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VHA Comprehensive Emergency Management Program Analysis Capabilities
Scoring Tool

Department of Veterans Affairs

Veterans Health Administration

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

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

**October 30, 2008**

**Table of Contents**

[Directions 1](#directions)

[1 Program Level Capabilities 2](#program-level-capabilities)

[1.1 Systems-Based Approach to the Development, Implementation,
Management, and Maintenance of the Emergency Management Program
2](#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
2](#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
3](#development-implementation-management-and-maintenance-of-an-emergency-management-committee-process-to-support-the-emergency-management-program)

[1.4 Development, Implementation, and Maintenance of a Hazard
Vulnerability Analysis process as the Foundation for Conducting the
Emergency Management Program
3](#development-implementation-and-maintenance-of-a-hazard-vulnerability-analysis-process-as-the-foundation-for-conducting-the-emergency-management-program)

[1.5 Incorporation of Comprehensive Mitigation Planning into the
Facility's Emergency Management Program
4](#incorporation-of-comprehensive-mitigation-planning-into-the-facilitys-emergency-management-program)

[1.6 Incorporation of Comprehensive Preparedness Planning in the
Facility's Emergency Management Program
4](#incorporation-of-comprehensive-preparedness-planning-in-the-facilitys-emergency-management-program)

[1.7 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
5](#incorporation-of-continuity-planning-into-the-activities-of-the-facilitys-emergency-management-program-to-ensure-organizational-continuity-and-resiliency-of-mission-critical-functions-processes-and-systems)

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

[1.9 Incorporation of Comprehensive Instructional Activity into the
Preparedness Activities of the Facility's Emergency Management Program
6](#incorporation-of-comprehensive-instructional-activity-into-the-preparedness-activities-of-the-facilitys-emergency-management-program)

[1.10 Incorporation of a Range of Exercise Types that Test the
Facility's Emergency Management Program
6](#incorporation-of-a-range-of-exercise-types-that-test-the-facilitys-emergency-management-program)

[1.11 Demonstration of Systems-Based Evaluation of the Facility's
Overall Emergency Management Program and its Emergency Operations Plan
7](#demonstration-of-systems-based-evaluation-of-the-facilitys-overall-emergency-management-program-and-its-emergency-operations-plan)

[1.12 Incorporation of Accepted Improvement Recommendations into the
Emergency Management Program and its Components such that the process
becomes one of a Learning Organization.
8](#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 8](#_Toc212995508)

[2.1 Initial Incident Actions 8](#initial-incident-actions)

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

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

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

[2.1.4 Management of Extended Incident Operations
10](#management-of-extended-incident-operations)

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

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

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

[2.5 Processes and Procedures for a Return to Readiness of Staff and
Equipment 12](#_Toc212995517)

[3 Occupant Safety Capabilities 12](#_Toc212995518)

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

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

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

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

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

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

[3.4 Infection Control 16](#_Toc212995525)

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

[3.4.2 Selection and Use of Personal Protective Equipment for Incident
Response and Recovery Operations
16](#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)
17](#processes-and-procedures-for-staff-and-family-mass-prophylaxis-during-an-infectious-outbreak-i.e.-influenza)

[3.5 Fire Protection and Rescue Services for Response to Incidents
17](#fire-protection-and-rescue-services-for-response-to-incidents)

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

[4.1 Personnel Resiliency 18](#personnel-resiliency)

[4.1.1 Transporting Critical Staff to the Facility during an Emergency
18](#transporting-critical-staff-to-the-facility-during-an-emergency)

[4.1.2 Maintaining Authorized Leadership (Leadership Succession)
19](#maintaining-authorized-leadership-leadership-succession)

[4.1.3 Processes and Procedures for Personal Preparedness and Employee
Welfare 19](#_Toc212995534)

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

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

[4.2.1 Development, Implementation, Management, and Maintenance of an
Electrical Power System
20](#development-implementation-management-and-maintenance-of-an-electrical-power-system)

[4.2.2 Management and Maintenance of Fixed and Portable Electrical
Generator Resiliency 21](#_Toc212995538)

[4.2.3 Maintaining Fuel, Fuel Storage, and Fuel Pumps for Generators,
Heating, and Vehicles Resiliency
22](#maintaining-fuel-fuel-storage-and-fuel-pumps-for-generators-heating-and-vehicles-resiliency)

[4.2.4 Development, Implementation, Management, and Maintenance of an
Emergency Water Conservation Plan
22](#development-implementation-management-and-maintenance-of-an-emergency-water-conservation-plan)

[4.2.5 Maintaining Emergency Potable Water Supply Resiliency
23](#maintaining-emergency-potable-water-supply-resiliency)

[4.2.6 Maintaining Sewage and Waste Resiliency
23](#maintaining-sewage-and-waste-resiliency)

[4.2.7 Maintaining Medical Gases and Vacuum Resiliency
24](#maintaining-medical-gases-and-vacuum-resiliency)

[4.2.8 Maintaining Heating Ventilation and Air Conditioning (HVAC)
Resiliency
25](#maintaining-heating-ventilation-and-air-conditioning-hvac-resiliency)

[4.2.9 Maintaining Information Technology (IT) and Computing Systems
Resiliency
26](#maintaining-information-technology-it-and-computing-systems-resiliency)

[4.2.10 Maintaining Access to Critical Commodities and Services during
Response and Recovery Operations 26](#_Toc212995546)

[4.2.11 Internal and External (to the VA) Alternate Care Sites
27](#_Toc212995547)

[4.2.12 Cash to Purchase Supplies/Services/Payroll During an Emergency
27](#cash-to-purchase-suppliesservicespayroll-during-an-emergency)

