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Hospital Preparedness Exercises Guidebook

Public Health Emergency Preparedness

This resource was part of AHRQ's Public Health Emergency Preparedness program, which was discontinued on June 30, 2011, in a realignment of Federal efforts.

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Part III: Exercise Strategies

Chapter 10. Overview of Exercise Strategies

This section provides an overview of strategies that can be used for certain types of exercises and exercise planning settings.

  • Maximizing Efficacy and Efficiency of Exercises
  • Unannounced Exercises
  • Real Events
  • Improving a Hospital's Emergency Operations Plan
  • Exercise Planning: Challenges and Strategies
  • Urban Hospitals: Challenges and Strategies
  • Rural Hospitals: Challenges and Strategies
  • Suburban Hospitals: Challenges and Strategies

Maximizing Efficacy and Efficiency of Exercises

Because exercises take a considerable amount of planning and resources, it is essential to get the most value out of each exercise, both in meeting Federal, State, local jurisdiction, and accreditation requirements and in preparing the hospital to manage any incident or threat. Some key areas for maximizing efficacy and efficiency are below.


An exercise can only effectively test what the participants know. Participants must be trained in the emergency operations plan and their roles during an emergency situation, especially if they are key members of the incident command system. An announced exercise can be useful in that it allows the hospital an opportunity to review response procedures, communications (important points of contact, call trees, etc.), and other educational material.

Small Scale Drills

These may be useful because they require less planning time and resources. Because fewer departments and outside agencies are involved, this can shorten meetings and reduce the number of staff needed for exercise planning. Small Scale Drills can also effectively target specific deficiencies discovered in previous exercises and offer an opportunity to practice responses and demonstrate improvement. Having very clear, defined, SMART (simple, measurable, achievable, realistic, and task]oriented) objectives is critical for smaller exercises so that they can be specifically designed to test those objectives.

Knowing Requirements

A single exercise may meet requirements of multiple organizations. Knowing these requirements and planning for them during early stages of exercise design will be useful when planners seek to fulfill requirements of relevant organizations. It may be necessary to write up more than one After Action Report/Improvement Plan according to the needs of each organization.

Work with Community Partners

Few incidents affect a single entity, so it is important to use exercises that involve the community. Some accreditation organizations such as the Joint Commission require involvement of community partners such as local police, fire, and public health department. It is important to have the participation of community partners so that the hospital can establish lines of communication, identify key points of contact for various agencies, and determine where key resources are.

In addition, ESAR-VHP (Emergency System for Advance Registration of Volunteer Health Professionals) may be able to provide additional staff in emergencies. When conducting exercises with the community, additional planning and resources may be needed, so it is important to ensure that your hospital is still meeting the necessary requirements. Making the exercise as realistic as possible will also effectively test cooperation and communication with other agencies in real time.

Unannounced Exercises

Unannounced exercises resemble a real]life situation by preventing prepositioning of materials, such as personal protective equipment, or prior review of emergency plans in preparation for the exercise. They are useful for testing the hospital staff's ability to quickly recall emergency plans and respond to an incident as well as their ability to find resources such as extra equipment, additional staff, and information related to the hazard. It can also foster communication between different agencies (e.g., other hospitals, police or public health departments) in order to acquire those resources. Unannounced exercises may also accurately test an institution's ability to restrict access or quickly notify staff, visitors, and patients of an event and which actions to take.

Unannounced exercises are also required by certain accreditation organizations' standards. In conducting these types of exercises, it is important to remember the following:

  • It is challenging for an exercise to be completely unannounced in a health care setting. Often, participants are given at minimum a range of dates for when the exercise should take place.
  • Exercise controllers that know all details of the exercise (time, date, scenario, injects) should be easily identified on location to insure the safety of patients, visitors, and staff during exercise play.
  • Evaluators should also be present and briefed with the details prior to the unannounced exercise because it is important to make sure the staff's response is thoroughly assessed when there is no prior notice of an exercise.
  • Unannounced exercises may cause disruption of routine activities and therefore may be more disorganized than announced exercises.
  • Staff should have prior training and knowledge of emergency plans and procedures, and the exercise should test those established plans.

Real Events

For some accreditation organizations, real events may be used in lieu of an exercise to meet certain requirements. Real events can demonstrate the hospital's ability to manage an emergency situation. In using these events, it is important to complete the following shortly after an event:

  • Form a committee of key personnel from the response effort, additional technical or subject matter experts, and critical partners to document and evaluate the response to the event.
  • Solicit feedback and meet with key staff and partners involved in the response to discuss the sequence of events, their observations, and their use of and familiarity with activating the hospital's emergency operations plan(s).
  • Determine what would have been the appropriate response to the event.
  • Evaluate the actual response to the determined appropriate response.
  • Write an After Action Report/Improvement Plan to identify strengths and gaps.
  • Make improvements to procedures, policies, infrastructure, or training as identified in the AAR and outlined in the Improvement Plan.

Improving a Hospital's Emergency Operations Plan

A Hospital's Emergency Operations Plan (EOP) is meant to be continually improved and changed as needed. Exercises are meant to test the activation and operation of the EOP, but also provide a means of evaluating and improving it.

