After-Action Report/Improvement Plan Template



Severe Weather Tabletop ExerciseAfter-Action Report/Improvement PlanJuly 21, 2017; 1300 -1500Clark County Health Care CoalitionThe After-Action Report/Improvement Plan (AAR/IP) aligns exercise objectives with preparedness doctrine to include the National Preparedness Goal and related frameworks and guidance. Specific to this report, the exercise objectives align with ASPR’s National Guidance for Healthcare Preparedness and the Hospital Preparedness Program Measures. Record of Change11/2017Created AAR/IPC.Conover, CCCHDExercise OverviewExercise NameSevere Weather Tabletop ExerciseExercise DatesJuly 21, 2017 ScopeThis exercise is a discussion based Table Top Exercise (TTX), planned for two (2) hours among Health Care Partners in Clark County, Ohio. Core Capabilities2017- 2022 Health Care Preparedness and Response Capabilities, ASPR; 2. Health Care and Medical Response CoordinationCapability 3. Continuity of Health Care Service DeliveryObjectivesCap 2-Objective 3: Coordinate Response Strategy, Resources and CommunicationsCap 3-Objective 2: Plan for Continuity of OperationsCap 3-Objective 3: Maintain Access to Non-Personnel Resources during an EmergencyThreat or HazardSevere Weather/TornadoScenarioFor the purposes of this exercise, the main driver will be a severe weather event, including a tornado that causes damage to the home office facility or residential care facility. Additionally, many other response needs are taxing the availability of Emergency Medical Services (EMS). Traditional communication systems and transportation systems are disrupted. SponsorClark County Emergency Management Agency (EMA), OhioParticipating OrganizationsHealth Care Partners within the Clark County Health Care CoalitionPoint of ContactClark County EMASelinda Sizemore (937) 521-2177; ssizemore@ Ken Johnson (937) 521-2178; kjohnson@SummaryThis exercise was a tabletop exercise conducted among agencies that serve clients within their facilities. The severe weather scenario facilitated discussion regarding the probably response activities of the agencies. The discussed activities addressed both staff safety and client safety during attempts to continue operations in less than optimal circumstances. A demonstrated benefit of this successful exercise was the idea sharing that occurred between agencies. Strengths and areas for improvement are noted below. Analysis of Health Care Preparedness (HPP) CapabilitiesThis table includes the exercise/event objectives, aligned HPP capabilities, and performance ratings for each HPP capability as observed during the exercise or real world response and determined by the evaluation/AAR team.Table 1. Summary of HPP Capability PerformanceObjectivePHEP/HPP CapabilityPerformed without Challenges (P)Performed with Some Challenges (S)Performed with Major Challenges (M)Unable to be Performed (U)Identify and coordinate resource needs during an emergency. Capability 2: Health Care and Medical Response CoordinationXCommunicate with health care providers, non-clinical staff, patients and visitors during an emergencyCapability 2: Health Care and Medical Response CoordinationXContinue administrative and finance functionsCapability 3. Continuity of Health Care Service DeliveryXPlan for health care organization shelter in placeCapability 3. Continuity of Health Care Service DeliveryXAssess supply chain integrityCapability 3. Continuity of Health Care Service DeliveryXAssess and address equipment, supply, and pharmaceutical requirementsCapability 3. Continuity of Health Care Service DeliveryXThe rating scale includes four ratings:Performed without Challenges (P): The PHEP functions, tasks, and performance measures or the HPP activities, objectives, and performance measures associated with the capability were completed in a manner that achieved the objective(s) and did not negatively impact the performance of other activities. Performance of this activity did not contribute to additional health and/or safety risks for the public or for emergency workers, and it was conducted in accordance with applicable plans, policies, procedures, regulations, and laws. Performed with Some Challenges (S): The PHEP functions, tasks, and performance measures or the HPP activities, objectives, and performance measures associated with the capability were completed in a manner that achieved the objective(s) and did not negatively impact the performance of other activities. Performance of this activity did not contribute to additional health and/or safety risks for the public or for emergency workers, and it was conducted in accordance with applicable plans, policies, procedures, regulations, and