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VHA Comprehensive Emergency Management Program

Capability Assessor's Guide

**Results from VAMCs Evaluations**

Department of Veterans Affairs

Veterans Health Administration

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

![vaseal](media/image3.png){width="1.0972222222222223in"
height="1.0972222222222223in"}

**October 30, 2008**

**VHA Emergency Management Capability Assessment Process Overview for VA
Medical Centers**

\* \* \* \* \*

**TABLE OF CONTENTS**

[1 Executive Summary 1](#executive-summary)

[2 Introduction 3](#introduction)

[3 Project Background 3](#project-background)

[4 Purpose 3](#purpose)

[5 Site Visit Activities 4](#site-visit-activities)

[5.1 Opening Conference 5](#opening-conference)

[5.2 Individual and Group Interviews
5](#individual-and-group-interviews)

[5.2.1 Associate Director (AD) 5](#associate-director-ad)

[5.2.2 Chief of Staff 5](#chief-of-staff)

[5.2.3 Nurse Executive, Associate Chief Nurse for Emergency Care,
Emergency Department Nurse Manager, Designated Learning Officer, Mental
Health Clinician
6](#nurse-executive-associate-chief-nurse-for-emergency-care-emergency-department-nurse-manager-designated-learning-officer-mental-health-clinician)

[5.2.4 Chief of Medicine 6](#chief-of-medicine)

[5.2.5 Emergency Department (ED) Director
7](#emergency-department-ed-director)

[5.2.6 Emergency Management Committee
7](#emergency-management-committee)

[5.2.7 Emergency Program Coordinator 7](#emergency-program-coordinator)

[5.2.8 Safety Manager 7](#safety-manager)

[5.2.9 Chief Information Officer (CIO)
8](#chief-information-officer-cio)

[5.2.10 Deployment Support Coordinator
8](#deployment-support-coordinator)

[5.2.11 Chief Engineer 8](#chief-engineer)

[5.2.12 Chief of Police 9](#chief-of-police)

[5.2.13 Chief of Pharmacy 9](#chief-of-pharmacy)

[5.2.14 Chief of Food Services, Chief of Dietary
9](#chief-of-food-services-chief-of-dietary)

[5.2.15 Chief of Acquisition and Materials Management
9](#chief-of-acquisition-and-materials-management)

[5.2.16 Chief of Infectious Diseases 10](#chief-of-infectious-diseases)

[5.2.17 Chief of Human Resources (HR) 10](#chief-of-human-resources-hr)

[5.2.18 Public Affairs Officer (PAO) 10](#public-affairs-officer-pao)

[5.2.19 Employee Representative(s) 10](#employee-representatives)

[5.2.20 National Disaster Medical System (NDMS) Coordinator
10](#national-disaster-medical-system-ndms-coordinator)

[5.3 Focused Facility Tours 10](#focused-facility-tours)

[5.3.1 Emergency Department 11](#emergency-department)

[5.3.2 VA All-Hazards Emergency Caches
11](#va-all-hazards-emergency-caches)

[5.3.3 Hospital Emergency Operations Center (Hospital Command Center)
11](#hospital-emergency-operations-center-hospital-command-center)

[5.3.4 Physician Manpower Pool Staffing Area
12](#physician-manpower-pool-staffing-area)

[5.3.5 General Manpower Pool Staffing Area
12](#general-manpower-pool-staffing-area)

[5.3.6 Media Relations/Public Affairs Coordinating Area
12](#media-relationspublic-affairs-coordinating-area)

[5.3.7 Other Areas as Appropriate 12](#other-areas-as-appropriate)

[5.4 Document Reviews 13](#document-reviews)

[5.4.1 Hazard Vulnerability Assessments
13](#hazard-vulnerability-assessments)

[5.4.2 Emergency Operations Plan 13](#emergency-operations-plan)

[5.4.3 Emergency Management Committee Documentation
14](#emergency-management-committee-documentation)

[5.4.4 Exercise After Action Reports 14](#exercise-after-action-reports)

[5.4.5 Memoranda of Understanding/Contracts and Memoranda of Agreement
with Key Vendors
15](#memoranda-of-understandingcontracts-and-memoranda-of-agreement-with-key-vendors)

[5.4.6 Signed MOAs for the NDMS 15](#signed-moas-for-the-ndms)

