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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 3. Federal and State/Local Jurisdiction Requirements

This chapter provides an overview of Federal and State/local jurisdiction hospital preparedness exercise requirements in the following sections:

  • Overview: Federal and State/Local Jurisdiction Requirements.
  • Centers for Medicare & Medicaid Services (CMS).
  • National Hospital Preparedness Program (NHPP).
  • Homeland Security Exercise and Evaluation Program (HSEEP).
  • National Incident Management System (NIMS) and Hospital Incident Command System (HICS).
  • Occupational Safety & Health Administration (OSHA).
  • Centers for Disease Control and Prevention (CDC).
  • Useful Resources and Tools.

Overview: Federal and State/Local Jurisdiction Requirements

Federal agencies serve as regulators and funding sources to ensure the well-being of both providers and recipients of health care. Regulations help maintain a safe environment of care at hospitals, ranging from routine operations to responding and recovering from an event.

The Federal Government has a number of programs, systems, and funding mechanisms to assist hospitals in developing the capability to function during an emergency. These are outlined in this chapter. However, individual States may have additional requirements for preparedness exercises, and it may be necessary to refer to your State's emergency management office for information on specific requirements and deliverables.

Federal Funding Stream

Federal funds are normally distributed to States or local jurisdictions, which distribute the funding to the hospitals.

Figure 1. This figure illustrates the flow of Federal funds for hospital preparedness activities. The Federal Government provides grants to States and/or local jurisdictions and these in turn dispense funds to hospitals.

Figure consists of three text blocks. The topmost is labeled 'Federal Government'; an arrow points down to the second block, labeled 'States or Local Jurisdictions'; an arrow points down to the bottom block, labeled 'Hospitals'.

Centers for Medicare & Medicaid Services (CMS)

CMS is responsible for administration of the Medicare and Medicaid programs, which provide a substantial proportion of reimbursements for patient care services to most U.S. hospitals. As a requirement for receiving CMS reimbursements, hospitals must be compliant with certain regulations known as the Conditions of Participation (CoPs). These regulations are the "minimum health and safety standards for improving the quality of care and protecting the health and safety of recipients" (CMS, 2009).

Non-Accredited Hospitals

If a hospital is not accredited10 by the Joint Commission, AOA, or DNV Healthcare, Inc., it must comply directly with CMS' CoPs in order to receive Medicare and Medicaid reimbursement. Non-accredited hospitals can achieve compliance with CoPs through surveys conducted by a State agency (e.g., a Department of Health) or a CMS Regional Office.

CMS and Emergency Preparedness Exercises

Currently, there are no specific requirements related to hospital preparedness exercises in the CoPs.11 The emergency preparedness requirements for hospitals in the CoPs include:12

  • Assuring medical staff has written policies and procedures for appraisal of emergencies and needs anticipated by the facility.
  • Developing and implementing emergency plans to ensure the safety and well-being of staff and patients during emergency situations.
  • Meeting applicable standards of the National Fire Protection Association (NFPA), Life Safety Code (2000 edition).

Hospitals may comply with these requirements through conducting exercises. CMS recommends that hospitals conduct exercises semiannually that test elements of their emergency plans, as well as interrelated elements, and the entire plan. CMS also recommends that the hospital takes corrective actions on any deficiencies identified from the exercise.13

National Hospital Preparedness Program (NHPP)

NHPP is administered by the U.S. Department of Health and Human Services' Office of the Assistant Secretary for Preparedness and Response (ASPR). NHPP is the main source of Federal funding and guidance specifically related to hospital preparedness. It was created to enhance the capability of hospitals to prevent, respond to, and recover from incidents.

NHPP Funding Opportunity Announcement

Annually, NHPP releases a Funding Opportunity Announcement to State and local jurisdictions with instructions on how to apply for funds for the upcoming fiscal year. This funding opportunity requires States and local jurisdictions to demonstrate: 1) how certain overarching requirements and current sub-capabilities will be "maintained and refined" and 2) activities that will be conducted and how funding will be applied to meet the overarching requirements and ASPR expectations.

Select for the NHPP Overarching Requirements and Level 1 and Level 2 Sub-Capabilities from the Fiscal Year 2009 FOA.

NHPP Funding Distribution to Hospitals

NHPP14 funding is awarded to a State or local jurisdiction, which is then responsible for distributing this funding to hospitals. Hospitals, in turn, are awarded NHPP funds by their respective State or local jurisdiction after demonstrating the completion of a set of deliverables. The hospitals' State or local jurisdiction develops and issues these deliverables based on the NHPP-required funding capabilities and overarching requirements from the most recent FOA. Hospitals may enter into a contract with the State or local jurisdiction agreeing to achieve those deliverables.

