The VISN has a designated meeting     |
|                         |     > area for members of the media and   |
|                         |     > relevant facility staff.            |
+-------------------------+-------------------------------------------+
| > Personnel             | -   There is a cadre of qualified and     |
|                         |     > trained personnel identified to     |
|                         |     > conduct this messaging to the       |
|                         |     > media, staff, patients and          |
|                         |     > families.                           |
|                         |                                           |
|                         | -   Media and other public contacts is    |
|                         |     > generally overseen and conducted by |
|                         |     > the VISN PAO.                       |
+-------------------------+-------------------------------------------+
| Process                 | -   Personnel can identify the contacts   |
|                         |     > within local and national media     |
|                         |     > outlets identified in the media     |
|                         |     > relations plan.                     |
+-------------------------+-------------------------------------------+
| Education/Training      | -   The individual designated to          |
|                         |     > communicate with the media has      |
|                         |     > received training on their role in  |
|                         |     > media relations.                    |
|                         |                                           |
|                         | -   This individual also has training and |
|                         |     > experience interacting with senior  |
|                         |     > government officials and other      |
|                         |     > "VIPs" likely to be communicating   |
|                         |     > with the VISN during and after the  |
|                         |     > emergency event.                    |
|                         |                                           |
|                         | -   Staff understand their roles and the  |
|                         |     > chain of communication in relation  |
|                         |     > to local and national media.        |
+-------------------------+-------------------------------------------+
| Exercise                | -   Public information plans are          |
|                         |     > exercised at least once a year.     |
|                         |                                           |
|                         | -   This capability is fully integrated   |
|                         |     > with State and community wide       |
|                         |     > exercises at least once a year.     |
+-------------------------+-------------------------------------------+
| Evaluation              | -   The facility performs an AAR after    |
|                         |     > each exercise.                      |
+-------------------------+-------------------------------------------+
| Organizational Learning | -   The findings from the AARs inform     |
|                         |     > improvements in public information  |
|                         |     > process.                            |
+-------------------------+-------------------------------------------+

**Questions:**

VISN Oversight:

1.  What regular interactions do you have with the facility PAOs?

    a.  Media resource sharing?

    b.  Have your reviewed their communication plans?

    c.  How do you support a facility that has limited resources?

2.  Is your plan tested with facilities?

3.  Describe your training in crisis communication planning and actual
    practice?

    a.  Is there media training for individuals that are not PAOs?

    b.  Have you received Health Insurance Portability and
        Accountability Act (HIPAA) compliance training?

    c.  In particular, have you received training regarding HIPAA
        compliance as it pertains to sharing of information (including
        TJC standard) that is necessary for emergency operations, where
        waivers may be required?

    d.  How are VISN office staff knowledgeable regarding HIPAA
        compliance?

4.  Who are your alternate PAOs for the VISN?

5.  What interactions have you had with VAMC facilities' and State or
    local agency PAOs?

6.  Are there any plans for any types of call-in "hotlines" to provide
    information to remote VISN staff and other VISN employees not
    actively involved in the crisis management process?

VISN Office EMP:

7.  Is the PAO part of the immediate EOC team?

8.  Describe the VISN Public Information Crisis Management Plan
    including media relations and also providing information to the
    general public.

9.  Is there an area designated to meet press that may appear at the
    VISN?

10. Do you have a list of planned media contacts to use during an
    emergency?

11. Who is designated to talk with the media during a crisis?

12. Describe early PAO contact with VACO. How do you provide regular
    updates to VACO and OPA?

13. What is your role in keeping VACO informed?

14. How do you keep VISN employees, stake holders and patients informed
    during an emergency?

15. Describe actual experiences with your crisis plan been used?

16. Is your plan also tested? With facilities?

17. Have you provided training to facility PAOs? To key VISN staff?

18. What is the plan to support any VIPs who may be at a site or at the
    VISN during an emergency with the proper level of information and
    other needs?

**Tabletop Observation**

PAO is involved in situation briefing, management meeting and planning
meeting.

### Management and Acquisition of Resources for Incident Response and Recovery Operations

**Description**: To demonstrate this capability the VISN must develop
and regularly maintain a resource management plan as directed by the
EMC.

**Rationale**: During an incident, VISNs will require resources to
effectively operate during the response and recovery periods. The
management and timely acquisition of resources will determine the
capability to which the VISN can operate and return to normal status.
The mitigation strategies of individual VAMCs often require significant
capital dollars. VISNs have oversight for the facilities' Non-Recurring
Maintenance and Minor Construction Programs that fund these capital
projects.

**Measurement**:

-   Review of resource inventory

-   Review of EOP and/or Logistics Section Checklist

-   **Review any Memorandums of Understanding (MOUs)/contracts with Key
    Vendors**

-   Scenario-based discussion with DND, VISN EPC and Capital Asset
    Manager (CAM).

Framework for Capability Description

+-------------------------+-------------------------------------------+
| Capability Element      | Assessment components                     |
+=========================+===========================================+
| Policy/Organization     | -   The VISN can demonstrate appropriate  |
|                         |     > management and acquisition of       |
|                         |     > resources from a variety of         |
|                         |     > agencies/vendors.                   |
|                         |                                           |
|                         | ```{=html}                                |
|                         | <!-- -->                                  |
|                         | ```                                       |
|                         | -   Resource management is a component of |
|                         |     > the EOC during its activation.      |
|                         |                                           |
|                         | -   The VISN has a process for            |
|                         |     > prioritizing hazard mitigation and  |
|                         |     > other emergency preparedness        |
|                         |     > construction projects as part of    |
|                         |     > its facility construction program   |
|                         |     > oversight.                          |
+-------------------------+-------------------------------------------+
| Resources               |                                           |
+-------------------------+-------------------------------------------+
| > Supplies              | -   Forms/agreements and systems needed   |
|                         |     > to inventory, request, allocate,    |
|                         |     > and track resources.                |
+-------------------------+-------------------------------------------+
| > Facilities/Equipment  | -   The VISN has a designated             |
|                         |     > room/staging area utilized for      |
|                         |     > resources prior to, and during an   |
|                         |     > incident.                           |
+-------------------------+-------------------------------------------+
| > Personnel             | -   Qualified and trained personnel to    |
|                         |     > manage processes involved in        |
|                         |     > resource acquisition, management,   |
|                         |     > allocation, inventory, and          |
|                         |     > deployment procedures.              |
|                         |                                           |
|                         | -   VISN CAM oversees all NRM and Minor   |
|                         |     > construction programming that       |
|                         |     > includes hazard mitigation          |
|                         |     > projects.                           |
+-------------------------+-------------------------------------------+
| Process                 | -   There is a process for the management |
|                         |     > and inventory of all facility       |
|                         |     > resources.                          |
|                         |                                           |
|                         | -   There is a process to include hazard  |
|                         |     > mitigation and other emergency      |
|                         |     > preparedness projects within the    |
|                         |     > NRM and Minor construction          |
|                         |     > prioritization process.             |
|                         |                                           |
|                         | -   There is a process for the activation |
|                         |     > of the resource manager during EOC  |
|                         |     > activation.                         |
|                         |                                           |
|                         | -   There is a process for the            |
|                         |     > management, acquisition,            |
|                         |     > allocation, and deployment of       |
|                         |     > resources during an incident.       |
|                         |                                           |
|                         | -   There is a process for acquiring      |
|                         |     > resources from outside              |
|                         |     > agencies/vendors.                   |
|                         |                                           |
|                         | -   There is a process for returning      |
|                         |     > equipment, supplies, and personnel  |
|                         |     > to a normal state after incident    |
|                         |     > recovery.                           |
+-------------------------+-------------------------------------------+
| Education/Training      | -   Personnel work in the pre-planning    |
|                         |     > process to identify resources that  |
|                         |     > may be needed for all- hazards      |
|                         |     > preparedness.                       |
|                         |                                           |
|                         | -   Personnel are trained as a component  |
|                         |     > of the ICS structure and operate    |
|                         |     > within the EOC during activation.   |
+-------------------------+-------------------------------------------+
| Exercise                | -   Resource management plans are         |
|                         |     > exercised at least once a year.     |
|                         |                                           |
|                         | -   This capability is fully integrated   |
|                         |     > with Federal and State wide         |
|                         |     > exercises at least once a year.     |
+-------------------------+-------------------------------------------+
| Evaluation              | -   The facility performs an AAR after    |
|                         |     > each exercise.                      |
+-------------------------+-------------------------------------------+
| Organizational Learning | -   The findings from the AARs inform     |
|                         |     > improvements in the resource        |
|                         |     > management process.                 |
+-------------------------+-------------------------------------------+

**Questions**:

VISN Oversight:

1.  Does the VISN have processes in place for the preplanning of
    resource allocation to include operational and NRM/Minor
    Construction funding to mitigate hazards and support other emergency
    preparedness needs?

2.  Please describe how the VISN and its capital asset planning process
    include hazard mitigation and emergency preparedness in the overall
    prioritization of NRM and Minor Construction.

3.  Does the VISNs EOP identify how resources and assets will be
    solicited and acquired from a range of possible sources, such as
    vendors, neighboring health care providers, other community
    organizations, state affiliates?

4.  Does the VISNs planning include establishing priority contracts with
    local suppliers to ensure delivery of critical healthcare and other
    supplies when others may be competing for same resources?

5.  Does the VISNs plan for potential sharing of resources and assets
    with health care organizations outside of the community in the event
    of a regional or prolonged disaster?

6.  Does the VISNs planning include identifying how to replenish
    non-medical supplies that will be required throughout response and
    recovery?

7.  Does the VISN plan for obtaining resources and assets with health
    care organizations outside of the community in the event of a
    regional or prolonged disaster?

**Tabletop Observation**

Logistics Section Chief attends situation briefing. During meeting,
identifies critical resource issues; in planning meeting identifies
resources Operations may need to accomplish tactics, as well as
alternatives; coordinates with Finance/Administration on resource source
and ordering.

### Processes and Procedures for Demobilization of Personnel and Equipment 

The VISN initiates demobilization processes to disengage resources from
incident response and allow a return to normal operations or back to
standby status.

**Description:** To demonstrate this capability the VISN must be able to
return its personnel, equipment, and supplies to a pre-disaster or new
normal state.

**Rationale:** The VISN initiates demobilization processes to disengage
resources from incident response and allow a return to normal operations
or back to standby status. Equipment used heavily during the disaster
must be thoroughly inspected and supplies must be returned to central
storage and when necessary, restocked.

**Measurement**:

-   **Review of EOP**

-   **Interview with VISN EPC**

-   **Interview with DND/VISN COO**

Framework for Capability Description

+-------------------------+-------------------------------------------+
| Capability Element      | Assessment components                     |
+=========================+===========================================+
| Policy/Organization     | -   The VISN demonstrates the ability to  |
|                         |     > plan for and demobilize response    |
|                         |     > personnel and resources when their  |
|                         |     > missions are completed, and to      |
|                         |     > efficiently demobilize the IMT when |
|                         |     > indicated.                          |
+-------------------------+-------------------------------------------+
| Resources               |                                           |
+-------------------------+-------------------------------------------+
| > Supplies              | -   Demobilization supplies such as       |
|                         |     > forms, guides, Job Action Sheets.   |
|                         |                                           |
|                         | -   Unused supplies are returned to       |
|                         |     > storage areas and consumed supplies |
|                         |     > documented for replenishment as     |
|                         |     > part of demobilization.             |
+-------------------------+-------------------------------------------+
| > Facilities/Equipment  | -   Equipment is inspected and logged for |
|                         |     > re-packaging and returned for       |
|                         |     > proper storage.                     |
|                         |                                           |
|                         | -   Facilities used in response and       |
|                         |     > recovery are decommissioned and     |
|                         |     > response equipment/supplies         |
|                         |     > removed.                            |
+-------------------------+-------------------------------------------+
| > Personnel             | -   Planning Section personnel qualified  |
|                         |     > and trained to supervise            |
|                         |     > demobilization planning.            |
|                         |                                           |
|                         | -   Logistics and other personnel         |
|                         |     > qualified and trained to execute    |
|                         |     > the demobilization plan and to      |
|                         |     > conduct the demobilization          |
|                         |     > procedures.                         |
|                         |                                           |
|                         | -   Operation Section Personnel qualified |
|                         |     > and trained to carry out            |
|                         |     > demobilization                      |
+-------------------------+-------------------------------------------+
| Process                 | -   The IMT provides briefing to facility |
|                         |     > leadership and returns to their     |
|                         |     > regularly assigned duties.          |
|                         |                                           |
|                         | -   Responders are out-processed, which   |
|                         |     > includes confirming their record of |
|                         |     > participation, brief evaluation by  |
|                         |     > IMT superior, physical exam as      |
|                         |     > indicated (such as                  |
|                         |     > post-decontamination activities).   |
+-------------------------+-------------------------------------------+
| Education/Training      | -   Members of the IMT are trained with   |
|                         |     > respect to their role during        |
|                         |     > demobilization.                     |
+-------------------------+-------------------------------------------+
| Exercise                | -   Demobilization planning and the       |
|                         |     > demobilization process is exercised |
|                         |     > at least once every two years       |
|                         |     > during normally scheduled facility  |
|                         |     > exercises.                          |
+-------------------------+-------------------------------------------+
| Evaluation              | -   Demobilization is evaluated through   |
|                         |     > exercises and evaluative drills.    |
+-------------------------+-------------------------------------------+
| Organizational Learning | -   Findings from the AARs are            |
|                         |     > incorporated as improvements into   |
|                         |     > the demobilization process and      |
|                         |     > other aspects of the EMP at the     |
|                         |     > VAMC.                               |
+-------------------------+-------------------------------------------+

**Questions:**

VISN Office EMP:

1.  How is the VISN notified that the facility EOC as been demobilized?

2.  Who authorizes demobilization of the VISN EOC?

3.  When and how are AARs performed?

4.  Describe "after crisis" activities such as debriefings, staff
    support, inventory of supplies consumed, etc.

5.  How are AARs used to drive organizational improvements?

**Tabletop Observation**

As scenario progresses, IMT staff discuss demobilization of certain
positions.

### Processes and Procedures for a Return to Readiness of Personnel and Equipment

**Description:** To demonstrate this capability the VISN must have a
process to return to pre-incident function.

**Rationale:** Returning to the pre-emergency state is a crucial part of
the disaster response and recovery process. The stand-down of the
emergency allows operations to return to non-disaster modes.

**Measurement**:

-   **Review AARs from previous incidents**

-   **Interview with VISN EPC**

-   **Interview with VISN CLO**

Framework for Capability Description

+-------------------------+-------------------------------------------+
| Capability Element      | Assessment components                     |
+=========================+===========================================+
| Policy/Organization     | -   The VISN demonstrates the ability to  |
|                         |     > rapidly return to response          |
|                         |     > readiness.                          |
+-------------------------+-------------------------------------------+
| Resources               |                                           |
+-------------------------+-------------------------------------------+
| > Supplies              | -   N/A                                   |
+-------------------------+-------------------------------------------+
| > Facilities/Equipment  | -   New storage areas or equipment as     |
|                         |     > indicated                           |
+-------------------------+-------------------------------------------+
| > Personnel             | -   Logistics staff qualified and trained |
|                         |     > to rapidly restore the supplies and |
|                         |     > equipment to pre-response readiness |
|                         |     > status                              |
+-------------------------+-------------------------------------------+
| Process                 | -   Supplies used during response and     |
|                         |     > recovery operations are             |
|                         |     > replenished, repackaged and         |
|                         |     > properly stored.                    |
|                         |                                           |
|                         | -   Facilities used in response and       |
|                         |     > recovery are returned to their      |
|                         |     > pre-response functions and to       |
|                         |     > readiness for the next EOP          |
|                         |     > activation.                         |
|                         |                                           |
|                         | -   Equipment used during response and    |
|                         |     > recovery operations is inspected    |
|                         |     > and damaged equipment is replaced   |
|                         |     > and then secured.                   |
|                         |                                           |
|                         | -   Staff from the EOC and IMTs are       |
|                         |     > debriefed (including access to      |
|                         |     > critical incident stress debriefing |
|                         |     > sessions as warranted by the        |
|                         |     > incident).                          |
+-------------------------+-------------------------------------------+
| Education/Training      | -   Staff are trained on returning to     |
|                         |     > normal duties, replenishing         |
|                         |     > supplies, and                       |
|                         |     > inspecting/rehabilitating equipment |
|                         |     > and returning it to readiness and   |
|                         |     > storage.                            |
+-------------------------+-------------------------------------------+
| Exercise                | -   Return to readiness activities after  |
|                         |     > an exercise or incident may be      |
|                         |     > treated as an exercise to assess    |
|                         |     > effectiveness of process and        |
|                         |     > procedures.                         |
+-------------------------+-------------------------------------------+
| Evaluation              | -   The VISNs return to readiness is      |
|                         |     > evaluated through exercises and     |
|                         |     > evaluative drills.                  |
+-------------------------+-------------------------------------------+
| Organizational Learning | -   Findings from the AARs are            |
|                         |     > incorporated as improvements into   |
|                         |     > the return to readiness process and |
|                         |     > other aspects of the EMP at the     |
|                         |     > VAMC.                               |
+-------------------------+-------------------------------------------+

**Questions:**

VISN Office EMP:

1.  Who is responsible for replenishing supplies?

2.  Is there a process such as a site survey to ensure the VISN EOC is
    ready for another emergency?

**Occupant Safety Capabilities**
================================

The following occupant safety capabilities are critical to maintaining
the safety and security of occupants and facilities within the VISN:

-   Evacuation

-   Shelter-in-place

-   Security

The following sections describe these occupant safety capabilities,
including their rationale and measurement. These capabilities define the
occupant safety for VISN staff, as well as oversight for VISN
facilities.

