Marge McFarlane,PhD CHSP,HEM, MEP, CHEP

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HSEEP Train the Trainer Sustaining an Effective
Hospital Exercise Design Process
Marge McFarlane,PhD CHSP,HEM, MEP,
CHEP mcfarlane.marge_at_gmail.com715-835-3730Trac
y Buchman, DHA, CHPA, CHSPHSS, Inc.
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Objectives

• Apply Adult Learning Principles to the
• HSEEP Training Course
• Identify key elements needed for designing
  exercises
• Write SMART Objectives
• Develop Evaluation Forms
• Identify Criteria for Evaluator Selection,
  Training, and Etiquette

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Objectives

• Develop the Master Scenario Events List
• Discuss After Action Reports for exercises and
  actual events
• Identify elements needed to sustain the Exercise
  Program Management process

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Agenda
800 Section 1. Introductions and Overview
845 Section 2. Adult Learning and Exercise
Program Management 930 Section 3.
Introduction to the Modified Tools 1030
Section 4. Developing SMART Objectives and
Exercise Evaluation Guides 1115 Section 5.
Exercise Design Checklist
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Agenda

• 100 345 Section 6 - 8
• Small Group Activities
• Exercise Development and Presentation
• 400 Section 9
• Next Steps for Sustaining the Process
• 420 Section 10
• Q A and Program Evaluation

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Section 1Why Sustain an Effective Exercise
Design Process?

• To plan for succession
• To identify gaps in planning prior to actual
  events
• To lessen stress during disasters for staff,
  patients, hospital, victims, community
• To meet regulatory requirements

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Exercise Standards

• Joint Commission 2011 Emergency Management
  Standards contain 17 Elements of Performance
  directly related to exercises
• Centers for Medicare and Medicaid (CMS) issued an
  emergency planning checklist in 9/07 www.cms.gov
• Exercises must be operational rather than
  discussion-based

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What does it take to design an exercise?

• Time
• Tools
• Templates
• Training
• Team

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Methods of Exercise Design

• Pencil and paper
• Homeland Security Exercise and Evaluation Program
  (HSEEP)
• Agency for Healthcare Research and Quality (AHRQ)
  Exercise Evaluation Tools
• Modified tools prepared for this course

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What is HSEEP?

• Department of Homeland Security Exercise and
  Evaluation Program
• A capabilities-based program for the design,
  conduct, evaluation and improvement of emergency
  exercises
• HSEEP forms and templates provide a recipe for
  exercises

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HSEEP Background

• Developed from the National Exercise Program as a
  result of Homeland Security Presidential
  Directives (HSPD) 5 and 8
• HSPD 5 created the National Incident Management
  System (NIMS)
• HSPD 8 created HSEEP
• Has evolved since 2002 into an all-hazards
  focus
• Capability versus Capacity

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HSEEP Can Provide

• A method for response partners to exercise
  together over multiple years
• A common policy, language, and approach for
  exercise development and training among planning
  partners
• A repository for lessons learned and best
  practices so agencies can learn from one another

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HSEEP is NOT

• Another thing for you to do
• Endorsed or required by The Joint Commission or
  CMS
• As difficult as you may think

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Why Should Hospitals Use HSEEP?

• Helps to synchronize exercise scheduling with
  partners to avoid exercise fatigue
• Since 8/8/08 (FY08), Office of the Assistant
  Secretary for Preparedness and Response (ASPR)
  Grant funded exercises must follow HSEEP Guidance
• Incorporates National Incident Management System
  (NIMS)

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Section 2 Adult Learners

• This is a Train-the-Trainer Course
• Many of us have not had training on how to train
• Most of us have learned on the job

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Characteristics of Adult Learners

• Adults have specific expectations
• Training must be relevant
• Training must justify time spent
• Training materials must be credible
• The instructor(s) must be credible

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Engaging Adult Learners

• Presenting
• Questioning
• Facilitating
• Storytelling

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Qualities of an Effective Trainer

• Active Listening
• Peripheral Vision
• Empathy
• Timing
• Clarity

• Differentiation
• Variability
• Sensitivity
• Self disclosure
• Flexibility

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Behavior of an Effective Trainer

• Be prepared
• Be yourself
• Be energetic
• Be direct
• Use your sense of humor

• Be clear
• Be sensitive to learners
• Share leadership
• Be a role model
• Be positive

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Exercise Program Management

• Focus on the capabilities-based cycle
• Planning
• Training
• Exercising
• Improvement
• Plan, Do, Check, Act for the entire program not
  just for each exercise

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What is the HSEEP Program Management Process?