[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 Maintaining Satellite Telephone Resiliency
28](#maintaining-satellite-telephone-resiliency)

[4.3.3 Interoperable Communications with External Agenices'
29](#interoperable-communications-with-external-agenices)

[4.3.4 Interoperable Communications with VAMC Facilities'
29](#_Toc212995553)

[4.4 Healthcare Service System Resiliency
30](#healthcare-service-system-resiliency)

[4.4.1 Development, Implementation, Management, and Maintenance of
Community Based Outpatient Clinic (CBOC) EOP
30](#development-implementation-management-and-maintenance-of-community-based-outpatient-clinic-cboc-eop)

[4.4.2 Management of Care for Home-Based Primary Care Patients during
Incidents
31](#management-of-care-for-home-based-primary-care-patients-during-incidents)

[4.4.3 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)
31](#specialty-outpatient-services-e.g.-dialysis-persons-with-spinal-cord-injury-dependent-scid-on-communityoutside-assistance-in-their-home-oxygen-therapy-patients-and-dementia-or-other-cognitive-impairment)

[4.4.4 Provision of Ambulatory Clinical Services during Incidents
32](#provision-of-ambulatory-clinical-services-during-incidents)

[4.5 Development, Implementation, Management, and Maintenance of a
Research Program EOP 32](#_Toc212995559)

[4.6 Maintaining Patient Mental Health and Welfare
33](#maintaining-patient-mental-health-and-welfare)

[5 Medical Surge 34](#medical-surge)

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

[5.2 Management of External Volunteers and Donations during Emergencies
34](#management-of-external-volunteers-and-donations-during-emergencies)

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

[5.4 Expansion of Evaluation and Treatment Services 35](#_Toc212995565)

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

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

[5.4.3 Designation and Operation of Isolation Rooms
37](#designation-and-operation-of-isolation-rooms)

[5.4.4 Integration of Patient Reception, Surge and Decontamination Teams
37](#integration-of-patient-reception-surge-and-decontamination-teams)

[5.4.5 Maintaining Laboratory, Blood Bank, and Diagnostic Imaging Surge
Capability
38](#maintaining-laboratory-blood-bank-and-diagnostic-imaging-surge-capability)

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

[6 Support to external requirements
39](#support-to-external-requirements)

[6.1 Support of Patient Care Requirements
39](#support-of-patient-care-requirements)

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

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

[6.2 Liaison 40](#liaison)

[6.2.1 Response/Interface with State and Community Emergency Management
Authorities and State and Local Public Health
40](#responseinterface-with-state-and-community-emergency-management-authorities-and-state-and-local-public-health)

[6.2.2 Response/Interface with Community Healthcare Organizations
41](#responseinterface-with-community-healthcare-organizations)

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

Directions
==========

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 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 "Comprehensive
Emergency Management Program Analysis Capabilities Description." Once
this tool is complete, the measurements and scoring can be transferred
to the site final report.

**See example below:**

     4   Exemplary                All of the above assessment components are present.
  -- --- ------------------------ --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent                Resources and training are in place and the EMP is reviewed annually. There is documented evidence that the HVA is an essential component of program development and implementation.
     2   Developed                Resources and training are in place. Facility 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, as evidenced by not using HVA for activity planning, training and exercises.
     0   Needs Attention          There is an absence of capability, as evidenced by lack of an annual review of the EMP.
         **Comment/Rationale:**        

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

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

**Measurement Factors and Score**

     4   Exemplary                All of the above assessment components are present.
  -- --- ------------------------ --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent                Resources and training are in place and the EMP is reviewed annually. There is documented evidence that the HVA is an essential component of program development and implementation.
     2   Developed                Resources and training are in place. Facility 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, as evidenced by not using HVA for activity planning, training and exercises.
     0   Needs Attention          There is an absence of capability, as evidenced by lack of an annual review of the EMP.
         **Comment/Rationale:**        

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

**Measurement Factors and Score**

     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:**        

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

**Measurement Factors and Scoring**

     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                Resources and training are in place. EMC meets TJC requirements.
     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.
     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.
         **Comment/Rationale:**        

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

**Measurement Factors and Scoring**

     4   Exemplary                All of the above assessment components are present.
  -- --- ------------------------ --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent                Resources and training are in place and the HVA is updated annually.
     2   Developed                Resources and training are in place. The HVA meets TJC requirements.
     1   Being Developed          Some capability elements exist; however, some key components are not yet developed, including annual briefing and analysis by the EMC or are not used to develop required exercises.
     0   Needs Attention          There is an absence of capability indicated by an incomplete HVA or less than annual reviews of this capability.
         **Comment/Rationale:**        

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

**Measurement Factors and Scoring**

     4   Exemplary                All of the above assessment components are present including an annual briefing on mitigation activities to the EMC.
  -- --- ------------------------ ---------------------------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent                Resources and training are in place and mitigation activities evaluated at least annually with report to the EMC.
     2   Developed                Resources and training are in place including documented mitigation activities in a number of Operating Units at the facility.
     1   Being Developed          Some mitigation activities are under way; however, the program is not fully implemented and an annual report is not provided to the EMC and/or facility management.
     0   Needs Attention          Facility has few, if any, mitigation activities underway.
         **Comment/Rationale:**        

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

**Measurement Factors and Scoring**

     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:**        

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
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

