VHA Comprehensive Emergency Management Program Analysis

Capabilities Scoring Tool

**VISN Office Comprehensive Emergency Management**

**Program**

Department of Veterans Affairs

Veterans Health Administration

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

![](media/image1.png){width="1.0972222222222223in" height="1.0972222222222223in"} {#section .list-paragraph}
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 {#section-1 .list-paragraph}

 {#section-2 .list-paragraph}

 {#section-3 .list-paragraph}

 {#section-4 .list-paragraph}

**November 6, 2008**

![](media/image2.jpeg){width="2.2597222222222224in"
height="11.003472222222221in"}\
[Directions 5](#directions)

[1 PROGRAM LEVEL CAPABILITIES 6](#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
6](#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
7](#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.
8](#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
8](#incorporation-of-continuity-planning-into-the-coordination-activities-of-the-visn-offices-emergency-management-program)

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

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

[1.8 Incorporation of a Range of Exercise Types into the VISN Emergency
Management Program
10](#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
11](#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.
12](#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
13](#incident-management-capabilities)

[2.1 Initial Incident Actions (e.g., First 4 Hours)
13](#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
13](#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
13](#mobilization-of-critical-staff-and-equipment-for-incident-response)

[2.1.3 Situational Assessment of Response and Coordination Efforts for
Initial Incident Management
14](#situational-assessment-of-response-and-coordination-efforts-for-initial-incident-management-and-eoc-activation)

[2.2 Management of Extended Operations (e.g., After First 4 Hours)
15](#management-of-extended-operations-e.g.-after-first-four-hours)

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

[2.2.2 Public Information Management Services during an Incident
15](#public-information-management-services-during-an-incident)

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

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

[2.2.5 Processes and Procedures for a Return to readiness of Staff and
Equipment
17](#processes-and-procedures-for-a-return-to-readiness-of-staff-and-equipment)

[3 Occupant Safety Capabilities 18](#occupant-safety-capabilities)

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

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

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

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

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

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

[3.4 Infection Control 22](#infection-control)

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

[3.4.2 Selection and Use of Personal Protective Equipment for Incident
Response and Recovery Operations
23](#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)
23](#processes-and-procedures-for-staff-and-family-mass-prophylaxis-during-an-infectious-outbreak-i.e.-influenza)

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

[4.1 Personnel Resiliency 24](#personnel-resiliency)

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

[4.1.2 Maintaining Employee Physical and Mental Welfare during an
Incident
25](#processes-and-procedures-for-personal-preparedness-and-employee-welfare)

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

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

[4.2.1 Maintaining Information Technology (IT) and Computing Systems
Resiliency during an Incident
26](#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
27](#maintaining-access-to-critical-commodities-and-services-during-response-and-recovery-operations)

[4.3 Communications 28](#communications)

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

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

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

[4.4 Healthcare Systems Resiliency 30](#healthcare-systems-resiliency)

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

[5 Medical Surge 30](#medical-surge)

[5.1 Processes and Procedures for Expansion of Staff for Response and
Recovery Operations
30](#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
31](#management-of-volunteers-deployment-support-e.g.-demps-during-response-and-recovery-operations)

[5.3.1 Processes and Procedures for Deployment and Return to Readiness
of the VA All-Hazards Emergency Cache Program
32](#processes-and-procedures-for-deployment-and-return-to-readiness-of-the-va-all-hazards-emergency-cache-program)

[5.3.2 Designated Capability for Expanded Patient Triage, Evaluation and
Treatment during Surge
33](#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
34](#processes-and-procedures-for-control-and-coordination-of-mass-fatality-management)

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

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

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

[6.3 Support under the National Response Framework
36](#support-under-the-national-response-framework)

 Directions {#directions .list-paragraph}
==========

The purpose of this document is to assist the assessment team in scoring
each individual capability. Please use the following document at the end
of each day of each day by placing an "X" next to the appropriate
measure. Include justification for your score in the comment/rationale
box. Detailed descriptions of each capability are included in the "VHA
Comprehensive Emergency Management Program Analysis Capabilities
Description." Once this tool is complete, the measurements and scoring
can be transferred to the site final report.

 {#section-5 .list-paragraph}

**See example below**

     4   Exemplary           All of the above assessment components are present, including a 1-800 number for employee call-in and advising. Program is tested semiannually.
  -- --- ------------------- -------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent           Resources and training are in place with an employee call-in number. System is tested annually.
     2   Developed           VISN has an established call-in number and/or communications plan for notifying and advising employees. Program is tested annually.
     1   Being Developed     VISN has a plan for notifying and advising employees during an emergency.
     0   Needs Attention     There is an absence of capability and appropriate planning to keep employees informed during an emergency.
         Comment/Rationale   

 PROGRAM LEVEL CAPABILITIES
==========================

1.1 Systems-Based Approach to the Development, Implementation, Management, and Maintenance of the Emergency Management Program  {#systems-based-approach-to-the-development-implementation-management-and-maintenance-of-the-emergency-management-program .list-paragraph}
------------------------------------------------------------------------------------------------------------------------------

Measurement Factors

     4   Exemplary           All of the above assessment components are present.
  -- --- ------------------- --------------------------------------------------------------------------------------------------------------------
     3   Excellent           Resources and training are in place and the EMP is reviewed annually.
     2   Developed           Resources and training are in place. VISN meets the underlying requirement of annual review and update of the EMP.
     1   Being Developed     Some capability elements exist; however, some key components are not yet developed.
     0   Needs Attention     There is an absence of capability, as evidenced by lack of an EMP planning process.
         Comment/Rationale   

