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VHA Emergency Management Capability Assessment Final Report

**Results from** **Site Visit**

*Submitted to:*

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"}

**9 February 2009**

**VHA Emergency Management Capability Assessment Final Report**

\* \* \* \* \*

**TABLE OF CONTENTS**

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

[2 Introduction 1](#introduction)

[3 Methodology 1](#methodology)

[3.1 Capability Element Description 1](#capability-element-description)

[3.2 Capability Assessment and Measurement
5](#capability-assessment-and-measurement)

[3.3 Data Collection Methodology 6](#data-collection-methodology)

[4 Overall Program Capabilities 7](#overall-program-capabilities)

[5 Discussion of Facility Profile 7](#_Toc213225782)

[5.1 Program Level Exemplary Practices
7](#program-level-exemplary-practices)

[5.2 Operational Level Exemplary Practices
8](#operational-level-exemplary-practices)

[6 Program Level Recommendations and Enhancements
8](#program-level-recommendations-and-enhancements)

[7 Operational Level Recommendations and Enhancements
8](#operational-level-recommendations-and-enhancements)

[8 The Joint Commission and NIMS Scorecards
8](#the-joint-commission-and-nims-scorecards)

[8.1 The Joint Commission Scorecard 8](#the-joint-commission-scorecard)

[8.2 The National Incident Management Scorecard
8](#the-national-incident-management-scorecard)

[Appendix A 9](#appendix-a)

[Acronym List 9](#acronym-list)

[Appendix B 11](#_Toc213225792)

[Capability Descriptor List 11](#capability-descriptor-list)

[Appendix C 15](#appendix-c)

[The Joint Commission Scorecard 15](#the-joint-commission-scorecard-1)

[Appendix D 16](#appendix-d)

[The National Incident Management Scorecard
16](#the-national-incident-management-scorecard-1)

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

A site assessment was conducted by the Comprehensive Emergency
Management Program (CEMP) Assessment Team from \<Date of Assessments\>.
The Assessment Team included \<List of Assessment Team\>. The team
appreciated the cooperation and enthusiasm of the staff and their
willingness to assist in a very successful visit.

\<Describe how the VAMC met standards/requirements and facility status\>

\<Describe areas for capability enhancement and any recommendations
given\>

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

The, located in, is identified as a \<list identifiers and
affiliations\>.

\<Describe site location and purpose of visit\>.

Methodology
===========

Prior to the site visits, the Assessment Team worked closely with
experts in the field of emergency medicine and preparedness to define
the assessment elements for the study. These experts represented VHA,
other federal agencies including the Department of Homeland Security
(DHS), Health and Human Services (HHS), and Defense, academia, and
clinical medicine. Through consultation with these experts the
Assessment Team defined the 69 capabilities for assessment as well as
the measurement scheme. The following sections will provide a high level
summary of the overall assessment protocol.

Capability Element Description
------------------------------

To determine the elements for assessment during the site visits and
pre-survey, the VHA capabilities were categorized into six groups. These
included capabilities relevant to:

-   **Program Level** capabilities help to ensure the facility addresses
    issues relative to planning and preparedness as a crucial building
    block for facility capabilities. These program level capabilities
    were categorized into the following groups:

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

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

-   **Development, Implementation, Management, and Maintenance of an
    > Emergency Management Committee process to Support the Emergency
    > Management Program**

-   **Development, Implementation, and Maintenance of a Hazard
    > Vulnerability Analysis process as the Foundation for Conducting
    > the Emergency Management Program**

-   **Incorporation of Comprehensive Mitigation Planning into the
    > Facility's Emergency Management Program**

-   **Incorporation of Comprehensive Preparedness Planning into the
    > Facility's Emergency Management Program**

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

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

-   **Incorporation of Comprehensive Instructional Activity into the
    > Preparedness Activities of the Facility's Emergency Management
    > Program**

-   **Incorporation of a Range of Exercise Types that Test the
    > Facility's Emergency Management Program**

-   **Demonstration of Systems-Based Evaluation of the Facility's
    > Overall Emergency Management Program and its Emergency Operations
    > Plan**

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

    -   **Incident Management** capabilities help to ensure the facility
        > can manage all incidents regardless of scope. These
        > capabilities were categorized into the following groups:

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```
-   Initial Incident Actions

