U.S. Department of Health and Human Services 
Office of Inspector General 
 
 
Hospitals Reported 
Improved 
Preparedness for 
Emerging Infectious 
Diseases After the 
Ebola Outbreak   
OEI-06-15-00230 
October 2018 
 
oig.hhs.gov 
Suzanne Murrin 
Deputy Inspector General for 
Evaluation and Inspections  Report in Brief  U.S. Department of Health & Human Services 
October 2018 
Office  of Inspector General 
OEI-06-15-00230 
 
 
Hospitals Reported Improved Preparedness for 
Why OIG Did This Review 
Emerging Infectious Diseases After the Ebola Outbreak 
HHS is the lead Federal agency 
responsible for medical support and 
What OIG Found 
coordination during public health 
Most hospitals in the United States were not  Key Takeaway  emergencies.  In 2014, the domestic 
prepared for the outbreak of Ebola virus  Most U.S. hospitals  outbreak of Ebola tested U.S. 
disease (Ebola) in 2014, with 71 percent of 
reported that they were  hospitals ability to respond to 
hospital administrators reporting that their 
not prepared for the 2014  a serious infectious disease.  Very few 
facilities were unprepared to receive Ebola 
Ebola outbreak, but have  hospitals received suspected or 
patients.   
diagnosed cases of Ebola, but the 
since taken action to 
By 2017, administrators from only 14 percent  diseases presence caused hospitals to 
improve preparedness for 
of hospitals reported their facilities were still  assess and improve their 
emerging infectious 
unprepared for emerging infectious disease  preparedness for Ebola and other 
diseases.  Hospitals 
(EID) threats such as Ebola.  Hospital actions  EIDs.  HHS agencies took action to 
reported improved 
to improve preparedness included updating  respond to the outbreak, including 
emergency plans, training staff to care for  preparedness by 2017,  providing guidance to hospitals and 
patients with EIDs, purchasing additional  although hospital  revising requirements for hospital 
supplies, and conducting EID-focused drills.   administrators expressed  emergency preparedness.  This study 
Hospitals also used a wide range of resources  concerns about sustaining  seeks to assess those efforts by 
provided by the Department of Health and  preparedness over time.   describing the reflections of hospital 
Human Services (HHS).    administrators regarding the outbreak 
and the actions that hospitals have 
Although most hospital administrators believe 
taken to improve readiness since 
that their hospitals are ready to respond to a future EID threat, they cited 
2014.  This study builds on OIGs body 
challenges to maintaining that preparedness, given competing priorities for 
of work in emergency preparedness, 
hospital resources and staff time.  Administrators also cited the need to focus 
which includes a prior study of 
efforts on more common hazards, such as natural disasters, and cited difficulty 
hospital responses to a natural 
in using government guidance to prepare for EIDs.  We also found that 
disaster. 
administrators from one-third of hospitals did not know their hospitals role in a 
tiered hospital framework designed by the Centers for Disease Control and  How OIG Did This Review 
Prevention (CDC) to guide hospitals in receiving and treating cases of Ebola.  We administered an online survey to 
a national sample of hospitals in early 
What OIG Recommended and How the Agencies Responded  2017.  We selected a stratified sample 
A future EID threat could require substantial management and resources by  of 410 hospitals that participate in 
hospitals, other health care providers, and government at all levels, including  Medicare and that have emergency 
HHS.  To improve hospital preparedness and HHS assistance and oversight, we  departments.  We received responses 
recommend that the Office of the Assistant Secretary for Preparedness and  from 368 of the 410 hospitals 
Response (ASPR), CDC, and the Centers for Medicare & Medicaid Services (CMS)  (a 90-percent response rate) and 
continue to support hospital preparedness for potential EIDs by coordinating  projected those findings nationally.  
guidance and providing practical advice for all hospitals.  We also recommend  The survey included questions about 
that CDC clarify and promote the details and ongoing status of its tiered  hospital administrators perceptions of 
framework for hospitals, so that hospitals are clear regarding their responsibilities  preparedness in 2014 and 2017; 
during an EID outbreak.  Further, we recommend that CMS add EIDs to the  actions taken to prepare; and 
definition of all hazards in the State Operations Manual to promote inclusion of  challenges to sustaining preparedness 
EIDs in hospital emergency planning.  ASPR, CDC, and CMS concurred with our  for potential future EIDs.  We analyzed 
recommendations.       some responses by whether hospitals 
served as Special Pathogen Centers, 
Full report can be found at oig.hhs.gov/oei/reports/oei-06-15-00230.asp.  as designated by ASPR, and/or as 
Critical Access Hospitals, as 
designated by CMS.   
TABLE OF CONTENTS 
BACKGROUND  1 
Methodology  7 
Prior OIG Work  7 
   
FINDINGS   
Most hospitals reported they were not prepared for Ebola in 2014, but reported improved  9 
readiness for EIDs in the years since  
Hospitals took action to improve readiness after the 2014 Ebola outbreak, and also reported  11 
challenges to preparedness 
Hospitals expressed concerns about sustaining EID preparedness, given competing priorities  16 
and confusion in following guidance 
   
CONCLUSION AND RECOMMENDATIONS   
ASPR, CDC, and CMS should continue to help hospitals sustain preparedness for EIDs,   21 
by coordinating guidance and providing practical advice for all hospitals 
CDC should clarify and promote the details and ongoing status of its tiered framework to  21 
ensure that hospitals are aware of their responsibilities in the event of a future EID 
CMS should add EIDs to the definition of all hazards in the State Operations Manual to  22 
promote inclusion of EIDs in hospital emergency planning 
 
AGENCY COMMENTS AND OIG RESPONSE  23 
   
APPENDIXES   
A.  Study Statistics  24 
B.  HHS Agency Resources  27 
C.  Agency Comments  29 
   
ACKNOWLEDGMENTS  34 
 
ENDNOTES  35 
 
   
 
   
BACKGROUND 
 
  Objective 
To describe the perceptions of hospital administrators regarding hospital 
 
preparedness to respond to emerging infectious diseases and actions taken 
  to improve readiness for such diseases following the 2014 outbreak of Ebola 
in the United States.  
 
Ebola Virus Disease 
In 201416, thousands of people worldwide were infected with Ebola, 
a deadly emerging infectious disease (EID) that requires extensive patient 
care.  This outbreak was the largest to date and was concentrated in a small 
number of West African nations.  It resulted in 28,616 suspected and 
confirmed cases, with 11,310 deaths.1  See Exhibit 1 for an abbreviated 
definition of Ebola from the Centers for Disease Control and Prevention 
(CDC).     
 
Exhibit 1:  Ebola Virus Disease 
Ebola (\ e- bo-l\)  is a viral hemorrhagic fever that infects people and nonhuman 
primates.  The presence of Ebola causes excessive vomiting, diarrhea, and rash; 
 
damages the liver and kidneys; and can cause internal and external bleeding.  Death is 
often the  result of low blood pressure from fluid loss. 
Sources: CD C, Ebola (Ebola Virus Disease): Transmission and Signs and Symptoms, 2016. 
   
Ebola was first identified in 1976 in what was then Zaire and is now the 
Democratic Republic of the Congo (also known as Congo-Kinshasa).2  Ebola 
spreads through direct contact with bodily fluidsparticularly bloodof 
a person who is sick or has died from the disease.  Ebola can also spread 
indirectly by contact with previously contaminated surfaces or objects.3  
Ebola poses a high risk to health care workers, who must use personal 
protective equipment, including masks, gloves, goggles, and gowns, to 
avoid infection.  There is currently no antiviral drug licensed to treat Ebola, 
but supportive and symptom-specific interventions can improve chances of 
survival. 4  Presence of the virus results in a high mortality rate, with 
approximately half of those infected succumbing to the disease.   
In August 2014, the World Health Organization (WHO) declared Ebola 
a public health emergency of international concern.5  Ebola was confirmed 
in the United States on September 30, 2014.6  From September through 
November 2014, several U.S. hospitals treated 11 patients diagnosed with 
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Ebola, including two nurses who were exposed to the disease while treating 
a patient in a Dallas, Texas hospital.  One of the U.S. patients died from the 
disease; the others survived.  No new cases of Ebola have been diagnosed 
in the United States since that time, although a small number of cases have 
emerged internationally since the outbreak ended in 2016.7  The largest 
since 2014 was an outbreak in the Democratic Republic of the Congo 
(Congo-Kinshasa) in May 2018, which spread to an urban area and included 
58 cases and 27 deaths.8 
Definition and  CDC defines an EID as a contagion or condition for which incidence in 
humans has increased in the past 2 decades or threatens to increase in the 
Instances of EIDs 
near future. 9  In 2016, CDC tracked 37 pathogens in more than 
130 countries.10  Although EIDs are more common elsewhere, the United 
States has experienced small numbers of cases of EIDs.  In the last 15 years, 
the United States has had cases of Middle East Respiratory Syndrome 
(MERS), Severe Acute Respiratory Syndrome (SARS), and pandemic 
(widespread) influenza.  See Exhibit 2 for examples and descriptions of 
recent EIDs worldwide since 2003. 
Public health officials caution that future EID threats are difficult to 
anticipate, given the complexity of identifying such diseases and predicting 
their spread.11  With this being the case, the United Nations World Health 
Organization (WHO) called in February 2018 for nations to accelerate 
research and development for eight EIDs, including what it labeled 
Disease Xany pathogen currently unknown that could cause human 
disease with the potential for widespread impact.12  In April 2018, the Gates 
Foundation announced additional funding toward development of 
a universal influenza vaccine, citing research indicating a significant 
probability of a large and lethal, modern-day pandemic occurring in our 
lifetimes.13  
 Exhibit 2: Examples and descriptions of EIDs worldwide since 2003. 
Emerging Infectious Disease  Year(s) of  Impact 
Outbreak 
H7N9 Pandemic Influenza (bird flu)  2013  1,589 cases and 616 deaths in China 
Middle East Respiratory Syndrome (MERS)  2012  2,143 cases in 27 countries, and 750 deaths 
H1N1 (2009) Pandemic Influenza (swine flu)  2009  More than 284,000 deaths worldwide 
H5N1 Pandemic Influenza (bird flu)  20032016  850 cases and 449 deaths worldwide 
Severe Acute Respiratory Syndrome (SARS)  2003  8,096 cases and 774 deaths worldwide 
Sources: Kaiser Family Foundation, The U.S. Government and Global Health Security, 2016; World Health Organization, Middle East respiratory 
syndrome coronavirus (MERS-CoV), 2018. 
 
