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Prepare for the worst with repetition


October 1, 2010

What The Joint Commission expects from your emergency exercises

There’s a good reason why The Joint Commission expects hospitals to regularly conduct emergency drills or exercises, says Joseph L. Cappiello, MA, BSN.

“We do best what we do often,” says Cappiello, chair of Cappiello & Associates in Elmhurst, IL.

“Why do we do drills? We’re trying to ingrain in our staff an automatic response,” he says. In an emergency—a hurricane, an ice storm that wipes out power, or a terrorist attack—you want your staff prepared to operate in a crisis.

Cappiello compares emergency preparation to the five weeks of airborne training he once went through. In two or three hours, instructors can train soldiers to jump out of an airplane and land safely on the ground. But repeating this training for five weeks means if soldiers have to jump from a plane in a stressful combat situation, they’ll be able to do so without hesitation.

Exercises build competence and confidence in staff when they have to do things they don’t ordinarily do, Cappiello says. Staff need to develop skills and be exposed to experiences that are uncommon in their work routines, he told the audience at the 4th annual Hospital Safety Center Symposium in Las Vegas in May.


Joint Commission requirements

Exercises are also important to The Joint Commission, says Cappiello, the former vice president for accreditation field operations at the organization. Cappiello helped develop The Joint Commission’s emergency management (EM) standards.

In 2008, The Joint Commission moved the EM standards into their own chapter within the Comprehensive Accreditation Manual for Hospitals. “That was a shot across the bow,” Cappiello says. “The Joint Commission was saying to leadership, ‘The emergency management standards are important. We’re putting you on notice that you better be doing these things.’ ”

The EM standards require that hospitals have an emergency operations plan (EOP) that outlines how the facility will deal with a disaster, whether it’s a sewer line backup or a flood. The standards also require hospitals to activate the EOP at least twice each year, Cappiello says.

If you activate the plan in response to an actual emergency, that counts as one of your required exercises. If you are in doubt whether a particular event counts, call The Joint Commission and describe the event; officials will give you a ruling, Cappiello says.

The standards also require that at least one of the two exercises includes:

  • An escalating event in which the community is unable to support the hospital
  • An influx of patients
  • Participation in a communitywide exercise 


These requirements are based on the debriefing of hundreds of facilities that experienced emergencies, Cappiello says. 

In many disasters, events escalated and hospitals found themselves without any community support. Patients flooded local medical centers, and the hospitals’ best chance of surviving the disasters was to be closely connected to their communities, he says.

Exercises have real benefits and value to hospitals, Cappiello says. The emergency exercises you perform make for a prepared organization. However, it is not enough to conduct an exercise that ends in an exchange of high-fives and the CEO saying everyone did a terrific job. A successful exercise demonstrates how, when, and why the critical systems needed for survival or recovery break down. The value of the exercise comes from learning how to improve those systems and extend their functionality.

Another benefit of exercises is that they increase staff and leadership’s sense of competency. Exercises don’t just help prepare staff; they also help ensure that hospital leadership is ready to cope in a disaster. “The last thing we want is a leadership team not sure what to do,” says Cappiello. “Leaders need to understand how to manage escalating and complex events.”

Cappiello outlines the following tips to get the most out of your emergency exercises:

• Make sure your exercises mirror reality. Significant disasters, such as a major hurricane or flood, are sustained events that can last for multiple days or weeks, Cappiello says. A large-scale disaster can affect multiple communities, both near and far. Disasters often affect or debilitate public services, and they can overwhelm state and federal response teams. If your response to a disaster is to rely on outsiders for support, you have created an unrealistic and potentially harmful plan, he says.

 In one case, four large hurricanes hit Florida back to back, Cappiello says. In a disaster of that magnitude, help may not get to you very fast. 

In fact, major disasters can threaten the entire healthcare infrastructure, he says. Many facilities must begin providing services they normally don’t provide. Hospitals can expect the chronically ill to arrive seeking medical support, such as dialysis patients who get their care from freestanding centers that may have been forced to shut down.