**Measurement Factors and Scoring**

     4   Exemplary                All of the above assessment components are present, including a semiannual briefing to the EMC 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.
     2   Developed                Facility has ongoing continuity planning program coordinated with the EMC.
     1   Being Developed          There are elements of a continuity planning program but is not fully coordinated with the EMC.
     0   Needs Attention          Facility lacks an integrated continuity planning program.
         **Comment/Rationale:**        

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

**Measurement Factors and Scoring**

     4   Exemplary                All of the above assessment components are present, including a semiannual briefing to the EMC on EOP activities. 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.
     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:**        

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

**Measurement Factors and Scoring**

     4   Exemplary                All of the above assessment components are present, including a semiannual briefing to the EMC 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.
     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:**        

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

**Measurement Factors and Scoring**

     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. Exercise program for TJC is integrated with the VAMC decontamination program exercises and at least one exercise involves the simulated activation of the VA All-Hazards Emergency Cache. The EPC also participates with the community in designing and/or planning a community exercise that involves the VAMC.
  -- --- ------------------------ -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     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. Exercise program for TJC is integrated with the VAMC decontamination program exercises and at least one exercise involves the simulated activation of the VA All-Hazards Emergency Cache.
     2   Developed                Resources and training are in place. Facility meets underlying requirement where applicable. 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.
     1   Being Developed          Some capability elements exist; however, some key components are not yet developed. VAMC conducts the required two exercises, 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, and the VAMC exercise program does not meet TJC requirements.
         **Comment/Rationale:**        

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

**Measurement Factors and Scoring**

     4   Exemplary                All of the above assessment components are present, including a semiannual briefing to the EMC 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                Facility 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.
     0   Needs Attention          Facility lacks an integrated program evaluation activity.
         **Comment/Rationale:**        

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

**Measurement Factors and Scoring**

     4   Exemplary                All of the above assessment components are present, including a semiannual briefing to the EMC on organizational learning activities.
  -- --- ------------------------ --------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent                Resources and training activities are in place including an annual evaluation and report submitted to the EMC.
     2   Developed                Facility has ongoing organizational learning program coordinated with the EMC 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 coordinated with the EMC.
     0   Needs Attention          Facility lacks an integrated organizational learning program.
         **Comment/Rationale:**        

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

Initial Incident Actions
------------------------

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

**Measurement Factors and Scoring**

     4   Exemplary                All of the above assessment components are present, including a semiannual activation of the EOC.
  -- --- ------------------------ --------------------------------------------------------------------------------------------------------------
     3   Excellent                Resources and training are in place, and the EOC activation is tested annually.
     2   Developed                Resources and training are in place. Facility can activate the EOC.
     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.
         **Comment/Rationale:**        

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

**Measurement Factors and Scoring**

     4   Exemplary                All of the above assessment components are present, including establishing IMTs consistent with the facility's SOPs for high-risk hazards. Mobilization plan is practiced semi-annually.
  -- --- ------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     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          There is an absence of a mobilization plan.
         **Comment/Rationale:**        

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

**Measurement Factors and Scoring**

     4   Exemplary                All of the above assessment components are present, including a semiannual 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. Facility 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.
         **Comment/Rationale:**        

### Management of Extended Incident Operations 

**Measurement Factors and Scoring**

     4   Exemplary                All of the above assessment components are present including an annual briefing to the EMC 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.
     2   Developed                Facility has ongoing continuity planning program coordinated with the EMC.
     1   Being Developed          There are elements of an extended operations plan, but it is not fully coordinated with the EMC.
     0   Needs Attention          Facility lacks an extended hours plan.
         **Comment/Rationale:**        

Public Information Management Services during an Incident
---------------------------------------------------------

**Measurement Factors and Scoring**

     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 mobilization plan.
         **Comment/Rationale:**        

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

**Measurement Factors and Scoring**

     4   Exemplary                All of the above assessment components are present, including a pre-planning incident assessment for resource allocation. 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.
     2   Developed                Resources and training are in place including a written resource management plan.
     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.
         **Comment/Rationale:**        

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

**Measurement Factors and Scoring**

     4   Exemplary                All of the above assessment components are present, including established demobilization procedures. Demobilization plan is practiced semiannually.
  -- --- ------------------------ -----------------------------------------------------------------------------------------------------------------------------------------------------
     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.
         **Comment/Rationale:**        

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

**Measurement Factors and Scoring**

     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.
         **Comment/Rationale:**        

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

Evacuation vs. Shelter-in-Place
-------------------------------

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

**Measurement Factors and Scoring**

     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                Evacuation plan meets TJC standards.
     1   Being Developed          Facility has horizontal but lacks a vertical evacuation plan or has not exercised the vertical evacuation plan within 15 months.
     0   Needs Attention          There is an absence of capability, including lack of an evacuation plan.
         **Comment/Rationale:**        

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

**Measurement Factors and Scoring**

     4   Exemplary                All of the above assessment components are present, including pre-identified locations within the facility suitable for shelter-in-place activation for patients and staff. Plan includes provisions for continuity of care, including medical records should VistA become disabled, as well as 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 continuity of care, including medical records should VistA become disabled, as well as 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 facility.
     1   Being Developed          Facility lacks a detailed shelter- in laboratory -place plan and does not test its capability on a regular basis. Facility 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.
         **Comment/Rationale:**        

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

**Measurement Factors and Scoring**

     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                Facility has a family shelter plan for critical employees.
     1   Being Developed          Facility does not have a family shelter plan for families of critical employees, but it is developing one.
     0   Needs Attention          Facility does not have a family shelter plan for families of critical employees.
         **Comment/Rationale:**        