• Conduct an annual Training and Exercise Plan
  Workshop (TEPW) to develop and maintain
  Multi-year Training and Exercise Plan
• 2. Plan and conduct exercises in accordance with
  guidelines in HSEEP 8 step model

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What is the HSEEP Program Management Process?
3. Develop a properly formatted After Action
Report/Improvement Plan (AAR/IP) 4.Track and
Implement corrective actions identified in the
AAR/IP
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Training Exercise Workshop Internal

• The annual review of internal multi-year exercise
  plan to include
• Completion of multi-year exercise analysis (what
  has been tested in previous years?)
• Review of improvements from previous exercises
  (what was fixed and is the fix still
  effective?)

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Training Exercise Workshop Internal
3. Review internal and regional HVA for risks,
gaps and vulnerabilities (what still needs to be
tested?) 4. Review experience from actual
emergencies or events (what was fixed and is
the fix effective?) 5. Review current
capabilities to identify staff training needs-
i.e., bed tracking, evacuation equipment,
electronic stethoscopes
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Training Exercise Workshop Internal

• 6. Develop internal exercise and training plan
• (identify objectives to be tested future drills)
• Consider 3 year exercise training plan
• Current capabilities
• Improvements from previous exercises
• Risk (as Identified on HVA)
• Experience with actual emergencies or events
• New equipment acquisitions, staff turnover

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Preparedness Partners Training and Exercise Grid

REGION x PREPAREDNESS PARTNERS TRAINING AND EXERCISE SCHEDULE 20xx PREPAREDNESS PARTNERS TRAINING AND EXERCISE SCHEDULE 20xx PREPAREDNESS PARTNERS TRAINING AND EXERCISE SCHEDULE 20xx PREPAREDNESS PARTNERS TRAINING AND EXERCISE SCHEDULE 20xx PREPAREDNESS PARTNERS TRAINING AND EXERCISE SCHEDULE 20xx PREPAREDNESS PARTNERS TRAINING AND EXERCISE SCHEDULE 20xx PREPAREDNESS PARTNERS TRAINING AND EXERCISE SCHEDULE 20xx PREPAREDNESS PARTNERS TRAINING AND EXERCISE SCHEDULE 20xx PREPAREDNESS PARTNERS TRAINING AND EXERCISE SCHEDULE 20xx PREPAREDNESS PARTNERS TRAINING AND EXERCISE SCHEDULE 20xx PREPAREDNESS PARTNERS TRAINING AND EXERCISE SCHEDULE 20xx PREPAREDNESS PARTNERS TRAINING AND EXERCISE SCHEDULE 20xx
REGION x Qtr 1 Qtr 1 Qtr 1 Qtr 2 Qtr 2 Qtr 2 Qtr 3 Qtr 3 Qtr 3 Qtr 4 Qtr 4 Qtr 4
REGION x J F M A M J J A S O N D
Public Health
Hospitals
EMS
Emergency Management
Fire
Law Enforcement
Other
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Training Exercise WorkshopExternal Partners

• Hospital meets annually with local preparedness
  partners to coordinate exercises and grant
  objectives, where possible
• Jointly develop a multi-year exercise plan with
  increasing complexity
• The development of the multi-year exercise plan
  will evolve over time with changes in federal
  grant guidance

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Questions so far?
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Section 3 Introduction to the Tools

• KEY SECTION DOCUMENTS
• Section 3.1
• Gathering Exercise Planning Documents
• Section 3.2
• Multi-year Exercise Review Grid
• Section 3.3
• Example After-Action Report with Improvement
  Plan (AAR/IP)

