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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 I: Overview, Requirements, and Guidance

Chapter 1. Overview

This section provides an overview of hospital preparedness exercises in the following sections:

  • Hospital Emergency Management Programs.
  • Definition of Exercises.
  • Purpose of Exercises.
  • Types of Exercises.
  • Hospital Preparedness Exercises Roadmap.

Hospital Emergency Management Programs

Hospitals are the cornerstone of health care in a community. During catastrophic emergencies due to all types of hazards, hospitals must continue critical ongoing operations, but may also face large surges of patient arrivals. These events can disrupt patient treatment, threaten the safety and security of patients and hospital staff, and even completely shut down a facility. Hospitals generally have an emergency management program (also sometimes referred to as an emergency management system) to help effectively prepare for, respond to, and recover from an emergency. An emergency management program ideally focuses on the capabilities necessary to respond to any type of emergency.

Components of this program may vary according to each hospital's needs but often include the following:

  • Emergency Operations Plan (EOP)—An EOP outlines the hospital's plan for response to emergencies, and should include protocols for communications, resources, safety, and continuity of operations for continued patient care. A hospital may have a single all-encompassing EOP or multiple, hazard-specific EOPs.
  • Incident Command System (ICS)—The ICS is a standardized organizational structure for managing any size emergency events. The ICS can be scaled to the size of the event. The ICS generally consists of one Incident Commander and a team of people who are in charge and accountable for the various actions an organization must take to manage an incident. The major components of incident command are operations, finance, planning, and logistics. These are further broken down into many other components that allow the appropriate span of control and accountability, depending on the extent and specifics of the incident.
  • Emergency Operations Center (EOC)—Also known as the Hospital Command Center, the EOC is where the emergency operations team (operating under the Incident Command System) convenes during an emergency to coordinate management of the incident.
  • Hazard Vulnerability Analysis (HVA)—The HVA is a document created by an interdisciplinary process that a hospital uses to determine the key operational threats that the hospital is likely to encounter. Although a hospital should ideally be prepared for all types of emergencies, the HVA gives planners an idea of vulnerabilities and hazards that need to be addressed first in their planning and conduct of exercises and in the EOP(s). Certain hospital accreditation programs require conduct and review of an HVA annually, with the identified threats used to guide planning activities and addressed with community and State partners.
  • Key Contacts—Incidents often require coordination between multiple community - or government-based agencies. In order to ensure a coordinated response to an incident, a list of key contacts and agreements is essential. These contacts may include government officials (local, State and Federal), police, public health department, fire department, and local utilities companies. During an incident, the hospital ICS may need to directly link to the local EOC. This can be by direct communications or by the formal identification of a liaison person within the ICS which may be placed in the local EOC.
  • Exercises—Exercises help hospital staff evaluate their preparedness capacities and capabilities to respond to a wide variety of events, many of which may have a profound and potentially catastrophic impact on hospital operations, staff, patients, the surrounding community and related infrastructure. Exercises are essential to helping emergency staff prepare to respond to these incidents before they occur. Hospitals should work with their surrounding community when planning and performing exercises. The remainder of this guidebook focuses on hospital preparedness exercises.


In general terms, a hospital preparedness exercise is a means for a hospital to test and evaluate its capacity and capabilities for preventing, preparing for, protecting from, responding to, and/or recovering from an event that may overwhelm a hospital's patient care or operating systems. Such a hazard or threat can either occur internally (within the hospital) or externally (outside the hospital). Exercises are an essential component of an emergency management program. They are one of the most effective ways a hospital can test, evaluate, and ultimately improve an emergency management program.

Purpose of Hospital Preparedness Exercises

As part of an emergency management program, hospital preparedness exercises may have several specific purposes.

Purpose of Hospital Preparedness Exercises
1. Evaluation of a Hospital's Emergency Management Program
  • Testing an Emergency Operations Plan(s) or program components.
  • Identifying strengths and weaknesses.
  • Adapting the hospital operations system to changing threats.
2. Familiarization of Hospital Staff with Plans
  • Providing an opportunity for staff to recognize strengths and identify gaps.
  • Providing an opportunity for staff to practice emergency response procedures.
  • Ensuring staff has capabilities to communicate, plan, respond, and recover from events.
  • Ensuring staff has the resources to communicate, plan, respond, and recover from events.
  • Ensuring staff can better understand their individual roles in an emergency.
3. Integration with Community and Local Partners
  • Educating community and local partners on hospital capabilities and procedures.
  • Providing an opportunity for hospital staff and community stakeholders to practice integrating their systems by planning and exercising together.
  • Enhancing planning, coordination, and communication with community and local agencies involved in response efforts.
4. Compliance with Requirements
  • Hospital accreditation requirements.
  • Federal and State funding requirements.
  • Other professional organizations' requirements.
5. Improvement of Emergency Management Program
  • Enhancing the hospital's capability to plan for, prevent, protect from, respond to, and recover from incidents and/or threats.
  • Taking action on identified weaknesses.
  • Maintaining identified strengths and determining best practices.
  • Building awareness among hospital staff and administration of components of emergency management program.
  • Decreasing liability, protecting hospital infrastructure, and improving community resiliency.