Evacuation vs. Shelter-In-Place
-------------------------------

The facility demonstrates the ability to either evacuate or
shelter-in-place (or a sequence of the two if appropriate to the
incident) in order to maintain a safe, medically effective environment
for staff, patients and visitors.

### Processes and Procedures for Evacuation of Patients', Staff, and Visitors'

**Description:** To demonstrate this capability the VISN must have a
plan that includes criteria for evacuation and a means for safe
accomplishment.

**Rationale:** One of the important lessons learned from Hurricane
Katrina is the realization that VISN facilities may not be able to
sustain operations after a major emergency. Because of this, it is
critical that facilities have plans to evacuate quickly and safely to a
facility that is operational.

**Measurement**:

-   **Pre-Survey**

-   **Review of EOP**

-   **Review of evacuation plan (i.e., procedures, evacuation equipment,
    training)**

-   **Interviews with DND, EPC, and Chief Medical Officer (CMO)**

Framework for Capability Description

+-------------------------+-------------------------------------------+
| Capability Element      | Assessment components                     |
+=========================+===========================================+
| Policy/Organization     | -   The VISN demonstrates the ability to  |
|                         |     > determine the evacuation decision   |
|                         |     > in the face of incident             |
|                         |     > circumstances, and rapidly conduct  |
|                         |     > a partial or full evacuation in a   |
|                         |     > controlled, orderly, and safe       |
|                         |     > manner.                             |
+-------------------------+-------------------------------------------+
| Resources               |                                           |
+-------------------------+-------------------------------------------+
| > Supplies              | -   Relevant EOP forms, guidance          |
|                         |     > (operational checklists or Job      |
|                         |     > Action Sheets)                      |
+-------------------------+-------------------------------------------+
| > Facilities/Equipment  | -   Appropriate communications            |
|                         |                                           |
|                         | -   Staging and loading areas             |
|                         |                                           |
|                         | -   Vehicle staging areas                 |
+-------------------------+-------------------------------------------+
| > Personnel             | -   The VISN has identified personnel to  |
|                         |     > staff rapid managed evacuation,     |
|                         |     > both management ("Floor Marshals"   |
|                         |     > or equivalent) and personnel        |
|                         |     > trained and qualified to transport  |
|                         |     > patients with emergency evacuation  |
|                         |     > devices.                            |
+-------------------------+-------------------------------------------+
| Process                 | -   VISN has an evacuation plan.          |
|                         |                                           |
|                         | -   There is a process for transporting   |
|                         |     > patients, their medications and     |
|                         |     > critical equipment, records, and    |
|                         |     > staff to an alternate care site.    |
|                         |                                           |
|                         | -   There is a process for securing       |
|                         |     > facilities after evacuation of      |
|                         |     > patients, visitors and staff.       |
|                         |                                           |
|                         | -   A Planning Process is described to    |
|                         |     > resolve the hazard and return the   |
|                         |     > facilities to function as rapidly   |
|                         |     > as possible.                        |
|                         |                                           |
|                         | -   There is a process to communicate     |
|                         |     > with patients and their families    |
|                         |     > during emergencies, including       |
|                         |     > notification when patients are      |
|                         |     > relocated to alternate care sites.  |
+-------------------------+-------------------------------------------+
| Education/Training      | -   VISN staff charged with conducting    |
|                         |     > the evacuation are trained to an    |
|                         |     > operational level to carry out the  |
|                         |     > plan.                               |
|                         |                                           |
|                         | -   Staff are trained in their role on    |
|                         |     > the VISN evacuation plan (e.g.,     |
|                         |     > patient movement, mobilizing        |
|                         |     > medical records, meds and critical  |
|                         |     > medical equipment, use of           |
|                         |     > evacuation devices).                |
|                         |                                           |
|                         | -   Staff can explain the criteria that   |
|                         |     > would necessitate an occupant       |
|                         |     > safety evacuation.                  |
+-------------------------+-------------------------------------------+
| Exercise                | -   Exercise of the full evacuation plan  |
|                         |     > is conducted annually.              |
|                         |                                           |
|                         | -   The vertical evacuation plan is       |
|                         |     > tested via Tabletop at least        |
|                         |     > annually including use of           |
|                         |     > evacuation devices as part of the   |
|                         |     > exercise.                           |
+-------------------------+-------------------------------------------+
| Evaluation              | -   Evacuation is evaluated through       |
|                         |     > exercises and evaluative drills.    |
+-------------------------+-------------------------------------------+
| Organizational Learning | -   Findings from the AARs are            |
|                         |     > incorporated as improvements into   |
|                         |     > the evacuation process and other    |
|                         |     > aspects of the EMP at the VISN.     |
+-------------------------+-------------------------------------------+

**Questions**:

VISN Office EMP:

1.  Is there a documented procedure for how to determine when evacuation
    > of the VISN office or shelter-in-place is necessary?

2.  Is there a signal that can reach ALL areas of the VISN Office for
    > emergency/immediate evacuation or shelter-in-place?

3.  Are there pre-established meetings places ("rally points" for
    > accountability) VISN staff once immediately evacuated?

4.  Describe the process for securing VISN Office priority documents
    > during an evacuation.

5.  Does the VISN Office landlord or servicing VA facility initiate
    > security and safety measures for evacuation procedures?

### Processes and Procedures for Sheltering-in-Place 

**Description:** To demonstrate this capability the VISN should have a
plan to ensure the safety of employees, patients, and visitors who may
be required to remain at the facility for an extended period of time
during an emergency.

**Rationale:** Some emergencies require the VISN or its VAMCs to house
additional employees, families, and visitors and serve as a safe refuge
until the emergency response and recovery has been completed. The VISN
needs to develop a shelter-in-place plan for these kinds of
circumstances.

**Measurement**:

-   **Pre-Survey**

-   **Review of EOP**

-   Review of shelter-in-place plan (i.e., procedures, designated areas,
    training)

-   **Interviews with DND, CMO, and EPC**

Framework for Capability Description

+-------------------------+-------------------------------------------+
| Capability Element      | Assessment components                     |
+=========================+===========================================+
| Policy/Organization     | -   The VISN demonstrates the ability to  |
|                         |     > shelter patients, visitors, and     |
|                         |     > staff within the VISN or its VAMCs  |
|                         |     > in a medically and physically safe  |
|                         |     > environment.                        |
+-------------------------+-------------------------------------------+
| Resources               |                                           |
+-------------------------+-------------------------------------------+
| > Supplies              | -   VISN has identified critical supplies |
|                         |     > needed to sustain a VISN            |
|                         |     > shelter-in-place operation for an   |
|                         |     > extended period of time. These      |
|                         |     > supplies include water, food,       |
|                         |     > housing, beds linens, etc.          |
+-------------------------+-------------------------------------------+
| > Facilities/Equipment  | -   Immediate safe-havens away from       |
|                         |     > hazards                             |
|                         |                                           |
|                         | -   A location within the VISN is         |
|                         |     > identified for a safe and effective |
|                         |     > and potentially prolonged           |
|                         |     > shelter-in-place, providing both    |
|                         |     > shelter for those seeking refuge    |
|                         |     > and the supporting infrastructure   |
|                         |     > for continuity of critical medical  |
|                         |     > services.                           |
|                         |                                           |
|                         | -   Facility for conducting the IMT       |
|                         |     > (back-up EOC) if regular EOC must   |
|                         |     > be abandoned to shelter-in-place.   |
|                         |                                           |
|                         | -   Communications and IT equipment and   |
|                         |     > services to maintain contact with   |
|                         |     > VISN and outside response agencies  |
|                         |     > from the shelter                    |
+-------------------------+-------------------------------------------+
| > Personnel             | -   VISN identifies qualified and trained |
|                         |     > staff to activate and manage a      |
|                         |     > shelter-in-place activity.          |
+-------------------------+-------------------------------------------+
| Process                 | -   A shelter-in-place process is         |
|                         |     > described in the EOP.               |
|                         |                                           |
|                         | -   Process for moving patients, visitors |
|                         |     > and staff immediately away from     |
|                         |     > danger (shattering windows, fire,   |
|                         |     > flooding, collapse) and then for    |
|                         |     > transport to the shelter.           |
|                         |                                           |
|                         | -   Process for continually assessing     |
|                         |     > medical and physical safety while   |
|                         |     > remaining in the shelter-in-place   |
|                         |     > location.                           |
+-------------------------+-------------------------------------------+
| Education/Training      | -   Staff assigned to the                 |
|                         |     > shelter-in-place activity are       |
|                         |     > trained consistent with their roles |
|                         |     > and responsibilities.               |
+-------------------------+-------------------------------------------+
| Exercise                | -   A shelter-in-place activity is part   |
|                         |     > of a VISN exercise at least         |
|                         |     > annually.                           |
+-------------------------+-------------------------------------------+
| Evaluation              | -   Shelter-in-place is evaluated through |
|                         |     > the exercise AAR process.           |
+-------------------------+-------------------------------------------+
| Organizational Learning | -   AAR findings are analyzed and         |
|                         |     > improvements in the                 |
|                         |     > shelter-in-place process are        |
|                         |     > incorporated into the VISN's EOP,   |
|                         |     > facilities, training or other       |
|                         |     > elements of the EMP.                |
+-------------------------+-------------------------------------------+

**Questions:**

VISN Office EMP:

1.  Does the EOP identify a scalable response for sheltering in place?

2.  If yes, does it include:

    a.  Decision process for shelter-in-place;

    b.  Ability to shut down Heating Ventilation and Air Conditioning
        (HVAC) systems (If yes, how quickly?);

    c.  Plans for relocation of patients into sheltered areas of your
        facility?

3.  Is there a signal that can reach ALL areas of the VISN for
    emergency/immediate evacuation or shelter-in-place for the VISN?

4.  Does the VISN have a plan for managing staff support activities?

5.  What is the level of involvement of the VISN with individual VAMC
    shelter-in-place plans?

6.  How are facility resource needs to improve shelter-in-place plans
    reviewed and funded?

### Processes and Procedures for Sheltering Family of Critical Staff

**Description:** To demonstrate this capability the VISN will be able to
house family members of staff who may be required for extended
operations during an emergency.

**Rationale:** To ensure that critical employees will come to work and
be assured that their families are well cared for, it is essential to
provide shelter for the families of critical employees.

**Measurement**:

-   **Site Tour (view area of proposed shelter)**

-   **Review of EOP**

-   Review of shelter-in-place plan for family of critical staff (i.e.,
    procedures, resources, training)

-   **Interview with VISN EPC and DND**

Framework for Capability Description

+-------------------------+-------------------------------------------+
| Capability Element      | Assessment components                     |
+=========================+===========================================+
| Policy/Organization     | -   The VISN demonstrates the ability to  |
|                         |     > provide safe shelter for families   |
|                         |     > of critical VISN staff during       |
|                         |     > emergencies and disasters and       |
|                         |     > oversee and assist VISN VAMCs in    |
|                         |     > similar operations.                 |
+-------------------------+-------------------------------------------+
| Resources               |                                           |
+-------------------------+-------------------------------------------+
| > Supplies              | -   The VISN has housing arrangements,    |
|                         |     > food, and other essential services  |
|                         |     > necessary to maintain a shelter for |
|                         |     > family members.                     |
+-------------------------+-------------------------------------------+
| > Facilities/Equipment  | -   The VISN has a designated area for    |
|                         |     > shelter of staff's family members.  |
|                         |                                           |
|                         | -   Plans include housing arrangements,   |
|                         |     > food, childcare and other essential |
|                         |     > services.                           |
+-------------------------+-------------------------------------------+
| > Personnel             | -   VISN assigns staff to manage the      |
|                         |     > Family Shelter plan.                |
|                         |                                           |
|                         | -   Chaplain support to families is       |
|                         |     > available.                          |
+-------------------------+-------------------------------------------+
| Process                 | -   The family shelter process is         |
|                         |     > delineated as an element in the     |
|                         |     > EOP.                                |
|                         |                                           |
|                         | -   Procedure for assessing and           |
|                         |     > registering family members for      |
|                         |     > accountability and needs.           |
|                         |                                           |
|                         | -   Procedure for orienting family        |
|                         |     > members to facility rules,          |
|                         |     > available services.                 |
|                         |                                           |
|                         | -   Procedure for assigning living space. |
+-------------------------+-------------------------------------------+
| Education/Training      | -   VISN staff who manage the plan are    |
|                         |     > trained with respect to their role  |
|                         |     > concerning activation, operation,   |
|                         |     > and decommissioning of the plan.    |
+-------------------------+-------------------------------------------+
| Exercise                | -   The plan is exercised at least        |
|                         |     > annually.                           |
+-------------------------+-------------------------------------------+
| Evaluation              | -   VISN conducts an annual evaluation of |
|                         |     > the family shelter plan at the      |
|                         |     > VISN.                               |
+-------------------------+-------------------------------------------+
| Organizational Learning | -   Findings from the annual review are   |
|                         |     > incorporated into the family        |
|                         |     > shelter plan.                       |
+-------------------------+-------------------------------------------+

**Questions:**

VISN Office EMP:

1.  Does the VISN have a plan for sheltering family members of essential
    > facility staff during and emergency?

2.  If yes, does this policy include sheltering of pets?

3.  Does the VISN provide transportation for staff family members to the
    > facility?

4.  Does the VISN communicate the need for family members to bring
    > personal items for the duration of the shelter-in-place period?

5.  Does the VISN institute occupant safety measures for
    > shelter-in-place?

6.  Has the VISN allocated external alternative shelter-in-place
    > locations for family members?

7.  How does the VISN interact and support individual VAMCs family
    > shelter plans?

Perimeter Management of Access/Egress to Facility during an Incident (e.g., Lock Down)
--------------------------------------------------------------------------------------

**Description:** To demonstrate this capability the VISN must be able to
restrict access to and from the campus and individual buildings during
an emergency.

**Rationale:** During emergencies, it is essential to be able to secure
the VISN and VAMCs to protect all occupants.

**How Measured**:

-   **Review of EOP -- Perimeter management procedure should address
    traffic control; access to buildings; crowd control and special
    security procedures for the higher levels of the Homeland Security
    Advisory System (HSAS)**

-   **Interview with EPC and VISN Safety Manager**

Framework for Capability Description

+-------------------------+-------------------------------------------+
| Capability Element      | Assessment components                     |
+=========================+===========================================+
| Policy/Organization     | -   The VISN demonstrates the ability to  |
|                         |     > rapidly control the facility        |
|                         |     > perimeter and manage appropriate    |
|                         |     > access/egress.                      |
|                         |                                           |
|                         | -   VISN provides perimeter management    |
|                         |     > oversight for VAMCs as needed       |
|                         |     > during incidents                    |
+-------------------------+-------------------------------------------+
| Resources               |                                           |
+-------------------------+-------------------------------------------+
| > Supplies              | -   The VISN has appropriate signage and  |
|                         |     > SOPs in place.                      |
+-------------------------+-------------------------------------------+
| > Facilities/Equipment  | -   VISN has devices installed and        |
|                         |     > operational to lockdown the         |
|                         |     > facility.                           |
|                         |                                           |
|                         | -   Communication equipment to receive    |
|                         |     > orders and confirm actions          |
|                         |     > completed, including for any        |
|                         |     > non-security surge staff recruited  |
|                         |     > for this effort.                    |
+-------------------------+-------------------------------------------+
| > Personnel             | -   Security and police personnel plus    |
|                         |     > additional staff qualified and      |
|                         |     > trained to support the perimeter    |
|                         |     > management activities.              |
|                         |                                           |
|                         | -   A POC is identified to communicate    |
|                         |     > with the VAMCs during exercises and |
|                         |     > incidents regarding perimeter       |
|                         |     > management issues/policy            |
+-------------------------+-------------------------------------------+
| Process                 | -   VISN has a documented plan to         |
|                         |     > accomplish a lock down program      |
|                         |     > including adequate assigned         |
|                         |     > personnel.                          |
|                         |                                           |
|                         | -   Procedure for perimeter patrol to     |
|                         |     > confirm perimeter control.          |
|                         |                                           |
|                         | -   When the VISN is in lockdown mode,    |
|                         |     > security personnel enforce          |
|                         |     > effective traffic controlling       |
|                         |     > measures.                           |
+-------------------------+-------------------------------------------+
| Education/Training      | -   VISN staff are trained with respect   |
|                         |     > to their role during a campus or    |
|                         |     > facility lock down.                 |
+-------------------------+-------------------------------------------+
| Exercise                | -   The Perimeter Control Process is      |
|                         |     > tested.                             |
+-------------------------+-------------------------------------------+
| Evaluation              | -   Evaluation of the perimeter           |
|                         |     > management is conducted during      |
|                         |     > exercises and captures in AARs      |
|                         |     > after exercises and actual          |
|                         |     > incidents.                          |
+-------------------------+-------------------------------------------+
| Organizational Learning | -   AAR findings are analyzed and         |
|                         |     > improvements in the perimeter       |
|                         |     > control process are incorporated    |
|                         |     > into the EOP, training or other     |
|                         |     > elements of the EMP.                |
+-------------------------+-------------------------------------------+

**Questions**:

VISN Office EMP:

1.  Does the VISN office have procedures in place to ensure the physical
    > security?

2.  Does the VISN office have a lock down procedure?

3.  If yes, how quickly can it be completed?

4.  How often is this procedure tested?

5.  Does the plan include the following:

    a.  Verifying identification of staff accessing the VISN Office?

    b.  Providing identification to individuals (non-staff) granted
        access to the VISN Office?

    c.  Providing methods to control the movements of non-staff within
        the VISN Office ?

    d.  Pre-established procedures for a bomb threat?

    e.  Pre-established procedures for the receipt of a suspicious
        package?

    f.  Pre-established procedures for the receipt of a white powder
        package?

    g.  Pre-established procedures for the de-escalation of violent
        situations?