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YEAR COMMUNITY HOSPITAL, ANYCOUNTY, USA MULTIYEAR EXERCISE REVIEW COMMUNITY HOSPITAL, ANYCOUNTY, USA MULTIYEAR EXERCISE REVIEW COMMUNITY HOSPITAL, ANYCOUNTY, USA MULTIYEAR EXERCISE REVIEW COMMUNITY HOSPITAL, ANYCOUNTY, USA MULTIYEAR EXERCISE REVIEW COMMUNITY HOSPITAL, ANYCOUNTY, USA MULTIYEAR EXERCISE REVIEW COMMUNITY HOSPITAL, ANYCOUNTY, USA MULTIYEAR EXERCISE REVIEW COMMUNITY HOSPITAL, ANYCOUNTY, USA MULTIYEAR EXERCISE REVIEW COMMUNITY HOSPITAL, ANYCOUNTY, USA MULTIYEAR EXERCISE REVIEW COMMUNITY HOSPITAL, ANYCOUNTY, USA MULTIYEAR EXERCISE REVIEW COMMUNITY HOSPITAL, ANYCOUNTY, USA MULTIYEAR EXERCISE REVIEW COMMUNITY HOSPITAL, ANYCOUNTY, USA MULTIYEAR EXERCISE REVIEW COMMUNITY HOSPITAL, ANYCOUNTY, USA MULTIYEAR EXERCISE REVIEW
YEAR Qtr 1 Qtr 1 Qtr 1 Qtr 2 Qtr 2 Qtr 2 Qtr 3 Qtr 3 Qtr 3 Qtr 4 Qtr 4 Qtr 4
YEAR J F M A M J J A S O N D
2006 FEMA Radiation exercise Hazmat decon tent, victims
2007 Haz mat drill Lab evac trauma influx, triage tags, bed capacity
2008 Event high census focus on early dischg County Drill Hospital EOC Liaison ICS, Pneumonic Plague, influx of pts
2009 Event Extended High census ER Holding, documentation of care Event H1N1 County Exercise Chlorine Leak
2010 Apartment fire with evacuation OR Sprinkler activation FEMA Radiation Exercise
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MULTIYEAR EXERCISE REVIEW REMAINING
OPPORTUNITIES FOR IMPROVEMENT OR RETESTING
2009 Inpatient Surge Notification to families of need for prompt discharge High turnover of IV pumps, battery charging issues Mechanism for charting second doses of med given in ER
2008 Trauma surge Phone bank for family calling looking for family members Family waiting area new construction issues Family parking issues Coordinator for billing for green triage area
2007 Tornado warnings Location for visitors now that Community Auditorium is available Budget for security film for CCU/SICU windows Non- clinical areas reporting for labor pool North wings closed for Construction Alternate areas for evac





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Capabilities, Critical Tasks Objectives

• Capabilities are broad categories of competency
  communications, medical surge, decontamination
• Critical Task are the major processes within the
  capabilities notification of decon event, set up
  of decon area, actual decon, post decon triage
  and treatment
• Objectives are SMART

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Capabilities and Critical Tasks

• Sample capabilities can be found in the
• target capability list (HSEEP)
• critical functions (Joint Commission)
• Section 3.4 Sample activities and tasks
• HICS planning and response guides
• www.emsa.ca.gov

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Critical Functions

• Communications, internal and external
• Resources Mobilization and Allocation
• Staff Roles and Responsibilities
• Safety and Security
• Utilities
• Patient Care and Staff Support

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Capabilities and Critical Tasks

• Hospital Incident Command
• Implement Incident Command
• Establish Full Hospital Incident Command
• Resource Management
• Develop Incident Action Plan (IAP)
• Execute Plan

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Objectives Selection Drives the Exercise
Evaluation

• Objectives should be SMART
• Simple straightforward, easy to understand
• Measurable specific and observable
• Achievable challenging but not impossible
• Realistic reflect actual goals of time,
  personnel, resources
• Task-Oriented specific operations

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Exercise Objectives

• Discussion based objectives
• Focus on Plans, Policies, Procedures
• Inter-agency or interdepartmental coordination
  and decision making
• Operations based objectives
• Identify player actions of who will do what,
  under what conditions, according to what
  standards

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Section 4
Evaluation
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Exercise Evaluation Guides (EEGs)

• Identifies what observers should evaluate
• Promotes consistent performance measurements
• Act not as a scorecard, but as an
  observations-collection method
• Provided input to the writers for the development
  of the AAR/IP

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Exercise Evaluator Selection and Training