 
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EIDs not only threaten public health, but also stress the surrounding health 
care infrastructure, including hospitals.  Receiving EID cases requires 
hospitals to learn about the disease pathology and recommended 
protocols, and may require substantial staff training, additional equipment, 
and supplies.  EIDs also require hospitals to collaborate with other providers 
and government entities, and to maintain government and clinical 
standards for treating patients with unusual diagnoses.14  For example, 
a hospital that receives an EID case may divert other patients to nearby 
hospitals to focus resources on the EID patient and to reduce the risk of 
contagion.   
Role of HHS in EID  The Department of Health and Human Services (HHS) is the lead Federal 
department responsible for providing medical support and coordination 
Preparation and 
during public health emergencies, such as disease outbreaks.15  HHS 
Response 
provides guidance to health care providers and communities regarding 
medical preparedness and response capabilities for EIDs.  Three HHS 
agencies share most of the responsibility for these efforts: the Office of the 
Assistant Secretary for Preparedness and Response (ASPR), CDC, and the 
Centers for Medicare & Medicaid Services (CMS).     
Office of the Assistant Secretary for Preparedness and Response 
ASPR coordinates HHSs response to public health emergencies with other 
Federal agencies, such as the Federal Emergency Management Agency 
(FEMA).16  ASPR also coordinates and oversees Healthcare Coalitions, which 
are groups of health care providers and public health entities that work 
together to prepare for, respond to, and recover from emergencies.17  ASPR 
created the Technical Resources, Assistance Center, and Information 
Exchange (TRACIE) to provide information and technical assistance to 
Healthcare Coalitions, health care providers, and others during public health 
emergencies.18  Since 2010, ASPR has managed the Hospital Preparedness 
Program, which provides grants to States and localities to distribute to 
hospitals and Healthcare Coalitions for improved preparedness.19  Guidance 
for this program states that hospitals and other health care facilities should 
conduct hazard vulnerability assessments to determine and prioritize the 
hazards that pose the greatest risk to their respective facilities.20  
In 2014, in response to the Ebola outbreak, Congress appropriated 
supplemental Hospital Preparedness Program funding, to be allocated by 
ASPR for 5 years.21  ASPR awarded the additional allocations for the 
program in May and June of 2015, so the funding will expire in May and 
June of 2020.22  The Presidents Budget for fiscal year includes $227 million 
for the Hospital Preparedness Program.  ASPR has stated that it is 
distributing this $227 million to locations with the greatest need for 
preparedness.23   
   
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Centers for Disease Control and Prevention 
CDC monitors and responds to public health emergencies such as EIDs, 
conducts research, and provides guidance to health care providers, 
government entities, and the public.24  CDC also maintains the Strategic 
National Stockpile, which supplements State and local stocks of vaccines, 
medicines, and supplies for emergencies.25  CDC provides funding to public 
health departments for emergency preparedness through the Public Health 
Emergency Preparedness cooperative agreements.26  In response to the 
Ebola outbreak in 2014, CDC provided additional Public Health Emergency 
Preparedness funding to States and localities;27 stockpiled protective 
equipment for health care workers;28 and revised its infection control 
guidance for health care providers, communities, and other public entities.29 
Also in 2014, CDC worked with States to establish a framework for hospitals 
to share responsibilities in receiving and treating cases of Ebola.30  The 
hospital framework placed facilities in three tiers of responsibility, 
depending on their capability to receive patients, their geographic location, 
and other factors:   
  Tier 1: Ebola Treatment Centers were expected to receive and diagnose 
patients with suspected disease, and to provide care for diagnosed 
patients.31   
  Tier 2: Ebola Assessment Hospitals were expected to receive, diagnose, 
and provide care for patients with suspected disease, and to transfer 
diagnosed patients to a treatment center.   
  Tier 3: Frontline Healthcare Facilities were expected to receive and 
provide care for patients with suspected disease and to transfer 
suspected patients to the nearest Tier 1 or 2 hospital. 
Beginning in 2014, CDC released lists of the hospitals designated as being in 
the first tier, i.e., Ebola Treatment Centers.32  CDC has not made public the 
lists of hospitals in the second and third tiers, citing security concerns with 
identifying hospitals that may not be as equipped to receive patients with 
EIDs. 
CDC created the tiered structure specifically to prepare for additional cases 
of Ebola.  However, CDC has not specified that the framework applies more 
broadly to other EIDs, and it has not updated the hospital framework since 
2015.  In guidance documents that CDC released in 2016, it indicated that it 
anticipates using the tiered framework approach in the event of any future 
EID threats.33  CDC guidance also emphasized the importance of all 
U.S. health care facilities preparing to identify, isolate, and evaluate 
potentially infected patients with any EID, and stated that it plans to 
re-engage the hospital framework if faced with another outbreak.34   
   
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In 2015, ASPR built on CDCs tiered system by designating 9 of the 64 Ebola 
Treatment Centersspecifically, those with the greatest capacity and most 
critical locationsas Ebola and Other Special Pathogen Centers (hereafter 
referred to as Special Pathogen Centers).35  ASPR defines special 
pathogens as highly infectious agents that produce severe disease in 
humans.36  In 2017, ASPR elevated an additional Ebola Treatment Center to 
the status of Special Pathogen Center, leaving 63 hospitals as Ebola 
Treatment Centers.37   
ASPR guidance states that these Special Pathogen Centers are to maintain 
capability to accept patients with suspected or diagnosed illness (Ebola or 
other special pathogen) within 8 hours of notification and to conduct 
quarterly exercises to prepare for an EID outbreak.38  The Special Pathogen 
Centers receive annual assessments from the National Ebola Training and 
Education Center, which is a collaborative effort involving ASPR, CDC, and 
several academic institutions.  The center was created to provide technical 
assistance and training to health care providers regarding Ebola and other 
EIDs.39, 40  See Exhibit 3 for a map of the Special Pathogen Centers and 
Ebola Treatment Centers.   
Exhibit 3: Special Pathogen Centers and Ebola Treatment Centers are 
located across the country. 
 
Special Pathogen Centers   Ebola Treatment Centers 
Source: OIG analysis of HHS documentation, 2017. 
 
   
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Centers for Medicare & Medicaid Services 
CMS oversees hospitals participating in Medicare and Medicaid by requiring 
Conditions of Participation (Medicare CoPs), a set of minimum health and 
safety standards enforced by State Agencies (SAs) and accrediting 
organizations (AOs).41, 42  CMSs State Operations Manual provides guidance 
to SAs and AOs regarding how they should assess hospitals on the 
Medicare CoPs.43   
The Medicare CoPs require hospitals to have policies and procedures 
to prepare for potential emergencies, and to also operate programs 
to prevent, control, and investigate infectious and communicable diseases.44  
In November 2016, CMS issued a new CoP for emergency preparedness.  
State surveyors and accrediting organizations began assessing the CoP 
requirements in November 2017.45  The new CoP provides greater specificity 
regarding actions that hospitals must take toward emergency preparation; 
however, it does not specify preparation for EIDs or any other specific type 
of disaster or emergency.   
The CoP requires that hospitals maintain compliance with all requirements  
regarding four core elements of emergency preparedness: (1) annually-
updating emergency plans using an all hazards approach that 
encompasses a range of potential emergencies (although not specifically 
EIDs);46 (2) developing and maintaining a communication plan for 
interacting with other entities involved in disaster response; (3) developing 
and maintaining policies and procedures that include both the emergency 
plan and the communication plan; and (4) developing and maintaining an 
emergency training program, testing the plan annually, and making 
revisions based on the results of exercises, which could include both 
tabletop exercises and full-scale drills (see Exhibit 4).47   
   
 Exhibit 4: Tabletop Exercises and Full-Scale Drills 
 Tabletop Exercise: A meeting of hospital officials and staff to review and discuss roles and 
responsibilities in emergency situations.  Tabletop exercises are usually structured like a board game 
with an imagined scenario.  They can identify gaps in planning documents and communication. 
 
 Full-Scale Drill: An active test using a simulation (e.g., an EID outbreak) to evaluate coordination 
among entities while monitoring adherence to accreditation standards, capabilities, procedures, and 
functions.  Full-scale drills require extensive resources and often include multiple entities.  
Source: Agency for Healthcare Research and Quality, Hospital Preparedness Exercises Pocket Guide. 2010. 
 