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

**Measurement Factors and Scoring**

     4   Exemplary                All of the above assessment components are present, including the ability to lockdown the campus and individual buildings. Methods for securing means of egress to and from the facility are equipped with panic hardware to prevent entrance but allow egress. Plan is tested quarterly.
  -- --- ------------------------ -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent                The lockdown plan includes the ability to lockdown the campus and individual buildings. Methods for securing means of egress to and from the facility are equipped with panic hardware to prevent entrance but allow egress. Plan is tested quarterly.
     2   Developed                Resources and training are in place. Regular testing of lockdown procedure as defined by the VAMC 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 campus.
         **Comment/Rationale:**        

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

**Measurement Factors and Scoring**

     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-Hazards 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.
         **Comment/Rationale:**        

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

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

**Measurement Factors and Scoring**

     4   Exemplary                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 is integrated with the facility wide exercise.
  -- --- ------------------------ ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent                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. Facility meets 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.
         **Comment/Rationale:**        

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

**Measurement Factors and Scoring**

     4   Exemplary                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, 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.
         **Comment/Rationale:**        

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

**Measurement Factors and Scoring**

     4   Exemplary                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.
         **Comment/Rationale:**        

Fire Protection and Rescue Services for Response to Incidents
-------------------------------------------------------------

**Measurement Factors and Scoring**

     4   Exemplary                All of the above assessment components are present, including fire department mutual aid agreements that include responsibilities to the community during emergencies reviewed and approved by Regional or General Counsel.
  -- --- ------------------------ -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent                Resources and training are in place, and the capability is tested at least annually jointly with the community within the scope of mutual aid agreements.
     2   Developed                Resources and training are in place. VA fire department staff are trained to support the activities within their scope during emergencies.
     1   Being Developed          Some capability elements exist; however, some key components are not yet developed such as mutual aid agreements to provide support to the community during emergencies.
     0   Needs Attention          There is an absence of capability including lack of mutual aid agreements or MOUs/contracts with the community defining their role in emergencies.
         **Comment/Rationale:**        

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

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

### Transporting Critical Staff to the Facility during an Emergency

**Measurement Factors and Scoring**

     4   Exemplary                All of the above assessment components are present, including the ability to screen volunteer drivers and pre-approve their vehicles. The staff transport capability is tested annually and is integrated with the facility-wide exercise.
  -- --- ------------------------ --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent                Resources and training are in place to support the safe transport of staff, and the plan for critical employees to return to work during off-hours is tested quarterly.
     2   Developed                Resources and training are in place. Plan is exercised at least annually.
     1   Being Developed          Some capability exists to safely transport staff; however, some key components are not yet developed.
     0   Needs Attention          There is an absence of capability evidenced by lack of a plan to ensure access to transportation for critical staff during an emergency.
         **Comment/Rationale:**        

### Maintaining Authorized Leadership (Leadership Succession)

**Measurement Factors and Scoring**

     4   Exemplary                All of the above assessment components are present, including the immediate ability for personnel to take on leadership roles. Leadership succession is exercised in integration with the facility-wide exercise.
  -- --- ------------------------ -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent                Resources and training are in place. The line of succession is published and distributed to those in the line of succession and documentation is stored in the Executive Office and/or 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. Facility may have a line of succession but not have it documented.
     0   Needs Attention          There is an absence of line of succession at the facility.
         **Comment/Rationale:**        

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

**Measurement Factors and Scoring**

     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. Facility has provided physicals and vaccinations for employees volunteering for deployment.
  -- --- ------------------------ ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent                Critical employees have been identified; are on a call back roster; and have "go kits" ready in the event of an emergency activation. Program is reviewed annually.
     2   Developed                VAMC 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.
         **Comment/Rationale:**        

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

**Measurement Factors and Scoring**

     4   Exemplary                All of the above assessment components are present, including an 800 number and/or a program coordinated through VAMC media relations.
  -- --- ------------------------ ----------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent                Resources and training are in place, and an employee call-in number is tested annually.
     2   Developed                VAMC has an established call-in number and/or communications plan with the media for notifying employees who are unable to call in.
     1   Being Developed          VAMC has a call-in number or a plan for notifying the media to advise employees on facility operational status.
     0   Needs Attention          There is an absence of capability evidenced by lack of a call-in capability and a media notification program.
         **Comment/Rationale:**        

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

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

**Measurement Factors and Scoring**

     4   Exemplary                All of the above assessment components are present, including the utility disconnect test tri-annually for at least four hours. VAMC has a contingency plan for areas not provided with emergency power.
  -- --- ------------------------ ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent                Resources and training are in place. The emergency generators are tested monthly and the utility disconnect test conducted tri-annually is run for at least four hours.
     2   Developed                Emergency generators are tested monthly as required by TJC and the NFPA. Planning has occurred for the utility disconnect test conducted per year but the test has not yet been conducted it.
     1   Being Developed          Emergency generators are tested monthly as required by TJC and the NFPA.
     0   Needs Attention          Absence of capability demonstrated by less then monthly testing of the emergency generators.
         **Comment/Rationale:**        

### Management and Maintenance of Fixed and Portable Electrical Generator Resiliency

**Measurement Factors and Scoring**

     4   Exemplary                All of the above assessment components are present, including a needs-based supply of portable generators included in the preventive maintenance program at the facility. Generators are properly stored in a secure environment. Generator program includes deploying generators for a mission to the VAMC.
  -- --- ------------------------ --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent                All of the above assessment components are present, including a needs-based supply of portable generators included in the preventive maintenance program at the facility. Generators are properly stored in a secure environment.
     2   Developed                Resources and training are in place. VAMC has some portable generator capacity.
     1   Being Developed          VAMC is planning to develop a portable generator program, as evidenced by EMC minutes or discussions with the Director Facilities/Chief Engineer.
     0   Needs Attention          There is an absence of capability evidenced by no portable generators at the facility to support emergency operations for areas not served by emergency power or fixed generators.
         **Comment/Rationale:**        