1.2 Administrative Activities ensure the Emergency Management Program meets its Mission and Objectives {#administrative-activities-ensure-the-emergency-management-program-meets-its-mission-and-objectives .list-paragraph}
------------------------------------------------------------------------------------------------------

Measurement Factors

     4   Exemplary           All of the above assessment components are present.
  -- --- ------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent           Resources and training are in place and there is an annual assessment of the resources needed to sustain the EMP and accomplish the defined operational objectives for the upcoming year.
     2   Developed           Resources and training are in place. Funding is provided as needed.
     1   Being Developed     Some capability elements exist; however, some key components are not yet developed, including a lack of staffing to accomplish the full scope of the EMP.
     0   Needs Attention     There is an absence of capability exhibited by a lack of staffing to accomplish the full scope of the EMP to the point that accreditation is at risk.
         Comment/Rationale   

1.3 Development, Implementation, Management, and Maintenance of an Emergency Management Committee process to support the Emergency Management Program  {#development-implementation-management-and-maintenance-of-an-emergency-management-committee-process-to-support-the-emergency-management-program .list-paragraph}
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Measurement Factors

     4   Exemplary           All of the above assessment components are present.
  -- --- ------------------- -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent           Resources and training are in place and the EMC meets at least quarterly with ad hoc meetings as necessary.
     2   Developed           There is an equivalent meeting of individuals at the VISN level to oversee VISN facility preparedness. Resources and training are in place.
     1   Being Developed     The EMC has been appointed, but does not meet at least quarterly, and the role of the EMC is not fully developed, including a lack of meeting minutes. Or, there is only ad hoc meetings at the VISN level on facility preparedness.
     0   Needs Attention     There is an absence of capability because the EMC meets sporadically, lacks meeting minutes, and does not play a significant role in the overall management of the program. Or there is no equivalent VISN level meetings to assess facility preparedness and VISN coordination capabilities.
         Comment/Rationale   

 {#section-6 .list-paragraph}

 {#section-7 .list-paragraph}

1.4 Incorporation of Comprehensive Preparedness Planning in the VISN's Coordination Activities in Conjunction with the Individual Facility Emergency Management Programs.  {#incorporation-of-comprehensive-preparedness-planning-in-the-visns-coordination-activities-in-conjunction-with-the-individual-facility-emergency-management-programs. .list-paragraph}
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Measurement Factors

     4   Exemplary           All of the above assessment components are present including a semiannual briefing to the EMC on planning activities. A written report summarizing planning activities and identifying recommended planning objectives is submitted annually.
  -- --- ------------------- -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent           Resources and training are in place including an annual evaluation and report submitted to the EMC.
     2   Developed           Facility has an ongoing emergency management planning program coordinated with the EMC.
     1   Being Developed     There are elements of an emergency management planning program, but it is not fully coordinated with the EMC.
     0   Needs Attention     Facility lacks an integrated emergency management planning program.
         Comment/Rationale   

1.5 Incorporation of Continuity Planning into the Coordination Activities of the VISN Office's Emergency Management Program  {#incorporation-of-continuity-planning-into-the-coordination-activities-of-the-visn-offices-emergency-management-program .list-paragraph}
---------------------------------------------------------------------------------------------------------------------------

Measurement Factors

     4   Exemplary           All of the above assessment components are present, including briefings to the EMC and ELC on continuity planning activities. A written report summarizing continuity planning activities and identifying recommended continuity planning objectives is submitted annually.
  -- --- ------------------- -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent           Resources and training are in place including an annual evaluation and report submitted to the EMC and ELC.
     2   Developed           VISN has ongoing continuity planning program.
     1   Being Developed     There are elements of a continuity planning program.
     0   Needs Attention     VISN lacks an integrated continuity planning program.
         Comment/Rationale   

 {#section-8 .list-paragraph}

1.6 Development, Implementation, Management, and Maintenance of an Emergency Operations Plan {#development-implementation-management-and-maintenance-of-an-emergency-operations-plan .list-paragraph}
--------------------------------------------------------------------------------------------

Measurement Factors

     4   Exemplary           All of the above assessment components are present, including a semiannual briefing to the EMC and/or ELC on EOP activities. A written report summarizing continuity planning activities identifying recommended continuity planning objectives is submitted annually. At least one exercise is conducted annually.
  -- --- ------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent           Resources and training are in place including, an annual evaluation, exercise and report submitted to the EMC and/or ELC.
     2   Developed           Facility has one EOP briefing coordinated with the EMC.
     1   Being Developed     There are elements of a program to update the EOP, but it is not fully coordinated with the EMC.
     0   Needs Attention     Facility lacks an integrated EOP.
         Comment/Rationale   

 {#section-9 .list-paragraph}

1.7 Incorporation of Comprehensive Instructional Activity into the Preparedness Activities of the VISN's Emergency Management Program  {#incorporation-of-comprehensive-instructional-activity-into-the-preparedness-activities-of-the-visns-emergency-management-program .list-paragraph}
-------------------------------------------------------------------------------------------------------------------------------------

Measurement Factors

     4   Exemplary           All of the above assessment components are present, including a semiannual briefing to the EMC and/or ELC on continuing education activities. A written report summarizing continuity education activities and identifying a recommended training objective is submitted annually.
  -- --- ------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent           Resources and training activities are in place including an annual evaluation and report submitted to the EMC/ELC.
     2   Developed           Facility has an ongoing continuity education program coordinated with the EMC.
     1   Being Developed     There are elements of a continuing education program, but it is not fully coordinated with the EMC.
     0   Needs Attention     Facility lacks an integrated continuing education program.
         Comment/Rationale   