Patients who normally receive home care may be left without services if nurses cannot reach them. Ventilator-dependent patients who live at home may come to your hospital if the community loses power. 

Well-run exercises keep returning to the point where a facility’s systems begin to break down and fail, Cappiello says. The goal is to improve the performance of responders.

“It’s not about having a great exercise, it’s about having a realistic exercise that challenges us, that strains our systems, where learning takes place and we make improvements. That is where exercises need to go,” he explains. 

• Design your exercises to prepare for the real challenges you may face. In a disaster, a hospital is likely to see increased admissions along with decreased discharges. Citizens may come to your hospital seeking non-healthcare-related services and shelter, especially if you are the only place in the community with power and water.

You can count on the fact that not everything you usually depend on will work. Staff that you need may not be on hand and may not be able to get to the hospital if roads are blocked by downed trees or clogged with snow.

Escalating pressures will continue to be applied to your limited resources, Cappiello says. Your facility itself will face challenges when it comes to space, safety, and power. You should address how you will take care of these needs in your EOP, and you should exercise those plans.

“One of the issues we’ve seen time and time again is that exercises don’t reflect reality,” Cappiello says. Instead, hospitals run the same old exercise every time, such as a pile-up of cars on the interstate. “They don’t put a lot of time into their exercises,” he says. “It’s a  ho-hum event that’s not challenging to the staff and not stressing your systems.”

However, be sure your exercises are practical. Cappiello recalls a hospital in the Midwest that based its exercise around a volcanic eruption. Hospital officials said they wanted to make the exercise entertaining to staff by doing something unusual. 

The problem with such a scenario is that you learn nothing, he says. “It’s a waste of time and energy.”

Good exercises can also be expensive and disruptive, Cappiello says. If a scenario calls for a hospital to close down one of its operating rooms, that will cost revenue. So you have to balance a realistic plan with the disruption to your facility.

• Take threats and the exercise process seriously. In July 2004, emergency planners at the Federal Emergency Management Agency created a simulated hurricane exercise called “Hurricane Pam.” The five-day exercise was held at the State Emergency Operations Center in Baton Rouge, LA, involving emergency officials from 50 parish, state, federal, and volunteer organizations. In the scenario, a slow-moving Category 3 hurricane carrying 20 inches of rain hit New Orleans. Levees overflowed, the city flooded, and 100,000 “low-mobility” people could not evacuate the area. In the scenario, an estimated 25,000 people died.

Yet the government didn’t take it seriously, Cappiello says, adding that state and federal groups thought the exercise was a joke. They did not think the scenario was plausible. The participants didn’t engage in the exercise, and leaps of faith and assumptions were rampant.

“A year later there was a real hurricane named Katrina,” Cappiello says, referring to the storm that devastated New Orleans. If people had taken the lessons of Pam seriously, “we could have prepared that city so much better.”

• Construct your emergency exercise by taking eight steps. Start constructing your exercise by assessing the needs of your hospital. Your hospital vulnerability assessment tool will show you the types of disasters that are likely to occur. Follow these steps:

  1. Assess your needs 
  2. Define the scope of the exercise
  3. Write a statement of purpose 
  4. Record the objectives of your exercise
  5. Compose a narrative of what will occur
  6. Write and detail the events 
  7. List the expected actions
  8. Prepare messages

The last step on the list is to prepare messages. This means you start with a given scenario, but as the exercise progresses the leaders continually send messages that develop the situation, Cappiello says. For example, you may start with a scenario in which a tornado hits the south wing of your building. Then leaders send a message: The tornado has hit the local power plant—you no longer have power. Another message follows: Dozens of injured people are now making their way to your ER.

“It’s these messages that add complexity and challenges,” Cappiello says.

You can get help designing your exercises from the Homeland Security Exercise and Evaluation Program. Go to www.hseep.dhs.gov

• Start thinking about your exercise with the end in mind. Determine exactly what you want to test, says Cappiello. Is it your communication systems? Your technology? Existing resources? Knowledge? Skills? Adaptability?