laws. However, opportunities to enhance effectiveness and/or efficiency were identified.Performed with Major Challenges (M): The PHEP functions, tasks, and performance measures and or the HPP activities, objectives, and performance measures associated with the capability were completed in a manner that achieved the objective(s), but some or all of the following were observed: demonstrated performance had a negative impact on the performance of other activities; contributed to additional health and/or safety risks for the public or for emergency workers; and/or was not conducted in accordance with applicable plans, policies, procedures, regulations, and laws.Unable to be Performed (U): The PHEP functions, tasks, and performance measures or the HPP activities, objectives, and performance measures associated with the capability were not performed in a manner that achieved the objective(s).Objectives of the Exercise: Identify and coordinate resource needs during an emergency. Communicate with health care providers, non-clinical staff, patients and visitors during an emergencyContinue administrative and finance functionsPlan for health care organization shelter in placeAssess supply chain integrityAssess and address equipment, supply, and pharmaceutical requirementsStrengths and Opportunites: Note: Due to the facilities all having unique challenges and ideas, some of the opportunities for one or more agencies is also noted as strength for others. This highlights the value of information and idea sharing through a tabletop exercise. Strengths Identified During Discussion:Existing agreements for food storage when power is out.Ability to have paper/printed MARs/TARs in preparation for relocation of patients or inability to access electronic records. All agencies had well identified safe rooms/areas. Incident Command /Control is well practiced and is a strength. The use of 2-way radios is positive and works well. Easy to use flip book with protocols for emergencies has been helpful for staff knowledge of protocolsAgency has a backup generator in place.Agency has many items/equipment with back up batteries. Accountability protocols in place every day. Staff trained in emergency procedures. Opportunities for Improvement Identified During Discussion:Need to develop staff roles and responsibilities in emergencies and increase their comfort level with the existing protocols. Need to evaluate safety, security protocols. Evaluate preparedness plans against the 96 hour rule: how long can you work when emergency resources begin to be used?Agency needs longer term “back up” plan for relocation or shelter in placeReview MOUs/Agreements for non-personnel resources. Consider battery backup for computer. Have staff use different cell services to increase likelihood of ability to make calls.Create protocol to alert driver. Look for easier way to remotely access MARS. Need to consider purchase of generator or investigate places to rent a generator. Become more familiar with protocol for accessing resources through EMA when all other plans fail. Store water for emergencies. Investigate refrigerated storage from Gordons. Develop better coordination with community, communications with other facilities. Invest in 2 way radios, digital thermometers to track temp in refrigerators during outage. Incident Management training could be helpful for some agenciesConsider benefit of plain language vs. code language for effective communication*****Notes for Participants:Each participating agency is asked to review the overall strengths and areas for improvement noted above and customize these lists according to the specific needs of the agency. The opportunities for improvement should then be included in the Improvement Plan in Appendix A. It is important that the issues identified for Improvement are addressed through subsequent planning, training and exercise. Appendix A: Improvement PlanThis IP has been developed specifically for Clark County Health Care Coalition as a result of Severe Weather Tabletop Exercise conducted on July 21, 2017 from 9AM-11AM. (Participant: See note on previous page)Issue/Area for ImprovementCorrective ActionPrimary Responsible OrganizationOrganization POCStart DateCompletion DateEvaluate agency’s sustainability and emergency suppliesUse the 96 hour rule tool to evaluate agency’s current sustainability.AgencyIdentify some useful tools for the 96 hour rule assessmentEMAK. JohnsonDevelop staff roles/responsibilities; increase staff familiarization Develop and deliver staff training on unfamiliar aspects of Emergency Plan. AgencyInvolve staff in exercises. AgencyReview and add to MOUs/Agreements for non-personnel resourcesInvestigate