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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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Chapter 9. Improvement Planning

This section provides an overview of the improvement planning phase of a hospital preparedness exercise in the following sections:

  • Overview: Improvement Planning
  • Step 5: Conduct an After Action Conference
  • Step 6: Identify Corrective Actions to Be Implemented
  • Step 7: Finalize After Action Report/Improvement Plan
  • Step 8: Track Implementation
  • Checklist: Improvement Planning
  • Useful Resources and Tools

Overview: Improvement Planning

The purpose of the Improvement Planning phase is to incorporate lessons learned and best practices developed from each exercise into both the hospital's emergency management program and future hospital exercises. Conducting exercises is not only to test system-wide capabilities, but also to identify ways of improving those systems.

The steps of the Improvement Planning phase continue with the steps from the Evaluation phase. Some hospitals may choose to condense these steps in fewer meetings due to limited staff, resources, and time.

Step 5: Conduct an After Action Conference

An After Action Conference is conducted after a draft AAR has been written. Participants in an After Action Conference include evaluators, exercise planning team members, and parties that may be involved in implementing the improvement plan. The main purpose of an After Action Conference is to edit the draft AAR and develop an Improvement Plan (IP). It may also be an opportunity to further analyze and compile data if necessary and provide additional information or insights that were not available during the post-exercise debriefing meeting.

Step 6: Identify Corrective Actions to Be Implemented

After modifying the AAR to incorporate feedback from the After Action Conference, corrective actions need to be identified that correspond with recommendations listed in the AAR. When identifying corrective actions to be implemented, the following issues need to be addressed:

  1. Changes needed to plans and procedures.
  2. Changes needed to organizational structures.
  3. Changes needed to leadership and management processes.
  4. Training needed.
  5. Changes to or additions to equipment; and
  6. Lessons learned.

Corrective actions should be written so that they could be measured based on progress of implementation. These corrective actions should be written into the Improvement Plan.

An Improvement Plan consists of the list of corrective actions that should be taken to improve the emergency management program. It may be organized into a table according to capabilities or critical areas that need improvement, along with specific corrective actions and responsible parties. It may also contain timeframes or deadlines for completion of those actions.

Step 7: Finalize After Action Report/Improvement Plan

This step entails finalizing and incorporating all changes into the AAR/IP and distributing it to all relevant parties, such as evaluators and exercise planning team members. The AAR/IP should also be distributed to key stakeholders identified in the Foundation phase, and may also be distributed to the proper accreditation organizations and Federal, State, or local jurisdictions as needed. The AAR/IP is to be used in future emergency management planning, such as exercise planning, developing strategies, and changing policies or procedures.

Tip: The terminology used in the AAR/IP and the framing of the information contained in it should be tailored to the intended audience. For example, a hospital may need to write the AAR/IP in a way that demonstrates how they achieved their State's deliverables for HPP funds.

Step 8: Track Implementation

The last step involves tracking the implementation of corrective actions. This involves assigning team members to be event points of contact (POC) (HSEEP terminology, may differ in your organization) who are responsible for tracking implementation of corrective actions. Event POCs serve as the central POC for exercise improvements, along with progress and documentation of corrective actions. In addition to event POCs, participating entity POCs need to be identified who are responsible for monitoring corrective actions at outside entities that participated in the exercise. A responsible party is also assigned to each corrective action to make sure the action is completed.

Figure consists of six blocks in two columns. The first column reads from top to bottom: 'Corrective action within hospital system,' arrow points down to 'Event POC,' arrow points down to 'Responsible party'.  The second column reads from top to bottom: 'Corrective action involving outside entities,' arrow points down to 'Participating Entity POC,' arrow points down to 'Responsible party'.

Checklist: Improvement Planning

The following are some essential steps for the Improvement Planning phase:

Conduct an After Action Conference

  • Hold an After Action Conference with the exercise planning team and evaluators.

Identify Corrective Actions

  • Determine changes necessary for plans, organizational structures, and equipment and additional training needed for staff.
  • Determine time frames and methods of measuring completion of corrective actions.
  • Write corrective actions into the Improvement Plan.

Finalize AAR/IP

  • Create final draft of AAR/IP that includes all changes.
  • Distribute to planning team members, evaluators, key stakeholders, and government agencies and accreditation groups as needed.

Track Implementation

  • Assign team members to be event points of contact for each corrective action.
  • Assign participating entity points of contact to monitor corrective actions at entities outside of the hospital.
  • Follow up with responsible parties to make sure each action is completed.

Useful Resources and Tools

Below is a list of useful resources and tools related to improvement planning for an exercise.

Step 5: Conduct an After Action Conference

  • After Action Conference Presentation (HSEEP Vol. IV*, see under Improvement Planning)

    This presentation is used during an After Action Conference to present the draft After Action Report, revise the AAR, and develop an Improvement Plan.

Step 6: Identify Corrective Actions to Be Implemented

  • Corrective Action Program (CAP) System (HSEEP login required)

    This Web-based application developed by HSEEP allows the user to create and track the implementation of corrective actions from Improvement Plans.
    https://hseep.dhs.gov/support/CAPSOverviewandFAQ.pdf [PDF Help] (Login required for access)

Step 7: Finalize AAR/IP

  • After Action Report/Improvement Plan

    These are templates of HSEEP-style After Action Reports with an Improvement Plan Matrix in the appendix. The HSEEP Web site also has examples of AAR/IPs available with an HSEEP login.
    Operations-Based Exercises: AAR (HSEEP Vol. IV, see under Evaluation > After Action Report)
    Discussion-Based Exercises: After Action Reports (HSEEP Vol. IV, see under Evaluation > After Action Report)

Step 8: Track Implementation

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