[5.4.7 Presence of Inventory of Critical Resources (Pharmaceuticals,
Equipment, and Supplies)
16](#presence-of-inventory-of-critical-resources-pharmaceuticals-equipment-and-supplies)

[5.5 Tabletop Exercises 16](#tabletop-exercises)

[5.6 Capability Demonstrations 17](#capability-demonstrations)

[5.7 Pre-Survey Distribution 17](#pre-survey-distribution)

[6 Out-brief and Concluding Conference
18](#out-brief-and-concluding-conference)

[6.1 Use of Data Collection Tools 18](#use-of-data-collection-tools)

[6.2 Site Visit Report 19](#site-visit-report)

[7 Acronym List 20](#acronym-list)

[Appendix A: Capability Descriptor Document
21](#appendix-a-capability-descriptor-document)

[Appendix B: Pre-Survey 21](#appendix-b-pre-survey)

[Appendix C: Site Visit Agenda 21](#appendix-c-site-visit-agenda)

[Appendix D: Questions for Site Visit Activity
21](#appendix-d-questions-for-site-visit-activity)

[Appendix E: Capability Scoring Tool
21](#appendix-e-capability-scoring-tool)

[Appendix F: Opening Conference PowerPoint
21](#appendix-f-opening-conference-powerpoint)

[Appendix G: Closing Conference PowerPoint
22](#appendix-g-closing-conference-powerpoint)

[Appendix H: Final Report 22](#appendix-h-final-report)

[Appendix I: TJC Scoring Tool 22](#appendix-i-tjc-scoring-tool)

[Appendix J: The NIMS Scoring Tool
22](#appendix-j-the-nims-scoring-tool)

Executive Summary
=================

According to the United States Federal Emergency Management Agency
(FEMA), during Hurricane Katrina, the agency provided a substantiated
support network to Hurricane Katrina victims, emergency responders, and
states. However, where it excelled in support, it lacked in response
capabilities. Specifically in the areas of:

-   Command and Management

-   Communication

-   Resource Management

-   Mobilization

These deficiencies confirmed the need to enhance FEMA's disaster
response capability and all-hazards preparedness.

Two predictors of a well defined Emergency Management Program (EMP) are
the integration of all-hazards preparedness and the facility's response
and recovery capability. These factors are what have distinguished the
Veterans Health Administration (VHA) as a leader in emergency
management.

Through the ongoing effort to further assess and enhance the VHA's EMP
with emphasis on all-hazards preparedness, the VHA initiated a project
to help answer the question, "Are we ready?". This project was developed
under the guidance of the VHA's Emergency Management Strategic
Healthcare Group (EMSHG) and Booz Allen Hamilton (Booz Allen), composed
of members with deep knowledge in Department of Veterans Affairs (VA)
operations, emergency management and clinical healthcare expertise.
Specifically, there are two primary objectives to this study.

1.  **Formative guidance:** To further enhance and improve EMPs, the
    assessment teams, comprised of clinical, engineering, emergency
    management, and healthcare operations experts, shared lessons
    learned and promising practices from other VHA facilities as well as
    from the private sector.

2.  **Determine baseline status of preparedness:** To determine the
    areas in which the VHA should focus attention, the assessment teams
    gathered information on local, regional and system-wide issues and
    opportunities for improvement. These identified issues should be
    elevated to national attention, through the EMSHG and the Emergency
    Management Coordination Group (EMCG).

Site visits conducted by the VHA assessment team will examine six main
elements of emergency management. Figure 1 provides a depiction of these
elements.

**Figure 1. Emergency Management Elements**

![](media/image4.png){width="3.25in" height="2.5930555555555554in"}

The VHA assessment team, through collaboration with multiple steering
committees and expert panels, have identified 69 emergency management
capabilities that meet or exceed The Joint Commission (TJC), National
Fire Protection Association (NFPA) 1600, and Federal Emergency
Management standards. These capabilities will aid in assessing the six
main emergency management elements.

The VHA assessment team will conduct many activities designed to allow
an overall assessment of each of the 69 capabilities. These activities
will include individual and group interviews, facilitated discussions,
Table Top exercises, and capability demonstrations. The team will
interview key personnel in the facility and will interact extensively
with the Emergency Program Coordinator (EPC) and the Emergency
Management Committee (EMC).