1.8 Incorporation of a Range of Exercise Types that Test the VISN's Emergency Management Program  {#incorporation-of-a-range-of-exercise-types-that-test-the-visns-emergency-management-program .list-paragraph}
------------------------------------------------------------------------------------------------

Measurement Factors

     4   Exemplary            All of the above assessment components are present. Exercise program includes at least two exercises per year. An AAR is produced after each exercise, and the results are included in the EOP, which must be updated at least annually. The VISN EPC also participates with the community in designing and/or planning a community exercise that involves the VISN.
  -- --- -------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent            Resources and training are in place, and the capability is tested semiannually. Exercise program includes two exercises per year. An AAR is produced after each exercise, and the results are included in the EOP, which must be updated at least annually.
     2   Developed            Resources and training are in place. VISN meets underlying requirement where applicable. Exercise program includes one exercise per year. An AAR is produced after each exercise, and the results are included in the EOP, which must be updated at least annually.
     1   Being Developed      Some capability elements exist; however, some key components are not yet developed. VISN conducts one exercise annually, but it does not prepare detailed AARs or incorporate the recommendations into the annual review of the EOP.
     0   Needs Attention      There is an absence of capability.
         Comments/Rationale   

1.9 Demonstration of Systems-Based Evaluation of the VISN's overall Emergency Management Program and its Emergency Operations Plan  {#demonstration-of-systems-based-evaluation-of-the-visns-overall-emergency-management-program-and-its-emergency-operations-plan .list-paragraph}
----------------------------------------------------------------------------------------------------------------------------------

Measurement Factors

     4   Exemplary            All of the above assessment components are present, including a semiannual briefing to the EMC/ELC on program evaluation activities. A written report summarizing program activities and identifying recommended training objectives is submitted annually.
  -- --- -------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent            Resources and training activities are in place including an annual evaluation and report submitted to the EMC.
     2   Developed            VISN has ongoing program evaluation activities coordinated with the EMC.
     1   Being Developed      There are elements of program evaluation activities, but they are not fully coordinated with the EMC/ELC.
     0   Needs Attention      VISN lacks an integrated program evaluation activity.
         Comments/Rationale   

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. {#incorporation-of-accepted-improvement-recommendations-into-the-emergency-management-program-and-its-components-such-that-the-process-becomes-one-of-a-learning-organization. .list-paragraph}
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Measurement Factors

     4   Exemplary            All of the above assessment components are present, including a semiannual briefing to the EMC/ELC on organizational learning activities.
  -- --- -------------------- --------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent            Resources and training activities are in place including an annual evaluation and report submitted to the EMC/ELC.
     2   Developed            VISN has ongoing organizational learning program coordinated with the EMC/ELC to ensure consistency across the entire spectrum of this activity.
     1   Being Developed      There are elements of an organizational learning program, but they are not fully developed.
     0   Needs Attention      VISN lacks an integrated organizational learning program.
         Comments/Rationale   

 {#section-10 .list-paragraph}

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

2.1 Initial Incident Actions (e.g., First Four Hours) {#initial-incident-actions-e.g.-first-four-hours .list-paragraph}
-----------------------------------------------------

### 2.1.1 Processes and Procedures for Incident Recognition, Activation of EOP/EOC and Initial Notification of Staff {#processes-and-procedures-for-incident-recognition-activation-of-eopeoc-and-initial-notification-of-staff .list-paragraph}

     4   Exemplary            All of the above assessment components are present, including establishing an IMT consistent with the VISN's EOP and tested annually. AARs are developed and used for continuous quality improvement.
  -- --- -------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent            Resources and training are in place, and mobilization is practiced at least annually. AARs are developed and used for continuous improvement.
     2   Developed            Resources and training are in place, including a written mobilization plan. AARs are used.
     1   Being Developed      Some capability elements exist; however, mobilization plan is being developed and exercises are planned..
     0   Needs Attention      There is an absence of a mobilization plan or exercises.
         Comments/Rationale   

### 2.1.2 Mobilization of Critical Staff and Equipment for Incident Response {#mobilization-of-critical-staff-and-equipment-for-incident-response .list-paragraph}

Measurement Factors

     4   Exemplary            All of the above assessment components are present, including establishing an IMT consistent with the VISN's EOP and tested annually. AARs are developed and used for continuous quality improvement.
  -- --- -------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent            Resources and training are in place, and mobilization is practiced at least annually. AARs are developed and used for continuous improvement.
     2   Developed            Resources and training are in place, including a written mobilization plan. AARs are used.
     1   Being Developed      Some capability elements exist; however, mobilization plan is being developed and exercises are planned..
     0   Needs Attention      There is an absence of a mobilization plan or exercises.
         Comments/Rationale   

###  {#section-11 .list-paragraph}

### 2.1.3 Situational Assessment of Response and Coordination Efforts for Initial Incident Management and EOC Activation {#situational-assessment-of-response-and-coordination-efforts-for-initial-incident-management-and-eoc-activation .list-paragraph}

Measurement Factors

     4   Exemplary            All of the above assessment components are present, including an annual activation of the EOC and accomplishment of a risk assessment.
  -- --- -------------------- ----------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent            Resources and training are in place, and the EOC activation is tested annually.
     2   Developed            Resources and training are in place. VISN can activate the EOC and perform a hazard risk assessment.
     1   Being Developed      Some capability elements exist; however, some key components, as described above are not yet developed.
     0   Needs Attention      There is an absence of an EOC activation plan and/or major components as described in the above assessment.
         Comments/Rationale   