-   Public Information Management Services during an Incident

-   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

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```
-   **Occupant Safety** capabilities help to ensure the facility and its
    occupants are protected and out of harm's way. These capabilities
    were categorized into the following groups:

```{=html}
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```
-   Evacuation vs. Shelter-In-Place

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

-   Processes and Procedures for Managing a Hazardous Substance Incident

-   Infection Control

-   Fire Protection and Rescue Services for Response to Incidents

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```
-   **Resiliency and Continuity of Operations** **(COOP)** capabilities
    help to ensure the facility can continue to provide high quality
    healthcare, and that all facility based operations can continue
    during an emergency. These capabilities were categorized into the
    following groups:

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```
-   Personnel Resiliency

-   Mission Critical Systems Resiliency

-   Communications

-   Healthcare Service System Resiliency

-   Development, Implementation, Management, and Maintenance of a
    Research Program EOP

-   Maintaining Patient Mental Health and Welfare

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```
-   **Medical Surge** capabilities help to ensure the facility can meet
    the increased demand for health care services during an emergency.
    These capabilities were categorized into the following groups:

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

-   Management of External Volunteers and Donations during Emergencies

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

> Expansion of Evaluation and Treatment Services

-   **Support to External Requirements** help to ensure the facility can
    > integrate with the community and other federal health partners
    > such as HHS, including Centers for Disease Control and
    > Prevention (CDC) and Assistant Secretary for Preparedness and
    > Response (ASPR), DHS, and Department of Defense (DOD). This
    > capability included the ability to conduct patient reception
    > activities under the VA/DOD Contingency Hospital System and
    > National Disaster Medical System (NDMS). These capabilities were
    > categorized into the following groups:

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```
-   Support of Patient Care Requirements

-   Liaison

To describe each capability, the Assessment Team developed a framework
that includes the following components:

-   **Policies or Guidance** that govern, guide, or direct that activity

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

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

-   **Processes** in place to allow for consistency across departments
    and organizations

-   **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

An example of this descriptive framework is presented in Table 1 below.

**Table 1. Descriptive Framework for Mobilization Capability**

+------------------------+--------------------------------------------+
| Capability Element     | Assessment components                      |
+========================+============================================+
| Policy                 | The organization has established effective |
|                        | mechanisms to rapidly mobilize essential   |
|                        | personnel, facilities, equipment and       |
|                        | supplies to support emergency response.    |
+------------------------+--------------------------------------------+
| Resources              |                                            |
+------------------------+--------------------------------------------+
| > Supplies             | -   Supplies needed for mobilization       |
+------------------------+--------------------------------------------+
| > Facilities/Equipment | -   Storage facilities for equipment and   |
|                        |     > supplies.                            |
+------------------------+--------------------------------------------+
| > Personnel            | -   The organization has identified        |
|                        |     > qualified and trained personnel to   |
|                        |     > manage mobilization of key response  |
|                        |     > areas.                               |
+------------------------+--------------------------------------------+
| Process                | -   Supplies, equipment and temporary      |
|                        |     > facilities to be mobilized should be |
|                        |     > pre-positioned or staged for         |
|                        |     > response and recovery to allow rapid |
|                        |     > mobilization.                        |
|                        |                                            |
|                        | -   The Emergency Operations Center (EOC)  |
|                        |     > facility is pre-identified and       |
|                        |     > equipped with emergency power,       |
|                        |     > back-up communications, FAX          |
|                        |     > machines, printers, laptops, and     |
|                        |     > other essential equipment (e.g.,     |
|                        |     > satellite phone) and services        |
|                        |     > sufficient to operate throughout the |
|                        |     > duration of the emergency.           |
|                        |                                            |
|                        | -   There are written procedures including |
|                        |     > job descriptions for key EOC         |
|                        |     > personnel                            |