At the conclusion of each site visit, the VHA assessment team will
provide a brief closing conference, followed by a written report within
30 days that will provide insight into the facilities' exemplary
practices, its opportunities for improvement, and any recommendations
the assessment team has for program improvement.

Aggregate results will be presented quarterly to the EMSHG for the
purpose of highlighting systemic regional and national issues and
opportunities for improvement

 {#section .list-paragraph}

Introduction
============

The VA is currently engaging in continuous quality improvement for
emergency preparedness after having embraced the need to establish a
more systematic strategy for proactively identifying system weaknesses.
Such a strategy will not only allow the VA to consistently meet TJC,
NFPA 1600, and FEMA standards, but also will position the VA as a leader
in emergency preparedness for every community with a VA presence. In
this way, the VA will be better able to ensure the safety of its
employees and better serve Veterans and the communities in which they
live.

Project Background
==================

The VHA EMSHG has requested that Booz Allen conduct extensive hospital
program reviews as part of this continuous quality improvement process
for emergency preparedness. This review will encompass up to 150 site
visits over three years. The assessment team will consist of three team
members, two analysts from Booz Allen and one from the VA system. The
site visits will focus on assessing each facility's overall emergency
management capabilities, particularly those related to event response
and recovery. For this review process, the assessment team developed a
framework to define each capability. This framework includes the
following components:

-   **Resources** (including supplies, facilities, and equipment)
    assigned to maintain or enable that capability

-   **Personnel** designated to manage or staff that area

-   **Education/Training** provided to staff regarding that capability

-   **Exercise** activities used to promote evaluation of that
    capability

-   **Evaluation** of the exercise results

-   **Organizational Learning** and process improvement that takes place
    as a result of the exercise and resulting evaluation.

Purpose 
=======

This guide presents a consistent study methodology, provides a means for
uniformly analyzing data, and offers a template for assessment team
members conducting EMP site at select VA Medical Centers (VAMCs). It
also offers a standardized approach to limit the evaluation variability
that would naturally enter the review process given the number of
facilities and evaluators who will be involved in the site review
process.

Site Visit Activities
=====================

Each VAMC site visit is envisioned to last 2½ to 3 days, and Veterans
Integrated Service Network (VISN) visits will last approximately 1½
days. Figure 2 provides a high-level overview of site visit activities.

**Figure 2. Site visit activities**

**Appendix A** contains the comprehensive list of capabilities, a subset
of which constitute the potential assessment elements of each site
visit. The assessment team will customize the list of capabilities for
assessment elements based on the result of the facility's Hazards
Vulnerability Analysis (HVA), its size, and mission

**Appendix B** contains the Pre-survey questionnaire, sent out to the
VAMC prior to site visit assessment.

**Appendix C** contains the VAMC site visit agenda that the VHA
Assessment Team will follow while on-site. This agenda may be modified
to account for the VAMCs changing schedule (e.g., staff availability,
capability demonstrations).

**Appendix D** contains the specific questions the assessment team will
ask of each individual or the specific attributes to be observed during
a facility tour or capability observation.

**Appendix E** contains the Capability Scoring Tool developed to assist
the VHA Assessment Team in documenting the capability elements.

**Appendix F** contains the Opening Conference PowerPoint presentation.

**Appendix G** contains the Closing Conference PowerPoint presentation.

**Appendix H** contains a VAMC Site Visit Final Report Template.

**Appendix I** contains TJC Scoring Tool.

**Appendix J** contains the National Management System (NIMS) Scoring
Tool.

The following sections describe each site visit activity and the
capabilities the assessment team will evaluate during those activities.

Opening Conference 
------------------

The site survey will begin by assembling all key VAMC personnel who are
stakeholders in the delivery of emergency management capabilities at the
healthcare facility. At this opening conference, the assessment team
will introduce itself; present the project's goals, deliverables, and
outcomes; and describe the projected agenda for the site visit.

VAMC personnel will then introduce themselves and describe the
functional areas that they oversee. At the end of this conference,
specific times and locations for individual interviews will be
established and confirmed, as will the times and locations of the other
EMP-wide assessment activities.