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Prior OIG Work  OIG previously conducted two studies related to hospital preparedness for 
emergencies, including EIDs.  In both cases, OIG recommended that ASPR 
improve planning for emergencies and collaboration during emergencies.  
In 2009, OIG found that State and local communities varied in the level to 
which they were prepared for a medical surge during an influenza 
pandemic, and that hospital administrators anticipated problems with 
obtaining equipment through normal channels during a pandemic.  
Administrators also questioned whether vendors would be able to honor 
their contracts with an influx of competing orders to fill.48   
In 2014, an OIG study of hospital responses to a hurricane-caliber storm in 
densely populated areas (i.e., Superstorm Sandy) found that most hospitals, 
prior to the storm, received citations from AOs for emergency-related 
deficiencies such as lack of supplies, and that administrators reported 
difficulty in prioritizing emergency preparedness and maintaining staff and 
supplies when an emergency was widespread.  OIG recommended that 
ASPR continue to promote collaboration in major disasters, and that it 
encourage Hospital Preparedness Program awardees to participate in 
tabletop exercises or full-scale drills that include their broader communities 
and other health care providers. 49  ASPR concurred and reported that it had 
recently shifted the focus of the Hospital Preparedness Program from the 
preparedness of individual hospitals to the preparedness of comprehensive 
health care systems. 
Methodology  To examine hospital experiences in preparing for Ebola and other EIDs, we 
surveyed a sample of Medicare-certified hospitals.  We selected a stratified 
simple random sample of 410 of the 4,489 hospitals with emergency 
departments that participated in the Medicare program in 2016.  The two 
strata included (1) all 10 Special Pathogen Centers, and (2) all other hospitals 
with an emergency department.   
Data Collection and Analysis 
We submitted an online survey to hospital administrators from sampled 
hospitals in December 2016 and accepted responses through April 2017.  
The survey included both closed- and open-ended questions, and pertained 
to hospital administrators perceptions of preparedness for possible Ebola 
cases in 2014 and to their current preparedness, efforts to prepare, and 
challenges in achieving and sustaining preparedness.50  For non-open-
ended survey questions, we provide the projected responses in the 
report.  For open-ended survey questions, we provide selected responses in 
the report to serve as illustrations. 
We also interviewed 40 hospital administrators from the responding 
hospitals (11 percent) to gain additional information, including 2 of the 
10 Special Pathogen Centers.  We purposely selected these 
40 administrators as our analysis progressed, either because their responses 
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were unclear or because they cited examples that we wanted to understand 
in more detail.   
We contacted nonrespondents up to four times through email and 
telephone.  We received responses from 368 of the 410 hospitals in the 
sample, a 90-percent overall response rate.  See Exhibit 5 for sample and 
response statistics.  Our projected findings represent approximately 4,019 of 
the 4,489 hospitals in our sampling frame.   
Exhibit 5: Sampling Frame, Sample Size, and Response Rate by Strata 
Sampling  Sample  Number of  Response 
Stratum 
Frame  Size  Respondents  Rate 
1  Special Pathogen Centers  10  10  10  100% 
2  All Other Hospitals   4,479  400  358  90% 
Total  4,489  410  368  90% 
 Source: OIG analysis of data from OIG survey on hospital preparedness, 2018. 
See Appendix A for point estimates and 95-percent confidence intervals for 
statistics in our report. 
Limitation 
We did not independently verify hospital responses related to their 
preparedness efforts or perceptions of their preparedness.   
Standards 
This study was conducted in accordance with the Quality Standards for 
Inspection and Evaluation issued by the Council of the Inspectors General on 
Integrity and Efficiency.   
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FINDINGS 
Most hospitals  Very few U.S. hospitals received patients with suspected or diagnosed Ebola 
in 2014, but the domestic presence of the disease caused hospitals 
reported they were 
nationwide to assess and improve their preparedness.   
not prepared for 
Ebola in 2014, but  Administrators from 71 percent of hospitals reported that their 
facilities were not prepared to receive Ebola cases in 2014   
reported improved 
Administrators from the remaining 29 percent of hospitals reported that 
readiness for EIDs in 
they were prepared to receive such cases in 2014 (see Exhibit 6).  
the years since  In assessing their preparedness, administrators considered a number of 
factors regarding their capacity to diagnose and treat patients: 
  the adequacy of their staffing in both numbers and expertise;  
  access to supplies, equipment, and vendor services; and  
  facility characteristics that would allow patient isolation and 
transport.  
Exhibit 6: Hospitals reported an increase in preparedness for receiving cases 
of EIDs from 2014 to 2017 (n=368). 
Not Prepared Prepared
2014 71% 29%
2017 14% 86%
0% 100%  
Source: OIG analysis of data from OIG survey on hospital preparedness, 2018. 
 
Among the 10 hospitals later designated as Special Pathogen Centers, 
4 hospitals reported that they were not prepared for Ebola cases in 2014.    
Administrators reported improved preparedness in the years since 
the Ebola cases, with only 14 percent of hospitals reporting they are 
not prepared for a future EID threat  
Administrators from most hospitals (86 percent) reported that by 2017, they 
were prepared to receive cases of a serious EID such as Ebola.  As one 
would expect, all 10 of the Special Pathogen Centers reported they were 
prepared in 2017.  Although multiple factors may have contributed to an 
enhanced perception of preparedness, OIG found that many hospitals 
noted an increase in overall EID awareness.  For example, many hospital 
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administrators cited group discussions regarding EID preparedness and the 
creation of Ebola-specific plans following the 2014 Ebola outbreak.   
Adding explanations to their surveys, many administrators also noted that, 
although their hospitals would be prepared in the event of an outbreak, 
receiving such cases would strain their resources.  One administrator 
reported that EID preparedness had improved following the Ebola cases, 
but the hospital was unsure about the effect of an actual EID patient since it 
lacked firsthand experience.  Hospital administrators in areas affected by 
other types of emergenciessuch as Gulf States, which often encounter 
hurricanesoften noted that these experiences helped to improve overall 
preparedness.   
Critical access hospitals reported a lower rate of preparedness than all 
other hospitals in both 2014 and 2017  
Critical access hospitals (CAHs) are acute-care hospitals that provide 
services for populations with few medical service providers, such as in rural 
areas.51  Medicare reimburses CAHs using a different system than it does 
acute-care hospitals,52 and requires a different set of Medicare CoPs for 
CAHs than for acute-care hospitals.  For example, CAHs are not required to 
have a physician onsite at all times.53, 54  To be designated as a CAH by CMS, 
hospitals must have no more than 25 beds, be located certain distances 
from other hospitals, and furnish 24-hour emergency care. 55  The CAHs in 
our sample were more likely to be located in rural areas (81 percent, 
compared to 23 percent for all other hospitals).56  CAHs were also less likely 
to report ownership by a health care system that might provide support in 
improving preparedness; 39 percent reported such membership, compared 
to 80 percent of all other hospitals. 
Administrators from CAHs were more likely than administrators from all 
other hospitals to report that their hospitals were unprepared, both during 
and after the Ebola outbreak.  Eighty-six percent of hospital administrators 
from CAHs reported their hospitals were unprepared for Ebola in 2014, 
compared to 65 percent of all other hospitals.  (The rate for all hospitals 
combined was 71 percent.)  Twenty-three percent of hospital administrators 
from CAHs reported they were still unprepared by 2017, compared to 
10 percent of all other hospitals.  (The rate for all hospitals combined was 
14 percent.)57   
   
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Hospitals took  All hospital administrators reported taking action to improve their 
preparation for EID threats after the 2014 Ebola outbreak   
action to improve 
Administrators reported that the 2014 Ebola outbreak served as an alert for 
readiness after the 
them to improve their capability to respond to EIDs.  In the weeks following 
2014 Ebola 
the U.S. Ebola cases, hospitals nationwide took the following actions:  
outbreak, and also  seeking guidance from government sources such as CDC; increasing staff 
training and exercises; and acquiring additional equipment and supplies 
reported 
(see Exhibit 7).  Responses indicated that these efforts were first focused on 
challenges to 
Ebola, then continued after the Ebola threat was considered past and 
preparedness   included preparation for a broader range of potential future EIDs. 
Exhibit 7: All hospitals took action to improve preparedness for EID threats following the 
2014 Ebola outbreak (n=368). 
Description of Action  Percentage of Hospitals 
Sought guidance from CDC  100% 
Conducted additional staff training  94% 
Purchased additional equipment and supplies  92% 
Sought guidance from CMS and related oversight entities  92% 
Conducted full-scale drills or tabletop exercises with staff  87% 
Revised infectious disease and emergency plans  84% 
Used ASPR resources, such as TRACIE technical assistance  84% 
Participated in ASPR-funded Healthcare Coalitions  78% 
Enhanced collaboration with local government entities  75% 
Reviewed agreements with supply and service contractors  73% 
Engaged hospital board or system management  70% 
Created an EID rapid response clinical team  49% 
Source: OIG analysis of data from OIG survey of hospital preparedness, 2018. 
 