feasibility of purchasing generator, pigtail for generator or an MOU for renting a generator. AgencyReview MOUS/plans to check for more than one company listed in plans for generator fuel. AgencyInvestigate alternate communication tools Have staff use different companies for cell service to increase the opportunity for successful communication during a disaster event. AgencyCreate protocol to alert agency drivers of severe weather. AgencyEnhance collaboration with community agenciesSend one representative to the Clark County Health Care Coalition meetings. AgencyParticipate in exercises with regional partners when opportunity is available. Agency/CCCHD/ EMAK. JohnsonC. ConoverAppendix B: Exercise/Event ParticipantsParticipating OrganizationsLocal GovernmentClark County Combined Health DistrictClark County Emergency Management AgencyBethel Township FireNon-Government Coalition Members and PartnersDevelopmental Disabilities of Clark CountyEaster Seals Adult Day Services- SpringfieldFriends Care CommunityGood Shepherd VillageOakwood Village/ Mercy McAuley CenterSpringfield Assisted LivingClark MemorialOtherConsultant/SMEAppendix C: AcronymsTable E.1: AcronymsAcronymMeaningAAR/IPAfter-Action Report/Improvement PlanARCAmerican Red CrossASPRAssistant Secretary for Preparedness and ResponseCCCHDClark County Combined Health DistrictDHSU.S. Department of Homeland SecurityEOCEmergency Operations CenterEMAEmergency Management AgencyEMSEmergency Medical ServicesESFEmergency Support FunctionGDAHAGreater Dayton Area Hospital AssociationHCCHealth Care CoalitionHSEEPHomeland Security Exercise and Evaluation ProgramIAPIncident Action PlanIPImprovement PlanMOUMemorandum of UnderstandingODHOhio Department of HealthPHEP/HPPPublic Health Emergency Preparedness/Health Care PreparednessPOCPoint of ContactSitManSituation ManualSMESubject Matter ExpertTTXTable Top ExerciseAppendix D: Exercise/Event SummaryDayExercise TimeEvent/Action1 08:30Severe Thunderstorm Warning109:30A Tornado Warning is IssuedInject Detail:July 12th 2017 around 0830 AM. It’s a muggy, overcast day with a very light breeze. Temperatures are projected to reach 92*F, with a low of 81*F. The National Weather Service has issued a severe thunder storm warning for Clark County. NWS is advising several strong storm cells capable of producing high winds, excessive rain, and pea sized hail is traveling east at 25 to 35 mph. The National Weather Service has deemed the first cell unstable as it gains speed and strength. This cell is expected to reach your area around 10 AM.Is this an incident? How do you receive information? What plans do you activate? What are the triggers? Who activates them, and how is that communicated? Are there plans to shelter in place? Who is included, and what is the capacity? How long could you sustain operations with the supplies you have right now including: Food, Water, medical supplies, medications?Discussion 107/21/170942The first of several storm cells reach your area. Local media is advising to take cover07/21/170946Local media confirms a tornado touchdown07/21/170948Power is lost to the facility, generators have failed to engage.07/21/170950Significant damage is sustained to the structure from the flying debris07/21/170955Immediate threat has cleared the area07/21/171015Tornado warning has been lifted.Inject Detail: Emergency services are tied up with search and rescueMany roads are blocked by trees and debris. All phone and internet communication is unusable. Heavy rain continues with the next passing storms and rain water is coming into your facility. Temperatures inside begin to climb as you are starting to obtain a better picture of damages and strive for accountability. How many people are at your facility? How do you account for everyone including patients, staff, contractors, visitors and volunteers? Has your staff been trained to operate the backup generator and troubleshoot issues? How are internal and external communication taking place? Discussion 2 Inject Detail: Staff is trying to manage injuries and maintain scheduled medications and care. Generator was made operational through troubleshooting. Inside temperatures are a problem.Bandaging supplies are running low, and much of your equipment is being damaged from the leaking roof.Many patients have medications due.It is time for dinner. Is the generator capable of running A/C, refrigeration, food preparation, appliances, phones, sewage and emergency lighting? What is not covered and how do you overcome that? What fuel does the generator use, and how long can you sustain operations with your current fuel level? How will you document your medications and care, as well as view