|                        |                                            |
|                        | -   The EOC should have battery powered    |
|                        |     > lighting in case generators don't    |
|                        |     > energize                             |
|                        |                                            |
|                        | -   Laptops should be operational within a |
|                        |     > few minutes of EOC activation        |
|                        |                                            |
|                        | -   There are written procedures for       |
|                        |     > identifying alternative sites for    |
|                        |     > the EOC                              |
|                        |                                            |
|                        | -   VAMC has a callback roster for the     |
|                        |     > Incident Management Team (IMT) and   |
|                        |     > each department of the facility.     |
|                        |                                            |
|                        | -   Staff callback rosters are maintained  |
|                        |     > for each Operating Unit.             |
|                        |                                            |
|                        | -   Staff will establish phone bank        |
|                        |     > messaging capability and coordinate  |
|                        |     > message alerts with local media.     |
|                        |                                            |
|                        | -   VAMC has job action sheets for the     |
|                        |     > Agency Executive and the IMT         |
+------------------------+--------------------------------------------+
| Education/training     | -   Members of the IMT and other key areas |
|                        |     > need to be trained with respect to   |
|                        |     > their role in mobilizing the actions |
|                        |     > upon incident notification.          |
+------------------------+--------------------------------------------+
| Exercise               | -   Callback rosters are tested at least   |
|                        |     > quarterly                            |
|                        |                                            |
|                        | -   There is an exercise component that    |
|                        |     > practices bringing some key staff    |
|                        |     > back to the facility during regular  |
|                        |     > exercises.                           |
+------------------------+--------------------------------------------+

Capability Assessment and Measurement
-------------------------------------

After the team defined the critical capabilities and used the
descriptive framework to define the capability, the Assessment Team
developed a measurement scheme. This scheme includes a five level scale
to include the following indicators:

-   **Exemplary:** The facility often performs at a higher level than
    industry standards call for. This would be considered a "best in
    class" or "best practice"

-   **Excellent:** The facility often goes above and beyond the required
    standards

-   **Developed:** When present, the facility meets industry standards
    relative to that capability

-   **Being developed:** The capability is in its infancy, and initial
    attempts to build the capability are underway

-   **Needs attention:** There is no evidence the capability exists.

Table 2 depicts the measurement factors for the above highlighted
mobilization capability.

**Table 2. Measurement Factors for Mobilization Capability**

  4   Exemplary         All of the above assessment components are present including establishing Incident Management teams consistent with the facility's SOPs for high risk hazards. Mobilization plan is practiced semiannually.
  --- ----------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
  3   Excellent         Resources and training are in place and mobilization is practiced at least annually.
  2   Developed         Resources and training are in place including a written mobilization plan.
  1   Being Developed   Some capability elements exist, however mobilization plan is not written or practiced at least annually.
  0   Needs Attention   Absence of mobilization plan.

Data Collection Methodology
---------------------------

To capture data relevant to each of these capabilities, the Assessment
Team undertook a number of activities, as shown in Figure 1. Each of
these will be discussed in subsequent sections.

**Figure 1. Assessment Methodology**

![](media/image4.wmf){width="5.999305555555556in"
height="2.9277777777777776in"}

**Pre-Survey:**

During the initial assessment phase, the Assessment Team evaluated the
results of a pre-survey administered to the facility one week before the
visit. During the normal site visit cycle, the facility would have a
much longer time period in which to complete this survey. Key parts of
this self-reported survey were validated against the findings of the
site visit. During a normal site visit, the Assessment Team will inform
the agenda by analysis of the pre-survey.

**Site Visit:**

During the site visit the Assessment Team conducted an opening briefing,
interviewed several key members of the emergency management team,
conducted a tour of the medical center units critical to the EMP,
participated in facilitated discussions, conducted a document review,
and had a closing conference with the medical center management. Based
upon these activities, the Assessment Team was able to observe and
evaluate a number of competencies needed for an effective EMP.

**Reporting:**

In addition to this final report, lessons learned and best practices
identified in this site visit will be generalized and shared with other