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

**Measurement Factors and Scoring**

     4   Exemplary                All of the above assessment components are present, including a contingency plan for re-supply of fuel to power equipment essential to VAMC operations of equipment, heating system, and vehicles. There should also be a back-up supply of fuel at the facility that is properly stored. VAMC staff should also know how to access the BPA for fuel supply negotiated by the VACO.
  -- --- ------------------------ -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent                All of the above assessment components are present, including a contingency plan for re-supply of fuel to power equipment essential to VAMC operations of equipment, heating system, and vehicles. There should also be a back up supply of fuel at the facility that is properly stored.
     2   Developed                There should be a back up supply of fuel at the facility and a plan for obtaining additional fuel.
     1   Being Developed          Facility has back up supply of fuel but lacks an agreement or contract for priority re-supply or vice versa.
     0   Needs Attention          There is an absence of capability indicated by lack of fuel reserves at the facility.
         **Comment/Rationale:**        

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

**Measurement Factors and Scoring**

     4   Exemplary                All of the above assessment components are present, including a comprehensive water conservation plan that also includes priority for re-supply with bulk delivery. There is evidence that VAMC has conducted assessment to improve water supply resiliency with study or application for project funding when resources exceed the facility's capabilities.
  -- --- ------------------------ --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent                All of the above assessment components are present, including a comprehensive water conservation plan that also includes priority for re-supply with bulk delivery.
     2   Developed                There is a comprehensive water conservation plan that also includes priority for re-supply for bulk delivery.
     1   Being Developed          There is a comprehensive water conservation plan, but it does not include priority for re-supply with bulk delivery.
     0   Needs Attention          There is an absence of capability evidenced by lack of a water conservation plan.
         **Comment/Rationale:**        

### Maintaining Emergency Potable Water Supply Resiliency

**Measurement Factors and Scoring**

     4   Exemplary                All of the above assessment components are present, including an assessment to determine how the on-site, supply of potable water was determined. Stock is rotated to ensure freshness of water cache, and the program is reviewed annually. Cache is properly stored and secured. It also includes priority contracts for re-supply during an emergency.
  -- --- ------------------------ -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent                All of the above assessment components are present, including an assessment to determine how the on-site supply of potable water was determined. Stock is rotated to ensure freshness of water cache. Cache is properly stored and secured.
     2   Developed                Facility has supply of water as required by VHA Directive 2006-007.
     1   Being Developed          Facility has an on-site supply of potable water stored, but it does not conduct an annual review or have priority contracts for re-supply of water.
     0   Needs Attention          There is an absence of a water supply capability.
         **Comment/Rationale:**        

### Maintaining Sewage and Waste Resiliency

**Measurement Factors and Scoring**

     4   Exemplary                All of the above assessment components are present, including contracts for priority supply of portable toilets and removal by truck of waste during emergencies. There should be evidence the plan is evaluated at least annually.
  -- --- ------------------------ -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent                All of the above assessment components are present, including contracts for priority supply of portable toilets and removal by truck of waste during emergencies.
     2   Developed                Facility has a plan for disposal of waste products during an emergency.
     1   Being Developed          Facility has not yet developed a waste disposal plan including how to maintain a sanitary environment.
     0   Needs Attention          There is an absence of a plan for maintaining a sanitary environment and/or disposal of waste during an emergency.
         **Comment/Rationale:**        

### Maintaining Medical Gases and Vacuum Resiliency

**Measurement Factors and Scoring**

     4   Exemplary                All of the above assessment components are present, including emergency power to vacuum and medical air systems. Facility also has oxygen tanks and regulators as backup for bulk oxygen system for at least 48 hours. Facility has detailed contingency plans for loss of these systems during an emergency. Systems receive preventive maintenance at least quarterly, including alarm verification and exercising. Findings from regular testing and annual evaluation inform improvements and are incorporated into this program.
  -- --- ------------------------ ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent                All of the above assessment components are present, including emergency power to vacuum and medical air systems. Facility also has oxygen tanks and regulators as backup for bulk oxygen system for at least 48 hours. Facility has detailed contingency plans for loss of these systems during an emergency. Systems receive preventive maintenance at least annually including alarm verification and exercising.
     2   Developed                Facility has medical gas systems, including oxygen, medical air and vacuum identified as critical utilities in The Joint Commission's Environment of Care Utilities Management program, and has a preventive maintenance program for these systems.
     1   Being Developed          Facility has medical gas systems, including oxygen, medical air, and vacuum identified as critical utilities in The Joint Commission Environment of Care Utilities Management program, but it may lack system redundancy such as a vacuum back up pump or emergency power to these systems.
     0   Needs Attention          There is an absence of capability, including lack of emergency power for medical air and vacuum systems or a lack of oxygen tanks and regulators as backup for the bulk oxygen system.
         **Comment/Rationale:**        