patient charts within HIPAA compliance? What medical care are you continuing under emergency operations? Are you using altered standards of care? If yes, describe. Discussion: 3See belowInject Detail: Emergency crews have cleared roadways and made it to your facility the following morning. Injured have been transported by ambulance.You have accounted for everyone remaining at the facility. Do you have MOU’s established with other facilities for evacuation? If so, how are they to be transported? Do you have MOU’s for equipment if some parts of your facility are still functional? Do you have any long term relocation plans? Discussion: 4See belowDiscussion Summary of Actions and Plans (grouped by topic area) Patient Care/ SafetyIn many of the agencies, procedures direct staff to move patients to safe places based on the severe weather warning. Nursing is prompted to brings meds/records with them to the safe place; sometimes this is the whirlpool room; areas are marked as safe Some protocols have ambulatory clients move to a safe space and non-ambulatory stay in room with extra blankets over the client to keep safe from flying debris. Code Black is used in some facilities as indication to shut blinds and doors, cubicle curtains; approximately 10 – 15 minutes to move patients. Remove things from windows Evacuate to inner roomsSpringfield Masonic Home: Flashlights on hallwaysSometimes the warning is trigger to put shoes by the client’s bed or to put shoes on the client to assist with quick evacuation. This could also be considered with Assisted Living. Friends mentioned a suitcase that is always prepared and at the Nurses station. It holds batteries, flashlights, etc. Emergency supplies are checked monthly and documented. Sometimes a clip is used for supplies and as long as clip is not broken off, supplies are assumed maintained. Mentioned 1135 Waiver CMS Many clients have O2 concentrators rather than tanks for ambulationFriends Care: 16 safe rooms. Mattresses and blankets placed in patient rooms that cannot be moved. Tornado siren behind facility. NOAA radios.NotificationCommon Sources of Notification: Weather RadioTornado SirenApps on phoneDiscussed Hyper-Reach (seamless from NWS)Don’t forget traditional media, common sense (sometimes NOAA not operational)Developmental Disabilities: Weather radios in each cottage,CommunicationDrivers-Protocol to Alert drivers about weather conditions predicted2 way radios-(VHF)-in buses with driversEaster Seals: Text staff to avoid weather or driving into weather.One agency attached to Hospital-Discussed using Runners; they would also have access to Multi Agency Radio Communications System (MARCS) due to this arrangement.Satellite phones mentioned; some availabililtyDiscussed some agencies using walkie-talkies/2 way to increase communicationAmateur Radio is a possibility if agencies have staff who have HAM license; Discussed amateur radio group established locallyDiscussed Statewide MARCS System but cost prohibitiveIf multiple staff carry cell phones, don’t have them all with same carrierSometimes texts work better than calls. Texts stack and wait for an opportunity to transmit when service is overtaxedBattery backed up itemsSuppliesMajority of the organizations have supplies to maintain for 72 hoursOne agency mentioned they have a 30 day supply of meds; so it depends when the incident occurs as to how many of the 30 day supply they still have. ResourcesOne agency mentioned fans ready for temperature maintenanceGenerator: Staff trained in preventive maintenance & trouble shootingConnections with 2 companies that fuel generatorsPumping fuel is a concernBackup generator kept on a nearby property for quick accessKeeps Fuel for generator-7 daysClark Memorial on Natural GasFriends Care Community: 2 staff trained on generators. 2 different companies that deliver fuel.Agency keeps a laptop on emergency power for access to electronic records even in emergency. Client ChartsMany agencies use web-based charts; remote users are able to print MARSOne agency still uses paper MARSSituation AssessmentOhio Edison: online tools for updates of power restorationAccountabilityAll agencies had sign in/out which they felt would allow for accountabilityDiscussed need to assign someone to do accountability MOU/ContractMemorandums of Understanding/Agreement:MOU/Contract with Gordon Foods for food storage & canned foods for backupExample-Clark Memorial has an agreement with Sterling House to move patients as needed.EMA can help coordinate finding beds & look for transportation resources to moveMcCauley mentioned MOUs local schools for HC buses ................
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