NHPP Overarching Requirements (FY 2009)15

Overarching requirements16 need to be incorporated into the development and maintenance of all sub-capabilities. The following four overarching requirements for NHPP awardees (that is, the State or local jurisdictions) must be incorporated in the development and maintenance of all sub-capabilities:

  1. National Incident Management System (NIMS): ASPR expects awardees will evaluate and report which of the NHPP participating hospitals have adopted all implementation objectives of NIMS.
  2. Education and Preparedness Training: ASPR expects awardees will insure the development and use of education and preparedness training programs for all hospital personnel; ASPR also expects awardees will work with hospitals to maximize the number of hospital staff participating in preparedness drills and exercises.
  3. Exercises, Evaluation, and Corrective Actions: ASPR expects all exercise programs either wholly or partially funded by NHPP funds will be HSEEP-compliant. It also expects each exercise to test the operational capabilities of the three critical components of medical surge: (1) Interoperable Communications and ESAR-VHP; (2) a tabletop component to test memoranda of understanding; and (3) fatality management, medical facility evacuation, and tracking of bed availability.
  4. Needs of At-Risk Populations: ASPR expects awardees will work with hospitals to address at-risk populations and ensure their medical needs will be met during a disaster or public health emergency.

NHPP Level 1 Sub-Capabilities (FY 2009)

These capabilities are recognized as critical for the sustainability of State preparedness efforts. There were five required funding capabilities for NHPP awardees (States or local jurisdictions):

  1. Interoperable Communications System: ASPR expectations include having communication devices and systems that permit interoperable communications both within hospitals and with community partners.
  2. Tracking System: ASPR expectations include having an operational bed tracking system compatible with the Hospital Available Beds for Emergencies and Disasters (HAvBED) definitions and standards.
  3. Emergency System for Advance Registration of Volunteer Health Professionals (ESAR-VHP): The goal of the ESAR-VHP program is to create a national network of State-based registries of volunteer health professionals that can be effectively used in the event of an emergency.
  4. Fatality Management Plans: ASPR expectations include collaborating and working with hospitals to make sure facility-level fatality management plans are incorporated in State and local jurisdiction plans.
  5. Hospital Evacuation Plans: ASPR expectations include working with healthcare facilities, emergency medical services, emergency management officials, fire departments, and other community partners in developing and integrating evacuation plans and evaluating situations (e.g., whether an organization should conduct a shelter-in-place vs. full or partial evacuation).

NHPP Level 2 Sub-Capabilities (FY 2009)

Level 2 Sub-Capabilities are capabilities which ASPR strongly encourages each State or local jurisdiction to address to expand their preparedness efforts. There are five optional funding capabilities for NHPP awardees:

  1. Alternate Care Sites (ACS): ASPR expectations include establishing ACS, continuous development and improvement of ACS plans and concept of operations for providing supplemental surge capacity to the healthcare system.
  2. Mobile Medical Assets: This involves having the ability to provide care outside of an awardees' health care system by using mobile medical units (e.g., tents, trailers).
  3. Pharmaceutical Caches: ASPR expectations include developing an operational plan related to dispensing, storing, and rotating critical antibiotic medications for hospital staff and families.
  4. Personal Protective Equipment (PPE): ASPR expectations include ensuring sufficient types and amounts of PPE for protecting healthcare workers.
  5. Decontamination: This involves ensuring the portable or fixed decontamination system is sufficient for handling exposed adult patients, pediatric patients, and healthcare workers.

NHPP Requirements and State or Local Jurisdiction Deliverables

States or local jurisdictions are responsible for following NHPP requirements in order to receive NHPP funds. Hospitals may need to apply for NHPP funding in some States or local jurisdictions. In other States or local jurisdictions, hospitals may be designated to receive a certain amount of NHPP funding without an application. Hospitals may be expected to meet certain requirements and/or achieve certain deliverables required by their State or local jurisdiction. An example of a deliverable would be an "interoperable communications exercise" evidenced by submitting an After Action Report. The State/local jurisdiction would then report back to the Federal NHPP program to demonstrate their compliance with the requirements.

Figure 2: As previously described, Federal funding flows from the Federal government to State or local jurisdictions to hospitals. Hospitals in turn give deliverables back to the State or local jurisdictions as required, who in turn report the fulfillment of requirements to the Federal government.

Figure consists of three text blocks. The topmost is labeled 'Federal Government'; an arrow points down to the second block, labeled 'States or Local Jurisdictions'; an arrow points down to the bottom block, labeled 'Hospitals'. An arrow labeled 'Reporting/Application for Funds' points back up from the bottom block to the one above. An arrow labeled 'Reporting/Application for Funds' points back up from the middle block to the one above. Between each block is the text, 'Funding and Requirements.'

Homeland Security Exercise and Evaluation Program (HSEEP)

HSEEP was developed by the U.S. Department of Homeland Security to provide standardized policy, methodology, and terminology for exercise-related activities. The program emphasizes assessing capabilities through performance (exercises). One of the overarching requirements of NHPP is Exercises, Evaluation, and Corrective Actions. Under this requirement, ASPR expects all exercises funded completely or partially by NHPP funds to be built on the HSEEP framework and guidelines.