###  {#section-12 .list-paragraph}

2.2 Management of Extended Operations (e.g., After First Four Hours) {#management-of-extended-operations-e.g.-after-first-four-hours .list-paragraph}
--------------------------------------------------------------------

### 2.2.1 Management of Extended Operations  {#management-of-extended-operations .list-paragraph}

Measurement Factors

     4   Exemplary            All of the above assessment components are present including an annual briefing to the EMC/ELC on the plan for extended operations. A written report summarizing continuity planning activities identifying recommended continuity planning objectives is submitted annually.
  -- --- -------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent            Resources and training are in place, including an annual evaluation and report submitted to the EMC/ELC.
     2   Developed            VISN has ongoing continuity planning program
     1   Being Developed      There are elements of an extended operations plan
     0   Needs Attention      VISN lacks an extended hours plan.
         Comments/Rationale   

2.2.2 Public Information Management Services during an Incident {#public-information-management-services-during-an-incident .list-paragraph}
---------------------------------------------------------------

Measurement Factors

     4   Exemplary            All of the above assessment components are present, including establishing contact with the local mass media. The media communications plan is practiced semiannually.
  -- --- -------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent            Resources and training are in place and the media communications plan is practiced at least annually.
     2   Developed            Resources and training are in place including a written media communications plan.
     1   Being Developed      Some capability elements exist; however, a media communications plan is not written or practiced at least annually.
     0   Needs Attention      There is an absence of a VISN media relations plan.
         Comments/Rationale   

2.2.3 Management and Acquisition of Resources for Incident Response and Recovery Operations {#management-and-acquisition-of-resources-for-incident-response-and-recovery-operations .list-paragraph}
-------------------------------------------------------------------------------------------

Measurement Factors

     4   Exemplary            All of the above assessment components are present, including a pre-planning incident assessment for resource allocation and evidence of including facility hazard mitigation and other emergency preparedness projects in VISN NRM and Minor Construction Programs.. Resources are identified by kind and type. Facility has a system in place to identify, inventory, track, allocate, deploy, and return resources to normal status during and after an incident. The resource management plan is practiced semiannually.
  -- --- -------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent            Resources and training are in place and the resource management plan is practiced at least annually. Hazard mitigation and other emergency preparedness projects are included in VISN NRM and Minor Construction programming.
     2   Developed            Resources and training are in place including a written resource management plan that covers operational and NRM/Minor construction funding..
     1   Being Developed      Some capability elements exist; however, a resource management plan is not written or practiced at least annually.
     0   Needs Attention      There is an absence of a resource management plan.
         Comments/Rationale   

2.2.4 Processes and Procedures for Demobilization of Personnel and Equipment {#processes-and-procedures-for-demobilization-of-personnel-and-equipment .list-paragraph}
----------------------------------------------------------------------------

Measurement Factors

     4   Exemplary            All of the above assessment components are present, including established demobilization procedures. Demobilization plan is practiced semi-annually.
  -- --- -------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent            Resources and training are in place, and demobilization is practiced at least annually.
     2   Developed            Resources and training are in place, including a written demobilization plan.
     1   Being Developed      Some capability elements exist; however, the demobilization plan is not written or practiced at least annually.
     0   Needs Attention      There is an absence of a mobilization plan.
         Comments/Rationale   

2.2.5 Processes and Procedures for a Return to Readiness of Staff and Equipment {#processes-and-procedures-for-a-return-to-readiness-of-staff-and-equipment .list-paragraph}
-------------------------------------------------------------------------------

Measurement Factors

     4   Exemplary            All of the above assessment components are present, including established demobilization procedures. The Return to Readiness Plan is practiced semiannually.
  -- --- -------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent            Resources and training are in place and the Return to Readiness Plan is practiced at least annually.
     2   Developed            Resources and training are in place including a written Return to Readiness Plan.
     1   Being Developed      Some capability elements exist; however, the Return to Readiness Plan is not written or practiced at least annually.
     0   Needs Attention      There is an absence of Return to Readiness Plan.
         Comments/Rationale   

 {#section-13 .list-paragraph}

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

3.1 Evacuation vs. Shelter-in-Place {#evacuation-vs.-shelter-in-place .list-paragraph}
-----------------------------------

### 3.1.1 Processes and Procedures for Evacuation of Patients', Staff, and Visitors' {#processes-and-procedures-for-evacuation-of-patients-staff-and-visitors .list-paragraph}

Measurement Factors

     4   Exemplary             All of the above assessment components are present, including identifying of an evacuation area, alternate care sites, and safe transportation. The evacuation plan should be exercised at least annually. The plan should include horizontal and vertical evacuations. Facilities should have evacuation devices at or under the patient beds where applicable.
  -- --- --------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent             Evacuation plan includes identifying an evacuation area, alternate care sites, and safe transportation. Evacuation plan is exercised at least annually. The plan includes horizontal and vertical evacuations.
     2   Developed             VISN evacuation plan is current and coordinated with facility plans.
     1   Being Developed       VISN lacks evacuation plan or has not exercised the evacuation plan within 15 months.
     0   Needs Attention       There is an absence of capability, including lack of an evacuation plan.
         Comments//Rationale   

### 3.1.2 Processes and Procedures for Sheltering-in-Place {#processes-and-procedures-for-sheltering-in-place .list-paragraph}