All hospital administrators reported seeking guidance from HHS to 
prepare for the possibility of receiving Ebola cases in 201415 
Hospital administrators reported using many guidance materials from HHS 
agencies.  All hospitals sought guidance from CDC about how to respond to 
potential cases of Ebola.  Most hospitals (92 percent) also sought guidance 
from CMS and related oversight entities, such as State survey agencies and 
accreditation organizations.  Eighty-four percent of hospitals also used 
ASPR resources such as TRACIE technical assistance, and 78 percent of all 
hospitals participated in ASPR-funded Healthcare Coalitions. 
Administrators from 94 percent of hospitals reported conducting 
additional staff training in preparation for receiving EID cases 
Administrators from nearly all hospitals (94 percent) reported that they 
conducted staff training in emergency procedures and clinical procedures to 
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handle patients with suspected or diagnosed EIDs.  Half of hospitals  
(49 percent) focused their training on forming rapid response teams to be 
deployed as needed.  These teams included selected clinicians and staff 
members across disciplines, such as emergency management, infection 
control, nurse leadership, and laboratory operations. 
A number of administrators noted the value of providing training across the 
hospital, including to both clinical and nonclinical hospital staff 
(e.g., physicians, administrators, frontline reception staff, and environmental 
service workers).  One hospital administrator stated that having 
departments train together created more open communication, which 
served to better identify and address the needs of each department.  
Training existing staff was much more common than hiring new staff in 
anticipation of an Ebola case.  While 5 of the 10 Special Pathogen Centers 
reported that they hired additional staff, only 1 of the remaining 
358 hospitals hired additional staff in response to the 2014 Ebola outbreak.   
However, some administrators reported difficulty in obtaining full 
participation from clinicians and staff at all levels and disciplines.  They cited 
a variety of reasons for these individuals reluctance to participate, such as 
not perceiving it as being within their job descriptions or having too many 
other responsibilities.  Other administrators reported that a small 
contingency of staff were reluctant to train for possible EIDs out of fear of 
disease transmission.  Administrators also noted difficulty in some cases 
gaining involvement from their respective facilities Boards of Directors, who 
had not previously been involved in emergency planning and response.  For 
70 percent of hospitals, administrators reported they actively reached out to 
their respective hospital Boards of Directors following the 2014 Ebola cases 
to encourage more Board involvement in emergency preparation.  
In their survey responses, administrators included explanations about how 
training is not the same thing as experience, and that staff would likely have 
little or no experience with actual EID cases until an emergency occurred.  
One administrator further noted that even if the hospital conducted 
an EID-related exercise every year, recently hired staff would not have the 
opportunity to train on EID-specific procedures, such as the use of 
protective gear.  An administrator at a hospital designated as a Special 
Pathogen Center reported that EID training is particularly costly, and that 
frequent turnover of frontline caregiversthe staff most critical to receiving 
patientsincreases those costs.   
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Some hospital administrators reported that the staff most needed in 
handling complex EID cases were already among the most in-demand 
across the hospital.  Using these staff for extended periods to manage 
an EID case could affect critical hospital operations, such as emergency 
departments and intensive care units.  However, keeping staff in their 
regular core functions limits the pool of candidates to treat EID cases.   
One administrator described this by saying that the staff handling 
emergency preparedness were wearing many hats and that if the hospital 
were faced with an EID outbreak, it would be nearly impossible for these 
staff to complete all of the procedures as planned.  For example, in this 
case, the same person is in charge of quality improvement, emergency 
preparedness, infection control, risk management, maintenance, and 
employee health.  Another administrator from a small, rural CAH also noted 
that in the event of a mass outbreak, staffs own families would likely be 
affected, further limiting staff availability to report to work.  
Administrators from 92 percent of hospitals reported purchasing 
additional resources, such as equipment and supplies, and also 
reported difficulty in acquiring these resources  
Common types of purchased supplies included additional clinical equipment 
that hospitals planned to dedicate exclusively to EID patients; protective 
equipment; and medical waste equipment.  In 201415, many hospitals  
(73 percent) encountered difficulty in acquiring these supplies, as a result 
both of manufacturer shortages of high-demand supplies and the limited 
number of providers of relevant services, such as medical-waste disposal 
vendors that were certified to provide services for hazardous waste.   
Some administrators reported that because hospitals had been unsure what 
might be needed, they had stockpiled equipment to ensure sufficient 
supply.  However, a few administrators referenced past lessons learned 
that had made them cautious of overbuying, such as one hospital that had 
stockpiled respirators during the 2009 H1N1 flu pandemic, only to have to 
discard them later because they expired before they could be used.  Others 
were unable to acquire additional supplies as quickly as they had hoped, 
which could have posed a problem had the Ebola outbreak spread more 
broadly.  Among the supplies that were unavailable were elongated face 
shields that fully cover mouth, nose and eyes to prevent contamination 
while treating patients.  To mitigate the acquisition difficulties, some 
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hospitals shared supplies within their networks or with neighboring facilities.  
One hospital improvised by purchasing hoods and coveralls from a local 
paint supply store as an interim measure while supplies were on order.   
Administrators also reported challenges in contracting with vendors that 
were capable of handling both transportation and disposal of Ebola 
hazardous waste.  These tasks require that vendors hold specific 
certifications and meet Federal and State guidelines.  Administrators found 
that vendors in their communities with the proper credentials and capability 
often contracted with more hospitals than they could actually service if 
multiple hospitals were to require services at the same time.  After learning 
of this problem during the Ebola outbreak, 73 percent of hospitals reviewed 
their contracts with supply and service vendors.  Some changed their 
contracts because these reviews identified gaps; for example, locating 
additional vendors and including provisions in the contracts to account for 
the possibilities of sharing services.     
Administrators from 87 percent of hospitals reported their facilities 
conducted drills or exercises that included an EID-related scenario 
Most administrators (70 percent of all hospitals) reported that their hospitals 
conducted full-scale drillsmore labor-intensive and cost-intensive than 
tabletop exercises.  Several explained that they were strong proponents of 
this practice because full-scale drills were more insightful than tabletop 
exercises in identifying gaps in preparedness, particularly gaps related to 
facility infrastructure and patient care handoffs.  The administrators 
explained that these activities gave staff a much better understanding of 
their roles and coordination points, and also revealed gaps that might 
emerge in the event of an EID-related emergency.  As one administrator put 
it: [D]rills and exercises allow us to see our strengths and opportunities for 
learning.  Administrators from hospitals that performed tabletop exercises 
(79 percent of all hospitals) also touted the merits of this approach.  One 
benefit cited for tabletop exercises was that hospitals could plan and 
conduct them more easily.  For example, one administrator reported that 
the hospital was able to conduct tabletop exercises for all EIDs that are of 
concern, because the time investment for such exercises is relatively small.  
Many hospitals chose to train staff using both of these methods.  
Administrators from 63 percent of hospitals, including all 10 Special 
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Pathogen Centers, reported conducting both full-scale drills and tabletop 
exercises to prepare for possible EIDs.  Administrators from 17 percent of 
hospitals reported that their facilities conducted only tabletop exercises.  
Some of these hospitals explained they planned to conduct drills or 
exercises using an EID scenario, but had not yet done so at the time of our 
survey.       
Of the hospitals that reported conducting full-scale, EID-related drills after 
the Ebola outbreak (52 percent), over half (52 percent) used Ebola as the 
drill scenario; the remaining half used a variety of other EIDs, including 
pandemic influenza.  From the administrators descriptions, many of these 
exercises focused largely on other types of emergencies and included 
a component specific to EIDs.  For example, one hospital drilled for a flood 
emergency and designed its exercise to include a patient with a suspected 
EID, so as to test the hospitals ability to handle both scenarios. 
Administrators from 84 percent of hospitals reported they revised 
their emergency plans to improve EID preparedness  
Much of the improvement in emergency plans appeared to focus on 
building in redundancies for needed staffing and supplies.  For example, 
hospitals sometimes used their plans to map out which staff they would 
need during each particular kind of emergency and where they would turn 
for supplemental staffing (e.g., another hospital within their network).   
Although the Medicare CoP for emergency planning calls for hospitals to 
adopt an all hazards approach in developing emergency plans, CMS does 
not call for specific provisions to address EIDs.  From their responses to 
open-ended survey questions, hospitals appeared to include EIDs within 
their interpretations of all hazards.  A number of administrators noted that 
the wide range of possible hazards made it nearly impossible to plan for all 
potential crises, making information-sharing and communication among 
stakeholders critical.  Nearly all administrators (99 percent) noted that it was 
most important for their emergency plans to include contacts for 
government, community, and other entities involved in emergency 
preparedness.  One administrator referred to this as part of a broader 
initiative for the hospital to have overall situational awareness about its 
role in the community in the context of other key community entities. 
Administrators from 52 percent of hospitals reported that they would have 
difficulty updating their emergency plans annually, an action newly required 
by CMS.  Examples from administrators included not having enough staff 
time to complete the updates.  Some administrators also noted difficulty in 
integrating procedures specific to EIDssuch as infection controlinto 
emergency plans.  One administrator wrote:  [W]hen an infectious disease 
becomes the disaster, most of the emergency preparedness coordinators 
are well outside their comfort zone.     
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Administrators who reported their facilities were still unprepared for 
an EID in 2017 reported having taken fewer actions and having 
experienced more challenges 
Hospital administrators who reported that their facilities were still 
unprepared for an EID in 2017 (14 percent) responded significantly 
differently to some survey questions than did administrators who reported 
their hospitals were prepared for another EID.  For example, the first group 
of administrators were less likely to report that they had taken key actions, 
such as conducting drills and exercises (68 percent among unprepared 
hospitals, vs. 89 percent among prepared hospitals).58  Although all of the 
unprepared hospitals sought guidance from HHS, they were less likely to 
seek guidance across multiple agencies.  Whereas 82 percent of prepared 
hospitals sought guidance from ASPR, CDC, and CMS, the rate for 
unprepared hospitals was 65 percent.59  Moreover, unprepared hospitals 
were more likely to report that they faced challenges in preparing for EIDs, 
such as maintaining adequate equipment and supplies, including vendor 
services (90 percent compared to 70 percent).60       
Hospitals expressed  Despite reporting greater preparedness, administrators expressed 
concerns about sustaining preparedness for EIDs  
concerns about 
Administrators reported that preparedness for a particular threat often 
sustaining EID 
tapers after the immediate crisis is over, in light of the many obligations that 
preparedness, given 
hospitals fulfill.  One administrator stated that after each crisis, the 
competing priorities  collaborative network of emergency preparedness across all the relevant 
partners could wither and fade away before the next threat arrives.  Others 
and confusion in 
noted that the Ebola outbreak did not serve as a true test, given the small 
following guidance 
number of hospitals that were ultimately affected. 
Administrators most commonly cited staffing as a challenge to sustaining 
preparedness (see Exhibit 8).  Specifically, administrators expressed concerns 
about preparedness activities taking too much time away from the many 
routine duties that staff perform (90 percent) and about maintaining staff 
expertise and competency to treat EID patients (87 percent). 
   