Types of Exercises

Based on available resources and objectives, exercises can be conducted in a variety of forms and scales. While objectives may range from testing certain capabilities to evaluating an entire Emergency Operations Plan (EOP), most exercises may be categorized as discussion-based or operations-based activities according to the definitions of the Homeland Security Exercise and Evaluation Program (HSEEP) of the Department of Homeland Security (DHS).

Discussion-Based Exercises

Discussion-Based Exercises allow hospital emergency management personnel to educate staff on strategic issues related to plans, policies, agreements, protocols, or procedures.

  • Pros: Do not require extensive funds, resources, or coordination; can be developed in a short period of time; can help prepare for and eventually transition to an operations-based exercise.
  • Cons: No real exercise play (not as realistic); may not fulfill certain requirements (e.g., Joint Commission standards).

Types of Discussion-Based Exercises

Type of Exercise Exercise Scale Definition & Purpose
Seminar Small Provides a synopsis of authorities, strategies, plans, policies, procedures, protocols, resources, concepts, and ideas
Workshop Small Provides an overview of relevant information for an emergency management program; more participant interaction than a seminar; aims to create a product/tool for exercise conduct
Tabletop Small-Medium Staff and key decision makers convene to discuss and verbally act out incident response under simulated emergency settings
Game Small-Medium Adapts actions of participants and focuses on consequences of decisions and actions during exercise play
Model/Simulation Small Used to visualize and quantify a scenario and consequences of specific decisions made by participants; cost-effective way of conducting scenario-based exercises

Operations-Based Exercises

Operations-Based Exercises allow the emergency management program to test and evaluate certain capabilities, procedures, and functions.

  • Pros: Real exercise play (more realistic than discussion-based exercises); may meet certain accreditation requirements.
  • Cons: May be costly; may require extensive planning, coordination, resources, and administrative commitment.

Types of Operations-Based Exercises

Type of Exercise Exercise Scale Definition & Purpose
Drill1 Small-Medium Small scale way of testing a specific function of an organization (e.g., fire evacuation drill) and used to practice or develop skills
Functional Medium Targets broader capabilities than drills; used to determine whether the hospital can effectively perform a function related to exercise plans, policies, or procedures
Full-Scale Exercise2 Medium-Large Most elaborate exercise form; requires extensive resources; often involves multiple entities besides hospitals (e.g., EMS, police, and local health departments); and includes coordination between these entities to respond to an incident

Hospital Preparedness Exercise Roadmap

This schematic illustrates the order in which hospital preparedness planners typically address hospital preparedness exercise requirements.

Image is a decision tree titled 'Hospital Preparedness Exercise Requirements'. The first question is 'Hospital accredited by JC, AOA or DNV?' Yes: Comply with relevant accreditation standards (includes CMS, CoPS, and NFPS code); No: Comply with CMS, CoPS, and NFPS code. Both Yes and No options point to 'Hospital receives Federal ASPR/NHPP funds from State or local jurisdiction'. Yes: Comply with State or local jurisdiction (includes HSEEP, NIMS/HICS); No.

Key Acronyms

ASPR: Assistant Secretary for Preparedness and Response.
AOA: American Osteopathic Association.
CMS CoPs: Centers for Medicare & Medicaid Services, Conditions of Participation.
DNV: Det Norske Veritas, Inc.
HICS: Hospital Incident Command System.
JC: The Joint Commission (formerly Joint Commission for the Accreditation of Healthcare Organizations, JCAHO).
NHPP: National Hospital Preparedness Program (NHPP).
NIMS: National Incident Management System.
NFPA: National Fire Protection Association.


  • Hospital preparedness exercises are an integral part of an emergency management program.
  • Discussion-based exercises focus on strategies outlined in emergency plans and policies. One example is a tabletop exercise.
  • Operations-based exercises involve the activation of the emergency operations plan (or parts thereof) and test capabilities, procedures, and functions. One example is a full-scale exercise.

1 In some circumstances, the term "drills" may be used interchangeably with "exercises." However, for the purposes of this guidebook, a drill is a type of exercise.
2 Sometimes hospitals participate in full-scale exercises that are developed and coordinated by other entities.

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