• Create a more effective exercise. Choose the right type of exercise for your facility. The scenario you pick makes a big difference, Cappiello says. Choose an event that is realistic and poses a real threat to your hospital.

Develop a role for the general medical staff, including your physicians. What happens when you can’t get the supplies you need? What happens if you suddenly have patients of a type or quantity that you are not used to? For instance, if you are a children’s hospital and adults are arriving at your facility, which patients will be prioritized if resources run short? Say there are only 75 ventilators in your entire state. Are you prepared to move to an altered standard of care if there are too many casualties for your staff to treat? Are physicians and nurses prepared to turn their backs on patients if they simply can’t treat them?

You should engage nongovernment organizations whenever possible. Remember that surprises are good when it comes to emergency exercises. 

Get the media involved. Leadership will take an interest and it is a good chance to demonstrate your role in the community, Cappiello says.

• Recognize why exercises fail. Exercise design often fails to include breakdowns in communication, Cappiello says. In reality, communication failure is the single biggest problem in an actual disaster. How will you communicate when normal channels are disrupted? What happens when cell phones and landlines don’t function?

It’s often effective to write messages on a notepad and have someone deliver them from your command center to staff, Cappiello says. “The written word is clearer than messages relayed verbally and provides a record of actions taken.”

Another reason for failure is the after-action review, which is seldom as honest as it needs to be for lessons to emerge, Cappiello says. Nobody wants to be very critical. Everyone worked hard on the exercise, making it difficult to say something failed. Bringing in an objective party to evaluate your exercise is a worthwhile step, he says. One possibility is to get your community’s fire chief to look over the exercise. Fire chiefs are involved in exercises all the time and are not tied to your facility. Tell the evaluator to be blunt with his or her criticism. The point of the review is to be aware of your limitations and build a better response.

An additional problem is that the exercise evaluation is not documented or circulated to the offices and agencies that need it the most. Too often this valuable report sits on someone’s desk, Cappiello says, or the person with authority to respond to the issues raised fails to read it. Create some urgency for your hospital leadership to read the evaluation. 

• Escalate your exercise scenarios. Running an exercise is an art form, Cappiello says. The basic scenario must allow for feasible and realistic escalation to keep all parties engaged.

The messages you add into your scenario need to take specific groups out of their comfort zone, he says. Don’t allow anything to run smoothly for very long, especially communication.

When a solution is developed, ask “How?” three to five times to explore its feasibility, says Cappiello. For instance, you decide you can prevent flooding by sandbagging the levees around your community. How are you going to accomplish this? Where will you get the trucks? Who is going to fill the sandbags? Where will you get the sand?

Stress the goal during exercises, but remember that you are not setting out to find fault or embarrass anyone. You are trying to discover where your systems are vulnerable.

“Why do we do fire drills? We want to prepare staff to react instinctively to protect themselves and the patients they serve,” Cappiello says. “Exercises are no different.”


The benefits of emergency exercises

Conducting exercises has real benefits for hospitals, says Joseph L. Cappiello, MA, BSN, chair of Cappiello & Associates in Elmhurst, IL. Those benefits include:

  • Significantly increasing the likelihood of survival 
  • Minimizing business or service interruptions
  • Preserving and enhancing an organization’s reputation
  • Minimizing the impact of disaster on the community and environment
  • Minimizing the social, political, legal, and financial consequences of the disaster
  • Identifying an organization’s areas of vulnerability
  • Improving the performance of responders


What emergency exercises can do for your hospital

Emergency exercises help hospitals do the following:

  • Teach automatic responses that are less easily eroded by stress 
  • Increase staff and leadership’s sense of competency
  • Identify gaps in response planning
  • Highlight organizational system failures
  • Reduce dependency on outside agencies
  • Validate the usefulness of tools
  • Reduce uncertainty and help control anxiety 


Source: Joseph L. Cappiello, MA, BSN, chair of Cappiello & Associates in Elmhurst, IL.

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