Exhibit 8: Challenges reported by hospitals to sustaining preparedness for EIDs (n=368). 
Challenge  Percentage of Hospitals  
Staff time taken away from other duties  90% 
Sustaining staff competency to treat EID patients  87% 
Competing priorities for funding and other resources   82% 
Difficulty scheduling time to conduct EID-based drills and exercises  81% 
Maintaining adequate equipment and supplies, including vendor services  73% 
Difficulty following government guidance, either conflicting or impractical  72% 
Source: OIG analysis of data from OIG survey of hospital preparedness, 2018. 
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Administrators from 95 percent of hospitals reported that competing 
priorities reduced focus on EIDs   
Nearly all hospital administrators (95 percent) reported that their facilities 
had too many other obligations to afford substantial time on EID 
preparedness in the absence of a current threat.  Administrators noted that 
a focus on any particular threat inherently took time away from other 
efforts, and that hospitals had to prioritize problems as they emerged.  For 
example, some hospitals reported that over the previous year their 
emergency preparation focus had been on preparing for the possibility of 
an active shooter.  Others spoke of the opportunity cost of devoting 
resources to preparing for future EID threats.  Said one: Preparing for Ebola 
took countless hours from many departments and one could argue 
detracted from normal infection prevention and control tactics to prevent 
hospital-acquired infections. 
The financial cost of preparedness can also divert needed resources from 
other important hospital efforts.  Administrators noted that many of the 
specialized protective items, such as air-purifying respirators, were not only 
costly but also expired after a given date, meaning that regulations require 
hospitals to discard them.  These administrators expressed concern that 
having to purchase or replace gear in a developing EID emergency would 
be a significant financial cost.  Another hospital official commented on the 
difficulty of budgeting funds for the what ifs when there is only so much 
money available and there are other priorities you know will happen. 
Administrators from 79 percent of hospitals reported that they 
believed other types of emergencies were more likely than 
EID threats, further shifting focus from EID preparedness 
The emergencies most often mentioned by administrators as likely to affect 
their hospital and community were widespread natural disasterssuch as 
hurricanes, fires, and floodsand active shooters.  Natural disasters such as 
hurricanes require hospitals to coordinate with local government and other 
providers, while other emergencies like in-facility fires could affect only the 
hospitals surrounding area or facility.  Hospitals assessed their vulnerability 
to hazards using various risk assessment methods that considered factors 
such as geographic location, size, facility type, and patient population to 
determine the events most likely to occur.  For example, some hospitals are 
located in communities with international airports, increasing the risk of 
outbreaks of EIDs from other parts of the world. 
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Hospital administrators reported some difficulty using government 
guidance in preparing for Ebola, including guidance from HHS     
All hospitals (100 percent) sought guidance from CDC to prepare for the 
possibility of receiving Ebola cases in 20142015, but most administrators
72 percentreported they had some difficulty in interpreting and following 
this guidance during the Ebola outbreak.  This appeared to be the result of 
two factors: administrators from 64 percent of hospitals reported confusion 
over conflicting guidance from HHS agencies and other entities, such as 
State governments; and administrators from 50 percent of hospitals 
reported that guidance was sometimes not practical or easily employable at 
the hospital level.  For example, one hospital said that guidance seemed 
targeted towards larger organizations and was not scalable for smaller 
community hospitals that do not have staff dedicated for emergency 
preparedness.  Another hospital felt that the initial Ebola guidance from 
CDC was too generic to be readily implemented unless the staff already 
had expertise.   
Further, some hospital administrators complained that guidance from CDC 
and others changed through the course of the Ebola outbreak, but others 
said the changes were appropriate in response to a growing body of 
knowledge about the diseases transmission and care.  As one administrator 
explained, It would help stress levels if everyone accepted that a novel 
pathogen involves an iterative process to determine the best strategies for 
managing the threat.  Ongoing modifications to CDC recommendations 
should not be perceived as lack of expertise, but should be expected.   
In some cases, providers and suppliers adapted their products to 
incorporate new information.  For example, one administrator said that 
manufacturers of protective gear changed their product after the Ebola 
outbreak: When we first got the guidance, you could only use a hazmat 
suit, but the gowns on the market today meet the requirements.  On this 
point, administrators often noted that hospitals must consider a number of 
scenarios in preparing for future EID threats because different diseases 
require different treatment and prevention.  For example, Ebola presented 
an extreme situation in terms of difficulty in treatment and severity of illness, 
requiring complex and urgent patient care, strict isolation, and extreme 
protective measures to prevent contagion.  In contrast, pandemic influenza 
may result in a large influx of patients and a surge in demand for inpatient 
services.  As noted throughout the hospital survey responses, hospitals 
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gained insight about preparing for other hazards when they prepared for 
Ebola, but remain concerned about core preparedness issues such as 
staffing and supplies. 
In survey responses, hospital administrators provided input to HHS agencies 
regarding how the agencies could best support hospitals in preparing for 
EIDs and addressing concerns.  Summarized broadly, administrators called 
for improved communication between HHS and hospitals, and also with 
other stakeholders (see Exhibit 9).    
 Exhibit 9: Selected Feedback to HHS from Hospital Administrators  
 
 Simplify the message so that guidance is easier for hospitals without expertise to follow.  
  
 Coordinate so that hospitals hear a unified voice for guidance and requirements. 
 
 Maintain the tiered structure.  It reassures smaller hospitals that we will be covered.  
 
 Listen to our experiences with drills and real emergencies.  It plays out differently in real life. 
 
 Recognize that hospitals have competing priorities to meet the broader CoPs and serve patients. 
Source: OIG analysis of data from OIG survey on hospital preparedness, 2018. 
 
About one-third of hospitals reported not knowing their role in the 
CDC tiered hospital framework for Ebola response, which may affect 
the frameworks usefulness for future EID threats   
As a key indicator of the confusion that hospital administrators reported in 
using HHS guidance, some hospitals did not know their designation in 
CDCs tiered framework.  All of the Special Pathogen Centers and Ebola 
Treatment Centers (Tier 1) reported they were aware of their responsibility, 
but 36 percent of all other hospitals (assessment hospitals and front-line 
hospitals) were not aware of their designations.  This was despite 
administrators from all hospitals reporting that they communicated with 
CDC or accessed information on CDCs website, and that CDC and ASPR 
promoted the tiered concept following the Ebola outbreak and for some 
time after.   
Many of these hospitals also appeared unaware of the designations of 
nearby hospitals and the division of responsibilities between hospitals in the 
event of an outbreak, which could adversely affect their response upon 
receiving an EID case.  This was attributed in part to changing guidelines 
and requirements for the hospital tier designations in 201415 and also to 
the frameworks not being actively used in the absence of an EID.   
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Some hospital administrators reported decreasing their efforts to improve 
their own preparedness for Ebola when they learned about the specific roles 
of the Special Pathogen Centers and the other treatment centers, 
particularly if such a facility was located nearby.  Despite their decreased 
efforts, hospitals appeared to plan for at least patient screening and triaging 
before transferring suspected or diagnosed cases, and administrators 
mentioned adding screening questions to electronic health records systems 
 
to embed the practices for future EID threats.   
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CONCLUSION AND RECOMMENDATIONS 
The 2014 Ebola outbreak focused attention nationwide on the potential impact 
of EIDs on U.S. public health and hospital infrastructure.  Although the 
occurrence of a disease as severe as Ebola was an unusual one, a number of 
other EIDs have previously entered the United States and future outbreaks are 
possible.  Hospitals provide critical services in these instances, and must be 
prepared for EIDs without impairing their routine work.  Many hospital 
administrators reported their facilities were not prepared to receive Ebola cases 
in 2014, but improved preparedness for Ebola and other potential EIDs in the 
years since.  Administrators also reported challenges to prioritizing the planning 
and training needed to prepare for EIDs, given the competing demands for staff 
time and other resources, as well as some difficulty using government guidance.   
A future EID threat could require substantial management and resources by 
hospitals, other health care providers, and government at all levels, with key 
involvement from ASPR, CDC, and CMS.  To improve hospital preparedness, 
HHS assistance to hospitals, and oversight of emergency preparedness 
requirements, we recommend the following: 
ASPR, CDC, and CMS should continue to help hospitals sustain 
preparedness for EIDs, by coordinating guidance and providing 
practical advice for all hospitals 
To counter confusion about conflicting guidance and waning focus on EID 
preparedness, HHS agencies should continue to collaborate internally and 
externally with hospitals and other stakeholders, such as States and accrediting 
organizations.  ASPR, CDC, and CMS could coordinate efforts for three tasks:  
updating EID preparedness guidance to ensure that it is clear and concise; 
developing strategies for updating information about current EID threats; and 
providing practical advice that hospitals can more easily employ given 
competing priorities.  The agencies should also be aware that some hospitals 
continue to report a lack of preparedness, and the agencies should take steps 
to ensure that all hospitals receive preparedness guidance appropriate to their 
respective roles.  For example, CAHs reported lower rates of preparedness that 
other hospitals in 2017.  This coordination effort could include guidance related 
to CAH-specific challenges, such as acquiring equipment, staffing, and expertise 
in rural settings.       
CDC should clarify and promote the details and ongoing status of 
its tiered framework to ensure that hospitals are aware of their 
responsibilities in the event of a future EID 
The tiered framework could be critical in guiding hospitals in the event of 
a future EID, but CDC has not updated the framework since 2015.  To support 
hospital preparedness, CDC should ensure that it clarifies likely hospital roles 
and provides guidance about how it might adapt the framework in the future, 
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such as the expectations for hospitals in each category, strategies for 
communicating among tiers, and CDC resources available to assist in the 
implementation of the tiered approach. 
CMS should add EIDs to the definition of all hazards in the State 
Operations Manual to promote inclusion of EIDs in hospital 
emergency planning 
The Medicare CoP for emergency preparedness outlines actions hospitals must 
take to prepare for emergencies, including a provision that hospitals annually 
update emergency plans using an all hazards approach that encompasses a 
range of potential emergencies.  However, the provision does not specify that 
the potential emergencies could include EIDs.   
Given hospital administrators reported concern about sustaining EID 
preparedness and about updating plans annually, CMS should revise the State 
Operations Manual to specify that EIDs are included in the CMS definition of all 
hazards.  CMS should also consider providing further guidance to hospitals 
about incorporating EID preparedness into all hazards planning, and to 
surveyors and accrediting organizations for assessing hospital preparedness for 
EIDs.  For example, CMS could provide guidance to hospitals about 
incorporating specific EIDs into full-scale drills, tabletop exercises, and other 
staff training efforts, and CMS could educate surveyors in assessing the use of 
such actions in preparing for EIDs.  
   
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AGENCY COMMENTS AND OIG RESPONSE 
ASPR, CDC, and CMS concurred with our recommendations.  All three agencies 
responded that they would continue working together to help hospitals sustain 
preparedness for EIDs, including coordinating guidance and providing hospitals 
with practical advice.   
In response to our recommendation that CDC clarify and promote the details 
and ongoing status of the tiered hospital framework that it developed during 
the Ebola outbreak, CDC responded that it would work with health care facilities 
and systems; State, local, tribal, and territorial health departments; professional 
organizations; other Federal agencies; and relevant partners to provide clarity 
and guidance to support and improve hospital preparedness.  We would 
appreciate if in its final management decision, CDC could specifically address 
the status of the tiered framework. 
In response to our recommendation that CMS add EIDs to the definition of all 
hazards in the SOM, CMS responded that it would revise the SOM to 
specifically include EIDs.   
OIG appreciates the agencies concurrence and actions to further support 
hospital preparedness for potential future EIDs.  Given the concerns of hospital 
administrators regarding sustaining EID preparedness, we reiterate the 
importance of close coordination within HHS; providing clear, practical advice to 
hospitals; and ensuring that hospitals are aware of their responsibilities in the 
event of a future outbreak and that hospitals include EIDs in their emergency 
planning efforts.  
For the full text of the comments from ASPR, CDC, and CMS, see Appendix C. 
  