6.  Are VISN Office security personnel trained on how to manage issues
    > specific to a lockdown situation?

7.  Does the VISN Office integrate community law enforcement agencies
    > (i.e., police and sheriff) as needed for additional assistance?

Processes and Procedures for Managing a Hazardous Substance Incident 
--------------------------------------------------------------------

**Description:** To demonstrate this capability the VISN must have the
ability to protect patients, employees, and visitors, as well as the
infrastructure from a hazardous material incident.

**Rationale:** To maintain the safety of occupants and infrastructure,
as well as to ensure continued operations, the VHA Central Office (CO)
determined the need to institute a decontamination program at most
VAMCs.

**Measurement at VAMCs**:

-   **Pre-Survey**

-   **Review of EOP**

-   **Interviews with Emergency Manager and Safety Manager**

-   **Capability Demonstration (see below)**

Framework for Capability Description

+-------------------------+-------------------------------------------+
| Capability Element      | Assessment components                     |
+=========================+===========================================+
| Policy/Organization     | -   The VISN provides oversight to ensure |
|                         |     > facilities' have a program to       |
|                         |     > maintain safety when a hazardous    |
|                         |     > substance (chemical, biological,    |
|                         |     > radiological) incident occurs.      |
|                         |                                           |
|                         | -   VISN provides personal measures for   |
|                         |     > the protection of office staff,     |
|                         |     > visitors', and infrastructure from  |
|                         |     > hazardous substance incident.       |
+-------------------------+-------------------------------------------+
| Resources               |                                           |
+-------------------------+-------------------------------------------+
| > Supplies              | -   VAMC has identified and obtained the  |
|                         |     > necessary supplies to support the   |
|                         |     > decontamination program.            |
+-------------------------+-------------------------------------------+
| > Facilities/Equipment  | -   Decontamination facility and          |
|                         |     > equipment, including appropriate    |
|                         |     > PPE, signage, and equipment         |
+-------------------------+-------------------------------------------+
| > Personnel             | -   VAMC has a functioning program which  |
|                         |     > includes staff that are capable of  |
|                         |     > activating and operating a          |
|                         |     > decontamination program at the      |
|                         |     > facility.                           |
|                         |                                           |
|                         | -   Staff can describe patient            |
|                         |     > presentations that would require    |
|                         |     > decontamination.                    |
+-------------------------+-------------------------------------------+
| Process                 | -   VISN Office has a process for         |
|                         |     > communicating with and providing    |
|                         |     > necessary resources for VAMCs       |
|                         |     > involved in a hazardous substance   |
|                         |     > incident.                           |
|                         |                                           |
|                         | -   Facility has a process for handling   |
|                         |     > hazardous materials and waste once  |
|                         |     > response efforts are initiated.     |
|                         |                                           |
|                         | -   Facility has a process for            |
|                         |     > identifying chemical, biological,   |
|                         |     > and radiological materials,         |
|                         |     > including isolation and             |
|                         |     > decontamination.                    |
|                         |                                           |
|                         | -   VAMC has a functioning process which  |
|                         |     > includes staff that are capable of  |
|                         |     > activating and operating a          |
|                         |     > decontamination program at the      |
|                         |     > facility on all shifts.             |
|                         |                                           |
|                         | -   The VAMC has a comprehensive          |
|                         |     > decontamination process that        |
|                         |     > addresses facility/staff protection |
|                         |     > while rapidly providing             |
|                         |     > decontamination services in a safe  |
|                         |     > manner.                             |
|                         |                                           |
|                         | -   Portable decontamination facilities   |
|                         |     > are properly stored and readily     |
|                         |     > available for activation, with      |
|                         |     > mobilization guidance for 24/7/365  |
|                         |     > activation.                         |
|                         |                                           |
|                         | -   People on Decontamination Team are    |
|                         |     > enrolled in the VAMC Respiratory    |
|                         |     > Protection Program and meet the     |
|                         |     > requirements of the Occupational    |
|                         |     > Safety and Health Administration    |
|                         |     > (OSHA).                             |
|                         |                                           |
|                         | -   Staff can describe patient            |
|                         |     > presentations that would indicate   |
|                         |     > activation of facility protection   |
|                         |     > and victim decontamination          |
|                         |     > processes.                          |
+-------------------------+-------------------------------------------+
| Education/Training      | -   VISN Office staff (those designated)  |
|                         |     > are trained to the appropriate      |
|                         |     > level for Liaison support with the  |
|                         |     > VAMCs                               |
|                         |                                           |
|                         | -   VAMC staff on the Decontamination     |
|                         |     > Team are trained in accordance with |
|                         |     > OSHA standards consistent with the  |
|                         |     > First Receiver doctrine, and        |
|                         |     > trained to an operational level in  |
|                         |     > the specific VAMC decontamination   |
|                         |     > system.                             |
+-------------------------+-------------------------------------------+
| Exercise                | -   Regular exercises are conducted and   |
|                         |     > the decontamination team is         |
|                         |     > integrated with patient reception   |
|                         |     > and evacuation teams and perimeter  |
|                         |     > management personnel.               |
+-------------------------+-------------------------------------------+
| Evaluation              | -   Exercises are evaluated through the   |
|                         |     > AAR process and findings are        |
|                         |     > documented.                         |
+-------------------------+-------------------------------------------+
| Organizational Learning | -   VAMC Decontamination Program is       |
|                         |     > updated annually based upon AAR     |
|                         |     > findings from actual experiences    |
|                         |     > and exercises conducted during the  |
|                         |     > year with improvements incorporated |
|                         |     > into EOP, training equipment and    |
|                         |     > other mitigation/preparedness       |
|                         |     > activities.                         |
+-------------------------+-------------------------------------------+

**Questions:**

VISN Office EMP:

1.  Have the VISN office staff been trained in how to react to possible
    contamination of the outside environment and possible contact with
    victims approaching the VISN Office?

2.  Does the VISN Office conduct exercises with the servicing VAMC
    Decontamination Program? If yes, how often?

3.  If the VISN Office is not located on a VA facility campus, what
    instructions have been given to VISN Office staff in the event of
    possible contamination of staff or visitors?

**Capability Observation**:

1.  Staff demonstrates the proper donning and doffing procedure for a
    > Powered Air Purifying Respirator (PAPR).

2.  Staff demonstrates how to properly don and doff a Level C chemical
    > protective suit.

3.  Facility staff demonstrate procedure for disposal of contaminated
    > Personal Protective Equipment (PPE).

4.  Staff effectively demonstrates the set-up and break-down procedures
    > for a portable decontamination system, if applicable.

5.  Staff effectively set-up fixed decontamination system.

6.  Staff demonstrates the proper usage of equipment used to detect
    > chemical, biological, or radiological materials.

7.  Medical staff are capable of demonstrating how to set up a
    > decontamination corridor and provide security measures to contain
    > the area.

8.  Staff demonstrates inspection of waste water containment drum.

Infection Control
-----------------

VISN facilities provides Infection Control (IC) measures as appropriate
to the incident.

### Biohazard (Infection) Control Surge Services during Emergencies 

**Description:** To demonstrate this capability the VISN must have a
plan to protect the infrastructure and staff as well as safely manage
patients presenting with symptoms associated with potentially infectious
agents.

**Rationale:** In the setting of potentially infectious emergency
events, existing IC practitioners' capabilities will be greatly taxed.
Having additional staff trained on IC practices will help to ensure the
safety of patients and staff and visitors.

**Measured**:

-   **Review of EOP**

-   **Interviews with the DND and CMO**

Framework for Capability Description

+-------------------------+-------------------------------------------+
| Capability Element      | Assessment components                     |
+=========================+===========================================+
| Policy/Organization     | -   The facility demonstrates the ability |
|                         |     > to manage unusual and high-risk     |
|                         |     > infections in a surge of infected   |
|                         |     > patients while maintaining safety   |
|                         |     > for staff, other patients and       |
|                         |     > visitors and sustaining COOP.       |
+-------------------------+-------------------------------------------+
| Resources               |                                           |
+-------------------------+-------------------------------------------+
| > Supplies              | > VISNs ensure and are aware that the     |
|                         | > following supplies are available at the |
|                         | > VISN facilities:                        |
|                         |                                           |
|                         | -   Appropriate PPE                       |
|                         |                                           |
|                         | -   Appropriate isolation supplies        |
|                         |                                           |
|                         | -   Appropriate infection/contamination   |
|                         |     > monitoring supplies, including      |
|                         |     > additional diagnostic supplies in   |
|                         |     > the lab                             |
+-------------------------+-------------------------------------------+
| > Facilities/Equipment  | -   The VISN ensures that facilities can  |
|                         |     > identify all isolation rooms and    |
|                         |     > develop a plan for increasing the   |
|                         |     > number of rooms as practical during |
|                         |     > an emergency.                       |
|                         |                                           |
|                         | -   Facilities for screening staff,       |
|                         |     > patients and visitors for           |
|                         |     > contagious disease (such as Severe  |
|                         |     > Acute Respiratory Syndrome          |
|                         |     > \[SARS\]) prior to entry into       |
|                         |     > buildings are identified.           |
|                         |                                           |
|                         | -   Screening and diagnostic equipment    |
|                         |     > sufficient for the surge            |
+-------------------------+-------------------------------------------+
| > Personnel             | -   Facility identifies staff qualified   |
|                         |     > and trained in expanded IC roles    |
+-------------------------+-------------------------------------------+
| Process                 | > VISNs ensure and are aware that         |
|                         | > facilities engage in the following      |
|                         | > process to ensure readiness in the      |
|                         | > event of a surge of infected patients:  |
|                         |                                           |
|                         | -   The biohazard (IC) surge process is   |
|                         |     > delineated in the EOP, including    |
|                         |     > guidance for mobilizing the         |
|                         |     > indicated resources.                |
|                         |                                           |
|                         | -   Process for screening for the suspect |
|                         |     > disease prior to entry into VAMC    |
|                         |     > facilities as indicated (SARS and   |
|                         |     > others)                             |
|                         |                                           |
|                         | -   Process for separating potentially    |
|                         |     > infected cases from other patients, |
|                         |     > visitors, and unprotected staff     |
|                         |                                           |
|                         | -   Procedures for identifying and        |
|                         |     > adequately cleaning biohazard       |
|                         |     > contaminated areas                  |
|                         |                                           |
|                         | -   Procedure for relieving staff of      |
|                         |     > duties and providing paid leave in  |
|                         |     > case of significant exposure or     |
|                         |     > signs of suspect disease            |
|                         |                                           |
|                         | -   Process for treating personnel who    |
|                         |     > become ill from occupational        |
|                         |     > exposure to the suspect illness     |
|                         |                                           |
|                         | -   Supplies needed to expand the IC      |
|                         |     > program during an emergency are     |
|                         |     > pre-identified, cached, and stored  |
|                         |     > in a secure location                |
|                         |                                           |
|                         | -   The surge process for increased       |
|                         |     > biohazard contaminated trash is     |
|                         |     > delineated.                         |
+-------------------------+-------------------------------------------+
| Education/Training      | -   Staff are trained in their IC program |
|                         |     > roles, and their roles are          |
|                         |     > communicated within the facility.   |
+-------------------------+-------------------------------------------+
| Exercise                | -   Biohazard (IC) capability will be     |
|                         |     > exercised in facility-wide          |
|                         |     > exercises at least once a year and  |
|                         |     > will contribute to the after action |
|                         |     > reporting process.                  |
+-------------------------+-------------------------------------------+
| Evaluation              | -   The role of the expanded Biohazard    |
|                         |     > (IC) program is evaluated after     |
|                         |     > each exercise and findings are      |
|                         |     > documented                          |
+-------------------------+-------------------------------------------+
| Organizational Learning | -   The expanded biohazard (IC) plan is   |
|                         |     > updated annually as part of the     |
|                         |     > overall review of the VAMC's EOP    |
|                         |     > and EMP.                            |
+-------------------------+-------------------------------------------+

**Questions:**

VISN Office EMP:

1.  Are VISN Office staff trained in proper procedures in the event the
    office is visited by a potentially seriously infected patient?

2.  How is the VISN Office supported in this case by the servicing VAMC?

3.  Is the VISN Office able to control the HVAC systems in any hazard
    incident (e.g., smoke or biological agents)?

4.  Are VISN Office staff or security personnel trained on and have
    available PPE for: Dealing with contaminated patients; Dealing with
    infectious/contagious patients?

5.  How are procedures tested?

### Selection and Use of Personal Protective Equipment for Incident Response and Recovery Operations

**Description:** To demonstrate this capability the VISN must be able to
properly equip and train its staff in PPE, including the use of
appropriate respiratory protection.

**Rationale:** Healthcare worker selection and use of appropriate PPE
including respiratory protection, is a fundamental element of any
effective EMP, particularly when responding to biological and chemical
threats. VISN leadership should be aware that all VISN facilities have
the needed supply of proper PPE and a program of respiratory protection
and medical monitoring.

**Measurement**:

-   **Interviews with VISN EPC and Safety Officer**

-   **At the facility level the capability is measured through a
    demonstration (see below)**

Framework for Capability Description

+-------------------------+-------------------------------------------+
| Capability Element      | Assessment components                     |
+=========================+===========================================+
| Policy/Organization     | -   VISN assures that facilities can      |
|                         |     > demonstrate the ability to provide  |
|                         |     > PPE and training to VAMC personnel  |
|                         |     > for the safe and effective          |
|                         |     > management of hazards likely to be  |
|                         |     > encountered in the healthcare       |
|                         |     > facility environment.               |
+-------------------------+-------------------------------------------+
| Resources               |                                           |
+-------------------------+-------------------------------------------+
| > Supplies              | -   VAMC staff are issued PPE and         |
|                         |     > associated supplies as determined   |
|                         |     > by their role in emergency          |
|                         |     > response.                           |
+-------------------------+-------------------------------------------+
| > Facilities/Equipment  | -   PPE is assigned to VAMC staff as      |
|                         |     > appropriate.                        |
|                         |                                           |
|                         | -   Staff assigned PPE are responsible    |
|                         |     > for using and maintaining this      |
|                         |     > equipment.                          |
|                         |                                           |
|                         | -   Staff undergo regular PPE fit testing |
|                         |     > annually.                           |
+-------------------------+-------------------------------------------+
| > Personnel             | -   The facility identifies a cadre of    |
|                         |     > trained and otherwise qualified     |
|                         |     > personnel to safely wear the levels |
|                         |     > of PPE and operate in the projected |
|                         |     > hazardous substance environment.    |
+-------------------------+-------------------------------------------+
| Process                 | -   VISN assures that all VAMC staff that |
|                         |     > respond to emergencies have a job   |
|                         |     > hazard analysis (based on the       |
|                         |     > facility's HVA) and are assigned    |
|                         |     > suitable PPE including enrollment   |
|                         |     > in the Respiratory Protection       |
|                         |     > Program for those on the            |
|                         |     > decontamination team.               |
+-------------------------+-------------------------------------------+
| Education/Training      | -   VAMC staff issued PPE during          |
|                         |     > emergencies are trained in its      |
|                         |     > proper use and care on a recurring  |
|                         |     > basis                               |
|                         |                                           |
|                         | -   Training intervals are consistent     |
|                         |     > with OSHA requirements and          |
|                         |     > frequencies identified for PPE use  |
|                         |     > during normal operations.           |
|                         |                                           |
|                         | -   VAMC personnel are trained to an      |
|                         |     > operational level on their          |
|                         |     > particular decontamination system.  |
+-------------------------+-------------------------------------------+
| Exercise                | -   Activation of the decontamination     |
|                         |     > system in a Functional Exercise     |
|                         |     > should be conducted in conjunction  |
|                         |     > with a larger VAMC exercise.        |
+-------------------------+-------------------------------------------+
| Evaluation              | -   The AAR from exercise should include  |
|                         |     > evaluation of the decontamination   |
|                         |     > system performance. Safety Officer  |
|                         |     > conducts an annual evaluation of    |
|                         |     > the PPE program at the VAMC.        |
+-------------------------+-------------------------------------------+
| Organizational Learning | -   Findings from the AAR and from the    |
|                         |     > Safety Officer evaluation are used  |
|                         |     > to incorporate improvements into    |
|                         |     > the PPE program at the VAMC.        |
+-------------------------+-------------------------------------------+

**Questions:**

VISN Oversight:

1.  Discuss how the VISN ensures that facilities have pre-established
    procedures for medical monitoring of decontamination personnel
    wearing PPE and a tracking system in place to inventory all PPE.