• Criteria for Evaluator Selection
• Training to include guidance on
• What to look for
• What to record
• How to use the EEGs
• How to analyze data

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Section 5 Exercise Design Checklist
Tool adapted from AHRQ Exercise
Evaluation Report to limit the scope of the
exercise while including all key elements needed
to design an exercise
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Section 6 Scenarios

• Written based on the HVA and objectives selected
  for the exercise
• Set the scene so the exercise can begin
• Should be as realistic as possible to better
  engage players
• Most exercise designers begin with the scenario
  rather than the objectives

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Scenario Development
HICS website www.emsa.ca.gov Hospital
Incident Command Appendix H HICS for Rural
Hospitals www.preped.org/Resources/HICS-JAS-Form
s.htm
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Section 7
Master Scenario of Events List (MSEL)
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MSEL (mee-zul)

• Messages or injects keep the play moving in the
  direction of the objectives
• Written to bring the exercise back on
• track, sometimes spontaneously
• May need up to 40-80 injects per hour of exercise
  for a functional exercise because movement of
  equipment is simulated

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Elements of a Message or Inject
Delivered a designated scenario time Controller
responsible for delivering inject Includes
expected player action Identifies the intended
player
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Different Messages or Injects
Contextual Injects Developed by the Exercise
Design Team during the design process to keep
the exercise moving in the direction of the
objectives Contingency Injects Developed
just in case by the Exercise Design Team or
injects developed during the exercise because of
unexpected participant response
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Where Do the Messages (Injects) Come From in a
Functional or Full-Scale Exercise?
Other departments in the hospital Other response
agencies participating in the exercise, i.e.
Public Health, EMS, Emergency Operations Center
(EOC) A simulation cell who pretends to be other
response partners not participating in the
exercise
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How to Develop the MSEL
Review the scenario and exercise
objectives Develop a timeline of expected player
actions Identify the chronology of key actions
that must occur, either actual or
simulated Compile all MSEL events into a single
list Seek agreement from the exercise planning
team
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Message From Message Target Event (Message or Inject) Expected Action (Objective) Critical Areas/Tasks Targeted
1 Hospital IC Authorized persons establish need to activate Hospital Incident Command Hospital IC is activated Staff Roles- IC activated
2 Hospital IC Initial Incident Action Plan (IAP) for the first two hours is established Hospital IC completes written IAP Staff Roles- Incident Action plans
3 Hospital Facilities Roof leakage increases, generator threatened Facility infrastructure protection/ maintenance plan implemented Utilities
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Section 8 Evaluation Data Analysis

• Develop evaluation guides during exercise
  planning process
• Select and train evaluators to
• - Observe and record the actions of
  players during an exercise.
• - Assess exercise activities against
  exercise objectives.
• - Participate in data analysis and the
  drafting of the After-Action Report
  Improvement Plan (AAR/IP).

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What is an After Action Report (AAR) ?
Provides feedback to participants on their
performance during an exercise or event Provides
assessment about preparedness Identifies needed
resources and support
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After Action Report/ Improvement Plan (AAR/IP)

• Provides outline for development of final After
  Action Report and Improvement Plan
• Promotes consistent format across/between agencies

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Elements of an AAR/IP

• Executive summary
• Exercise design summary- scenario/participants
• Analysis of capabilities-strengths and
  opportunities for improvement with recommended
  actions
• Appendix A Improvement Plan Matrix

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Improvement Plan (Appendix A)
Includes the critical area or capability
tested Observation from the exercise or
event Recommendation for improvement Responsible
party or department Start and targeted completion
date
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Improvement Plan Corrective Action

• Must be measurable
• Includes a projected start/completion date
• Assigned to a specific department, point of
  contact or agency
• Monitored and reviewed as part of the improvement
  process
• Have a process for improvements to be retested
  with the next appropriate exercise cycle

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Section 9 Sustaining the Process

• Monitor the After Action Report and Improvement
  Plan
• Review progress and accountability for
  improvements at Emergency Management meetings
• Review identified resource needs at budget time
• Develop a multi-year strategy for continuous
  improvement

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Section 10 Questions and Evaluation

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Thank you!!!!To obtain online
documentsmcfarlane.marge_at_gmail.com