   
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APPENDIX A: Study Statistics 
Exhibit A-1 contains point estimates and 95-percent confidence intervals for statistics provided in the 
report.  All statistics are derived from the OIG survey on hospital preparedness, completed by 
368 hospitals (10 Special Pathogen Centers and 358 other hospitals) from December 2016 through 
April 2017. 
Exhibit A-1: Sample Sizes, Point Estimates, and Confidence Intervals 
Sample  Point  95-Percent  
Estimate Description 
Size  Estimate  Confidence Interval 
Hospitals reported preparedness to handle patients with suspected or actual Ebola in 2014 
Prepared  368  29.1%  24.8%33.8% 
    Among critical access hospitals  104  14.4%  9.0%22.2% 
    Among all other hospitals  264  35.1%  29.7%40.9% 
Not prepared  368  70.9%  66.2%75.2% 
    Among critical access hospitals  104  85.6%  77.8%91.0% 
    Among all other hospitals  264  64.9%  59.1%70.3% 
Hospitals reported preparedness to handle patients with suspected or actual EIDs in 2017 
Prepared  368  86.3%  82.6%89.4% 
    Among critical access hospitals  104  76.9%  68.2%83.8% 
    Among all other hospitals  264  90.2%  86.1%93.2% 
Not prepared  368  13.7%  10.6%17.4% 
    Among critical access hospitals  104  23.1%  16.2%31.8% 
    Among all other hospitals  264  9.8%  6.8%13.9% 
Hospitals actions taken to prepare for Ebola or other EID threats 
Sought guidance from CDC  368  100%  99.0%100% 
Sought guidance from CMS and related oversight entities  368  91.9%  88.8%94.3% 
Used ASPR resources  368  84.4%  80.4%87.7% 
Participated in ASPR-funded Healthcare Coalitions  368  78.3%  73.9%82.1% 
Conducted additional staff training  368  94.1%  91.3%96.1% 
Purchased additional equipment and supplies  368  92.4%  89.4%94.7% 
       
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Sample  Point  95-Percent  
Estimate Description 
Size  Estimate  Confidence Interval 
Hospitals actions taken to prepare for Ebola or other EID threats (continued) 
 
Conducted full-scale drills or tabletop exercises with staff  368  86.9%  83.2%89.9% 
Conducted full-scale drills since the Ebola outbreak  368  52.1%  47.1%57.0% 
     Used Ebola as drill scenario  196  51.8%  44.9%58.6% 
Conducted tabletop exercises  368  79.4%  75.1%83.1% 
Conducted full-scale drills  368  70.2%  65.4%74.5% 
Conducted both tabletop exercises and full-scale drills  368  62.7%  57.7%67.3% 
Revised infectious disease and emergency plans  368  84.3%  80.4%87.6% 
Enhanced collaboration with local government entities  368  74.9%  70.3%79.0% 
Reviewed agreements with supply and service contractors  368  73.4%  68.9%77.6% 
Engaged hospital board or health care system 
368  69.6%   64.8%74.0% 
management 
Created an EID rapid response clinical team  368  49.2%  44.3%54.2% 
Challenges that hampered hospitals ability to prepare for suspected or actual EIDs 
Staff time taken away from other duties  368  89.6%  86.2%92.3% 
Sustaining staff competency to treat EID patients  368  87.4%  83.7%90.4% 
Competing priorities for funding and other resources  368  82.1%  78.0%85.6% 
Difficulty scheduling time to conduct EID-based drills and 
368  80.7%  76.4%84.3% 
exercises 
Maintaining adequate equipment and supplies, including 
368  73.1%  68.5%77.3% 
vendor services 
    Among hospitals that were prepared for EID in 2017  319  70.4%  65.4%75.1% 
    Among hospitals that were not prepared for EID in 2017  49  89.8%  78.3%95.5% 
Difficulty following government guidance, either 
368  71.8%  67.1%76.1% 
conflicting or impractical 
    Conflicting guidance from government authorities  368  63.9%  59.0%68.6% 
    Impractical guidance from government authorities  368  49.8%  44.8%54.7% 
Difficulty implementing the new CMS emergency 
368  52.4%  47.5%57.4% 
preparedness regulations 
       
       
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Sample  Point  95-Percent  
Estimate Description 
Size  Estimate  Confidence Interval 
Estimates among hospitals that reported they were prepared for a possible EID in 2017  
Sought guidance from ASPR, CDC, and CMS  319  82.3%  77.8%86.0% 
Maintained adequate equipment and supplies, including 
319  70.4%  65.4%75.1% 
vendor services 
Estimates among hospitals that were not prepared for EIDs in 2017 
Conducted tabletop exercises or full-scale drills with staff  49  69.4%  55.8%80.3% 
Sought guidance from ASPR, CDC, and CMS  49  65.3%  51.6%76.8% 
Maintaining adequate equipment and supplies, including 
49  89.8%  78.3%95.5% 
vendor services 
Other Estimates 
Conducted full-scale drills and/or tabletop exercises and 
321  89.1%  85.3%92.0% 
were prepared for Ebola or other EIDs in 2017 
Did not conduct full-scale drills or tabletop exercises and 
47  68.1%  54.2%79.4% 
were prepared for Ebola or other EIDs in 2017 
Establishing collaborative relationships with local 
emergency preparedness management, public health  368  99.2%  97.5%99.7% 
department, and emergency medical transportation 
Competing priorities reduces focus on EIDs  368  95.0%  92.3%96.7% 
Hospitals believed other types of emergencies were more 
368  79.1%  74.8%82.9% 
likely than future EID threats 
Hospitals reported being a member of a health care 
368  68.2%  63.4%72.7% 
system 
    Among critical access hospitals  104  39.4%  30.8%48.7% 
    Among all other hospitals  264  80.0%  74.8%84.3% 
Hospitals that were in rural locations  368  39.7%  35.2%44.3% 
    Among critical access hospitals  104  80.8%  72.4%87.0% 
    Among all other hospitals  264  22.8%  18.2%28.1% 
Assessment hospitals or front-line hospitals that did not 
354  36.4%  31.8%41.4% 
know their designation 
Source: OIG analysis of data from OIG survey of hospital preparedness, 2018. 
 
 
 
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APPENDIX B: HHS Agency Resources 
Exhibit B-1 provides the HHS resources most commonly reported as being used by hospitals in preparing 
for EIDs, listed by HHS agency. 
   Exhibit B-1: Hospital use of HHS resources in preparing for or responding to EIDs 
Resources from CDC 
Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 
- Infection control recommendations for all types of health care providers   
Ebola Virus Disease: Hospitals website 
- Guidance for providers when caring for a patient with suspected or confirmed Ebola   
Health Advisory Network (HAN) 
- Notification network for government and providers about urgent public health incidents   
Hospital Pandemic Influenza Planning Checklist 
- Tool for developing or evaluating emergency and treatment plans for pandemic influenza   
Resources from ASPR 
ASPR-funded Healthcare Coalitions 
-  Organizations of health care providers and public entities focused on emergencies 
Hospital Surge Evaluation Tool 
- Tool used to identify gaps in hospital preparedness to respond to mass casualty events   
Technical Resources, Assistance Center, and Information Exchange (TRACIE) 
- Technical assistance and information exchange among ASPR, providers, and communities   
Resources from CMS 
Emergency Preparedness Checklist: Recommended Tool for Health Care Facility Planning 
- List of actions and resources recommended to hospitals in developing emergency plans    
Survey and Certification Emergency Preparedness website 
- Information for health care facilities in developing emergency plans and response   
Health Care Provider Voluntary After Action Report and Improvement Plan Template 
- Template for providers to document and assess emergency planning and responses   
 
   
Hospitals Reported Improved Preparedness for Emerging Infectious Diseases After the Ebola Outbreak    27 
OEI-06-15-00230   
Exhibit B-2 contains point estimates and 95-percent confidence intervals for statistics for specific HHS 
resources used by hospitals.  All statistics are derived from the OIG survey on hospital preparedness, 
completed by 368 hospitals (10 Special Pathogen Centers and 358 other hospitals) from December 2016 
through April 2017. 
Exhibit B-2: Sample Sizes, Point Estimates, and Confidence Intervals 
Sample  Point  95-Percent  
Estimate Description 
Size  Estimate  Confidence Interval 
Resources from CDC 
Guidelines for Isolation Precautions: Preventing 
368  94.1%  91.3%96.1% 
Transmission of Infectious Agents in Healthcare Settings 
Ebola Virus Disease: Hospitals website  368  88.6%  85.0%91.4% 
Health Advisory Network (HAN)  368  83.0%  78.9%86.4% 
Hospital Pandemic Influenza Planning Checklist  368  78.4%  74.1%82.3% 
Resources from CMS 
Emergency Preparedness Checklist: Recommended Tool 
368  59.2%  54.3%64.0% 
for Health Care Facility Planning 
Survey and Certification Emergency Preparedness website  368  35.7%  31.1%40.6% 
Health Care Provider Voluntary After Action Report and 
368  24.6%  20.5%29.1% 
Improvement Plan Template 
Resources from ASPR 
ASPR-funded Healthcare Coalitions  368  78.3%  73.9%82.1% 
Hospital Surge Evaluation Tool  368  35.5%  30.9%40.4% 
Technical, Assistance Center, and Information Exchange 
368  28.3%  24.0%33.0% 
(TRACIE) 
Source: OIG analysis of data from OIG survey of hospital preparedness, 2018. 
 
   
Hospitals Reported Improved Preparedness for Emerging Infectious Diseases After the Ebola Outbreak    28 
OEI-06-15-00230   
APPENDIX C: Agency Comments 
ASPR Comments 
,.,.l l~,aVIC-(t." <, 
( -.~-'~- DEPARTMENT OF HEALT H & HUMAN SERVICES  Office of the Secretary 
~>l-,110(;. 
Assistant Secretary for 
Preparedness & Response 
Washington, D.C. 20201 
TO:  Office of Inspector General, Department of Health and Human Services 
FROM:  Robert P. Kadlec, MD, MTM&H, MS 
Assistant Secretary for Preparedness and Response 
SUBJECT:  OIG Draft Report: Hospitals Reported Improved Preparedness for Emerging 
Infectious Diseases After the Ebola Outbreak-INFORMATION 
The Department of Health and Human Services's (HHS) Office of the Assistant Secretary for 
Preparedness and Response (ASPR), Centers for Disease Control and Prevention (CDC), and 
Centers for Medicare & Medicaid Services (CMS) appreciate the opportunity to review and 
comment on this draft report. ASPR, CDC, and CMS all work together to ensure hospitals and 
the nation's health care system are prepared for and able to support a response to future emerging 
infectious disease. AU three agencies support individual efforts to sustain investments made 
between 2014 to the present that build and enhance infrastructure to support capabilities to treat 
patients with, or suspected of having, an infectious disease such as Ebola.  The Office of 
Inspector General's (OIG) recommendation regarding all three agencies and ASPR, CDC, and 
CMS's response to that recommendation is discussed below. 
OIG Recommendation 
ASPR, CDC, and CMS should continue to help hospitals sustain preparedness for emerging 
infectious diseases (EID), by coordinating guidance and providing practical advice for all 
hospitals. 
HHS Response 
ASPR, CDC, and CMS concur with this recommendation and will continue to help hospitals 
sustain preparedness for EIDs by coordinating guidance and providing practical advice for all 
hospitals. 
ASPR, CDC, and CMS thank OIG for their efforts on this issue and look forward to working 
with OIG on this and other issues in the future. 
   