2.  How does the VISN assure that the VISN facilities sufficient PAPRs
    for decontamination operations?

3.  Do facilities have an adequate number of Chemical Resistive Suits,
    PPE and related items such as boots, gloves, tape, etc. (at least
    four pair for each position requiring Level C PPE in your facility's
    Contaminated Casualties/decontamination plan)?

VISN Office EMP:

4.  Discuss how the VISN Office ensures VISN Office staff have the
    necessary training and equipment to protect themselves during a
    hazardous incident.

**Capability Observation**:

1.  Facility staff are capable of selecting appropriate PPE for the
    > incident.

2.  Facility staff are capable of demonstrating proper techniques for
    > donning and doffing of PPE.

3.  Facility staff demonstrate procedure for disposal of contaminated
    > PPE

###  Processes and Procedures for Staff and Family Mass Prophylaxis during an Infectious Outbreak (i.e., Influenza)

**Description:** To demonstrate this capability the VISN must have the
ability to distribute medical counter measures to protect critical staff
and select family in the event of potential exposure to an infectious
agent.

**Rationale:** Prophylaxis of staff and the staff's family members is
crucial to maintaining an effective workforce.

**Measurement**:

-   **Review of EOP**

-   **Interviews with CMO and VISN Safety Officer**

-   **Interview with VISN Pharmacy Manager, if available**

Framework for Capability Description

+-------------------------+-------------------------------------------+
| Capability Element      | Assessment components                     |
+=========================+===========================================+
| Policy/Organization     | -   VISN facilities must be able to       |
|                         |     > protect staff and their families    |
|                         |     > from a virulent infectious agent    |
|                         |     > when effective prophylactic         |
|                         |     > medication or vaccines are          |
|                         |     > available.                          |
|                         |                                           |
|                         | -   Dispersal of Tamiflu for a Pandemic   |
|                         |     > will require a declaration from the |
|                         |     > World Health Organization (WHO) or  |
|                         |     > the Centers for Disease Control and |
|                         |     > Prevention (CDC)                    |
+-------------------------+-------------------------------------------+
| Resources               |                                           |
+-------------------------+-------------------------------------------+
| > Supplies              | -   Adequate supplies of pharmaceuticals  |
|                         |     > are available at the facility for   |
|                         |     > the prophylaxis program.            |
|                         |                                           |
|                         | -   Adequate packaging and labeling and   |
|                         |     > other supporting supplies are       |
|                         |     > available.                          |
+-------------------------+-------------------------------------------+
| > Facilities/Equipment  | -   Pharmaceutical dispensing and         |
|                         |     > labeling equipment, information     |
|                         |     > technology for logging recipients   |
|                         |     > and other appropriate equipment     |
+-------------------------+-------------------------------------------+
| > Personnel             | -   The facility has identified           |
|                         |     > pharmacists, nurses and dispensing  |
|                         |     > personnel to operate in the         |
|                         |     > dispensing program.                 |
+-------------------------+-------------------------------------------+
| Process                 | -   The processes for distribution of     |
|                         |     > prophylaxis are delineated in       |
|                         |     > accordance with the VA Pharmacy     |
|                         |     > Benefits Managements Service (PBM), |
|                         |     > including medical screening of      |
|                         |     > medication recipients,              |
|                         |     > accountability, and other key       |
|                         |     > issues.                             |
|                         |                                           |
|                         | -   Prophylaxis medications are stored in |
|                         |     > a proper and secure location.       |
|                         |                                           |
|                         | -   Equipment needed to support this      |
|                         |     > program are available, properly     |
|                         |     > stored in a secure location.        |
|                         |                                           |
|                         | -   VAMC staff can administer an          |
|                         |     > effective plan for mass prophylaxis |
|                         |     > for staff and staff's family        |
|                         |     > members.                            |
|                         |                                           |
|                         | -   VA All-Hazards Emergency Caches are   |
|                         |     > tracked by the Emergency Pharmacy   |
|                         |     > Service (EPS) and product removal   |
|                         |     > and replacement is done with        |
|                         |     > guidance by the EPS (facilities     |
|                         |     > should not discard products unless  |
|                         |     > directed to do so by the EPS).      |
+-------------------------+-------------------------------------------+
| Education/Training      | -   Staff are trained in their role in    |
|                         |     > the facility's prophylaxis program. |
+-------------------------+-------------------------------------------+
| Exercise                | -   The processes for distribution of     |
|                         |     > prophylaxis are evaluated at least  |
|                         |     > annually.                           |
+-------------------------+-------------------------------------------+
| Evaluation              | -   VAMC conducts an annual evaluation of |
|                         |     > the mass prophylaxis program at the |
|                         |     > VAMC.                               |
+-------------------------+-------------------------------------------+
| Organizational Learning | -   Findings from the exercise AAR and    |
|                         |     > the annual review inform            |
|                         |     > improvements that are incorporated  |
|                         |     > into the plan.                      |
+-------------------------+-------------------------------------------+

**Questions:**

VISN Oversight:

1.  Is the VISN office part of the servicing VAMC's staff and family
    mass prophylaxis plan?

2.  Describe how the VISN is involved in mass prophylaxis.

**Resiliency/Continuity of Operations** 
=======================================

Ensuring continuity of operations is essential to VISNs given the
expectation that they will be able to provide high-quality support and
coordination of VISN facilities during normal times and emergencies. To
ensure continuity of operations, the following capabilities are critical
to all VISNs:

-   Personnel Resiliency

-   Mission Critical Systems

-   Communications

The following sections will describe these resiliency/COOP capabilities,
including their rationale and measurement.

Personnel Resiliency
--------------------

The VISN demonstrates effective COOPs measures that address personnel
resiliency to the impact of emergency situations.

### Maintaining Authorized Leadership (Leadership Succession)

**Description:** To demonstrate this capability the VISN must have a
plan to ensure continuous operations in the event that the management
team is not able to convene or function.

**Rationale:** In the event that an emergency causes the existing
leadership team to be incapacitated, there must be well-defined and
communicated lines of leadership succession.

**How Measured**:

-   **Review of EOP**

-   **Interviews with DND/VISN COO**

Framework for Capability Description

+-------------------------+-------------------------------------------+
| Capability Element      | Assessment components                     |
+=========================+===========================================+
| Policy/Organization     | -   The VISN demonstrates an effective    |
|                         |     > and orderly process for maintaining |
|                         |     > leadership authorities.             |
+-------------------------+-------------------------------------------+
| Resources               |                                           |
+-------------------------+-------------------------------------------+
| > Supplies              | -   Relevant forms and action guidance    |
|                         |     > are available to staff.             |
+-------------------------+-------------------------------------------+
| > Facilities/Equipment  | -   Communications equipment to support   |
|                         |     > transition to new leadership, and   |
|                         |     > to notify VA authorities            |
+-------------------------+-------------------------------------------+
| > Personnel             | -   The positions in the line of          |
|                         |     > succession are staffed with         |
|                         |     > qualified and trained personnel.    |
+-------------------------+-------------------------------------------+
| Process                 | -   A process is described for temporary  |
|                         |     > or permanent transfer of authority  |
|                         |     > under emergency conditions.         |
|                         |                                           |
|                         | -   Lines of succession including job     |
|                         |     > descriptions are developed and      |
|                         |     > maintained in the EOP               |
|                         |                                           |
|                         | -   Process to provide VISN oversight for |
|                         |     > VAMC lines of succession            |
+-------------------------+-------------------------------------------+
| Education/Training      | -   VISN leadership is trained with       |
|                         |     > respect to their roles during       |
|                         |     > response and recovery operations.   |
|                         |                                           |
|                         | -   Incident Command staff at all levels  |
|                         |     > are educated about the leadership   |
|                         |     > succession plan.                    |
+-------------------------+-------------------------------------------+
| Exercise                | -   Leadership succession is tested       |
|                         |     > during VISN exercises.              |
+-------------------------+-------------------------------------------+
| Evaluation              | -   Lines of succession are reviewed      |
|                         |     > annually.                           |
+-------------------------+-------------------------------------------+
| Organizational Learning | -   Adjustments to the line of succession |
|                         |     > and the transition process are      |
|                         |     > accomplished based on reviews and   |
|                         |     > AARs from actual incidents.         |
+-------------------------+-------------------------------------------+

**Questions:**

VISN Office EMP:

1.  In the event of an emergency or serious disaster that affects VISN
    Office (such as an explosion) and/or its structure, how do employees
    know who is in charge?

2.  What/who has delegation authority?

3.  Is it always clear who will be in charge during an emergency?

4.  How is the chain of command during an emergency communicated?

5.  How does everyone in the VISN know who is in charge on a given day?

6.  What is the line of succession in case of injuries or other
    disruptions to the chain of command?

### Processes and Procedures for Personal Preparedness and Employee Welfare

**Description:** To demonstrate this capability the VISN should address
its employees' comprehensive preparedness to respond to a disaster
including physical and mental well being.

**Rationale:** Employees who feel safe and secure are more inclined to
report for duty and to stay on-site throughout an emergency. This
includes a family preparedness plan and support for physical and mental
health needs.

**Measurement**:

-   **Review of EOP to include Staff Hotline/Call Center procedures and
    HR Policies**

-   **Interviews with the VISN EPC, DND/VISN COO**

Framework for Capability Description

+-------------------------+-------------------------------------------+
| Capability Element      | Assessment components                     |
+=========================+===========================================+
| Policy/Organization     | -   The VISN demonstrates a method and    |
|                         |     > commitment to promoting the         |
|                         |     > maintenance of employee welfare,    |
|                         |     > availability for service.           |
+-------------------------+-------------------------------------------+
| Resources               |                                           |
+-------------------------+-------------------------------------------+
| > Supplies              | -   "Go kits" are available for staff     |
|                         |     > deployed to emergencies in the      |
|                         |     > region.                             |
|                         |                                           |
|                         | -   Food and water are available for      |
|                         |     > staff who are either sheltered in   |
|                         |     > place or who are at the facility    |
|                         |     > for prolonged periods of time.      |
|                         |                                           |
|                         | -   Personal/family supplies are          |
|                         |     > described for employees to consider |
+-------------------------+-------------------------------------------+
| > Facilities/Equipment  | -   Locations are identified for          |
|                         |     > personnel to take breaks and for    |
|                         |     > relaxing during prolonged           |
|                         |     > operations.                         |
+-------------------------+-------------------------------------------+
| > Personnel             | -   N/A                                   |
+-------------------------+-------------------------------------------+
| Process                 | -   The VISN has access to supporting     |
|                         |     > mental health professionals.        |
+-------------------------+-------------------------------------------+
| Education/Training      | -   All staff are briefed on VISN service |
|                         |     > expectations during emergencies.    |
|                         |                                           |
|                         | -   Staff receive training on the         |
|                         |     > resources that are available to     |
|                         |     > them during the disaster.           |
+-------------------------+-------------------------------------------+
| Exercise                | -   Resources that are available to staff |
|                         |     > are integrated exercises.           |
+-------------------------+-------------------------------------------+
| Evaluation              | -   The ability of the VISN to meet its   |
|                         |     > employees' needs is evaluated       |
|                         |     > through the exercise.               |
+-------------------------+-------------------------------------------+
| Organizational Learning | -   Lessons learned from exercises are    |
|                         |     > included in updates to the EOP.     |
+-------------------------+-------------------------------------------+

**Questions:**

VISN Office EMP:

1.  Are employees provided "go kits" for emergency response and
    prolonged shifts?

2.  Are staff aware of available mental health resources for use in the
    aftermath of a crisis, whether it is at the VISN Office or a by
    product of coordinating operations with a facility?

3.  What EAP services are available to VISN staff?

4.  How are VISN Office staff informed of HR policies that support them
    in the event of emergencies that primarily affect the VISN Office?

### Dissemination of Personnel Incident Information to Staff during an Incident

**Description:** To demonstrate this capability the VISN must be able to
communicate critical information to all staff at all levels in all
departments in a timely manner.

**Rationale:** Timely communication of pertinent information will help
alleviate stress and uncertainty amongst a facility's staff during an
emergency.

**Measurement**:

-   **Interview with VISN EPC and DND**

-   **Interview with VISN Chief Information Officer (CIO)**

-   **Interview with the VISN PAO**

Framework for Capability Description

+-------------------------+-------------------------------------------+
| Capability Element      | Assessment components                     |
+=========================+===========================================+
| Policy/Organization     | -   The VISN demonstrates the ability to  |
|                         |     > provide current incident            |
|                         |     > information to on- and off-campus   |
|                         |     > personnel, conveying situational    |
|                         |     > awareness to keep personnel safe    |
|                         |     > and to promote readiness and        |
|                         |     > availability for service.           |
+-------------------------+-------------------------------------------+
| Resources               |                                           |
+-------------------------+-------------------------------------------+
| > Supplies              | -   NA                                    |
+-------------------------+-------------------------------------------+
| > Facilities/Equipment  | -   Communications infrastructure (e.g.,  |
|                         |     > "employee hotline") is in place and |
|                         |     > operational and allows for the      |
|                         |     > efficient and accessible posting of |
|                         |     > information. This infrastructure    |
|                         |     > may include telephone and/or        |
|                         |     > Internet media.                     |
+-------------------------+-------------------------------------------+
| > Personnel             | -   Personnel are qualified and trained   |
|                         |     > to staff the IMT Information        |
|                         |     > Officer position and supporting     |
|                         |     > positions                           |
+-------------------------+-------------------------------------------+
| Process                 | -   Process delineated for developing     |
|                         |     > messages from information available |
|                         |     > to the IMT (Situation and Resource  |
|                         |     > Unit Leaders and other relevant     |
|                         |     > position).                          |
|                         |                                           |
|                         | -   Process to have messages developed,   |
|                         |     > approved by IC and/or VISN Director |
|                         |     > and posted very regularly (even if  |
|                         |     > message is "no new information").   |
|                         |                                           |
|                         | -   Process for receiving queries from    |
|                         |     > staff through IMT structure and     |
|                         |     > responding with information for all |
|                         |     > personnel where appropriate.        |
|                         |                                           |
|                         | -   Staff is designated to post and/or    |
|                         |     > transmit information to facility    |
|                         |     > personnel.                          |
+-------------------------+-------------------------------------------+
| Education/Training      | -   All personnel trained to access       |
|                         |     > incident information through        |
|                         |     > designated portals.                 |
|                         |                                           |
|                         | -   Information Officers are trained to   |
|                         |     > develop and disseminate messages.   |
|                         |                                           |
|                         | -   Incident Commander and VISN           |
|                         |     > leadership are trained to oversee   |
|                         |     > and rapidly approve appropriate     |
|                         |     > messages.                           |
+-------------------------+-------------------------------------------+
| Exercise                | -   Exchange of information with          |
|                         |     > personnel is integrated into the    |
|                         |     > VISN's exercises at least annually. |
+-------------------------+-------------------------------------------+
| Evaluation              | -   Exercise and incident AARs assess     |
|                         |     > effectiveness of keeping VISN       |
|                         |     > personnel informed about incident   |
|                         |     > information.                        |
+-------------------------+-------------------------------------------+
| Organizational Learning | -   Findings from AARs inform             |
|                         |     > improvements that are incorporated  |
|                         |     > into EOP and EMP initiatives (e.g., |
|                         |     > training).                          |
+-------------------------+-------------------------------------------+

**Questions:**

VISN Office EMP:

1.  Does the VISN have a means (such as a hotline) to provide
    > information to VISN staff during emergencies?

2.  What provisions are in place to assure VISN EOC can access computer
    > resources?

3.  Are there written procedures on how to access the information?

4.  How are these procedures distributed to VISN staff?

5.  How often are the procedures updated?

6.  Are these procedures ever tested in an exercise?

7.  What is the media used to distribute this information?

8.  How often is the hotline updated during an emergency?

9.  Who staffs the hotline?

Mission Critical Systems Resiliency
-----------------------------------

The organization initiates continuity of mission critical systems
measures as appropriate to the incident.

### Maintaining Information Technology (IT) and Computing Systems Resiliency during an Incident

**Description:** To demonstrate this capability the VISN must have a
business continuity and resiliency plan for critical IT systems.

**Rationale:** VISN offices rely heavily on IT systems for necessary and
efficient business processes and communication in support of VISN
facilities and emergency resource providers.