### Maintaining Heating Ventilation and Air Conditioning (HVAC) Resiliency

**Measurement Factors and Scoring**

     4   Exemplary                All of the above assessment components are present, including a means to control air flow to critical areas such as the ED or ICUs and to provide negative and positive pressure capabilities. Facility has an automated environmental control system or a means for mechanically accomplishing air flow control in critical areas.
  -- --- ------------------------ --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent                All of the above assessment components are present, including a means to control air flow to critical areas such as the ED or ICUs and to provide negative and positive pressure capabilities.
     2   Developed                Critical components of the HVAC system are included in a preventive maintenance program, including regular testing in accordance with The Joint Commission Utility Management standards and manufacturer's recommendations.
     1   Being Developed          Critical components of the HVAC system are included in a preventive maintenance program, including regular testing in accordance with The Joint Commission Utility Management standards and manufacturer's recommendations. Facility lacks contingency plan for emergency operations or the ability to control air flow to critical areas of the VAMC.
     0   Needs Attention          HVAC system is not identified as a critical utility in the Utilities Management program or lacks a preventive maintenance program for the HVAC system.
         **Comment/Rationale:**        

### Maintaining Information Technology (IT) and Computing Systems Resiliency

**Measurement Factors and Scoring**

     4   Exemplary                All of the above assessment components are present, including a business continuity and resiliency program meeting federal requirements and the backup of patient care data and other critical data systems to mirror the site at least daily. Facility has documented risk assessment identifying high-risk data systems.
  -- --- ------------------------ ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent                Facility has a business continuity and resiliency program meeting federal requirements and the backup of patient care data and other critical data systems to mirror the site at least weekly. Facility has documented risk assessment identifying high-risk data systems.
     2   Developed                Facility has a business continuity and resiliency program that meets VA standards.
     1   Being Developed          Facility has developed a business continuity and resiliency program for clinical data, but it may lack systems for less critical databases.
     0   Needs Attention          There is an absence of capability evidenced by a lack of business continuity and resiliency plan.
         **Comment/Rationale:**        

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

**Measurement Factors and Scoring**

     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. Facility can access VACO BPAs should local contractors be unable to provide the services and commodities needed. Facility evaluates needs 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. Facility evaluates needs at least annually.
     2   Developed                Facility has contracts for most critical items based on a needs assessment.
     1   Being Developed          Facility is 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 implemented.
         **Comment/Rationale:**        

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

**Measurement Factors and Scoring**

     4   Exemplary                All of the above assessment components are present, including contracts and/or mutual aid agreements to gain access to clinical services, including staffed beds during an emergency. Agreements/contracts are based on a needs assessment that is updated annually. Contracts provide priority of services to meet VA needs. These agreements supplement alternate care sites at the individual VAMC or at another VA care site.
  -- --- ------------------------ -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent                VAMC has identified alternate care sites at the facility or at another VA care site. Contracts and/or mutual aid agreements to gain access to clinical services, including staffed beds in the community, are developed. Agreements/contracts are updated annually.
     2   Developed                Contracts and/or mutual aid agreements are in place, and the contracts are evaluated annually, consistent with TJC requirements.
     1   Being Developed          Facility has a limited number of contracts, but it is making plans to include provisions for a full array of the clinical services needed.
     0   Needs Attention          There is an absence of capability due to few if any contracts/mutual aid agreements for access to alternate care sites in the community.
         **Comment/Rationale:**        

### Cash to Purchase Supplies/Services/Payroll During an Emergency

**Measurement Factors and Scoring**

     4   Exemplary                All of the above assessment components are present, including the processes to manage and secure large amounts of cash. The procedures for accessing cash are tested annually
  -- --- ------------------------ -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent                Resources and training are in place and the need for cash reserves is evaluated annually.
     2   Developed                Facility has cash on hand for emergencies.
     1   Being Developed          Facility has limited cash on hand for emergencies, but it needs to develop a needs assessment to better understand the funds needed.
     0   Needs Attention          Facility does not plan to have a cash reserve for emergencies.
         **Comment/Rationale:**        

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

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

**Measurement Factors and Scoring**

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

### Maintaining Satellite Telephone Resiliency

**Measurement Factors and Scoring**

     4   Exemplary                All of the above assessment components are present including testing of satellite phones at least weekly.
  -- --- ------------------------ -----------------------------------------------------------------------------------------------------------
     3   Excellent                Satellite phone in place and the capability is tested monthly.
     2   Developed                Satellite phone in place and the capability is tested quarterly.
     1   Being Developed          Satellite phone in place and the capability is tested less then quarterly.
     0   Needs Attention          No satellite phones at the facility.
         **Comment/Rationale:**        

### Interoperable Communications with External Agenices'

**Measurement Factors and Scoring**

     4   Exemplary                All of the above assessment components are present. 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 the exercise with the community.
     2   Developed                All of the above assessment components are present. Communications equipment is tested at least annually.
     1   Being Developed          Facility has interoperable communications equipment with at least two of the agencies, and capability is tested regularly. Has been tested with at least two of the agencies and capability tested regularly.
     0   Needs Attention          There is an absence of interoperable communications with police, fire, and EMS.
         **Comment/Rationale:**        

### Interoperable Communications with VAMC Facilities'

**Measurement Factors and Scoring**

     4   Exemplary                All of the above assessment components are present, including at least three means of internal communications such as pagers, handheld radios, and telephones. Communications are tested at least quarterly.
  -- --- ------------------------ --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent                Facility has at least two means of internal communications such as pagers, handheld radios, and telephones. Communications are tested at least semiannually.
     2   Developed                Facility has at least two means of internal communications such as pagers, handheld radios, and telephones. Communications are tested at least annually.
     1   Being Developed          Facility has one means of internal communications such as pagers, handheld radios, and telephones. Communications are tested at least annually.
     0   Needs Attention          There is an absence of backup means of internal communications.
         **Comment/Rationale:**        