Measurement Factors

     4   Exemplary            All of the above assessment components are present, including pre-identified locations within the VISN suitable for shelter-in-place activation for patients and staff. Plan includes provisions for housing, food, water, and security. Plan is exercised at least annually.
  -- --- -------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent            Resources and training are in place to support the shelter-in-place capability. Plan includes provisions for housing, food, water, and security. Plan is exercised at least annually.
     2   Developed            Shelter-in-place plan is developed and tested on regular basis at frequency determined by the VISN.
     1   Being Developed      VISN lacks a detailed shelter-in-place plan and does not test its capability on a regular basis. VISN is developing a plan but has not yet implemented it.
     0   Needs Attention      There is an absence of capability evidenced by lack of a shelter-in-place plan.
         Comments/Rationale   

### 3.1.3 Processes and Procedures for Sheltering for Family of Critical Staff {#processes-and-procedures-for-sheltering-for-family-of-critical-staff .list-paragraph}

Measurement Factors

     4   Exemplary            All of the above assessment components are present, including a written plan approved by the EMC. Plan includes identification of facilities for family shelter, housing, beds, food, and supplies and is tested annually. It also includes provisions for pets.
  -- --- -------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent            Resources and training are in place to support the family shelter, including identification of facilities for family shelter, housing, beds, food and supplies and is tested annually. It also includes provisions for pets.
     2   Developed            VISN has a Family Shelter plan for critical employees.
     1   Being Developed      VISN does not have a Family Shelter plan for families of critical employees, but it is developing one.
     0   Needs Attention      VISN does not have a Family Shelter plan for families of critical employees.
         Comments/Rationale   

3.2 Perimeter Security and Management of Access/Egress to Facility During an Incident (e.g., Lock Down) {#perimeter-security-and-management-of-accessegress-to-facility-during-an-incident-e.g.-lock-down .list-paragraph}
-------------------------------------------------------------------------------------------------------

Measurement Factors

     4   Exemplary            All of the above assessment components are present, including the ability to lockdown the VISN. Methods for securing means of egress to and from the VISN are equipped with panic hardware to prevent entrance but allow egress. Plan is tested annually.
  -- --- -------------------- -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent            The lockdown plan includes the ability to lockdown the VISN. Methods for securing means of egress to and from the VISN are equipped with panic hardware to prevent entrance but allow egress. Plan is tested annually.
     2   Developed            Resources and training are in place. Regular testing of lockdown procedure as defined by the VISN occurs.
     1   Being Developed      Some capability elements exist; however, some key components are not yet developed including a regular exercise of the campus and/or individual building lockdown procedures.
     0   Needs Attention      There is an absence of capability demonstrated by not being able to lockdown the VISN.
         Comments/Rationale   

3.3 Processes and Procedures for Managing a Hazardous Substance Incident  {#processes-and-procedures-for-managing-a-hazardous-substance-incident .list-paragraph}
------------------------------------------------------------------------

Measurement Factors

     4   Exemplary            All of the above assessment components are present, including the presence of a fixed decontamination capability. At least one annual exercise includes the VAMC's All-Hazards Emergency Cache. VAMC have the decontamination team integrated with patient reception and evacuation teams.
  -- --- -------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent            Resources and training are in place, and the decontamination program is tested annually with the VAMC All-Hazard Emergency Cache.
     2   Developed            Resources and training are in place. Facility meets underlying requirement, where applicable, including OSHA and Environmental Protection Agency (EPA) requirements under Hazardous Waste Operations and Emergency Response (OSHA 29 CFR, 1910.120) (HAZWOPER) and the Comprehensive Environmental Response, Compensation, and Liability Act (CERCLA) for decontamination team members and proper disposal of waste water.
     1   Being Developed      Some capability elements exist; however, some key components are not yet developed including integrating decontamination exercises with the VAMC All-Hazard Emergency Cache or integration of decontamination team with patient reception or evacuation.
     0   Needs Attention      There is an absence of capability demonstrated by not being able to activate decontamination equipment or lack of an annual decontamination exercise.
         Comments/Rationale   

3.4 Infection Control {#infection-control .list-paragraph}
---------------------

### 3.4.1 Biohazard (Infection) Control Surge Services during Emergencies  {#biohazard-infection-control-surge-services-during-emergencies .list-paragraph}

Measurement Factors

     4   Exemplary            VISNS ensure and are aware that all of the above assessment components are present, including the ability to identify and secure supplies and personnel to expand the IC program's capability as needed. The IC staff are trained on their role. The expanded program is tested at least once a year, and the exercise integrated with the facility wide exercise.
  -- --- -------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent            VISNS ensure that resources and training are in place, and the IC capability is tested annually. Facility staff are aware of the expanded capability and can identify personnel designated to serve as adjuncts to the IC program.
     2   Developed            Resources and training are in place. VISN facilities meet underlying requirements, where applicable, including OSHA requirements for personal protection.
     1   Being Developed      Some capability elements exist for the expanded IC program; however, some key components are not yet developed.
     0   Needs Attention      There is an absence of an expanded IC program.
         Comments/Rationale   

###  {#section-14 .list-paragraph}

### 3.4.2 Selection and Use of Personal Protective Equipment for Incident Response and Recovery Operations {#selection-and-use-of-personal-protective-equipment-for-incident-response-and-recovery-operations .list-paragraph}

Measurement Factors

     4   Exemplary            VISN assures that all of the above assessment components are present, including a hazard analysis of all employees with roles in emergency management response and recovery. This includes staff enrolled in the Respiratory Protection Program as part of the decontamination program.
  -- --- -------------------- -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent            Resources and training are in place at the VISN facilities, and the PPE issued to employees with a role in the EMP is reviewed annually for suitability, including fit testing for those in the decontamination program.
     2   Developed            Resources and training are in place for all employees with a role in response and recovery efforts.
     1   Being Developed      Some capability elements exist; however, some key components are not yet developed, including annual review of PPE suitability.
     0   Needs Attention      There is an absence of capability, including lack of a job hazard analysis or regular review of PPE issued to those with a role in emergency management response and recovery activities.
         Comments/Rationale   