Some strategies for improving the EOP may come from:

  • The Hazard Vulnerability Analysis—Based on the hazards that may face a hospital and its surrounding community, specific procedures and plans may need to be made to mitigate these risks.
  • Exercises—An institutional strategy for exercises that continues to test the facility's capability to respond to a variety of events realistically with increasing complexity is the most effective and efficient way for a hospital to prepare for an actual event.
  • Requirements by accreditation organizations and government agencies—Since standards for emergency planning are likely to change, it is important to keep track of the requirements of relevant accreditation organizations, Federal requirements, and State or local jurisdiction deliverables and requirements.
  • Previous After Action Reports/Improvement Plans—Once an exercise or actual incident is completed, the improvement plan outlines actions that need to be taken based on lessons learned during the exercise.

When any changes are made to the EOP, appropriate changes to hospital policies, procedures, protocols should also be made, and hospital staff should be notified of those changes.

Exercise Planning: Challenges and Strategies

Common challenges that hospitals face relate to staffing, budgets, and coordination with other groups. Some challenges and strategies for handling them are described here.

Challenge: Staffing and Coordination with Other Groups

Strategy: Do not wait until it is time to conduct the exercise to incorporate community involvement; continuously work with local emergency management officials and include them in hospital planning, exercise conduct, exercise evaluation, and response activities.

Strategy: Establish MOUs with agencies, healthcare facilities, and other critical partners that would enable the hospital when faced with significant infrastructure damage or a surge capacity event to maintain continuity of care. Specific MOUs may address issues including: equipment, pharmaceuticals, and staffing deficiencies that may occur in emergency situations.

Challenge: Integrating Emergency Operations Plans (EOPs)

Strategy: Whenever your hospital's EOP is being updated, notify other community partners and local government of your changes and ask those groups to provide any changes to their EOPs as well.

Challenge: Lack of Resources and Funding

Strategy: Checking with larger hospitals or State emergency planning agencies to find State or local training programs and exercises that your hospital may be able to participate in.

Challenge: Ensuring that Exercises Actually Improve Hospital Preparedness

Strategy: When designing the exercise objectives, make sure they align with the needs of your health care system and test capabilities that need to be addressed.

Urban Hospitals: Challenges and Strategies

Hospitals in urban settings face many specific challenges. They range from small to large and may face issues related to competition with other hospitals; synchronizing with other systems, particularly with large-scale incidents; and coordination with several hospitals or community agencies. Some of the strategies for addressing these challenges are below.

Challenge: Hospital Management/Leadership Support

Strategy: This is critical for all hospitals, but especially for hospitals in urban settings in order to ensure coordination across the entire hospital. The best way to ensure hospital management support is to include management in critical exercise planning and to demonstrate how essential exercises are to funding, to receiving accreditation, and to hospital sustainability.

Challenge: Coordination with Neighboring Entities

Strategy: While coordinating and synchronizing with neighboring entities, e.g., other healthcare facilities, may be a challenge, urban hospitals should use this to their advantage. Working with neighboring entities may be more cost-effective and will also strengthen preparedness capabilities of all participating entities.

Challenge: Ensuring All Staff Participate in Exercises

Strategy: Use train-the-trainer programs. The larger the hospital, the greater the staff, and the harder it is to make sure everyone is up-to-date on preparedness activities (especially due to the shift-based nature of hospitals). Developing train-the-trainer programs that enable staff that have participated in exercises to train and educate staff who have not participated can help boost the number of staff prepared to respond to an incident.

Rural Hospitals: Challenges and Strategies

Hospitals in rural settings often have challenges related to limited resources with regard to staff, equipment, and financing. Another one of their main challenges relates to geographical distance. Rural hospitals may be far from other neighboring hospital and supply vendors. Effective transportation and communications plans are critical. Strategies for addressing these challenges in exercises:

Challenge: Staffing Shortage

Strategy: Maximize use of staff. Since staff shortage is common in rural hospitals, consider assigning roles to all hospital staff, including those that do not work directly in patient care (administrative, custodial, etc.)

Strategy: Enlisting community volunteers can also help with staffing shortages and create greater awareness of preparedness activities.

Challenge: Staff Overwhelmed by Preparedness Exercises

Strategy: This is a challenge for all hospital exercises, but especially for rural hospitals with inexperienced staff. Make sure objectives are reasonable. Do not set staff up to fail. Exercises should not overwhelm staff, but instead teach and empower staff.

Strategy: Exercises should also build on in each other. Start with smaller-scale exercises, and gradually increase in size. Exercises are essential for funding, receiving accreditation, and hospital sustainability.

Challenge: Geographical Distances

Strategy: Conducting tabletop exercises that allow participants to take part in the exercise remotely may be less costly and more time efficient than having people travel to the exercises. Remote exercises also may have greater resemblance to what will take place during a real event.

Suburban Hospitals: Challenges and Strategies

Hospitals in suburban settings experience a hybrid of the challenges faced by urban and rural hospitals. Since the strategies depend largely on the size and location of your hospital it may be helpful to read both urban and rural challenges and strategies and determine which challenges and strategies are applicable.

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