**Measurement**:

-   Review of EOP, SOPs (identify impact of priority hazards on IT)

-   Tour of Primary and Alternate EOC

-   Tour of Computer and Telephone Room(s)

-   Interview with VISN CIO and IT support person(s) for VISN

-   Interview with VISN EPC and DND/VISN CO

Framework for Capability Description

+-------------------------+-------------------------------------------+
| Capability Element      | Assessment components                     |
+=========================+===========================================+
| Policy/Organization     | -   The VISN demonstrates the ability to  |
|                         |     > maintain essential business         |
|                         |     > services.                           |
+-------------------------+-------------------------------------------+
| Resources               |                                           |
+-------------------------+-------------------------------------------+
| > Supplies              | -   The supplies needed for operation of  |
|                         |     > IT systems are identified and       |
|                         |     > stored in an appropriate location.  |
+-------------------------+-------------------------------------------+
| > Facilities/Equipment  | -   IT systems are in an appropriate      |
|                         |     > location with back-up for power by  |
|                         |     > emergency power or through some     |
|                         |     > other means such as Uninterruptible |
|                         |     > Power Supply (UPS).                 |
|                         |                                           |
|                         | -   If telework arrangements exist,       |
|                         |     > personnel have the necessary        |
|                         |     > infrastructure to support remote    |
|                         |     > working arrangements.               |
|                         |                                           |
|                         | -   If telework arrangements exist, there |
|                         |     > is user support for individuals     |
|                         |     > experiencing technical difficulty   |
|                         |     > (e.g., help desk support).          |
+-------------------------+-------------------------------------------+
| > Personnel             | -   The VISN identifies personnel         |
|                         |     > qualified and trained to maintain   |
|                         |     > business operations or revert to    |
|                         |     > substitute process and procedures.  |
+-------------------------+-------------------------------------------+
| Process                 | -   The VISN documents a risk assessment  |
|                         |     > that identifies high risk data      |
|                         |     > systems as part of this capability. |
|                         |                                           |
|                         | -   Business continuity plan is           |
|                         |     > delineated for critical IT systems  |
|                         |                                           |
|                         | -   VISN staff has developed and can      |
|                         |     > operate a fully functional business |
|                         |     > continuity and resiliency program   |
|                         |                                           |
|                         | -   Employees teleworking have            |
|                         |     > established methods for ensuring    |
|                         |     > their continuous receipt of         |
|                         |     > information both from the facility  |
|                         |     > and from other personnel            |
|                         |     > teleworking. If telework            |
|                         |     > arrangements exist, there is user   |
|                         |     > support for individuals             |
|                         |     > experiencing technical difficulty   |
|                         |     > (i.e., help desk support)           |
+-------------------------+-------------------------------------------+
| Education/Training      | -   VISN staff are trained on how to      |
|                         |     > activate and implement the business |
|                         |     > continuity and resiliency plan,     |
|                         |     > including initiating back-up        |
|                         |     > procedures, access to key VISN      |
|                         |     > computer resources via VA VPN,      |
|                         |     > maintaining security during an      |
|                         |     > emergency, and recovering from an   |
|                         |     > unexpected outage of service.       |
+-------------------------+-------------------------------------------+
| Exercise                | -   The business continuity and           |
|                         |     > resiliency plan is exercised at     |
|                         |     > least annually and is incorporated  |
|                         |     > into the VISN preventive            |
|                         |     > maintenance program for hardware    |
|                         |     > and software.                       |
+-------------------------+-------------------------------------------+
| Evaluation              | -   The exercise (through the AAR         |
|                         |     > process) and the ongoing            |
|                         |     > maintenance activities are          |
|                         |     > evaluated periodically with trends  |
|                         |     > reported to the EMC or VISN         |
|                         |     > leadership.                         |
+-------------------------+-------------------------------------------+
| Organizational Learning | -   Findings from the AAR and maintenance |
|                         |     > activities inform improvements that |
|                         |     > are incorporated into the business  |
|                         |     > services continuity capability.     |
+-------------------------+-------------------------------------------+

**Questions:**

VISN Oversight

1.  How do you provide oversight of the facilities' business resiliency
    and COOP plans? Have they been tested in actual emergencies?

VISN Office EMP:

2.  Please describe your business resiliency and COOP plan for the VISN
    office.

3.  How is this plan incorporated into the overall VISN office COOP
    plan?

4.  Has this plan included a formal needs and risk assessment?

5.  What is the plan in the case of power outages?

6.  How does your plan include remote employees and any employees
    working from home?

7.  How is data backed up?

8.  What are the provisions for data communication in the event of
    computer network failure?

9.  Describe all available means of voice communication.

10. How have VISN Office staff been trained for the use of computers
    during any system disruptions?

11. Are VISN Office staff trained how to access VA systems through VPN
    or other resources?

12. How have resiliency and COOP plans been tested?

13. How do you provide urgent customer support, technical assistance and
    hardware/system repair in the event of an emergency, particularly to
    the VISN Office EOC?

14. Are you normally a part of the VISN EOC?

### Maintaining Access to Critical Commodities and Services during Response and Recovery Operations

**Description:** To demonstrate this capability the VISN should
establish contracts for priority supply of critical commodities. This
information should be available in the EOC at all times.

**Rationale:** During emergencies, many people and organizations compete
for the same commodities and services. Having priority contracts helps
ensure that critical supplies and services will be available and that
critical business operating units can continue to function.

**Measurement**:

-   Review of EOP

-   Review of Blanket Purchase Agreements (BPAs)

-   Review MOUs/contracts with Key Vendors

-   Interview with CLO and leader of the VISN Contracting Activity

Framework for Capability Description

+-------------------------+-------------------------------------------+
| Capability Element      | Assessment components                     |
+=========================+===========================================+
| Policy/Organization     | -   The VISN demonstrates the ability to  |
|                         |     > maintain continuity of business     |
|                         |     > services at VISN facilities by      |
|                         |     > establishing mechanisms to obtain a |
|                         |     > priority supply of critical         |
|                         |     > commodities and services from local |
|                         |     > vendors by using VISN level         |
|                         |     > contracts and the VHA National      |
|                         |     > Acquisition Center (NAC) BPAs.      |
+-------------------------+-------------------------------------------+
| Resources               |                                           |
+-------------------------+-------------------------------------------+
| > Supplies              | -   N/A                                   |
+-------------------------+-------------------------------------------+
| > Facilities/Equipment  | -   Copies of contracts for critical      |
|                         |     > re-supply of commodities and        |
|                         |     > services with POCs are maintained   |
|                         |     > at the EOC.                         |
+-------------------------+-------------------------------------------+
| > Personnel             | -   Qualified and trained personnel to    |
|                         |     > establish contracts and activate    |
|                         |     > contracts for critical supplies     |
|                         |     > during emergencies                  |
+-------------------------+-------------------------------------------+
| Process                 | -   Documentation of developing,          |
|                         |     > completing, and administering       |
|                         |     > priority contracts for supply of    |
|                         |     > critical commodities and services   |
|                         |     > needed during response and recovery |
|                         |     > operations.                         |
|                         |                                           |
|                         | -   Vendors are contacted periodically    |
|                         |     > and advised of the nature and scope |
|                         |     > of the contracts. Availability of   |
|                         |     > contracted items and services is    |
|                         |     > reconfirmed.                        |
+-------------------------+-------------------------------------------+
| Education/Training      | -   VISN staff assigned to activate these |
|                         |     > contracts are trained to understand |
|                         |     > their scope and how to use them     |
|                         |     > effectively.                        |
|                         |                                           |
|                         | -   Contracting personnel are trained to  |
|                         |     > access the BPAs.                    |
+-------------------------+-------------------------------------------+
| Exercise                | -   N/A                                   |
+-------------------------+-------------------------------------------+
| Evaluation              | -   Reliability of vendor contracts is    |
|                         |     > assessed based on experience and on |
|                         |     > vendor contact and spot check on    |
|                         |     > availability of contracted          |
|                         |     > good/services.                      |
|                         |                                           |
|                         | -   There is an annual needs assessment   |
|                         |     > to determine the adequacy of        |
|                         |     > existing contracts and priorities   |
|                         |     > for updating or establishing new    |
|                         |     > contracts.                          |
+-------------------------+-------------------------------------------+
| Organizational Learning | -   An annual briefing to the VISN EMC    |
|                         |     > and/or ELC is conducted on the      |
|                         |     > program to identify remaining gaps  |
|                         |     > and priorities for the next year.   |
+-------------------------+-------------------------------------------+

**Questions:**

VISN Oversight:

1.  Are there any facility-specific bulk purchases that have been made
    and are in storage for sharing throughout the VISN?

2.  Are there plans for transportation in order to evacuate a facility?
    If so, please describe these plans including any priority
    transportation contracts and/or existing transportation assets
    readily available for evacuations.

3.  Are you aware of NAC provided BPAs for emergency supplies? Do you
    use or are planning to use these BPAs?

4.  Is there an annual evaluation conducted on a VISN-wide basis, of
    emergency purchasing needs, contracts and vendor adequacy?

5.  How are contracting staff trained to know what and how to purchase
    critical supplies and services in an emergency, on a moment's
    notice?

6.  How are staff contacted and mobilized in an emergency with short
    notice?

7.  Who specifically is designated to conduct necessary emergency
    purchases?

8.  What are the back-up and contingency plans in case of loss of
    communications resources?

VISN Office EMP:

9.  Has there been a systematic needs assessment regarding critical
    commodities or availability to VISN Office staff in an emergency? If
    so, what is to be provided?

10. Describe all VISN level contracts that are in place to provide VISN
    facilities with needed commodities, bulk purchases and services in
    an emergency?

11. Who has purchase cards in the VISN Office in the event of
    deployment?

12. Describe any resource sharing agreements with non-VISN facilities
    including DOD facilities?

Communications
--------------

The VISN demonstrates the ability to sustain communications, or provide
substitute communications to maintain a safe environment and support
COOPs.

### Maintenance of Voice and Data Communication through Satellite Link

**Description:** To demonstrate this capability the VISN will maintain a
satellite link for voice and data. This will ensure continuity of
patient care data if connectivity to external data and communication
networks is disrupted.

**Rationale:** VISNs are highly dependent upon data transmission and
voice communications. Disruptions to these services through land lines
and commercial vendors that provide voice and data services will present
severe challenges to providing COOPs and support to VISN facilities.

**Measurement**:

-   Tour of VISN EOC

-   Interviews with CIO

-   Equipment Trials -- secure phone, satellite phone, High Frequency
    (HF) radio (where available) and pin-to-pin BlackBerry®
    communication

Framework for Capability Description

+-------------------------+-------------------------------------------+
| Capability Element      | Assessment components                     |
+=========================+===========================================+
| Policy/Organization     | -   The VISN demonstrates the ability to  |
|                         |     > address loss of normal voice and    |
|                         |     > data communications through a       |
|                         |     > satellite link back-up for voice    |
|                         |     > and data transmission.              |
+-------------------------+-------------------------------------------+
| Resources               |                                           |
+-------------------------+-------------------------------------------+
| > Supplies              | -   VISN has sufficient parts and         |
|                         |     > supplies to ensure the continued    |
|                         |     > operation of this satellite back-up |
|                         |     > capability.                         |
+-------------------------+-------------------------------------------+
| > Facilities/Equipment  | -   VISN has a satellite link for voice   |
|                         |     > and data, along with the            |
|                         |     > sending/receiving equipment to      |
|                         |     > connect to the satellite link.      |
+-------------------------+-------------------------------------------+
| > Personnel             | -   The VISN has qualified and trained    |
|                         |     > personnel to activate and operate   |
|                         |     > the satellite link.                 |
+-------------------------+-------------------------------------------+
| Process                 | -   The process for setting up,           |
|                         |     > activating and operating the link   |
|                         |     > should be clearly delineated.       |
|                         |                                           |
|                         | -   The connection of all elements of the |
|                         |     > satellite link to emergency power   |
|                         |     > outlets should be demonstrated.     |
+-------------------------+-------------------------------------------+
| Education/Training      | -   VISN staff are trained to activate    |
|                         |     > and operate the satellite link when |
|                         |     > needed.                             |
|                         |                                           |
|                         | -   Staff are trained to maintain the     |
|                         |     > equipment, identifying appropriate  |
|                         |     > preventive maintenance and          |
|                         |     > operating procedures.               |
+-------------------------+-------------------------------------------+
| Exercise                | -   This link is regularly tested and     |
|                         |     > exercised in accordance with        |
|                         |     > manufacturer's recommendations.     |
+-------------------------+-------------------------------------------+
| Evaluation              | -   Use of the satellite link during      |
|                         |     > exercises should be evaluated       |
|                         |     > through the AAR process.            |
+-------------------------+-------------------------------------------+
| Organizational Learning | -   The satellite link capability should  |
|                         |     > be improved as a result of the      |
|                         |     > preventive maintenance and findings |
|                         |     > from the exercise AARs.             |
+-------------------------+-------------------------------------------+

**Questions:**

VISN Oversight:

1.  Does your VISN have a satellite link to support data, voice and
    videoconferencing? If yes, please describe all the units available
    in the VISN?

2.  How are they maintained?

3.  Who is trained to operate the links?

4.  What are the plans to deploy the portable links?

5.  How often are the links tested?

6.  If there are no satellite links, what provisions have been made for
    voice and data communications in the event of complete VISN and
    local facility failures of these systems?

VISN Office EMP:

7.  Is the VISN office supported with any radio systems and/or amateur
    radio capabilities?

8.  Are VISN office staff aware and trained how to communicate using
    BlackBerry® pin-to-pin capabilities?

**Capability Observation**:

1.  Staff are capable of locating the satellite link and demonstrating
    > the proper usage.

2.  Procedures and policies are in place for initiating link's
    > activation.

### Interoperable Communications with External Agencies'

**Description:** To demonstrate this capability the VISN must be able to
establish interoperable communications with all emergency response
entities in the community, including emergency management, public
health, police, fire/rescue and EMS.

**Rationale:** VISNs must be have a working relationship with the First
Responder community because any emergency that occurs may require
assistance from any of these entities or the sharing of resources and/or
coordination of response and recovery operations.

**Measurement**:

-   Tour of VISN EOC

-   Review of EOP

-   Review of Key Personnel Resource Matrix

-   Interviews with VISN EPC, CIO

Framework for Capability Description

+-------------------------+-------------------------------------------+
| Capability Element      | Assessment components                     |
+=========================+===========================================+
| Policy/Organization     | -   The VISN demonstrates the ability to  |
|                         |     > maintain interoperable              |
|                         |     > communications with community,      |
|                         |     > State, and Federal emergency        |
|                         |     > management, public health and       |
|                         |     > public safety (fire, police, EMS)   |
|                         |     > agencies during emergency           |
|                         |     > operations where normal telephone   |
|                         |     > communications may be disrupted or  |
|                         |     > overwhelmed.                        |
+-------------------------+-------------------------------------------+
| Resources               |                                           |
+-------------------------+-------------------------------------------+
| > Supplies              | -   N/A                                   |
+-------------------------+-------------------------------------------+
| > Facilities/Equipment  | -   VISN has communications equipment     |
|                         |     > that effectively interfaces with    |
|                         |     > Federal and State emergency         |
|                         |     > management, public health, police,  |
|                         |     > fire and EMS and has a direct       |
|                         |     > back-up means of communications.    |
+-------------------------+-------------------------------------------+
| > Personnel             | -   Qualified and trained personnel are   |
|                         |     > identified to staff the liaison     |
|                         |     > position in the facility's IMT and  |
|                         |     > operate the communications          |
|                         |     > equipment.                          |
+-------------------------+-------------------------------------------+
| Process                 | -   VISN staff have pre-identified POCs,  |
|                         |     > and a plan for contacting the       |
|                         |     > appropriate response element of the |
|                         |     > relevant organizations.             |
+-------------------------+-------------------------------------------+
| Education/Training      | -   Training on operating the             |
|                         |     > communications equipment and use    |
|                         |     > the protocols established for       |
|                         |     > emergency communications.           |
|                         |                                           |
|                         | -   VISN staff assigned to work with      |
|                         |     > police, fire, EMS, emergency        |
|                         |     > management, and public health       |
|                         |     > organizations are trained on        |
|                         |     > communication equipment and         |
|                         |     > protocols.                          |
+-------------------------+-------------------------------------------+
| Exercise                | -   There is at least one joint activity  |
|                         |     > per year where the VISN             |
|                         |     > demonstrates its ability to         |
|                         |     > establish communications with       |
|                         |     > external agencies'.                 |
+-------------------------+-------------------------------------------+
| Evaluation              | -   Exercises are evaluated and lessons   |
|                         |     > learned are documented.             |
+-------------------------+-------------------------------------------+
| Organizational Learning | -   Communications equipment and          |
|                         |     > protocols are updated annually.     |
+-------------------------+-------------------------------------------+

**Questions:**

VISN Oversight:

1.  Is there a VISN plan to have all VISN facilities have the ability to
    communicate with First Responders via something other than their
    normal mode of communications such as radios? If not, which
    facilities have this capability?

2.  What types of training are provided for facilities on emergency
    communications?

3.  Has there been an overall assessment of VISN facility emergency
    communication needs?

VISN Office EMP:

4.  Who is designated to support the VISN Office EOC in emergency
    communications?

5.  What types of training are provided for VISN Office staff in
    emergency communications?

6.  Has there been an overall assessment of VISN Office emergency
    communication needs?

### Interoperable Communications with VISN Facilities'

**Description:** To demonstrate this capability the VISN ensures that
communication occurs internally with staff in all departments, patients
and visitors during an emergency.

**Rationale:** Effective communication is critical to the ability to
sustain business operations and support VISN facilities and VACO with
needed information.