Healthcare Service System Resiliency
------------------------------------

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

**Measurement Factors and Scoring**

     4   Exemplary                All of the above assessment components are present, including the ability of the EOC to conduct an HVA. Staff are trained on their role in an emergency and that role is tested in an exercise that is fully integrated with the VAMC.
  -- --- ------------------------ ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent                Resources and training are in place at the CBOC, and the capability is tested annually.
     2   Developed                Resources and training are in place at the CBOC to support emergency operations. Staff are trained on their roles, and the supplies and equipment needed to enable emergency operations are in place.
     1   Being Developed          Some capability elements exist to support emergency operations at the CBOC; however, some key components are not yet developed.
     0   Needs Attention          There is an absence of emergency operations at the CBOC.
         **Comment/Rationale:**        

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

**Measurement Factors and Scoring**

     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's yearly exercise.
  -- --- ------------------------ --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     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. Facility 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.
         **Comment/Rationale:**        

### 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)

**Measurement Factors and Scoring**

     4   Exemplary                All of the above assessment components are present, including the consistent ability to support special needs patients throughout the duration of the emergency. Care to all special needs patients is tested annually, and the capability is integrated with the VAMC's yearly exercise.
  -- --- ------------------------ -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent                Resources and training are in place to support continuous care of special needs patients in an emergency, and the capability is tested annually.
     2   Developed                Resources and training are in place. Facility meets underlying requirement where applicable.
     1   Being Developed          Some capability elements exist to support care to special needs patients; however, some key components are not yet developed.
     0   Needs Attention          There is an absence of continued services to special needs patients.
         **Comment/Rationale:**        

### Provision of Ambulatory Clinical Services during Incidents

**Measurement Factors and Scoring**

     4   Exemplary                All of the above assessment components are present, including the consistent ability to continue care to all ambulatory service patients during an emergency. Ambulatory service care is tested annually, and the capability is integrated with the VAMC's yearly exercise.
  -- --- ------------------------ -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent                Resources and training are in place to support continuous care to all ambulatory service patients during an emergency and the capability is tested annually.
     2   Developed                Resources and training are in place. Facility meets underlying requirement where applicable.
     1   Being Developed          Some capability elements exist to support ambulatory service's care; however, some key components are not yet developed.
     0   Needs Attention          There is an absence of continued ambulatory services.
         **Comment/Rationale:**        

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

**Measurement Factors and Scoring**

     4   Exemplary                All of the above assessment components are present.
  -- --- ------------------------ --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent                Resources and training are in place and the emergency management plan is reviewed annually. There is documented evidence that the plan includes coverage of any animal facilities with emergency power and plans for evacuation if needed.
     2   Developed                Resources and training are in place. Facility meets the underlying requirement of annual review and update of the Research emergency management plan
     1   Being Developed          Some capability elements exist; however, some key components are not yet developed, as evidenced by not planning for care and evacuation of animals, data and critical equipment.
     0   Needs Attention          There is an absence of capability as evidenced by lack of an EMP in Research at the facility.
         **Comment/Rationale:**        

Maintaining Patient Mental Health and Welfare
---------------------------------------------

**Measurement Factors and Scoring**

     4   Exemplary                All of the above assessment components are present, including the identification of mental health clinicians on a callback roster. Plan is in place to monitor patients for personal needs, i.e., food, water, personal hygiene. Facility integrates patient mental health and welfare into their exercise program and reviews annually. AARs of exercises are reported back to the EMC and the EOP is updated with lessons learned.
  -- --- ------------------------ --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent                Mental health clinicians have been identified and are on a callback roster. Facility integrates patient mental health and welfare into the exercise program and it is reviewed annually.
     2   Developed                VAMC has a plan for ensuring patient mental health and welfare.
     1   Being Developed          Some capability elements exist; however, there is evidence that some capabilities do not exist.
     0   Needs Attention          There is an absence of capability with respect to patient mental health and welfare.
         **Comment/Rationale:**        

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

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

**Measurement Factors and Scoring**

     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 call back staff is tested quarterly, and the capability is integrated into the facility's yearly exercise.
  -- --- ------------------------ -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent                Resources and training are in place to support the called back staff, and the capability is tested annually.
     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.
         **Comment/Rationale:**        

Management of External Volunteers and Donations during Emergencies
------------------------------------------------------------------

**Measurement Factors and Scoring**

     4   Exemplary                All of the above assessment components are present, including the ability to monitor and manage volunteers and materiel donations. Designated individuals manage the influx of individuals and supplies, and the resources are allocated appropriately. This component is integrated into the facility's yearly exercise.
  -- --- ------------------------ ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent                Resources and training are in place and the capability is tested annually.
     2   Developed                Resources and training are in place. Facility meets underlying requirement where applicable.
     1   Being Developed          Some capability elements exist; however, some key components are not yet developed.
     0   Needs Attention          There is an absence of volunteer and supply donation management capability.
         **Comment/Rationale:**        

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

**Measurement Factors and Scoring**

     4   Exemplary                All of the program elements are in place, including DEMPS being fully operational at the facility and a trained coordinator 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 facility and a trained coordinator is 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 the facility and a trained coordinator is 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 the facility.
         **Comment/Rationale:**        

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

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

**Measurement Factors and Scoring**

     4   Exemplary                All of 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.
         **Comment/Rationale:**        

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

**Measurement Factors and Scoring**

     4   Exemplary                All of the above assessment components are present, including the ability to care for victims of a number of scenarios. Personnel understand their role in the designated areas and are trained to recognize various biological agents. The setup 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.
     2   Developed                Resources and training are in place. Facility meets 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.
         **Comment/Rationale:**        