VAMCs, Veterans Integrated Service Networks (VISNs) and VHA Central
Office (CO). We will also summarize the findings and issues identified
for national attention and will share them with VHA CO senior management
to identify tools, resources, communications, policy, and programs that
leadership should consider for national deployment.

Overall Program Capabilities
============================

Table 2 below provides a summary of the emergency management
capabilities of the . Any capabilities that were not documented by the
Assessment Team are evident by a blank space in the capability element
box. Detailed discussion of some of these capabilities is provided in
subsequent sections.

**Table 2: Summary** **of** **Capabilities**

Discussion of Facility Profile
==============================

Based on the above table, there were several capabilities that were
identified as areas in which there were potential best practices as well
as opportunities for continued enhancement. These are discussed in
subsequent sections.

Program Level Exemplary Practices
---------------------------------

exhibited very strong capabilities in several areas. Examples are
discussed below.

\<Create Sub-headings here to describe each of the program level
practices in which excellence was observed\>

Operational Level Exemplary Practices
-------------------------------------

\<Create Sub-Headings here to describe each of the operational level
practices in which excellence was observed\>

Program Level Recommendations and Enhancements
==============================================

The Assessment Team has composed a listing of recommendations based on
the site visit and capability assessments. VAMCS should utilize the VHA
EMP Guidebook as the principle resource to developing and enhancing
their EMP along with recommendations discussed below:

\<Create Sub-Headings here to describe each of the program level
recommendations\>

Operational Level Recommendations and Enhancements
==================================================

\<Create Sub-Headings here to describe each of the program level
recommendations\>

The Joint Commission and NIMS Scorecards
========================================

The Joint Commission Scorecard
------------------------------

**Attachment C** was developed to identify where facilities might need
to strengthen their programs in advance of their next Joint Commission
review. It provides an overall summary of the medical center's
consistency with The Joint Commission Emergency Management Standard 4 as
part of the overall Environment of Care. The primary focus of this
analysis is on the standards that are new in 2008. In addition to the
2008 standards, the scorecard will also provide an assessment of
relevant existing standards that directly correlate to specific
capabilities, as outlined in the assessor\'s guide. This attachment was
developed through the pre-survey and analysis of data obtained
throughout the site visit.  Because the standards changed significantly
in January 2008, this profile in Attachment C may help prioritize where
to concentrate efforts to ensure compliance in the shortest time
possible.

The National Incident Management Scorecard
------------------------------------------

**Attachment D** provides an overall summary of the medical center's
consistency with the NIMS standards. This attachment was developed
through the pre-survey and site visit observations. Attachment D was
developed to identify where facilities might need to strengthen their
programs in support of NIMS standards.

Appendix A {#appendix-a .list-paragraph}
==========

Acronym List {#acronym-list .list-paragraph}
------------

  **Acronym**   **Definition**
  ------------- ------------------------------------------------------------
  AD            Associate Director
  APR           Air Purifying Respirator
  ASPR          Assistant Secretary for Preparedness and Response
  CBOC          Community-Based Outpatient Clinic
  CBRNE         Chemical, Biological, Radiological, Nuclear, and Explosive
  CDC           Centers for Disease Control and Prevention
  CEM           Certified Emergency Manager
  CEMP          Comprehensive Emergency Management Program
  CIO           Chief Information Officer
  CO            Central Office
  COOP          Continuity of Operations
  DEMPS         Disaster Emergency Medical Personnel System
  DHS           Department of Homeland Security
  DOD           Department of Defense
  ECG           Electrocardiogram
  EMC           Emergency Management Committee
  EMP           Emergency Management Program
  EMSHG         Emergency Management Strategic Healthcare Group
  EMT           Emergency Medical Technician
  EOC           Emergency Operations Center
  EOP           Emergency Operations Plan
  EPC           Emergency Planning Coordinator
  FCC           Federal Coordinating Center
  FEMA          Federal Emergency Management Agency
  HAZWOPER      Hazardous Waste Operations and Emergency Response
  HBPC          Home-based Primary Care
  HHS           Health and Human Services
  HVA           Hazard Vulnerability Analysis
  ICS           Incident Command System
  IMT           Incident Management Team
  IT            Information Technology
  TJC           The Joint Commission
  MOU           Memorandum of Understanding
  NDMS          National Disaster Medical System
  NFPA          National Fire Protection Association
  NIMS          National Incident Management System
  OSHA          Occupational Safety and Health Administration
  PAO           Public Affairs Officer
  PAPR          Powered Air Purifying Respirator
  PPE           Personal Protective Equipment
  PRC           Primary Receiving Center
  SOP           Standard Operating Procedure
  VA            Veterans Affairs
  VAMC          Veterans Affairs Medical Center
  VHA           Veterans Health Administration
  VISN          Veterans Integrated Service Network