**Measurement**:

-   Tour of VISN EOC to include communications (i.e., radios, satellite
    communications, designated computer systems)

-   Review of EOP (incident reporting procedures and forms)

-   Interviews with VISN CIO and Emergency Manager

Framework for Capability Description

+-------------------------+-------------------------------------------+
| Capability Element      | Assessment components                     |
+=========================+===========================================+
| Policy/Organization     | -   The VISN demonstrates the ability to  |
|                         |     > maintain internal communications    |
|                         |     > with VISN facilities and VACO in    |
|                         |     > order to provide necessary          |
|                         |     > information and coordination.       |
+-------------------------+-------------------------------------------+
| Resources               |                                           |
+-------------------------+-------------------------------------------+
| > Supplies              | -   Lists of key telephone numbers and    |
|                         |     > protocols.                          |
+-------------------------+-------------------------------------------+
| > Facilities/Equipment  | -   The communication infrastructure is   |
|                         |     > in place for key VISN staff to      |
|                         |     > communicate with VISN staff, VISN   |
|                         |     > facilities and VACO.                |
|                         |                                           |
|                         | -   A back-up communication               |
|                         |     > infrastructure/procedures are in    |
|                         |     > place if the event the primary      |
|                         |     > system is disrupted.                |
|                         |                                           |
|                         | -   An internal staff incident            |
|                         |     > information ("staff hotline") is    |
|                         |     > activated for employees to access   |
|                         |     > crucial information on the status   |
|                         |     > of the incident and any related     |
|                         |     > guidance.                           |
|                         |                                           |
|                         | -   The infrastructure used to            |
|                         |     > communicate critical information    |
|                         |     > takes into consideration those with |
|                         |     > limited knowledge of electronic     |
|                         |     > communication (e.g., e-mail) or     |
|                         |     > those with limited access to IT     |
|                         |     > equipment.                          |
+-------------------------+-------------------------------------------+
| > Personnel             | -   Qualified and trained personnel to    |
|                         |     > operate the communication           |
|                         |     > equipments.                         |
|                         |                                           |
|                         | -   Qualified and trained personnel to    |
|                         |     > staff the IMT Communications Unit   |
|                         |     > that mobilizes, distributes,        |
|                         |     > activates and supports the          |
|                         |     > emergency communications system.    |
+-------------------------+-------------------------------------------+
| Process                 | -   The process for deploying, operating  |
|                         |     > and demobilizing the emergency      |
|                         |     > communications equipment is         |
|                         |     > delineated.                         |
|                         |                                           |
|                         | -   POC is identified for communications  |
|                         |     > with the VAMCs (i.e., Liaison       |
|                         |     > Officer, PIO)                       |
+-------------------------+-------------------------------------------+
| Education/Training      | -   VISN staff are trained and aware of   |
|                         |     > all internal communication          |
|                         |     > processes/procedures.               |
|                         |                                           |
|                         | -   VISN staff are trained on the back-up |
|                         |     > communication procedures in the     |
|                         |     > event the primary system is         |
|                         |     > inoperable.                         |
|                         |                                           |
|                         | -   Personnel using the emergency         |
|                         |     > communications equipment are        |
|                         |     > trained on communication protocols  |
|                         |     > that stress brevity, privacy, plain |
|                         |     > language and limiting transmission  |
|                         |     > time to the minimum necessary to    |
|                         |     > accomplish the mission.             |
|                         |                                           |
|                         | -   Communications Unit personnel are     |
|                         |     > trained on mobilizing,              |
|                         |     > distributing, supporting,           |
|                         |     > demobilizing and returning to       |
|                         |     > readiness the emergency             |
|                         |     > communications systems.             |
+-------------------------+-------------------------------------------+
| Exercise                | -   There is at least one activity per    |
|                         |     > year where the VISN demonstrates    |
|                         |     > its ability to establish effective  |
|                         |     > internal emergency communication.   |
+-------------------------+-------------------------------------------+
| Evaluation              | -   The annual exercise is evaluated, and |
|                         |     > findings are documented in the AAR. |
+-------------------------+-------------------------------------------+
| Organizational Learning | -   Internal communications equipment and |
|                         |     > protocols are updated annually.     |
+-------------------------+-------------------------------------------+

**Questions:**

VISN Office EMP:

1.  In the event of a disaster primarily involving the VISN office
    directly, describe the flow of information during a crisis to VACO?
    To VISN facilities?

2.  What happens when the primary method(s) of internal communications
    fail?

3.  How are your communications plans tested?

4.  What improvements have been made as a result of testing?

5.  In the event of a disaster at a VISN facility, describe, similarly,
    the communication flow to VACO and other VISN facilities.

Healthcare Systems Resiliency
-----------------------------

### Management of Primary Care for Special Needs Patients, including Home-Based Care during Incidents

**Description:** To demonstrate this capability the VISN must be able to
continuously provide care to home-based patients during emergencies.

**Rationale:** Facilities must have a plan for providing continuity of
care for home based primary care patients that may be at risk for
disruption of services during an emergency. Facility personnel should
identify these patients before an emergency to plan for the provision of
care during response and recovery phases.

**Measurement**:

-   Review of EOP including Outreach Plan

-   Interviews with the VISN Community Care Coordinator

Framework for Capability Description

+-------------------------+-------------------------------------------+
| Capability Element      | Assessment components                     |
+=========================+===========================================+
| Policy/Organization     | -   The facility demonstrates the ability |
|                         |     > to maintain home care services      |
|                         |     > during emergencies. VISNs are aware |
|                         |     > of the level of home care provided  |
|                         |     > by VISN facilities.                 |
+-------------------------+-------------------------------------------+
| Resources               |                                           |
+-------------------------+-------------------------------------------+
| > Supplies              | -   A patient-based needs assessment is   |
|                         |     > conducted to determine what         |
|                         |     > supplies are needed to sustain      |
|                         |     > home-based care should an emergency |
|                         |     > occur.                              |
|                         |                                           |
|                         | -   Supplies (e.g., oxygen, batteries for |
|                         |     > medical equipment, hand-suction     |
|                         |     > devices) are provided to patients   |
|                         |     > to sustain home care for at least   |
|                         |     > 48 hours.                           |
|                         |                                           |
|                         | -   Fuel for vehicles is stored at the    |
|                         |     > VAMC with other vehicle fuel.       |
+-------------------------+-------------------------------------------+
| > Facilities/Equipment  | -   Any special needs equipment and the   |
|                         |     > facilities essential for home care  |
|                         |     > are assessed to determine how       |
|                         |     > patients could continue to receive  |
|                         |     > home care after an emergency        |
|                         |     > occurs.                             |
+-------------------------+-------------------------------------------+
| > Personnel             | -   Qualified and trained VAMC staff to   |
|                         |     > manage continuity of home-based     |
|                         |     > care and home care emergency        |
|                         |     > response using the EOP. The         |
|                         |     > individual assigned VISN community  |
|                         |     > care oversight responsibilities is  |
|                         |     > aware of emergency communication    |
|                         |     > requirements.                       |
+-------------------------+-------------------------------------------+
| Process                 | -   The EOP provides guidance for the     |
|                         |     > VAMC staff assigned to manage       |
|                         |     > coordination of care, identify      |
|                         |     > home-based patients at risk during  |
|                         |     > an emergency, and ensure access to  |
|                         |     > needed services through temporarily |
|                         |     > bringing them to the facility or    |
|                         |     > through contracted services in the  |
|                         |     > community.                          |
|                         |                                           |
|                         | -   At the VISN level, the VISN EOP       |
|                         |     > covers VISN oversight               |
|                         |     > responsibilities.                   |
|                         |                                           |
|                         | -   An Outreach Plan delineates the       |
|                         |     > processes to coordinate the         |
|                         |     > activities of all VAMCs in          |
|                         |     > identifying needs for access to     |
|                         |     > healthcare services and other basic |
|                         |     > human needs of Veterans during      |
|                         |     > major incidents.                    |
+-------------------------+-------------------------------------------+
| Education/Training      | -   VAMC and VISN staff are trained in    |
|                         |     > their role with respect to managing |
|                         |     > and providing home-based care       |
|                         |     > during emergencies.                 |
+-------------------------+-------------------------------------------+
| Exercise                | -   Staff periodically test their         |
|                         |     > contingency plans for home-based    |
|                         |     > care.                               |
+-------------------------+-------------------------------------------+
| Evaluation              | -   Exercise AARs evaluate management of  |
|                         |     > home-based services.                |
|                         |                                           |
|                         | -   The home-based care program during    |
|                         |     > emergencies is evaluated annually.  |
+-------------------------+-------------------------------------------+
| Organizational Learning | -   Results from the program evaluation   |
|                         |     > and findings from AARs inform       |
|                         |     > improvements that are incorporated  |
|                         |     > into the VAMC and VISN EOPs.        |
+-------------------------+-------------------------------------------+

**Questions:**

VISN Oversight:

1.  Describe the VISN's oversight of the facility responsibilities to
    > have a process for identifying populations at risk.

2.  How are these patients tracked and what information is kept?

3.  How are the special needs met for each population identified?

4.  Describe the VISN's involvement in supporting facilities'
    > responsibilities to continue to provide care, treatment and
    > services to their special needs patients?

Medical Surge
=============

Facilities have recognized the need to work as a community since many
emergencies may be more then a single facility can handle. More
frequently communities are working closer together to define roles
during a medical surge condition but even without a clearly defined
community role, people will migrate to the nearest hospital if care is
needed as a result of an emergency making it essential for facilities to
have capabilities for surge.

The VISN should demonstrate the ability to provide a medical surge
capacity for assisting VISN facilities with managing their excessive
patient volume, and manage additional surge capabilities for unusual
injury/illness, according to the targets projected in the VAMC's EMP and
EOP. This is particularly important when more than one facility within
the VISN is involved in an emergency. The VISN's role will likely be one
of coordination between facilities and also providing needed information
to VHA CO Officials.

To ensure the ability to provide both surge capacity and capability to
meet demand, several critical components are addressed as supporting
capabilities. These include the following:

-   Expansion of staffing

-   Expansion of treatment services

-   Establishing specialty treatment capabilities (e.g., expert
    > information/guidance, obtaining specialized equipment/supplies)

The following sections will describe the critical capabilities in
support of these components.

Processes and Procedures for Expansion of Staff for Response and Recovery Operations 
------------------------------------------------------------------------------------

**Description**: To demonstrate this capability the VISN should be able
to expand staffing capacity to care for additional patients/victims if
demand exceeds current capacities or current medical capabilities.

**Rationale**: During an emergency there is a potential for a surge in
patients. This may also include patient types not normally seen by VHA
staff (such as pediatrics/adolescents) or injury/illness types (such as
burns, severe blunt trauma, chemical injury).

**Measurement**:

-   Review of EOP

-   Interviews with DND, CMO, EPC and VISN HR Manager

Framework for Capability Description

+-------------------------+-------------------------------------------+
| Capability Element      | Assessment components                     |
+=========================+===========================================+
| Policy/Organization     | -   The VISN demonstrates the ability to  |
|                         |     > support VISN facilities capability  |
|                         |     > to provide a medical surge capacity |
|                         |     > and surge for unusual patient or    |
|                         |     > medical capabilities through        |
|                         |     > enhanced staffing and optimal use   |
|                         |     > of personnel services.              |
+-------------------------+-------------------------------------------+
| Resources               |                                           |
+-------------------------+-------------------------------------------+
| > Supplies              | -   Staff's physical needs (food, water,  |
|                         |     > shelter) are addressed throughout   |
|                         |     > the duration of the emergency.      |
+-------------------------+-------------------------------------------+
| > Facilities/Equipment  | -   There are designated locations at the |
|                         |     > facilities for staff to rest, take  |
|                         |     > breaks, and shower.                 |
+-------------------------+-------------------------------------------+
| > Personnel             | -   The VISN has a callback list for      |
|                         |     > additional staff that may be needed |
|                         |     > to help coordinate facility patient |
|                         |     > surge activities.                   |
|                         |                                           |
|                         | -   Mental health support is available to |
|                         |     > all staff if and when needed.       |
|                         |                                           |
|                         | -   Qualified and trained personnel are   |
|                         |     > identified to staff relevant EOP    |
|                         |     > positions that manage the           |
|                         |     > activation, mobilization, provision |
|                         |     > of surge services, surge support    |
|                         |     > services, demobilization and return |
|                         |     > to readiness actions.               |
|                         |                                           |
|                         | -   A POC is identified to manage         |
|                         |     > expansion of staff services         |
+-------------------------+-------------------------------------------+
| Process                 | -   The EOP provides actionable guidance  |
|                         |     > for managing the medical surge      |
|                         |     > activation, mobilization, provision |
|                         |     > of surge services, surge support    |
|                         |     > services, demobilization and return |
|                         |     > to readiness actions.               |
|                         |                                           |
|                         | -   Processes for surge staff             |
|                         |     > assignments, accountability, and    |
|                         |     > staff support are delineated.       |
|                         |                                           |
|                         | -   The EOP surge maintains safety        |
|                         |     > measures during surge actions       |
|                         |     > (e.g., fire suppression, rapid      |
|                         |     > evacuation from facilities).        |
|                         |                                           |
|                         | -   A process for VISN Office to manage   |
|                         |     > staff shortages at particular VAMCs |
|                         |     > or all VAMCs in the VISN.           |
+-------------------------+-------------------------------------------+
| Education/Training      | -   The called back staff know where to   |
|                         |     > report once they arrive at the      |
|                         |     > VISN.                               |
|                         |                                           |
|                         | -   The staff understand their roles in   |
|                         |     > the IMT and applicable ICS          |
|                         |     > principles when the EOP is          |
|                         |     > activated (e.g., reporting to       |
|                         |     > supervisor, reporting problems,     |
|                         |     > illness/injury, signing in and      |
|                         |     > out).                               |
|                         |                                           |
|                         | -   The staff understand the role of the  |
|                         |     > IMT and the Incident Commander.     |
+-------------------------+-------------------------------------------+
| Exercise                | -   The callback list is tested           |
|                         |     > quarterly. [ ]{.underline}          |
|                         |                                           |
|                         | -   The staff demonstrate an              |
|                         |     > understanding of their role in the  |
|                         |     > EOP.                                |
|                         |                                           |
|                         | -   The callback staff can report to duty |
|                         |     > within 12 [ ]{.underline} hours.    |
+-------------------------+-------------------------------------------+
| Evaluation              | -   The exercise AAR specifically         |
|                         |     > evaluates the staff surge process   |
|                         |     > and procedures.                     |
+-------------------------+-------------------------------------------+
| Organizational Learning | -   The findings from the AARs inform     |
|                         |     > improvements that are incorporated  |
|                         |     > into the EOP and EM program related |
|                         |     > to the staff expansion capability.  |
+-------------------------+-------------------------------------------+

**Questions:**

VISN Office EMP:

1.  Describe how the VISN supports any facility's needs for the
    expansion of staff during an emergency, such as during a medical
    surge.

2.  Describe how the VISN office manages its own needs to expand staff
    such as might be needed to conduct extended EOC operations.

3.  How does the VISN office callback staff to work, at any time of day
    or night?

4.  Does the VISN employ any automated callback systems for the VISN
    office staff?

5.  Are similar systems used throughout the VISN?

Management of Volunteers Deployment Support (e.g., DEMPS) during Response and Recovery Operations
-------------------------------------------------------------------------------------------------

**Description**: To demonstrate this capability the VISN should be able
to manage all facets of DEMPS.

**Rationale**: DEMPS is a system for overseeing the recruitment,
enrollment, preparation and deployment of facility employee volunteers.
As a VHA asset these volunteer employees are deployed within the VA as
needed to support emergency response.

**Measurement**:

-   Review of DEMPS enrollment process (i.e., marketing, program
    > maintenance, annual review for improvement)

-   Interview with VISN DEMPS Coordinator

Framework for Capability Description

+-------------------------+-------------------------------------------+
| Capability Element      | Assessment components                     |
+=========================+===========================================+
| Policy/Organization     | -   The DEMPS is a database developed to  |
|                         |     > collect specific information on VHA |
|                         |     > medical personnel who have          |
|                         |     > volunteered and been approved by    |
|                         |     > their Facility Director to be       |
|                         |     > deployed in the event of a          |
|                         |     > disaster. This includes the ability |
|                         |     > of the VISN to manage the DEMPS     |
|                         |     > Program.                            |
+-------------------------+-------------------------------------------+
| Resources               |                                           |
+-------------------------+-------------------------------------------+
| > Supplies              | -   N/A                                   |
+-------------------------+-------------------------------------------+
| > Facilities/Equipment  | -   VISN facilities have sufficient       |
|                         |     > equipment to access DEMPS           |
|                         |     > nationally to update the database   |
|                         |     > and change the status of volunteers |
|                         |     > in the system.                      |
+-------------------------+-------------------------------------------+
| > Personnel             | -   VISN facilities have a trained DEMPS  |
|                         |     > Coordinator.                        |
|                         |                                           |
|                         | -   There is evidence of senior           |
|                         |     > leadership support.                 |
|                         |                                           |
|                         | -   The DEMPS Coordinators have working   |
|                         |     > relationships with the national     |
|                         |     > DEMPS Program manager in EMSHG, and |
|                         |     > they work together to keep the      |
|                         |     > database up to date.                |
+-------------------------+-------------------------------------------+
| Process                 | -   The program has a number of           |
|                         |     > volunteers pre-identified.          |
|                         |                                           |
|                         | -   The program has a means for updating  |
|                         |     > the database quarterly.             |
|                         |                                           |
|                         | -   Process to communicate with VAMCs to  |
|                         |     > utilize volunteers as a resource    |
|                         |                                           |
|                         | -   Process for identifying DEMPS         |
|                         |     > Volunteers through deployment and   |
|                         |     > re-deployment in accordance with    |
|                         |     > 10N requests                        |
+-------------------------+-------------------------------------------+
| Education/Training      | -   Staff assigned to manage the DEMPS    |
|                         |     > database understand their roles and |
|                         |     > responsibilities.                   |
+-------------------------+-------------------------------------------+
| Exercise                | -   The DEMPS coordination processes are  |
|                         |     > exercised at least once a year.     |
+-------------------------+-------------------------------------------+
| Evaluation              | -   The VISN performs after action        |
|                         |     > reporting following each exercise.  |
+-------------------------+-------------------------------------------+
| Organizational Learning | -   The lessons learned from the AARs     |
|                         |     > inform improvements in deployment   |
|                         |     > support.                            |
+-------------------------+-------------------------------------------+

**Questions:**

VISN Oversight:

1.  Describe the VISN office's participation within the DEMPS Program.

2.  Does the VISN have a DEMPS Coordinator or are VISN office staff
    > enrolled by the DEMPS Coordinator of the servicing VAMC?