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

Measurement Factors

     4   Exemplary            VISN is aware and assures that all of the above assessment components are present, including an adequate inventory of prophylactic medications for staff and family. There is a well-documented process for administering the prophylaxis and that process is tested annually.
  -- --- -------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent            Resources and training are in place to support the mass prophylaxis program and the capability is tested annually.
     2   Developed            Resources and training are in place to support the mass prophylaxis program. Facility meets underlying requirements of VHA where applicable.
     1   Being Developed      Some capability elements exist; however, some key components of the mass prophylaxis program are not yet developed.
     0   Needs Attention      There is an absence of mass prophylaxis capability.
         Comments/Rationale   

 {#section-15 .list-paragraph}

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

4.1 Personnel Resiliency {#personnel-resiliency .list-paragraph}
------------------------

### 4.1.1 Maintaining Authorized Leadership (Leadership Succession) {#maintaining-authorized-leadership-leadership-succession .list-paragraph}

Measurement Factors

     4   Exemplary            All of the above assessment components are present, including the immediate ability for personnel to take on leadership roles. The line of succession is published and distributed to key VISN and facility staff and is located in the EOC. Leadership succession is exercised during drills and actual incidents.
  -- --- -------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent            Resources and training are in place. The line of succession is published and distributed to key VISN and facility staff. This information is also located in the EOC.
     2   Developed            Resources and training are in place.
     1   Being Developed      Some capability elements exist; however, some key components are not yet developed.
     0   Needs Attention      There is an absence of a line of succession at the VISN level.
         Comments/Rationale   

### 4.1.2 Processes and Procedures for Personal Preparedness and Employee Welfare {#processes-and-procedures-for-personal-preparedness-and-employee-welfare .list-paragraph}

Measurement Factors

     4   Exemplary            All of the above assessment components are present, including the identification of critical employees on a callback roster. "Go Kits" are also ready in the event of an evacuation.
  -- --- -------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent            Critical employees have been identified; are on a callback roster; and have "go kits" ready in the event of an emergency activation. Program is reviewed annually.
     2   Developed            VISN has a plan for ensuring critical employee wellness and safety, including personal preparedness plans.
     1   Being Developed      Some capability elements exist, with evidence that this capability is being addressed.
     0   Needs Attention      There is an absence of capability with respect to employee welfare and personal preparedness.
         Comments/Rationale   

###  {#section-16 .list-paragraph}

### 4.1.3 Dissemination of Personnel Incident Information to Staff during an Incident {#dissemination-of-personnel-incident-information-to-staff-during-an-incident .list-paragraph}

Measurement Factors

     4   Exemplary            All of the above assessment components are present, including a 1-800 number for employee call-in and advising. Program is tested semiannually.
  -- --- -------------------- -------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent            Resources and training are in place with an employee call-in number. System is tested annually.
     2   Developed            VISN has an established call-in number and/or communications plan for notifying and advising employees. Program is tested annually.
     1   Being Developed      VISN has a plan for notifying and advising employees during an emergency.
     0   Needs Attention      There is an absence of capability and appropriate planning to keep employees informed during an emergency.
         Comments/Rationale   

4.2 Mission Critical Systems Resiliency {#mission-critical-systems-resiliency .list-paragraph}
---------------------------------------

### 4.2.1 Maintaining Information Technology (IT) and Computing Systems Resiliency during an Incident {#maintaining-information-technology-it-and-computing-systems-resiliency-during-an-incident .list-paragraph}

Measurement Factors

     4   Exemplary            All of the above assessment components are present, including a business continuity and resiliency program as well as the back-up of business data and other critical data systems to mirror the site at least daily. VISN has documented risk assessment identifying high-risk data systems. Staff are fully and regularly trained. System is tested semiannually. Emergency power for extended (days) operation exists.
  -- --- -------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent            VISN has a business continuity and resiliency program. VISN has documented risk assessment identifying high-risk data systems. Staff are fully trained and system is tested annually. Emergency power is available.
     2   Developed            VISN has a business continuity and resiliency program. Only UPS power is available for a few hours. Provisions have been made to move to a fully supported EOC after UPS power has been exhausted. Staff are trained.
     1   Being Developed      VISN has developed a business continuity and resiliency program but staff need further training to fully implement.
     0   Needs Attention      There is an absence of capability evidenced by a lack of business continuity and resiliency plan.
         Comments/Rationale   

### 4.2.2 Maintaining Access to Critical Commodities and Services during Response and Recovery Operations  {#maintaining-access-to-critical-commodities-and-services-during-response-and-recovery-operations .list-paragraph}

Measurement Factors

     4   Exemplary            All of the above assessment components are present, including a needs assessment to determine the critical commodities and services requiring priority contracts during emergencies. The VISN and the facilities can access VACO BPAs should local contractors be unable to provide the services and commodities needed. A systematic evaluation of needs is conducted at least annually.
  -- --- -------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent            All of the above assessment components are present, including a needs assessment to determine the critical commodities and services requiring priority contracts during emergencies. Needs are evaluated at least annually.
     2   Developed            The VISN and VISN facilities have contracts for most critical items based on a needs assessment.
     1   Being Developed      The VISN and the facilities are developing a needs assessment but lacks the majority of priority contracts
     0   Needs Attention      There is an absence of capability because there is no needs assessment and few if any priority contracts have been implemented.
         Comments/Rationale   