The assessment team will evaluate the following during the opening
conference:

-   Management commitment

-   Level of understanding of the EMP

-   Level of engagement

Individual and Group Interviews
-------------------------------

Assessment team members will conduct interviews with those VAMC
personnel who contribute to the overall establishment and conduct of the
EMP. The site survey team will attempt to allot the interview
responsibilities based on the assessment team's composition and
expertise and will try to best match the team member by subject matter
expertise to the individual being interviewed. The following sections
describe the VAMC individuals and groups the assessment team will
interview.

### Associate Director (AD)

The assessment team will evaluate the following capabilities through
interviews with the AD:

-   Administrative Activities that ensure the EMP meets its Mission and
    Objectives

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

-   Maintaining Authorized Leadership (Leadership Succession)

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

### Chief of Staff

The assessment team will evaluate the following capabilities through
interviews with the Chief of Staff:

-   Support under the National Response Framework (NRF)

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

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

-   Maintaining Laboratory, Blood Bank, and Diagnostic Imaging Surge
    Capability

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

### Nurse Executive, Associate Chief Nurse for Emergency Care, Emergency Department Nurse Manager, Designated Learning Officer, Mental Health Clinician

The assessment team will evaluate the following capabilities through
interviews:

-   Management of Care for Home-Based Primary Care Patients' during
    Incidents

-   Specialty Outpatient Services (e.g., Dialysis, Persons with Spinal
    Cord Injury Dependent \[SCI/D\] on Community/Outside Assistance in
    their Home, Oxygen Therapy Patients, and Dementia or Other Cognitive
    Impairment

-   Internal and External (to the VA) Alternate Care Sites

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

-   Situational Assessment of Response and Coordination Efforts for
    Initial Incident Management and Emergency Operations Center (EOC)
    Activation

-   Maintaining Patient Mental Health and Welfare

### Chief of Medicine 

The assessment team will evaluate the following capabilities through
interviews with the Chief of Medicine:

-   Provision of Ambulatory Clinical Services during Incidents

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

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

-   Maintaining Laboratory, Blood Bank, and Diagnostic Imaging Surge
    Capability

### Emergency Department (ED) Director

The assessment team will evaluate the following capabilities through
interviews with the ED Director (conducted during facility tour):

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

-   Response/Interface with Community Healthcare Organizations

-   Integration of Patient Reception, Surge, and Decontamination Teams

### Emergency Management Committee

The assessment team will evaluate the following capabilities through
interviews with the EMC:

-   VHA Emergency Management Guidebook 9-step Process

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

-   Development, Implementation, Management, and Maintenance of an EMC
    process to Support the EMP

### Emergency Program Coordinator 

The assessment team will evaluate the following capabilities through
interviews with the EM:

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

-   Processes and Procedures for Sheltering-in-Place

-   Situational Assessment of Response and Coordination Efforts for
    Initial Incident Management and EOC Activation

-   Development, Implementation, Management, and Maintenance of
    Community Based Outpatient Clinic (CBOC) EOP

### Safety Manager

The assessment team will evaluate the following capabilities through
interviews with the Safety Manager:

-   Processes and Procedures for Sheltering-in-Place

-   Processes and Procedures for Managing a Hazardous Substance Incident

-   Selection and Use of Personal Protective Equipment (PPE) for
    Response and Recovery Operations

-   Transporting Critical Staff to the Facility during an Emergency

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

-   Integration of Patient Reception, Surge and Decontamination Teams

### Chief Information Officer (CIO)

The assessment team will evaluate the following capabilities through
interviews with the CIO:

-   Maintaining Information Technology (IT) and Computing Systems
    Resiliency

-   Maintenance of Voice and Data Communication through Satellite Link

-   Interoperable Communications with VAMC Facilities'

-   Maintaining Satellite Telephone Resiliency

-   Interoperable Communications with External Agencies'

###  {#section-1 .list-paragraph}

### Deployment Support Coordinator

The assessment team will evaluate the following capabilities through
interviews with the Disaster Emergency Medical Personnel System (DEMPS)
Coordinator:

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

### Chief Engineer

The assessment team will evaluate the following capabilities through
interviews with the Chief Engineer:

-   Development, Implementation, Management, and Maintenance of an
    Electrical Power Supply

-   Management and Maintenance of Fixed and Portable Electrical
    Generator Resiliency

-   Maintaining Fuel, Fuel Storage, and Fuel Pumps for Generators,
    Heating, and Vehicles Resiliency

-   Development, Implementation, Management, and Maintenance of an
    Emergency Potable Water Plan