3.  Does the DEMPS supporting the VISN office staff have a
    > pre-deployment program with the Occupational Health program to
    > ensure volunteers are evaluated and protected before they are
    > deployed away from your medical center?

4.  Does the VISN or the supporting DEMPS Coordinator contact
    > volunteers, at least annually, to ensure they wish to remain
    > volunteers and to update information?

5.  Are the EMSHG AEMs available to ensure that data entry is
    > accomplished in accordance with DEMPS database instructions for
    > VISN office staff enrolled in the program?

6.  Has the VISN office deployed personnel in response to emergencies?

7.  Describe the VISN leadership involvement with oversight of the DEMPS
    > Programs at the VISN's facilities.

8.  What has been the involvement of the VISN Liaison AEM in that
    > oversight?

9.  What has been the VISN's experience as a recipient and donor of
    > staff under the DEMPS Program?

10. How would the VISN access DEMPS resources to support VISN-wide
    > needs?

11. What system do you use to identify what the needs of the patients
    > are and what the capabilities the facility can offer?

12. How do you address external resources?

Expansion of Evaluation and Treatment Services
----------------------------------------------

The VISN facilities must demonstrate the ability to manage the
mobilization and operation of a wide range of activities and resources
necessary to meet the projected medical surge capacity and specialized
treatment capabilities in a mass casualty incident.

### Development, Implementation, Management, and Maintenance of the VA All-Hazards Emergency Cache 

**Description**: To demonstrate this capability the VISN has the ability
to access, store, distribute, and manage the VA All-Hazards Emergency
Caches.

**Rationale**: VA All-Hazards Emergency Caches allow the VA to maintain
its health delivery capability in the event of a natural disaster or
terrorist attack. The VA All-Hazards Emergency Caches are kept available
to treat veterans, staff, and visitors.

**Measurement**:

-   Review process of Pharmacy Cache Inspection Program by EMSHG staff

-   Review Facility Tours of All-Hazard Emergency Cache Storage Areas

-   Interviews with CMO, EPC, VISN Safety Officer and VISN Pharmacy
    Benefits Manager

Framework for Capability Description

+-------------------------+-------------------------------------------+
| Capability Element      | Assessment components                     |
+=========================+===========================================+
| Policy/Organization     | -   The facilities demonstrate the        |
|                         |     > ability for the VAMCs to implement  |
|                         |     > the VA All-Hazards Emergency Cache  |
|                         |     > program including provisions for    |
|                         |     > security, storage, access,          |
|                         |     > distribution of pharmaceuticals,    |
|                         |     > medical supplies, and management of |
|                         |     > the program.                        |
+-------------------------+-------------------------------------------+
| Resources               |                                           |
+-------------------------+-------------------------------------------+
| > Supplies              | -   The facilities have a VA All-Hazards  |
|                         |     > Emergency Cache that includes       |
|                         |     > prophylactic and treatment          |
|                         |     > pharmaceuticals, and medical        |
|                         |     > supplies.                           |
+-------------------------+-------------------------------------------+
| > Facilities/Equipment  | -   There is ample storage for all        |
|                         |     > components of the VA All-Hazards    |
|                         |     > Emergency Cache.                    |
|                         |                                           |
|                         | -   The VA All-Hazards Emergency Cache is |
|                         |     > stored in a secured location.       |
+-------------------------+-------------------------------------------+
| > Personnel             | -   Individuals are assigned to manage    |
|                         |     > the VA All-Hazards Emergency Cache  |
|                         |     > (e.g., store, mobilize, and         |
|                         |     > distribute).                        |
+-------------------------+-------------------------------------------+
| Process                 | -   Process to notify the EPS and EMSHG   |
|                         |     > if the VA All-Hazards Emergency     |
|                         |     > Cache is activated                  |
|                         |                                           |
|                         | -   Process for storage, inventory        |
|                         |     > tracking system, and security of    |
|                         |     > the VA All-Hazards Emergency Cache  |
|                         |     > are implemented                     |
|                         |                                           |
|                         | -   All products in the VA All-Hazards    |
|                         |     > Emergency Cache are tracked with    |
|                         |     > guidance from the EPS along with    |
|                         |     > replacement of products.            |
|                         |                                           |
|                         | -   The stock is rotated in accordance    |
|                         |     > with the Food and Drug              |
|                         |     > Administration (FDA)/DOD Shelf Life |
|                         |     > Extension Program (SLEP).           |
|                         |                                           |
|                         | -   Authority delineates the activation   |
|                         |     > of the VA All-Hazards Emergency     |
|                         |     > Cache to include provisions for     |
|                         |     > access to cache, security measures  |
|                         |     > of cache, dispersal of              |
|                         |     > pharmaceuticals to Veterans, and    |
|                         |     > staff                               |
|                         |                                           |
|                         | -   Process for monitoring and            |
|                         |     > documenting dispersal of            |
|                         |     > pharmaceuticals to include medical  |
|                         |     > monitoring                          |
|                         |                                           |
|                         | -   Process for communication with        |
|                         |     > state/federal entities during mass  |
|                         |     > prophylaxis                         |
|                         |                                           |
|                         | -   Process for restocking of the VA      |
|                         |     > All-Hazards Emergency Cache upon    |
|                         |     > demobilization and return to        |
|                         |     > readiness                           |
+-------------------------+-------------------------------------------+
| Education/Training      | -   Staff are trained on storage          |
|                         |     > procedures.                         |
|                         |                                           |
|                         | -   Staff are trained on mobilization     |
|                         |     > procedures.                         |
|                         |                                           |
|                         | -   Staff are trained on distribution     |
|                         |     > procedures.                         |
+-------------------------+-------------------------------------------+
| Exercise                | -   The distribution processes are tested |
|                         |     > annually.                           |
|                         |                                           |
|                         | -   The exercises are integrated with     |
|                         |     > system or Federal and State         |
|                         |     > exercises.                          |
+-------------------------+-------------------------------------------+
| Evaluation              | -   Facilities perform after action       |
|                         |     > reporting following each exercise.  |
+-------------------------+-------------------------------------------+
| Organizational Learning | -   The lessons learned from the AARs     |
|                         |     > inform improvements in the VA       |
|                         |     > All-Hazards Emergency Cache         |
|                         |     > management.                         |
+-------------------------+-------------------------------------------+

**Questions:**

VISN Oversight:

1.  How does the VISN assure that the policy regarding the activation
    and utilization of the cache is in accordance with criteria
    established by the VA PBM?

2.  Has the VISN been notified of any cache activations, in addition to
    the required notification of EPS and EMSHG in VACO?

3.  How does the VISN interact with the VISN facilities to assure that
    the cache is properly managed including storage requirements,
    rotation of stock, documentation of inspections, etc?

### **Designated Capability for Expanded Patient Triage, Evaluation and** Treatment during Surge

**Description**: To demonstrate this capability the VISN should be able
to designate and manage areas (beyond the facility's emergency
department \[ED\]) for patient scheduling, triage, assessment,
treatment, admission, transfer, discharge, and evacuation.

**Rationale**: Establishing additional areas for triage, evaluation, and
treatment during a mass casualty event can help offset workload in the
facility's ED and can vastly help throughput of the medical facility.
VISNs should be aware of each facility's surge plan and be ready to
coordinate surge activities among VISN facilities to assist impacted
VAMCs.

**Measurement**:

-   Review of VISN EOP

-   Review of Humanitarian assistance policy

-   Review of Altered standards of care policy

-   Interview with CMO, EPC and DND

Framework for Capability Description

+-------------------------+-------------------------------------------+
| Capability Element      | Assessment components                     |
+=========================+===========================================+
| Policy/Organization     | -   Facilities are able to provide        |
|                         |     > adequate expansion of patient       |
|                         |     > triage, evaluation and treatment    |
|                         |     > for the projected number of         |
|                         |     > patients and types of               |
|                         |     > medical/psychological problems.     |
+-------------------------+-------------------------------------------+
| Resources               |                                           |
+-------------------------+-------------------------------------------+
| > Supplies              | -   Facilities have supplies designated   |
|                         |     > for and housed in triage,           |
|                         |     > evaluation, and treatment areas.    |
|                         |                                           |
|                         | -   Facilities and equipment needed for   |
|                         |     > emergency response and recovery     |
|                         |     > activities are identified and       |
|                         |     > properly stored by the Operating    |
|                         |     > Units at the facility.              |
|                         |                                           |
|                         | -   PPE is available to all personnel and |
|                         |     > visitors within the isolation       |
|                         |     > areas.                              |
+-------------------------+-------------------------------------------+
| > Facilities/Equipment  | -   Facilities have designated areas for  |
|                         |     > expansion of triage, evaluation,    |
|                         |     > and treatment (emergency services,  |
|                         |     > operating suite, critical care      |
|                         |     > areas and others) during a mass     |
|                         |     > casualty event.                     |
|                         |                                           |
|                         | -   Visitors understand where to go for   |
|                         |     > information on patients housed in   |
|                         |     > additional triage, evaluation, and  |
|                         |     > treatment areas.                    |
|                         |                                           |
|                         | -   Facilities ensure that adequate       |
|                         |     > security for additional triage,     |
|                         |     > evaluation, and treatment areas.    |
|                         |                                           |
|                         | -   When necessary, there is appropriate  |
|                         |     > infrastructure to support           |
|                         |     > teletriage and telemedicine         |
|                         |     > capabilities.                       |
+-------------------------+-------------------------------------------+
| > Personnel             | -   Qualified and trained personnel to    |
|                         |     > manage the triage, evaluation and   |
|                         |     > treatment areas using the guidance  |
|                         |     > provided in the EOP                 |
|                         |                                           |
|                         | -   Qualified and trained personnel to    |
|                         |     > staff and operate or support        |
|                         |     > healthcare services in the surge    |
|                         |     > areas.                              |
+-------------------------+-------------------------------------------+
| Process                 | -   The processes for scheduling,         |
|                         |     > triaging, assessing, treating,      |
|                         |     > admitting, transferring,            |
|                         |     > discharging, and evacuating the     |
|                         |     > projected number and casualty types |
|                         |     > are delineated including expansion  |
|                         |     > of services in the usual patient    |
|                         |     > care areas and extension into surge |
|                         |     > areas.                              |
|                         |                                           |
|                         | -   A process is delineated for ensuring  |
|                         |     > adequate clinical and non-clinical  |
|                         |     > staffing of triage, evaluation, and |
|                         |     > treatment areas.                    |
|                         |                                           |
|                         | -   A process is delineated for           |
|                         |     > supervising and directing staff,    |
|                         |     > including volunteers, in their      |
|                         |     > activities under surge procedures.  |
|                         |                                           |
|                         | -   Personnel can provide the initial and |
|                         |     > stabilizing treatment for victims   |
|                         |     > with blunt trauma, blast/shrapnel   |
|                         |     > injuries, thermal and chemical      |
|                         |     > burns, and radiation exposure.      |
+-------------------------+-------------------------------------------+
| Education/Training      | -   Staff are trained and can demonstrate |
|                         |     > the ability to provide services     |
|                         |     > under the medical surge             |
|                         |     > protocols/procedures in regular and |
|                         |     > designated surge areas of the       |
|                         |     > facility.                           |
|                         |                                           |
|                         | -   Personnel are trained and can         |
|                         |     > demonstrate the ability to          |
|                         |     > categorize and triage patients      |
|                         |     > consistent with the protocols used  |
|                         |     > by other local healthcare           |
|                         |     > facilities and EMS.                 |
|                         |                                           |
|                         | -   Relevant clinical personnel are       |
|                         |     > trained and can recognize signs and |
|                         |     > symptoms of possible CDC Category A |
|                         |     > biological agents (e.g., Anthrax,   |
|                         |     > Smallpox, Botulism, Tularemia,      |
|                         |     > Plague, and Ebola).                 |
|                         |                                           |
|                         | -   Personnel are trained and can         |
|                         |     > demonstrate knowledge of secondary  |
|                         |     > hazards of Chemical, Biological,    |
|                         |     > Radiological, Nuclear materials.    |
|                         |                                           |
|                         | -   Personnel are trained in and can      |
|                         |     > demonstrate knowledge of antidotes, |
|                         |     > differential diagnosis, signs and   |
|                         |     > symptoms, treatment protocols, and  |
|                         |     > initial treatments for chemical,    |
|                         |     > biological, and radiological        |
|                         |     > events.                             |
+-------------------------+-------------------------------------------+
| Exercise                | -   Processes associated with designating |
|                         |     > and operating additional triage,    |
|                         |     > evaluation, and treatment areas are |
|                         |     > exercised periodically.             |
|                         |                                           |
|                         | -   The exercises are integrated with     |
|                         |     > system or Federal and State         |
|                         |     > exercises.                          |
+-------------------------+-------------------------------------------+
| Evaluation              | -   The AAR process assesses medical      |
|                         |     > surge performance                   |
+-------------------------+-------------------------------------------+
| Organizational Learning | -   The findings from the AAR informs     |
|                         |     > improvements that are incorporated  |
|                         |     > into the EOP and other EMP          |
|                         |     > activities (e.g., training,         |
|                         |     > resource management).               |
+-------------------------+-------------------------------------------+

**Questions:**

Scenario: There has been a large chemical spill nearby one of the
community hospitals that is situated near a VISN facility. Patients have
initially been transported or have transported themselves to that
facility. That facility's resources have been overwhelmed and patients
are being sent to the nearby VAMC. That VAMC has activated its EOC and
medical surge procedures.

VISN Oversight:

1.  Do you have a process in place assisting VISN facilities with
    medical surge operations?

2.  Is the VISN aware of the medical surge capabilities of individual
    VISN facilities?

3.  If the affected VAMC requires further assistance, is there a plan
    for the use of other VA facilities?

4.  What are your modes of transport to assist the VAMCs in managing
    medical surge?

5.  In lieu of transporting patients, are there plans to transport
    additional staff to assist the affected VAMC(s)?

6.  How does the VISN interact with the VAMC EOC in these situations?

7.  What are the VISN plans to assist in the housing of transported
    staff?

8.  How is the VISN prepared to assist with supporting a surge in demand
    of laboratory, blood bank and diagnostic imaging services?

### Processes and Procedures for Control and Coordination of Mass Fatality Management

**Description**: To demonstrate this capability the VISN should be able
to manage large numbers of fatalities that expire in-house or en route
to the facility.

**Rationale**: To ensure the health and welfare of those surviving the
incident, facilities must develop plans for the safe management of human
remains. The VISN should be aware of these plans at the VISN facilities
in order to supplement mass fatality resources from one VISN facility to
another.

**How Measured**:

-   Review of VISN EOP

-   Interview with the CMO, DND, EPC and Safety Officer

Framework for Capability Description

+-------------------------+-------------------------------------------+
| Capability Element      | Assessment components                     |
+=========================+===========================================+
| Policy/Organization     | -   The facility demonstrates the ability |
|                         |     > to manage mass fatalities in a      |
|                         |     > safe, secure, and sensitive manner, |
|                         |     > with orderly management of body     |
|                         |     > storage, forensic interface and     |
|                         |     > family reunification. VISNs are     |
|                         |     > aware of individual facility plans. |
+-------------------------+-------------------------------------------+
| Resources               |                                           |
+-------------------------+-------------------------------------------+
| > Supplies              | -   The facility has enough supplies to   |
|                         |     > manage large numbers of fatalities  |
|                         |     > (e.g., body bags).                  |
|                         |                                           |
|                         | -   The facility has an adequate amount   |
|                         |     > and level of PPE.                   |
+-------------------------+-------------------------------------------+
| > Facilities/Equipment  | -   The facility has established          |
|                         |     > arrangements with outside vendors   |
|                         |     > to provide additional storage of    |
|                         |     > human remains in a controlled       |
|                         |     > environment (MOUs/MOAs with         |
|                         |     > refrigerated trucking companies or  |
|                         |     > other refrigeration capabilities).  |
+-------------------------+-------------------------------------------+
| > Personnel             | -   Staff follow written procedures for   |
|                         |     > managing human remains.             |
+-------------------------+-------------------------------------------+
| Process                 | -   A process is delineated for           |
|                         |     > collecting the human remains in a   |
|                         |     > safe and sensitive manner,          |
|                         |     > establishing or maintaining         |
|                         |     > identification of each body/body    |
|                         |     > part, storing the human remains in  |
|                         |     > a secure, temperature controlled    |
|                         |     > environment, interfacing with the   |
|                         |     > medical examiner or coroner, and    |
|                         |     > providing family assistance in      |
|                         |     > identifying bodies and releasing    |
|                         |     > bodies once cleared by authorities. |
|                         |                                           |
|                         | -   The human remains process provides    |
|                         |     > guidance for managing bodies with   |
|                         |     > significant chemical, radioactive,  |
|                         |     > or biological contamination.        |
+-------------------------+-------------------------------------------+
| Education/Training      | -   Relevant personnel are trained on the |
|                         |     > management and operation of the     |
|                         |     > mass fatality process.              |
|                         |                                           |
|                         | -   If appropriate, personnel receive     |
|                         |     > training on how to manage           |
|                         |     > contaminated human remains.         |
+-------------------------+-------------------------------------------+
| Exercise                | -   Fatality management plans are         |
|                         |     > exercised at least once a year.     |
|                         |                                           |
|                         | -   This capability is fully integrated   |
|                         |     > with Federal and State-wide         |
|                         |     > exercises at least once a year.     |
+-------------------------+-------------------------------------------+
| Evaluation              | -   The exercise after action reporting   |
|                         |     > process includes evaluation of mass |
|                         |     > fatality management.                |
+-------------------------+-------------------------------------------+
| Organizational Learning | -   The findings from AARs inform         |
|                         |     > improvements that are incorporated  |
|                         |     > into the mass fatality management   |
|                         |     > capability.                         |
+-------------------------+-------------------------------------------+

**Question:**

VISN Oversight:

1.  Describe the VISN's plans to coordinate activities in order to
    supplement an individual facility's mass fatality capabilities?