4.3 Communications {#communications .list-paragraph}
------------------

### 4.3.1 Maintenance of Voice and Data Communication through Satellite Link {#maintenance-of-voice-and-data-communication-through-satellite-link .list-paragraph}

Measurement Factors

     4   Exemplary            All of the above assessment components are present, including a satellite link for back-up voice and data. Capability is tested quarterly.
  -- --- -------------------- -----------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent            VISN and/or servicing VAMC have a satellite link for back-up voice and data. Capability is tested annually.
     2   Developed            VISN has a limited voice and data back-up plan and contingency plan for restoration of services or mobile capability brought to the facility.
     1   Being Developed      VISN is developing a back-up capability, but is not yet in place.
     0   Needs Attention      There is an absence of satellite link for voice and data back-up and no plans to develop this capability.
         Comments/Rationale   

### 4.3.2 Interoperable Communications with External Agencies' {#interoperable-communications-with-external-agencies .list-paragraph}

Measurement Factors

     4   Exemplary            All of the above assessment components are present with all agencies. Communications equipment is tested at least quarterly and as part of the exercise with the community.
  -- --- -------------------- -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent            Interoperable communications with police, fire, and EMS are present. Communications equipment is tested at least annually as part of an exercise with the community.
     2   Developed            All of the above assessment components are present. Communications equipment is tested at least annually.
     1   Being Developed      VISN is developing interoperable communications capabilities and has identified a plan of operations.
     0   Needs Attention      There is an absence of interoperable communications with external agencies.
         Comments/Rationale   

###  {#section-17 .list-paragraph}

### 4.3.3 Interoperable Communications with VISN Facilities' {#interoperable-communications-with-visn-facilities .list-paragraph}

Measurement Factors

     4   Exemplary            All of the above assessment components are present, including at least three means of internal communications such as satellite phones, handheld radios, and telephones. Communications are tested at least quarterly.
  -- --- -------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent            Staff are properly trained and VISN has at least two means of internal communications. Communications are tested at least semiannually.
     2   Developed            VISN has at least two means of internal communications. Communications are tested at least annually.
     1   Being Developed      VISN has a means of internal communications. Communications are tested at least annually.
     0   Needs Attention      There is an absence of back-up means of internal communications or any testing.
         Comments/Rationale   

 {#section-18 .list-paragraph}

4.4 Healthcare Systems Resiliency {#healthcare-systems-resiliency .list-paragraph}
---------------------------------

### 4.4.1 Management of Primary Care for Special Needs Patients, including Home-Based Care during Incidents {#management-of-primary-care-for-special-needs-patients-including-home-based-care-during-incidents .list-paragraph}

Measurement Factors

     4   Exemplary            All of the above assessment components are present, including the consistent ability to support home-based patients throughout the duration of the emergency. Home-based care is tested annually and the capability is integrated with the VAMC and VISN yearly exercises.
  -- --- -------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent            Resources and training are in place to support continuous home-based care in an emergency and the capability is tested annually.
     2   Developed            Resources and training are in place. VISN meets underlying requirement where applicable.
     1   Being Developed      Some capability elements exist to support home-based care; however, some key components are not yet developed.
     0   Needs Attention      There is an absence of home-based services in an emergency.
         Comments/Rationale   

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

5.1 Processes and Procedures for Expansion of Staff for Response and Recovery Operations {#processes-and-procedures-for-expansion-of-staff-for-response-and-recovery-operations .list-paragraph}
----------------------------------------------------------------------------------------

Measurement Factors

     4   Exemplary            All of the above assessment components are present, including the ability for called back staff to report within 12 hours. Staff are trained on their role after being called back and understand the Incident Command structure. Physical and mental health needs are addressed. The ability to callback staff is tested quarterly, and the capability is integrated into the VISN's exercises.
  -- --- -------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent            Resources and training are in place to support the called back staff, and the capability is tested.
     2   Developed            Resources and training are in place. Facility meets the underlying requirement where applicable.
     1   Being Developed      Some capability elements exist to support staff expansion; however, some key components are not yet developed.
     0   Needs Attention      There is an absence of medical surge capability.
         Comments/Rationale   

 {#section-19 .list-paragraph}

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

Measurement Factors

     4   Exemplary            All of the program elements are in place, including DEMPS being fully operational at the VISN facilities and trained coordinators assigned. The program has a number of volunteers pre-identified and a means for updating the database at least quarterly. The program is supported by senior management, and employees are encouraged to enroll. The DEMPS coordinator has a working relationship with the national DEMPS program manager in Emergency Management Strategic Healthcare Group (EMSHG), and they work together to keep the database up to date.
  -- --- -------------------- -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent            DEMPS is fully operational at the VISN facilities and trained coordinators are assigned. The program has a number of volunteers pre-identified and a means for updating the database. The program is supported by senior management, and employees are encouraged to enroll.
     2   Developed            DEMPS is fully operational at VISN facilities and trained coordinators are assigned. The program has a number of volunteers pre-identified and a means for updating the database.
     1   Being Developed      DEMPS program is partially functional, but it has not identified all of the components. There are volunteers in the database but no regular means for updating it.
     0   Needs Attention      The DEMPS program is not functioning at VISN facilities.
         Comments/Rationale   

### 5.3.1 Processes and Procedures for Deployment and Return to Readiness of the VA All-Hazards Emergency Cache Program {#processes-and-procedures-for-deployment-and-return-to-readiness-of-the-va-all-hazards-emergency-cache-program .list-paragraph}