Hospitals Reported Improved Preparedness for Emerging Infectious Diseases After the Ebola Outbreak    29 
OEI-06-15-00230   
 
CDC Comments 
{.,  ..Jf_ 
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES  Public Health Service 
',.~tr 
Centers for Disease Control 
and Prevention (CDC) 
Atlanta GA 30329-4027 
TO:  Inspector General, U.S. Department of Health and Human Services 
FROM:  Director, Centers for Disease Control and Prevention 
DATE:  September 12, 2018 
SUBJECT:  Office of Inspector General (OIG) Draft Report: Hospitals Reported Improved 
Preparedness/or Emerging Infectious Diseases After the Ebola 0111break, OEl-
06-15-00230 
The Centers for Disease Control and Prevention (CDC) appreciates the opp rtunity lo review 
and comment on the Office of inspector General's (OIG) draft report regarding hospital 
preparedness for emerging infectious diseases (EIDs). The U.S. Depat1menl of Health and 
Human Services  (HHS) Office of the Assistant Secretary for Preparedness and Response 
(A  PR), the  enters for Medicare & Medicaid Services (CMS), and  DC all work together to 
ensure the nation's hospitals and healthcare system are prepared for and able lo support a 
response to an ETD in the future.  All three agencies are supporting individual effo1ts to sustain 
investments made between 2014 to the present in order to build and enhance infra tructure to 
suppo1t capabilities to treat patients with or suspected of having an infectious disease such as 
Ebola. 
CDC's response to OTG recommendations follow. 
OIG Recommendation 
ASPR, CD  , and  MS should continue to help hospitals sustain preparedness for EIDs by 
coordinating guidance and providing practical advice for all hospitals. 
HHS Response 
CDC concurs with this recommendation and welcomes continued collaboration with ASPR and 
CMS to protect patients and healthcare personnel from emerging infectious diseases. 
OIG Recommendation 
CDC should clarify and promote the details and ongoing status of its tiered framework to ensure 
that hospitals are aware of their responsibilities in the event of a future EID. 
CDC Response 
CDC concurs with this recommendation and will work with healthcare facilities and systems; 
state, local, tribal, and territo1ial health departments; professional organizations; other federal 
agencies; and other relevant partners to provide clarity and guidance to suppot1 and improve 
hospital preparedness in the event of an ElD outbreak. 
 
   
Hospitals Reported Improved Preparedness for Emerging Infectious Diseases After the Ebola Outbreak    30 
OEI-06-15-00230   
 
Page 2 - Inspector General, U.S. Department of Health and Human Services 
Thank you for the opportunity to review and respond to this report. I look forward to fmther 
collaboration in the future. 
~~+RSfab1t4 
Robert R. Redfield, MD 
 
   
Hospitals Reported Improved Preparedness for Emerging Infectious Diseases After the Ebola Outbreak    31 
OEI-06-15-00230   
 
CMS Comments 
(4-
DE_P'A_R_T_M_E_  __r_ 1_--L_ _r._; r_1_1_  H_u_M_A_N _sE _R_v_, __  _______:_ n_1,-:r:-:P-o~-:-:-:~-e-:-v-:nM-:-s-1-:idS-e_MC e__s 
Washington, DC 20201 
D  TR:  SEP  1 9 2018 
0:  Daniel R. L  in on 
In pector  eneral 
0-i / 
FRO  1:  eema Verma 
O V 
dministrator 
BJE  T:  ffice or In pector  eneral (OIG) Draft Repo11: Ho:pital  Reported Improved 
Preparedness for Emerging Infectious Disea e  tier the  ~bola  utbreak.  El-
06-15-00230 
The Center  for Medicare & Medicaid  er  ices ( 'M  ) appreciate  the opportunity to re  iew and 
comment on the  Hice of Inspector  'eneral'  (  I  ) draft report regarding hospital prcparedne   
for emerging infectious disease . The I IH  Ofllce of th  istant  ccrctary for Preparedness 
o  , 
and Response (  'PR), the  enters for Di ea e  ontrol and Pre cntion (  and  all 
work t gether to ensure ho pital  and the nation'  healthcare system arc pr  pared for and will be 
able to  uppol'l a response 10 an emerging infeetiou  di ca e in the future.  II three agencies are 
upporting individual efforts to sustain inve tmenls made between 2014 to the present to build 
and  nhance infrastru  turc to  upport capabilitic  to treat patient.  with or  u pc ted of having an 
infi cti  us di ca e  uch as  bola. 
OI    recommendation  and  'PR  D  , and CM ,.  re pon es to these recommendation are 
discussed bclo~ . 
for ' ID . by 
M  concur, iU1 thi  recommendation and will continue to help ho pitals 
u tain prcparedne  for emergin, infectiou  di eases by coordinating guidanc  and providing 
practical advice for all ho pital . 
OIG Recommendation 
rram 
D  hould clarify an I promote the detail  and ongoing statu  of its tiered  work to ensure 
that hospitals arc a" are of their re pon ibilities in th  ent of a future EID. 
D  concur  with thi  recommendation and will work with healthcare facilities and system: 
late, local. tribal, and territorial health department ; pr  fc  ional organization ; other federal 
 
Hospitals Reported Improved Preparedness for Emerging Infectious Diseases After the Ebola Outbreak    32 
OEI-06-15-00230   
 
agendes~ and other relevant pm1ners to provide clarity and guidance to support and improve 
hospital preparedness ln the event of an ElD outbreak. 
0  G Ret-0mn1cndation 
CM  should add Ems to the definition of .. aU-hazards' in the Sta e Operations Manual (SOM) 
to promote inclusion of EIDs in hospita  emergency planning. 
CMS Res~on e 
wu 
CM  ooncurs with OIO's recommendation.  M  include language in the  tat  Operafons 
Manual to specifically identify ernerging infectious diseases in the definition of' all-hazard.' 
 
 
 
 
 
 
   
Hospitals Reported Improved Preparedness for Emerging Infectious Diseases After the Ebola Outbreak    33 
OEI-06-15-00230   
ACKNOWLEDGMENTS 
Cory Carr, Deborah Cosimo, Nathan Dong, Malinda Hicks,  and Jesse Valente 
served as the analysis team for this study.  Office of Evaluation and 
Inspections staff who provided support include Kevin Farber, Seta 
Hovagimian, and Christine Moritz.  
We would also like to acknowledge the contributions of other  Office of 
Evaluation and Inspections regional office staff, including Ben Gaddis,  
Jennifer Hagen, Petra Nealy, and Anthony Soto McGrath.  
This report was prepared under the  direction of Ruth Ann Dorrill, Regional 
Inspector  General for Evaluation and Inspections in the Dallas regional 
office, and Amy Ashcraft,  Deputy Regional Inspector General.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
To obtain additional information concerning this report or to obtain copies, 
contact the Office of Public Affairs at  Public.Affairs@oig.hhs.gov.   
Hospitals Reported Improved Preparedness for Emerging Infectious Diseases After the Ebola Outbreak    34  
OEI-06-15-00230    
ENDNOTES 
 
1 CDC, 2014-2016 Ebola Outbreak in West Africa, December 2014.  Accessed at 
https://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/united-states-imported-case.html on July 17, 2018. 
2 CDC, About Ebola Virus Disease, December 2017.  Accessed at https://www.cdc.gov/vhf/ebola/about.html on 
April 16, 2018. 
3 World Health Organization, What we know about transmission of the Ebola virus among humans, October 6, 2014.  
Accessed at http://www.who.int/mediacentre/news/ebola/06-october-2014/en/ on April 19, 2018. 
4 World Health Organization, Ebola Virus Disease, February 12, 2018.  Accessed at http://www.who.int/en/news-
room/fact-sheets/detail/ebola-virus-disease on July 2, 2018.  CDC, Ebola (Ebola Virus Disease), December 27, 2017.  
Accessed at https://www.cdc.gov/vhf/ebola/treatment/index.html on August 10, 2018. 
5 World Health Organization, Statement on the 1st meeting of the IHR [International Health Regulations] Emergency 
Committee on the 2014 Ebola outbreak in West Africa, August 8, 2014.  Accessed at 
http://www.who.int/mediacentre/news/statements/ 
2014/ebola-20140808/en/ on April 16, 2018. 
6 CDC, 2014-2016 Ebola Outbreak in West Africa, December 2014.  (See endnote 1 for URL.) 
7 CDC, Years of Ebola Virus Disease Outbreaks, June 2017.  Accessed at 
https://www.cdc.gov/vhf/ebola/history/chronology.html on March 20, 2018. 
8 Kaiser Family Foundation, Issue Brief: The Latest Ebola Outbreak: What Has Changed in the International and U.S. 
Response Since 2014.  Accessed at https://www.kff.org/global-health-policy/issue-brief/the-latest-ebola-outbreak-
what-has-changed-in-the-international-and-u-s-response-since-2014/ on June 29, 2018. 
9 CDC, EID Journal Background and Goals, Emerging Infectious Diseases Journal.  Accessed at 
https://wwwnc.cdc.gov/eid/page/background-goals on March 20, 2018.    
10 CDC, Global Health Protection and SecurityGDD Operations Center: Detecting and Monitoring Health Threats 
Across the Globe 24/7.  Accessed at https://www.cdc.gov/globalhealth/healthprotection/fieldupdates/winter-
2016/global-operations-center-24-7.html on March 20, 2018. 
11 Woolhouse, Mark. How to make predictions about future infectious disease risks. Philosophical Transactions of The 
Royal Society B, Vol. 366 (1573), 2011, pp. 20452054.  Accessed at 
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3130384/pdf/rstb20100387.pdf on March 20, 2018. 
12 World Health Organization, R&D Blueprint:  List of Blueprint priority diseases.  Accessed at  
http://www.who.int/blueprint/priority-diseases/en/ on March 20, 2018. 
13 Bill Gates, lecture on pandemic preparedness, as prepared for the 2018 Shattuck Lecture on April 27, 2018.  
Accessed at https://www.gatesfoundation.org/Media-Center/Speeches/2018/04/Shattuck-Lecture-Innovation-for-
Pandemics on June 29, 2018. 
14 ASPR, Interim Healthcare Coalition Checklist for Pandemic Planning, National Healthcare Preparedness Programs 
(NHPP).  Accessed at https://www.phe.gov/Preparedness/planning/hpp/reports/Documents/pandemic-checklist.pdf 
on March 20, 2018. 
15 Federal Emergency Management Agency, Emergency Support Function #8Public Health and Medical Services 
Annex, January 2008.  Accessed at http://www.fema.gov/media-library-data/20130726-1825-25045-8027/ 
emergency_support_function_8_public_health___medical_services_annex_2008.pdf on March 20, 2018. 
16 Ibid. 
17 ASPR, 20172022 Health Care Preparedness and Response Capabilities.  Accessed at 
https://www.phe.gov/Preparedness/planning/hpp/reports/Documents/2017-2022-healthcare-pr-capablities.pdf on 
March 20, 2018.  
18 ASPR, TRACIE.  Accessed at https://asprtracie.hhs.gov/ on April 19, 2018. 
 