2.  Is your VISN aware of the individual mass fatality management plans
    of VISN facilities?

3.  Describe VISN-wide exercises and training that incorporate mass
    fatality management.

Support to External Requirements
================================

Many VA facilities within a VISN have roles with other federal agencies,
particularly under the NDMS and the fulfillment of VA's additional
mission of back-up to the Department of Defense (DOD) healthcare system.
As federal agencies with emergency management responsibilities are
moving toward a regional decentralized approach to emergency management,
it is essential that VA facilities integrate with the State and other
federal health partners such as Health and Humans Services (HHS),
Department of Homeland Security (DHS), DOD and the CDC.

Fulfilling those capabilities requires VISN knowledge of the external
mission expectations and demands on VISN facilities as well as an
ability to monitor facility fulfillment of these missions in order to
provide possible needed coordination.

Provision of Supplemental Health Services to Support the National Disaster Medical System 
-----------------------------------------------------------------------------------------

**Description**: To demonstrate this capability, those VISN facilities
acting as Federal Coordination Centers (FCCs) should be able to direct
and provide supplemental health and medical assistance in domestic
disasters at the request of state and local authorities.

**Rationale**: NDMS provides healthcare services, healthcare-related
social services, and other appropriate auxiliary services to respond to
the needs of victims of a public health emergency.

**Measurement**:

-   Review VISN EOP for NDMS Supplement

-   Identification and review of signed Memorandums of Agreements (MOAs)
    for NDMS with hospitals

-   Identification of FCCs within the VISN and review of FCC activities

-   Interview appropriate VISN leadership (VISN Director, Chief Medical
    Officer \[CMO\] or DND)

-   Interview with VISN-Liaison Area Emergency Manager, CMO and Network
    Emergency Manager (if designated)

-   Interview with FCC Director (can be by telephone)

Framework for Capability Description

+-------------------------+-------------------------------------------+
| Capability Element      | Assessment components                     |
+=========================+===========================================+
| Policy/Organization     | -   VA is a signatory member to the NDMS. |
+-------------------------+-------------------------------------------+
| Resources               |                                           |
+-------------------------+-------------------------------------------+
| > Supplies              | -   Sufficient supplies are in place at   |
|                         |     > FCCs.                               |
+-------------------------+-------------------------------------------+
| > Facilities/Equipment  | -   Key VISN staff are able to coordinate |
|                         |     > emergency activities and maintain   |
|                         |     > communications with VISN facility   |
|                         |     > FCC staff.                          |
|                         |                                           |
|                         | -   EOC resources support FCC             |
|                         |     > communications.                     |
+-------------------------+-------------------------------------------+
| > Personnel             | -   VISN staff are aware of FCC personnel |
|                         |     > at VISN facilities.                 |
+-------------------------+-------------------------------------------+
| Process                 | -   VISN staff are aware of lines of      |
|                         |     > authority, roles, and               |
|                         |     > responsibilities for FCC staff.     |
|                         |                                           |
|                         | -   Lines of authority are in place with  |
|                         |     > partner agencies.                   |
|                         |                                           |
|                         | -   Process to report bed availability,   |
|                         |     > patient reception,                  |
|                         |     > distribution/tracking of patients,  |
|                         |     > and management of patient reception |
|                         |                                           |
|                         | -   Process to identify and stand-up a    |
|                         |     > patient reception area              |
+-------------------------+-------------------------------------------+
| Education/Training      | -   Staff are trained in any VISN defined |
|                         |     > FCC roles.                          |
+-------------------------+-------------------------------------------+
| Exercise                | -   VISN participates with facility NDMS  |
|                         |     > exercises..                         |
+-------------------------+-------------------------------------------+
| Evaluation              | -   The VISN is aware of facility FCC     |
|                         |     > evaluations.                        |
+-------------------------+-------------------------------------------+
| Organizational Learning | -   The lessons learned from the          |
|                         |     > evaluations inform improvements in  |
|                         |     > NDMS planning.                      |
+-------------------------+-------------------------------------------+

**Questions:**

VISN Oversight:

1.  Please describe your understanding of NDMS.

2.  Is there an FCC for NDMS within your VISN? If so, what has been the
    level of any VISN involvement and how are you assured that the FCC
    is conducting the required exercises and is therefore properly
    prepared?

3.  Are you aware of the FCC's NDMS patient surge estimates and whether
    the FCC has the resources to meet these commitments?

4.  Are you knowledgeable if there are signed MOAs from participating
    community hospitals with your FCC and the identity of those
    hospitals?

5.  Has the VISN been included in any NDMS exercises or at least been
    notified during the exercise and informed of the assessments of any
    of the exercises? If so, please briefly describe the exercises and
    the assessments.

6.  Do you review the NDMS bed availability reports conducted
    periodically in your VISN?

VA/DOD Contingency Hospital System
----------------------------------

**Description**: To demonstrate this capability the VISN should be able
regularly report bed availability and provide beds to DOD during times
of national emergencies and war-time should DOD medical treatment
facilities be incapacitated or overwhelmed.

**Rationale**: The VA plays a statutory back-up role to the DOD during
national emergencies and war-time by providing staffed beds for the care
of wounded or ill Service members.

**Measurement**:

-   Review VISN EOP for VA/DOD Contingency Hospital System Supplement

-   Review of PRC and FCC EOPs

-   Interviews with VISN CMO, DND and Liaison AEM, Network Emergency
    Manager (if designated)

Framework for Capability Description

+-------------------------+-------------------------------------------+
| Capability Element      | Assessment components                     |
+=========================+===========================================+
| Policy/Organization     | -   VA is required to provide beds to DOD |
|                         |     during national emergencies and       |
|                         |     war-time                              |
+-------------------------+-------------------------------------------+
| Resources               |                                           |
+-------------------------+-------------------------------------------+
| > Supplies              | -   N/A                                   |
+-------------------------+-------------------------------------------+
| > Facilities/Equipment  | -   IT and communications equipment are   |
|                         |     > provided to complete bed reports    |
|                         |     > and support program at the national |
|                         |     > level.                              |
+-------------------------+-------------------------------------------+
| > Personnel             | -   VAMC staff are assigned to support    |
|                         |     > this program, including bed         |
|                         |     > reporting.                          |
+-------------------------+-------------------------------------------+
| Process                 | -   VAMC conducts bed reports and insures |
|                         |     > consistency with DOD.               |
+-------------------------+-------------------------------------------+
| Education/Training      | -   VAMC have been trained in their role  |
|                         |     > supporting this program.            |
+-------------------------+-------------------------------------------+
| Exercise                | -   VAMC completes all bed reports for    |
|                         |     > the year.                           |
+-------------------------+-------------------------------------------+
| Evaluation              | -   VAMC conducts an annual program       |
|                         |     > review to identify improvements.    |
+-------------------------+-------------------------------------------+
| Organizational Learning | -   The lessons learned from evaluation   |
|                         |     > inform improvements in the program. |
+-------------------------+-------------------------------------------+

**Questions:**

VISN Oversight:

1.  What VISN facilities are Primary Receiving Centers (PRC) for
    receiving any Service Members in the event of the emergent need to
    back-up DOD?

2.  Are you aware of what level of bed availability VISN facilities are
    reporting?

3.  Has the VISN been involved in any facility bed reporting or other
    DOD bed availability exercises?

4.  Has there been any contact on a VISN level with local or national
    DOD officials regarding DOD back-up?

5.  Are you aware of facility interactions with DOD facilities regarding
    emergency preparedness?

6.  Have there been any VISN interactions with DOD facilities regarding
    emergency preparedness?

Support Under the National Response Framework (NRF)
---------------------------------------------------

The VISN establishes liaison with all appropriate VHA and non-VHA
entities and officials, conducts information exchange, and coordinates
incident response strategies and tactics.

**Description**: To demonstrate this capability the VISN should be able
to communicate and coordinate with other Federal agencies.

**Rationale**: Responses to emergencies require collaboration with the
community as well as other Federal agencies located in the vicinity of
the emergency to receive needed supplies, support and report required
information.

**Measurement**:

-   **Tour of VISN EOC**

-   **Review VISN EOP for NDMS Supplement**

-   **Interview with VISN-Liaison AEM, CMO and Network Emergency Manager
    (if designated)**

Framework for Capability Description

+-------------------------+-------------------------------------------+
| Capability Element      | Assessment components                     |
+=========================+===========================================+
| Policy/Organization     | -   The VISN demonstrates an effective    |
|                         |     > interface with relevant federal,    |
|                         |     > state, and local emergency          |
|                         |     > management authorities and public   |
|                         |     > health departments. Activity on the |
|                         |     > federal level may include           |
|                         |     > involvement on a regional level     |
|                         |     > with HHS in accordance with         |
|                         |     > Emergency Support Function (ESF) 8, |
|                         |     > where VA is part of coordinated     |
|                         |     > Federal assistance to supplement    |
|                         |     > State and local resources in        |
|                         |     > response to public health and       |
|                         |     > medical care needs following a      |
|                         |     > major disaster or emergency, or     |
|                         |     > during a developing potential       |
|                         |     > medical situation.                  |
+-------------------------+-------------------------------------------+
| Resources               |                                           |
+-------------------------+-------------------------------------------+
| > Supplies              | -   EOP liaison position guidance         |
|                         |     > (position description, EOP forms    |
|                         |     > and Job Action Sheet)               |
|                         |                                           |
|                         | -   Forms used by the Federal and State   |
|                         |     > emergency management and public     |
|                         |     > health agencies for sharing         |
|                         |     > information, setting up work        |
|                         |     > assignments, etc.                   |
|                         |                                           |
|                         | -   VISN maintains lists of key POCs.     |
+-------------------------+-------------------------------------------+
| > Facilities/Equipment  | -   Communications and IT to accomplish   |
|                         |     > the liaison function                |
+-------------------------+-------------------------------------------+
| > Personnel             | -   Appropriately qualified and trained   |
|                         |     > personnel to staff the liaison      |
|                         |     > function.                           |
+-------------------------+-------------------------------------------+
| Process                 | -   The VISN has procedures for providing |
|                         |     > and receiving information from      |
|                         |     > Federal and State health            |
|                         |     > authorities and conveying that      |
|                         |     > information to the facility's IMT   |
|                         |     > and appropriate VHA response        |
|                         |     > elements.                           |
|                         |                                           |
|                         | -   Liaison position participates in      |
|                         |     > appropriate planning meetings and   |
|                         |     > briefings with the Federal and      |
|                         |     > State emergency management and      |
|                         |     > public health authorities.          |
|                         |                                           |
|                         | -   VISN has developed an external media  |
|                         |     > crisis communication plan.          |
+-------------------------+-------------------------------------------+
| Education/Training      | -   The individual designated to          |
|                         |     > communicate with the Federal and    |
|                         |     > State emergency management          |
|                         |     > authorities has received training   |
|                         |     > on their liaison role and           |
|                         |     > communication methods.              |
|                         |                                           |
|                         | -   IMT Command Staff understand their    |
|                         |     > roles and the chain of              |
|                         |     > communication in relation to        |
|                         |     > Federal and State emergency         |
|                         |     > management and public health        |
|                         |     > authorities.                        |
+-------------------------+-------------------------------------------+
| Exercise                | -   The liaison function with Federal and |
|                         |     > State emergency management and      |
|                         |     > public health authorities is        |
|                         |     > exercised at least once a year.     |
|                         |                                           |
|                         | -   The liaison capability is fully       |
|                         |     > exercised within a Federal and/or   |
|                         |     > State-wide exercise at least once a |
|                         |     > year.                               |
+-------------------------+-------------------------------------------+
| Evaluation              | -   AARs from exercises and drills are    |
|                         |     > evaluated annually.                 |
+-------------------------+-------------------------------------------+
| Organizational Learning | -   Lessons learned from AARs are         |
|                         |     > incorporated in the VISN EOP.       |
+-------------------------+-------------------------------------------+

**Questions:**

VISN Oversight:

1.  Have there been any clinical initiatives undertaken VISN-wide
    contributing to emergency preparedness? If so, have they been shared
    with external agencies?

2.  Describe your current interactions with other federal health and
    emergency organizations including CDC, HHS and the Federal Emergency
    Management Agency (FEMA).

3.  Are you involved with other federal agencies such as through the
    Regional Interagency Steering Committees as part of the Health and
    Human Services (HHS) NRF ESF 8?

4.  Describe the nature of your involvement with EMSHG at the VHACO
    level.

5.  Describe contacts you have made and current interactions with state
    health and/or EMS authorities.

6.  How are contact with all these governmental authorities part of your
    crisis communication plans?

7.  What has been the involvement of VISN facilities' or the VISN Office
    with emergency preparedness committees frequently organized as part
    of State hospital associations?

8.  What is the operational relationship with State EOCs in your VISN?

Acronym List
============

  **Acronym**   **Definition**
  ------------- --------------------------------------------------------------------------------------------------------
  AAR           After Action Report
  AEM           Area Emergency Manager
  BPA           Blanket Purchase Agreement
  CAM           Capital Asset Manager
  CDC           Centers for Disease Control and Prevention
  CIO           Chief Information Officer
  CLO           Chief Logistics Officer
  CMO           Chief Medical Officer
  CONOPS        Concept of Operations
  COO           Chief Operations Officer
  COOP          Continuity of Operations
  DEMPS         Disaster Emergency Medical Personnel System
  DHS           Department of Homeland Security
  DND           Deputy Network (VISN) Director
  DOD           Department of Defense
  ED            Emergency Department
  ELC           Executive Leadership Council
  EMC           Emergency Management Committee
  EMP           Emergency Management Program
  EMS           Emergency Medical Services
  EMSHG         Emergency Management Strategic Healthcare Group
  EOC           Emergency Operations Center
  EOP           Emergency Operations Plan
  EPC           Emergency Program Coordinator (relates to designated VISN staff or VISN-Liaison Area Emergency Manager
  EPS           Emergency Pharmacy Service
  ESF           Emergency Support Function
  FCC           Federal Coordinating Center
  FDA           Food and Drug Administration
  FEMA          Federal Emergency Management Agency
  GETS          Government Emergency Telecommunications Service
  HF            High Frequency
  HHS           Health and Human Services
  HIPAA         Health Insurance Portability and Accountability Act
  HR            Human Resource
  HSAS          **Homeland Security Advisory System**
  HVA           Hazard Vulnerability Analysis
  HVAC          Heating Ventilation and Air Conditioning
  IAP           Incident Action Plan
  IC            Infection Control
  ICS           Incident Command System
  IMT           Incident Management Team
  IAP           Incident Action Plan
  IT            Information Technology
  JOC           Joint Operations Center
  MBO           Management by Objective
  MOA           Memorandum of Agreement
  MOU           Memorandum of Understanding
  N/A or NA     Not Applicable
  NAC           National Acquisition Center
  NDMS          National Disaster Medical System
  NIMS          National Incident Management System
  NRF           National Response Framework
  NRM           Non-Recurring Maintenance
  OSHA          Occupational Safety & Health Administration
  PAO           Public Affairs Officer
  PAPR          Powered Air Purifying Respirator
  PBM           Pharmacy Benefits Management
  PIO           Public Information Officer
  POC           Point of Contact
  PPE           Personal Protective Equipment
  PRC           Primary Receiving Center
  SARS          Severe Acute Respiratory Syndrome
  SLEP          Shelf Life Extension Program
  SOP           Standard Operating Procedure
  TJC           The Joint Commission
  UPS           Uninterruptible Power Supply
  VA            Veterans Affairs
  VACO          Veterans Affairs Central Office
  VAMC          Veterans Affairs Medical Center
  VHA           Veterans Health Administration
  VHACO         Veterans Health Administration Central Office
  VISN          Veterans Integrated Service Network
  WHO           World Health Organization