-   Maintaining Sewage and Waste Resiliency

-   Maintaining Medical Gases and Vacuum Resiliency

-   Maintaining Heating Ventilation and Air Conditioning (HVAC)
    Resiliency

-   Biohazard (Infection) Control Surge Services during Emergencies

-   Development, Implementation, Management, and Maintenance of an
    Emergency Water Conservation Plan

### Chief of Police

The assessment team will evaluate the following capabilities through
interviews with the Chief of Police:

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

-   Biohazard (Infection) Control Surge Services during Emergencies

-   Interoperable Communications with External Agencies'

### Chief of Pharmacy

The assessment team will evaluate the following capabilities through
interviews with the Chief of Pharmacy (conducted during facility tour):

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

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

-   Specialty Outpatient Services (e.g., Dialysis, persons with SCI/D on
    community/outside assistance in their home, Oxygen Therapy Patients,
    and Dementia or Other Cognitive Impairment

### Chief of Food Services, Chief of Dietary

The assessment team will evaluate the following capabilities through
interviews with the Chief of Food Services and Chief of Dietary:

-   Processes and Procedures for Personal Preparedness and Employee
    Welfare

-   Maintaining Patient Mental Health and Welfare

### Chief of Acquisition and Materials Management

The assessment team will evaluate the following capabilities through
interviews with the Chief of Acquisitions and Materials Management:

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

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

### Chief of Infectious Diseases

The assessment team will evaluate the following capabilities through
interviews with the Chief of Infectious Diseases:

-   Response/Interface with Community Emergency Management Authorities
    and State and Local Public Health

-   Biohazard (Infection) Control Surge Services during Emergencies

### Chief of Human Resources (HR)

The assessment team will evaluate the following capabilities through
interviews with the Chief of HR:

-   Processes and Procedures for Personal Preparedness and Employee
    Welfare

-   Management of Extended Incident Operations

### Public Affairs Officer (PAO)

The assessment team will evaluate the following capabilities through
interviews with the PAO:

-   Public Information Management Services during an Incident

### Employee Representative(s)

The assessment team will evaluate the following capabilities through
interviews with the Union President: Safety Representative:

-   Processes and Procedures for Personal Preparedness and Employee
    Welfare

### National Disaster Medical System (NDMS) Coordinator

The assessment team will evaluate the following capabilities through
interviews with the NDMS Coordinator:

-   Provision of Supplemental Health Services to Support the NDMS

Focused Facility Tours
----------------------

The assessment team will tour selected areas of each medical center as
part of its site visit. These areas will reflect significant locations
and assets critical to an effective disaster response. Examples include
the ED, VA All-Hazards Emergency Cache storage areas, and the EOC. The
following sections present the capabilities of identified areas that the
assessment team will evaluate during each portion of the facility tour.
**Appendix B** includes the list of potential questions the assessment
team can ask during that portion of the tour.

### Emergency Department 

During the tour of the ED, the assessment team will interview the ED
Director and inquire about the following capabilities:

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

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

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

-   Designation and Operation of Isolation Rooms

-   Integration of Patient Reception, Surge, and Decontamination Teams

### VA All-Hazards Emergency Caches 

The assessment team will interview the Chief of Pharmacy and tour the
areas that store materials relative to the following capabilities:

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

-   Maintaining Emergency Potable Water System Resiliency

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

### Hospital Emergency Operations Center (Hospital Command Center)

During the tour of the EOC, the assessment team will gather information
relative to the following capabilities:

-   Mobilization of Critical Staff and Equipment for Incident Response

-   Situational Assessment of Response and Coordination Efforts for\
    Initial Incident Management and EOC Activation

-   Response/Interface with State and Community Emergency Management
    Authorities, and State and Local Public Health

-   Interoperable Communications with External Agencies'

-   Support under the NRF

-   Response/Interface with Community Healthcare Organizations

-   Management of Extended Incident Operations

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

-   Processes and Procedures for Demobilization of Personnel and
    Equipment

-   Processes and Procedures for a Return to Readiness of Staff and
    Equipment

-   Fire Protection and Rescue Services for Response to Incidents

-   Maintenance of Voice and Data Communication through Satellite Link

-   Interoperable Communications with VAMC Facilities'