Measurement Factors

     4   Exemplary            VISN assure that the above components are present, and the VA All-Hazards Emergency Cache is accessible. The stock is rotated to prevent shelf-life expiration in accordance with the Food and Drug Administration (FDA)/DOD Shelf Life Extension Program (SLEP). It is tested at least once a year. The cache is stored and secured consistent with VHA policy. Appointment of a Liaison with the Pharmacy Benefits Management Service (PBM).
  -- --- -------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent            The VA All-Hazards Emergency Cache is accessible. The stock is rotated to prevent shelf-life expiration in accordance with the Food and Drug Administration (FDA)/DOD Shelf Life Extension Program (SLEP). The cache is stored and secured. Mobilization procedures are exercised annually.
     2   Developed            The VA All-Hazards Emergency Cache is accessible. The stock is rotated to prevent shelf-life expiration in accordance with the Food and Drug Administration (FDA)/DOD Shelf Life Extension Program (SLEP) and the cache is secured.
     1   Being Developed      The VA All-Hazards Emergency Cache is accessible.
     0   Needs Attention      The infrastructure and processes necessary to manage the VA All-Hazards Emergency Cache are not developed.
         Comments/Rationale   

### **5.3.2 Designated Capability for Expanded Patient Triage, Evaluation and** Treatment during Surge {#designated-capability-for-expanded-patient-triage-evaluation-and-treatment-during-surge .list-paragraph}

Measurement Factors

     4   Exemplary            VISNs are aware and assure that all of the above assessment components are present, including the ability to care for victims of a number of scenarios. Facility personnel understand their role in the designated areas and are trained to recognize various biological agents. The set-up and management of the designated areas is well-exercised through facility exercises.
  -- --- -------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent            Resources and training are in place, and personnel understand their roles in the designated areas. The capability is tested annually at the facilities.
     2   Developed            Resources and training are in place. Facilities meet underlying requirement where applicable.
     1   Being Developed      Some capability elements exist; however, some key components are not yet developed.
     0   Needs Attention      There are no designated areas for patient triage, evaluation, and treatment in an emergency.
         Comments/Rationale   

### 5.3.3 Processes and Procedures for Control and Coordination of Mass Fatality Management {#processes-and-procedures-for-control-and-coordination-of-mass-fatality-management .list-paragraph}

Measurement Factors

     4   Exemplary            All of the above assessment components are present, including the ability to manage large numbers of fatalities (either through internal surge mechanisms or through MOAs/MOUs with community resources). Staff are trained on safe and appropriate handling of human remains and have adequate PPE. The capability is tested once a year in facility wide and/or community exercises. VISNs are fully aware of individual facility mass fatality plans in order to assist in supplementing individual facility resources.
  -- --- -------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent            Resources and training are in place and personnel are trained on their role in mass fatality management. The capability is tested annually. VISNs are aware of facility plans are able to coordinate the process of supplementing individual facility resources.
     2   Developed            Resources and training are in place. Facility meets underlying requirement where applicable. VISNs are aware of facility plans.
     1   Being Developed      Some capability elements exist to support mass fatality management; however, some key components are not yet developed.
     0   Needs Attention      There is an absence of a mass fatality management plan and resources.
         Comments/Rationale   

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

6.1 Provision of Supplemental Health Services to Support the National Disaster Medical System  {#provision-of-supplemental-health-services-to-support-the-national-disaster-medical-system .list-paragraph}
---------------------------------------------------------------------------------------------

Measurement Factors

     4   Exemplary            All of the above assessment components are present, including the ability to effectively communicate with the FCCs. Communication infrastructure is in place and the VISN is able to communicate with its community partners. Community facilities exercise together at least once a year.
  -- --- -------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent            Resources and training are in place, and the capability is tested through a facility or other exercise annually
     2   Developed            Resources and training are in place. VISN and FCC meets underlying requirement where applicable.
     1   Being Developed      Some capability elements exist to support NDMS; however, some key components are not yet developed.
     0   Needs Attention      There is an absence of NDMS capability.
         Comments/Rationale   

 {#section-20 .list-paragraph}

6.2 VA/DOD Contingency Hospital System {#vadod-contingency-hospital-system .list-paragraph}
--------------------------------------

Measurement Factors

     4   Exemplary            The VISN has oversight over, and is knowledgeable regarding, the responsibilities of VISN facilities for the above assessment components, including conducting all required bed counts and exercises.
  -- --- -------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent            The VISN is knowledgeable that all the resources and training are in place, and VA/DOD bed expansion is tested annually.
     2   Developed            Resources and training are in place. VISN meets underlying VA requirements for the oversight this program.
     1   Being Developed      Some bed expansion capability exists; however, some key components are not yet developed.
     0   Needs Attention      There is an absence of this capability.
         Comments/Rationale   

6.3 Support under the National Response Framework {#support-under-the-national-response-framework .list-paragraph}
-------------------------------------------------

Measurement Factors

     4   Exemplary           All of the above assessment components are present. Communications protocols are tested as part of the exercise with the community. Evidence of ongoing relationships with federal, local and state emergency management and public health agencies are present.
  -- --- ------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent           VISN has communications with emergency management authorities on an ongoing basis. Communications are tested at least annually as part of the exercise.
     2   Developed           VISN has identified POCs and developed relationships in the event of emergencies with emergency management authorities.
     1   Being Developed     VISN can communicate with emergency management authorities, but it does not have an established collaborative relationship.
     0   Needs Attention     There is an absence of collaboration with POCs and emergency management authorities.
         Comment/Rationale   

###  {#section-21 .list-paragraph}