### Designation and Operation of Isolation Rooms

**Measurement Factors and Scoring**

     4   Exemplary                All of the above assessment components are present, and the ability to use isolation rooms is rapid (either through the use of outfitted isolation rooms or designated in patient rooms). Staff are fitted for appropriate PPE, and all supplies and equipment are accessible. Staff, patients, and visitors are trained on appropriate isolation protocols and adhere to guidance. The ability to quickly isolate patients is tested annually with a facility-wide exercise.
  -- --- ------------------------ -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent                Resources and training are in place to support isolation practices. Staff are trained in PPE and isolation processes, and the capability is tested annually.
     2   Developed                Resources and training are in place. Facility meets underlying requirement where applicable.
     1   Being Developed          Some capability elements exist to support isolation rooms; however, some key components are not yet developed.
     0   Needs Attention          There is an absence of isolation rooms at the facility.
         **Comment/Rationale:**        

### Integration of Patient Reception, Surge and Decontamination Teams

**Measurement Factors and Scoring**

     4   Exemplary                All of the above assessment components are present, including the ability for staff assigned to decontamination and patient reception to communicate and collaborate on patient care issues. All personnel in the facility are aware of their roles, and those individuals assigned to patient reception and decontamination teams are easily recognizable. The ability for the teams to integrate is tested annually in a facility wide-exercise.
  -- --- ------------------------ ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent                Resources and training are in place to enable the integration of patient reception and decontamination teams, and the capability is tested annually.
     2   Developed                Resources and training are in place to enable integration of patient reception and decontamination teams; however, the communication and integration between the teams is not demonstrated.
     1   Being Developed          Some capability elements exist; however, some key components are not yet developed.
     0   Needs Attention          There is an absence of integration between decontamination and patient reception teams.
         **Comment/Rationale:**        

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

**Measurement Factors and Scoring**

     4   Exemplary                All of the above assessment components are present, including the ability to surge to meet increased demand for services (either through internal surge efforts or through MOUs/MOAs with community resources). Staff have adequate PPE and training to manage and handle infectious agents. Expanded laboratory capability is tested through the facility's annual exercise.
  -- --- ------------------------ -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent                Resources and training are in place to support increased Laboratory, Imaging, and Blood Bank demand. Staff are trained and the capability is tested annually,
     2   Developed                Resources and training are in place. Facility meets underlying requirement where applicable.
     1   Being Developed          Some capability elements exist; however, some key components are not yet developed.
     0   Needs Attention          There is an absence of ability of the facility to surge to meet increased demands.
         **Comment/Rationale:**        

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

**Measurement Factors and Scoring**

     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.
  -- --- ------------------------ ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent                Resources and training are in place and personnel are trained on their role in mass fatality management. The capability is tested annually.
     2   Developed                Resources and training are in place. Facility meets underlying requirement where applicable.
     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.
         **Comment/Rationale:**        

Support to external requirements
================================

Support of Patient Care Requirements
------------------------------------

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

**Measurement Factors and Scoring**

     4   Exemplary                All of the above assessment components are present, including the ability to effectively receive patients at the FCC. Communication infrastructure is in place and the facility 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 exercise annually
     2   Developed                Resources and training are in place. Facility 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.
         **Comment/Rationale:**        

### VA/DOD Contingency Hospital System

**Measurement Factors and Scoring**

     4   Exemplary                All of the above assessment components are present, including conducting all required bed counts and exercises.
  -- --- ------------------------ -----------------------------------------------------------------------------------------------------------------
     3   Excellent                Resources and training are in place, and VA/DOD bed expansion is tested annually.
     2   Developed                Resources and training are in place. Facility meets underlying VA requirements for managing 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.
         **Comment/Rationale:**        

Liaison 
-------

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

**Measurement Factors and Scoring**

     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 local and state emergency management and public health agencies are present.
  -- --- ------------------------ ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent                Facility has communications with emergency management authorities on an ongoing basis. Communications are tested at least annually as part of the exercise.
     2   Developed                Facility has identified Points of Contact with emergency management authorities, including during emergencies.
     1   Being Developed          Facility 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 POC and emergency management authorities.
         **Comment/Rationale:**        

###  Response/Interface with Community Healthcare Organizations

**Measurement Factors and Scoring**

     4   Exemplary                All of the above assessment components are present. Communications protocols are tested as part of exercise with the community. Evidence of ongoing relationship is present.
  -- --- ------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent                Facility communicates with community healthcare facilities on an ongoing basis. Communications are tested at least annually as part of the exercise.
     2   Developed                Facility has identified POCs with community health care facilities, including during emergencies.
     1   Being Developed          Facility can communicate with the community healthcare facilities, but it does not have an established collaborative relationship.
     0   Needs Attention          There is an absence of collaboration with POCs and community healthcare facilities.
         **Comment/Rationale:**        

###  Support under the National Response Framework

**Measurement Factors and Scoring**

     4   Exemplary                All of the above assessment components are present. Communications protocols are tested as part of exercise with the community. Evidence of ongoing relationship present. POC are identified and there is ongoing evidence of collaborative activities including exercise planning, training, and identified POCs for each of these agencies. Personnel can produce minutes from joint meetings
  -- --- ------------------------ -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
     3   Excellent                Facility communicates with other government agencies on an ongoing basis. Communications are tested at least annually as part of the exercise.
     2   Developed                Facility has identified POCs with other government agencies, including during emergencies.
     1   Being Developed          Facility communicates with the other government agencies, but it does not have an established collaborative relationship.
     0   Needs Attention          There is an absence of collaboration with POCs and other government agencies.
         **Comment/Rationale:**