-   Provision of Supplemental Health Services to Support the NDMS

-   VA/Department Of Defense (DOD) Contingency Hospital System

### Physician Manpower Pool Staffing Area

During the tour of the physician manpower pool staffing area, the
assessment team will gather information relative to the following
capabilities:

-   Management of Extended Incident Operations

-   Transporting Critical Staff to the Facility during an Emergency

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

-   Integration of Patient Reception, Surge and Decontamination Teams

### General Manpower Pool Staffing Area

During the tour of the general manpower pool staffing area, the
assessment team will gather information relative to the following
capabilities:

-   Management of Extended Incident Operations

-   Transporting Critical Staff to the Facility during an Emergency

-   Management of External Volunteers and Donations during Emergencies

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

-   Integration of Patient Reception, Surge and Decontamination Teams

### Media Relations/Public Affairs Coordinating Area

During the tour of the media relations coordinating area, the assessment
team will gather information relative to the media relations plan and
processes.

### Other Areas as Appropriate

In addition to the above areas, other areas that may be toured include
the following:

-   Shelters for family of critical staff

-   Medical gases storage areas

-   Internal alternate care sites

-   Isolation rooms

-   Patient reception area, including NDMS support

Document Reviews
----------------

During, and prior to, the site visit, the assessment team will review
various documents, include the following:

-   **HVAs**

-   **Emergency Operation Plans (EOPs)**

-   **EMC documentation**

-   **Exercise After Action Reviews (AARs)**

-   **Memoranda of Understanding (MOUs) with key vendors**

-   **Signed Memoranda of Agreement (MOAs) for NDMS.**

The specific capabilities that each document will help the assessment
team evaluate are presented in subsequent sections.

### Hazard Vulnerability Assessments

HVAs are a foundational element of every facility's EOP. In reviewing
HVAs, preferably prior to the site visit, the assessment team will
evaluate the following capabilities:

-   Development, Implementation, Management, and Maintenance of a HVA
    process as the Foundation for Conducting the EMP

-   Incorporation of Comprehensive Mitigation Planning in the
    Facility\'s EMP

-   Incorporation of Comprehensive Preparedness Planning in the
    Facility\'s EMP

-   Incorporation of Continuity Planning into the Activities of the
    Facility\'s EMP to ensure Organizational Continuity and Resiliency
    of Mission Critical Functions, Processes, and Systems

-   Demonstration of Systems-Based Evaluation of the Facility\'s overall
    EMP and its EOP

### Emergency Operations Plan 

Prior to the response phase of a disaster, the facility should have
well-documented processes for implementing each critical capability. The
EOP should document these processes and capabilities.

### Emergency Management Committee Documentation

Once on-site, the assessment team will review all EMC-generated
documentation, including meeting agendas and minutes. The specific
capabilities to be assessed from this documentation include the
following:

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

-   Administrative Activities ensure the EMP meets its Mission and
    Objectives

-   Development, Implementation, Management, and Maintenance of an EMC
    process to Support the EMP

-   Development, Implementation, Management, and Maintenance of an HVA
    process as the Foundation for Conducting the EMP

-   Incorporation of Comprehensive Mitigation Planning into the
    Facility\'s EMP

-   Incorporation of Comprehensive Preparedness Planning in the
    Facility\'s EMP

-   Incorporation of Continuity Planning into the Activities of the
    Facility\'s EMP to ensure Organizational Continuity and Resiliency
    of Mission Critical Functions, Processes, and Systems

-   Demonstration of Systems-Based Evaluation of the Facility\'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

### Exercise After Action Reports 

After reviewing the AARs, the assessment team will be able to determine
the role exercises play in the facility's overall planning efforts, the
significance of lessons learned in the planning process, and how the
facility has made improvements to its EOP based on the exercises' AARs.
The team will review the AARs with the following capabilities in mind:

-   Incorporation of Comprehensive Preparedness Planning in the
    Facility\'s EMP

-   Incorporation of Comprehensive Instructional Activity in the
    Preparedness Activities of the Facility\'s EMP

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

-   Demonstration of Systems-Based Evaluation of the Facility\'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

### Memoranda of Understanding/Contracts and Memoranda of Agreement with Key Vendors

Legally reviewing MOUs/MOAs with key vendors is a critical aspect of
disaster response. Supplies, equipment, and personnel will be in short
supply following a disaster, and having backup through external vendors
is crucial. During site visits, the assessment team will be looking for
MOUs/MOAs that relate to the following capabilities:

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

-   Processes and Procedures for Demobilization of Personnel and
    Equipment

-   Processes and Procedures for Return to Readiness of Staff and
    Equipment

-   Fire Protection and Rescue Services for Response to Incidents

-   Maintaining Fuel, Fuel storage, and Fuel pumps for Generators,
    Heating, and Vehicles Resiliency

-   Maintaining Emergency Potable Water System Resiliency

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

-   Internal and External (to the VA) Alternate Care Sites

-   Management of Care for Home-Based Primary Care Patients during
    Incidents

-   Specialty Outpatient Services (e.g., Dialysis, Persons with SCI/D on
    Community/Outside Assistance in their Home, Oxygen Therapy Patients,
    and Dementia or Other Cognitive Impairment

-   Provision of Ambulatory Clinical Services during Incidents

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

-   Maintaining Laboratory, Blood Bank Surge, and Diagnostic Imaging
    Surge Capability

-   Processes and Procedures for Personal Preparedness and Employee
    Welfare

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

### Signed MOAs for the NDMS 

The assessment team will examine whether there are signed MOAs in place
for the NDMS.

### Presence of Inventory of Critical Resources (Pharmaceuticals, Equipment, and Supplies)

The assessment team will review documentation to ensure that the
facility has performed and documented facility-wide resource levels of
pharmaceuticals, equipment and supplies. Through this review, the team
evaluate the following capabilities:

-   Development, Implementation, Management, and Maintenance of an EMC
    process to Support the EMP

-   Incorporation of Continuity Planning into the Activities of the
    Facility\'s EMP to ensure Organizational Continuity and Resiliency
    of Mission Critical Functions, Processes, and Systems

-   Situational Assessment of Response and Coordination Efforts for
    Initial Incident Management and EOC Activation

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

-   Management of Extended Incident Operations

-   Integration of Patient Reception, Surge and Decontamination Teams

Tabletop Exercises
------------------

The team will select one scenario for testing, with a specific focus on
the outcomes related to surge capacity planning, continuity of
operations capabilities, and implementation of facility security and
safety measures. This scenario should map back to the facility's recent
HVA. Examples of capabilities that will be assessed during tabletop
exercises include the following:

-   Mobilization of Critical Staff and Equipment for Incident Response

-   Situational Assessment of Response and Coordination Efforts for
    Initial Incident Management and EOC Activation

-   Response/Interface with State and Community Emergency Management
    Authorities, and State and Local Public Health

-   Response/Interface with Community Healthcare Organizations

-   Support under the NRF

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

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

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

-   Fire Protection and Rescue Services for Response to Incidents

-   Development, Implementation, Management, and Maintenance of an
    Electrical Power System

-   Management, and Maintenance of Fixed and Portable Electrical
    Generator Resiliency

-   Maintaining Fuel, Fuel Storage, and Fuel Pumps for Generators,
    Heating, and Vehicles Resiliency

-   Maintaining HVAC Resiliency

-   Maintaining IT and Computing Systems Resiliency

-   Interoperable Communications with External Agencies'

-   Interoperable Communications with VAMC Facilities'

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

-   Processes and Procedures for Personal Preparedness and Employee
    Welfare

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

-   Provision of Supplemental Health Services to Support the NDMS

-   VA/DOD Contingency Hospital System

By practicing these exercises at medical centers, valuable lessons will
be learned that could be provided to national policy makers in VA, the
Department of Homeland Security (DHS), Health and Human Services (HHS),
and DOD, among others. This feedback could be used to improve these
national scenarios and provide experience-based feedback to develop
exercises and advance this body of knowledge.

Capability Demonstrations
-------------------------

In addition to touring the facility and conducting the tabletop
exercises, the assessment team will requests demonstrations of several
capabilities, including the following:

-   **Decontamination:** Observe the facility decontamination team
    setting up the tent (if it is a portable system)

-   **PPE:** Identify the location of PPE storage and the ability of the
    staff to don it

-   **Staff Hotlines:** Understand how these are stood up and managed to
    deliver critical information to staff

-   **Portable Electrical Generators:** Identify where these are located

-   **Satellite Link for Back-Up Voice and Data:** Determine where the
    facility actually uses the satellite link to establish communication

-   **Satellite Telephones**

-   **Critical Infrastructure:** Demonstrate how the mission-critical
    systems are tested without actually performing the tests.