Hospitals Reported Improved Preparedness for Emerging Infectious Diseases After the Ebola Outbreak    35 
OEI-06-15-00230   
 
19 The Hospital Preparedness Program is authorized by section 319C-2 of the Public Health Service Act, and amended 
by the Pandemic and All-Hazards Preparedness Act.  The program authorizes the Secretary of Health and Human 
Services to award competitive grants or cooperative agreements to eligible entities.  These are funded through the 
Consolidated Appropriations Act, 2008. 
20 ASPR, 20182022 Healthcare Preparedness and Response Capabilities, Activity 1, pp. 1316, November 2016.  
Accessed on https://www.phe.gov/Preparedness/planning/hpp/reports/Documents/2017-2022-healthcare-pr-
capablities.pdf on August 14, 2018. 
21 The Consolidated and Further Continuing Appropriations Act, 2015, P.L. 113-235, December 16, 2014.  Accessed at 
https://www.congress.gov/bill/113th-congress/house-bill/83 on August 14, 2018. 
22 Ibid. 
23 HHS, HHS FY2018 Budget in Brief, PHSSEFPublic Health and Social Services Emergency Fund.  Accessed at 
https://www.hhs.gov/about/budget/fy2018/budget-in-brief/phssef/index.html on March 20, 2018. 
24 CDC, CDC: Mission, Role and Pledge, April 14, 2014.  Accessed at 
https://www.cdc.gov/about/organization/mission.htm on March 20, 2018. 
25 CDC, Strategic National Stockpile.  Accessed at https://www.cdc.gov/phpr/stockpile/index.htm on March 30, 2018. 
26 CDC, Public Health Emergency Preparedness (PHEP) Cooperative Agreement, April 10, 2018.  Accessed at 
https://www.cdc.gov/phpr/readiness/phep.htm on April 19, 2018. 
27 CDC, 2014 Ebola Response Supplemental Funding: PHEP Supplemental Funding for Ebola Preparedness and Response 
Activities, April 18, 2017.  Accessed at https://www.cdc.gov/phpr/readiness/funding-ebola.htm on March 20, 2018. 
28 CDC, CDC Increasing Supply of Ebola-specific Personal Protective Equipment for U.S. Hospitals.  Accessed at 
https://www.cdc.gov/media/releases/2014/p1107-ebola-PPE.html on March 20, 2018.    
29 CDC, Guidelines for Evaluation of US Patients Suspected of Having Ebola Virus Disease, distributed via the CDC 
Health Alert Network on August 1, 2014.  Accessed at https://stacks.cdc.gov/view/cdc/24830/cdc_24830_DS1.pdf on 
March 20, 2018. 
30 CDC, Interim Guidance for U.S. Hospital Preparedness for Patients Under Investigation (PUIs) or with Confirmed Ebola 
Virus Disease (EVD): A Framework for a Tiered Approach.  Accessed at https://www.cdc.gov/vhf/ebola/healthcare-
us/preparing/hospitals.html on March 20, 2018. 
31 CDC, Interim Guidance for Preparing Ebola Treatment Centers.  Accessed at 
https://www.cdc.gov/vhf/ebola/healthcare-us/preparing/treatment-centers.html on March 20, 2018. 
32 CDC, 2014 Ebola Response, July 31, 2015.  Accessed at https://www.cdc.gov/about/report/2014/ebola-response.html 
on July 20, 2018. 
33 CDC, Early Identification and Prevention of the Spread of EbolaUnited States. Morbidity and Mortality Weekly 
Report (MMWR), Vol. 65, No. 3, July 8, 2016, pp. 7584.  Accessed at 
https://www.cdc.gov/mmwr/volumes/65/su/pdfs/su6503a11.pdf on March 20, 2018. 
34 CDC, Interim Guidance for U.S. Hospital Preparedness for Patients Under Investigation (PUIs) or with Confirmed Ebola 
Virus Disease (EVD): A Framework for a Tiered Approach.  Accessed at https://www.cdc.gov/vhf/ebola/healthcare-
us/preparing/hospitals.html on March 20, 2018. 
35 HHS, HHS selects nine regional Ebola and other special pathogen treatment centers.  Accessed at 
https://web.archive.org/web/20151109151157/http:/www.hhs.gov/about/news/2015/06/12/hhs-selects-nine-regional-
ebola-and-other-special-pathogen-treatment-centers.html on October 1, 2018. 
36 Ibid. 
37 ASPR, Regional Treatment Network for Ebola and Other Special Pathogens.  Accessed at 
https://www.phe.gov/Preparedness/planning/hpp/reports/Documents/RETN-Ebola-Report-508.pdf on October 1, 
2018. 
38 ASPR, Regional Treatment Network for Ebola and Other Special Pathogens, p. 6.  Accessed at 
https://www.phe.gov/Preparedness/planning/hpp/reports/Documents/RETN-Ebola-Report-508.pdf on July 18, 2018. 
39 Ibid., p. 7. 
 
 
Hospitals Reported Improved Preparedness for Emerging Infectious Diseases After the Ebola Outbreak    36 
OEI-06-15-00230   
 
40 HHS, HHS Launches National Ebola Training and Education Center. July 1, 2015.  Accessed at 
https://web.archive.org/web/20151029101716/http://www.hhs.gov/about/news/2015/07/01/hhs-launches-national-
ebola-training-and-education-center.html on March 20, 2018. 
41 42 CFR pt. 482. 
42 Social Security Act,  1861(e); 42 U.S.C.  1395x(e); 42 CFR  488.3(a). 
43 CMS, State Operations Manual, ch. 2, Certification Process, Revision 179, July 6, 2018.  Accessed at 
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/som107c02.pdf on August 14, 2018. 
44 42 CFR  482.15 and 482.42. 
45 81 Fed. Reg. 63859 (Sept. 16, 2016).  
46 CMS defines an all hazards approach as one that focuses on capacities and capabilities that are critical to 
preparedness for a full spectrum of emergencies or disasters specific to the location of a provider or supplier, 81 Fed. 
Reg. 63861 (Sept. 16, 2016). 
47 42 CFR  482.15(a)-(d); 42 CFR  485.625(a)-(d). 
48 HHS, OIG, State and Local Pandemic Influenza Preparedness:  Medical Surge, OEI-02-08-00210, September 2009.  
Available at https://oig.hhs.gov/oei/reports/oei-02-08-00210.pdf.  
49 HHS, OIG, Hospital Emergency Preparedness and Response during Superstorm Sandy, OEI-06-13-00260, 
September 2014.  Available at https://oig.hhs.gov/oei/reports/oei-06-13-00260.pdf.  
50 As part of the pre-inspection process, we conducted site visits and interviews at five hospitals (three acute-care 
hospitals and two critical access hospitals) to learn more about critical issues affecting hospitals as they prepare to 
respond to EIDs.  We used information from these site visits to develop and refine the survey.  We excluded from the 
survey these 5 hospitals, as well as 16 other hospitals that were part of the same health care systems.  
51 CMS, Critical Access Hospitals.  Accessed at https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/CertificationandComplianc/CAHs.html on October 2, 2017. 
52 CMS, MLN Booklet: Critical Access Hospital, 2017.  Accessed at https://www.cms.gov/Outreach-and-
Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/CritAccessHospfctsht.pdf on March 20, 2018. 
53 42 U.S.C.  1395i-4.  
54 42 CFR  485.601-647. 
55 Prospective payment hospitals in urban areas may be reclassified as rural for the purposes of CAH designation if 
they meet the requirements set forth in 42 CFR  412.103. 
56 The Certification and Survey Provider Enhanced Reporting (CASPER) system is a CMS administrative database that 
includes hospital certification, results of onsite visits, and a summary of patient characteristics.  OIG received the 
CASPER data on June 7, 2016.   
57 The Rao Scott modified chi-squared test was statistically significant at the 95-percent confidence level for 
differences between CAHs and all other hospitals having different preparedness levels in in 2014 (p < 0.0001) and in 
2017 (p = 0.0040). 
58 The Rao Scott modified chi-squared test was statistically significant at the 95-percent confidence level for 
differences in preparedness levels between hospitals that conducted either drills or exercises and hospitals that did 
not conduct drills or exercises (p = 0.005). 
59 The Rao Scott modified chi-squared test was statistically significant at the 95-percent confidence level for 
differences between unprepared hospitals and prepared hospitals with regard to seeking guidance from all three 
relevant HHS agencies: ASPR, CDC, and CMS (p = 0.0225). 
60 The Rao Scott modified chi-squared test was statistically significant at the 95-percent confidence level for 
differences between unprepared hospitals and prepared hospitals with regard to challenges in maintaining adequate 
equipment and supplies, including vendor services (p = 0.0005). 
 
Hospitals Reported Improved Preparedness for Emerging Infectious Diseases After the Ebola Outbreak    37 
OEI-06-15-00230