Appendix B {#appendix-b .list-paragraph}
==========

Capability Descriptor List {#capability-descriptor-list .list-paragraph}
--------------------------

> **[Program Level Capabilities]{.underline}**

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

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

-   **Development, Implementation, Management, and Maintenance of an
    Emergency Management Committee process to Support the Emergency
    Management Program**

-   **Development, Implementation, and Maintenance of a Hazard
    Vulnerability Analysis process as the Foundation for Conducting the
    Emergency Management Program**

-   **Incorporation of Comprehensive Mitigation Planning into the
    Facility's Emergency Management Program**

-   **Incorporation of Comprehensive Preparedness Planning in the
    Facility's Emergency Management Program**

-   **Incorporation of Continuity Planning into the Activities of the
    Facility's Emergency Management Program to ensure Organizational
    Continuity and Resiliency of Mission Critical Functions, processes,
    and Systems**

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

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

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

-   **Demonstration of Systems-Based Evaluation of the Facility's
    Overall Emergency Management Program and its Emergency Operations
    Plan**

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

> **[Incident Management Capabilities]{.underline}**
>
> **Initial Incident Actions**

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

-   **Mobilization of Critical Staff and Equipment for Incident
    Response**

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

> **Management of Extended Incident Operations**
>
> **Public Information Management Services during an Incident**
>
> **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**
>
> **[Occupant Safety Capabilities]{.underline}**
>
> **Evacuation vs. Shelter-in-Place**

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

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

-   **Processes and Procedures for Sheltering Family of Critical Staff**

> **Perimeter Management of Access/Egress to Facility during an Incident
> (e.g. Lock Down)**
>
> **Processes and Procedures for Managing a Hazardous Substance
> Incident**
>
> **Infection Control**

-   **Biohazard (Infection) Control Surge Services during Emergencies**

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

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

> **Fire Protection and Rescue Services for Response to Incidents**
>
> **[Resiliency/Continuity of Operations Capabilities]{.underline}**
>
> **Personnel Resiliency**

-   **Transporting Critical Staff to the Facility during an Emergency**

-   **Maintaining Authorized Leadership (Leadership Succession)**

-   **Processes and Procedures for Personal Preparedness and Employee
    Welfare**

-   **Dissemination of Personnel Incident Information to Staff during an
    Incident**

> **Mission Critical Systems Resiliency**

-   **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**

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

-   **Maintaining Emergency Potable Water System Resiliency**

-   **Maintaining Sewage and Waste Resiliency**

-   **Maintaining Medical Gases and Vacuum Resiliency**

-   **Maintaining Heating Ventilation and Air Conditioning (HVAC)
    Resiliency**

-   **Maintaining Information Technology (IT) and Computing Systems
    Resiliency**

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

-   **Internal and external (to the VA) Alternate Care Sites**

-   **Cash to Purchase Supplies/Services/Payroll During an Emergency**

> **Communications**

-   **Maintenance of Voice and Data Communication through Satellite
    link**

-   **Maintaining Satellite Telephone Resiliency**

-   **Interoperable Communications with External Agencies'**

-   **Interoperable Communications with VAMC Facilities'**

> **Healthcare Service System Resiliency**

-   **Development, Implementation, Management, and Maintenance of
    Community Based Outpatient Clinics (CBOCs) EOP**

-   **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)**

-   **Provision of Ambulatory Clinical Services during Incidents**

> **Development, Implementation, Management, and Maintenance of a
> Research Program EOP**
>
> **Maintaining Patient Mental Health and Welfare**
>
> **[Medical Surge Capabilities]{.underline}**
>
> **Processes and Procedures for Expansion of Staff for Response and
> Recovery Operations**
>
> **Management of External Volunteers and Donations during Emergencies**
>
> **Management of Volunteers Deployment Support (e.g. DEMPS) during
> Response and Recovery Operations**
>
> **Expansion of Evaluation and Treatment Services**

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

-   **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**

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

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

> **[Support to External Requirements Capabilities]{.underline}**
>
> **Support of Patient Care Requirements**

-   **Provision of Supplemental Health Services to Support the NDMS**

-   **VA/DOD Contingency Hospital System**

> **Liaison**

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

-   **Response interface with Community Healthcare Organizations**

-   **Support under the NRF**

Appendix C {#appendix-c .list-paragraph}
==========

The Joint Commission Scorecard {#the-joint-commission-scorecard-1 .list-paragraph}
------------------------------

\<Cut and paste completed Joint Commission Scorecard here\>

Appendix D {#appendix-d .list-paragraph}
==========

The National Incident Management Scorecard {#the-national-incident-management-scorecard-1 .list-paragraph}
------------------------------------------

\<Cut and paste completed National Incident Management Scorecard here\>