Pre-Survey Distribution
-----------------------

The assessment team will distribute the pre-survey to the facility prior
to its scheduled site visit. The results of the pre-survey will inform
the team about specific capabilities they will need to focus on during
the site visit. **Appendix C** contains a copy of the pre-survey.

Out-brief and Concluding Conference
===================================

At the end of the site visit, the assessment team and the VAMC personnel
will reconvene. At this concluding conference, the assessment team will
deliver a preliminary capability assessment review (out-brief) in the
form of closing statements. This review will cover the functional
aspects of the capability assessments conducted (i.e., pre-site visit
survey results, facility tour assessment, document review analysis, and
tabletop scenario outcomes). The discussion will be based on the
capabilities observed, any gaps that should be addressed, and identified
opportunities for developing capabilities that do not yet exist. The
assessment team will also offer guidance on the kinds and types of
issues that should be raised and which follow-up actions should include
recommendations on how to improve or develop capabilities in the future.

Use of Data Collection Tools
----------------------------

To ensure an efficient, standardized process for recording observations
during the site visits, members of the assessment team will be equipped
with data collection tools. Figure 3 describes the overall process for
managing the data resulting from the site visits.

**Figure 3. Site Visit Data Management Processes**

Site Visit Report
-----------------

We will provide guidance to the assessors on how to complete this table
and how to assign a rating for each capability. We will define the ideal
state and various degrees of variation for each capability. This
approach will provide a structured approach to help ensure consistency
across assessors. It will also define objective criteria to explain to
the VAMC leadership at the out-brief.

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

  **Acronym**   **Definition**
  ------------- -------------------------------------------------
  AAR           After Action Report
  AD            Associate Director
  CBOC          Community-Based Outpatient Clinic
  CIO           Chief Information Officer
  DEMPS         Disaster Emergency Medical Personnel System
  DHS           Department of Homeland Security
  DOD           Department of Defense
  ED            Emergency Department
  EMC           Emergency Management Committee
  EMCG          Emergency Management Committee Group
  EMP           Emergency Management Program
  EMSHG         Emergency Management Strategic Healthcare Group
  EOC           Emergency Operations Center
  EOP           Emergency Operations Plan
  EPC           Emergency Planning Coordinator
  FEMA          Federal Emergency Management Agency
  HHS           Health and Human Services
  HR            Human Resources
  HVA           Hazard Vulnerability Analysis
  HVAC          Heating Ventilation and Air Conditioning
  IT            Information Technology
  TJC           The Joint Commission
  MOA           Memorandum of Agreement
  MOU           Memorandum of Understanding
  NDMS          National Disaster Medical System
  NFPA          National Fire Protection Association
  NIMS          National Incident Management System
  NRF           National Response Framework
  PAO           Public Affairs Officer
  PPE           Personal Protective Equipment
  SCI/D         Spinal Cord Injury Dependent
  VA            Veterans Affairs
  VAMC          Veterans Affairs/Administration Facility
  VHA           Veterans Health Administration
  VISN          Veterans Integrated Service Network

Appendix A: Capability Descriptor Document {#appendix-a-capability-descriptor-document .list-paragraph}
==========================================

Appendix B: Pre-Survey {#appendix-b-pre-survey .list-paragraph}
======================

Appendix C: Site Visit Agenda {#appendix-c-site-visit-agenda .list-paragraph}
=============================

Appendix D: Questions for Site Visit Activity {#appendix-d-questions-for-site-visit-activity .list-paragraph}
=============================================

Appendix E: Capability Scoring Tool {#appendix-e-capability-scoring-tool .list-paragraph}
===================================

Appendix F: Opening Conference PowerPoint  {#appendix-f-opening-conference-powerpoint .list-paragraph}
=========================================

Appendix G: Closing Conference PowerPoint {#appendix-g-closing-conference-powerpoint .list-paragraph}
=========================================

Appendix H: Final Report {#appendix-h-final-report .list-paragraph}
========================

Appendix I: TJC Scoring Tool {#appendix-i-tjc-scoring-tool .list-paragraph}
============================

Appendix J: The NIMS Scoring Tool {#appendix-j-the-nims-scoring-tool .list-paragraph}
=================================