Examples of complying with HSEEP guidelines include:

  • Exercise cycle growing more complex, uses a "building block approach."
  • Basing design, conduct, and evaluation on capabilities.
  • Basing exercise scenarios on risk/vulnerability assessment and adapting scenarios to validate capabilities, tasks, and objectives found in Exercise Evaluation Guides.
  • Using documents that correspond to guidelines and templates in HSEEP Volumes I-III.
  • Exercise conduct demonstrating NIMS principles.
  • Drafting an After Action Report/Improvement Plan; presenting findings and recommendations to key stakeholders at After Action Conference.

National Incident Management System (NIMS)

The NIMS, developed by the U.S. Department of Homeland Security's Federal Emergency Management Agency, provides a national standard for the organization of personnel, information flow, and lines of command for incident response. It enables government agencies, non-government agencies, and the private sector to work together in response to an incident. NIMS has 14 implementation objectives for health care organizations that NHPP grant awardees are expected to follow. Included in these objectives for NIMS compliance is an incident command system (ICS). Many hospitals use the Hospital Incident Command System (HICS) as their form of ICS.

Hospital Incident Command System (HICS)

The HICS is a form of ICS developed by the California Emergency Medical Services Authority and is tailored to hospitals. HICS is also consistent with NIMS guidelines in terms and definitions, response concepts, and procedures. For this reason, hospitals will often use HICS to meet some of the NIMS objectives. The purpose of HICS is "to assist [hospitals] with their emergency planning and response efforts for all hazards" (HICS, 2007). Because incident command systems such as HICS are used in emergency situations, they are often activated during exercises.

Occupational Safety & Health Administration (OSHA)

OSHA is a regulatory agency under the U.S. Department of Labor. OSHA is responsible for assuring safe and healthy working conditions for working men and women. The agency also provides guidance related to emergency preparedness and response on topics including: developing an Emergency Response Plan, communication, evacuation, lines of authority, decontamination, equipment, and security.

OSHA's Best Practices for Hospital-Based First Receivers of Victims from Mass-Casualty Incidents provides guidance to hospitals in creating and implementing emergency preparedness plans related to protecting hospital-based emergency department personnel who may receive contaminated victims from other locations. It also includes guidelines and procedures for handling victim decontamination and personal protective equipment (PPE) and training first receivers.

Currently, OSHA does not have specific requirements related to hospital preparedness exercises. However, hospitals may want to test compliance with OSHA regulations and guidelines by means of exercises.

Centers for Disease Control and Prevention (CDC)

CDC has an analogous program to the Assistant Secretary for Preparedness & Response's National Hospital Preparedness Program (NHPP), called the Public Health Emergency Preparedness (PHEP) cooperative agreement which provides funding to State, local, tribal, and territorial public health departments to support preparedness efforts. Since hospitals often conduct exercises with their respective public health departments, hospitals may need to comply with CDC-PHEP funding requirements.


  • The Federal government provides programs and funding to assist with hospital emergency management. These programs and funding are delivered to hospitals through the State/local jurisdiction.
  • The Centers for Medicare & Medicaid Services (CMS) publishes Conditions of Participation (CoPs) with which hospitals must comply in order to receive Medicare and Medicaid reimbursement. Hospitals can be compliant with the CoPs through accreditation by organizations with "deemed status" or by demonstrating compliance to relevant State agencies or the regional CMS office.
  • CMS CoPs do not have specific exercise requirements, but they do contain general preparedness requirements relevant to exercises.
  • The National Hospital Preparedness Program (NHPP) provides funds to States/local jurisdictions that meet their requirements. States/local jurisdictions distribute these funds to hospitals and may in turn require hospitals to provide certain deliverables as a condition of receiving funding.
  • Compliance with the National Incident Management System (NIMS) is part of the NHPP requirements. Using the Hospital Incident Command System (HICS) as part of an emergency management program assists hospitals in complying with NIMS.
    The Occupational Safety and Health Administration (OSHA) has additional guidance related to emergency preparedness, some of which can be found in the document, Best Practices for Hospital-Based First Receivers of Victims from Mass-Casualty Incidents.

Useful Resources and Tools

Below is a list of useful resources and tools for meeting Federal and State/local requirements.








10 Accreditation is voluntary.
11 It is important to consult the most recent CoPs, as future versions may include requirements related to hospital preparedness exercises.
12 CFR 482.55(b)(2)
13 CMS—Draft Emergency Preparedness Guide, 2008.
14 States or local jurisdictions may refer to their HPP funding program under a different name (e.g. New York City's program is called HEPP, the Healthcare Emergency Preparedness Program).
15 The FY 2010 HPP Funding Opportunity Agreement was unavailable at the time of publication, but should be consulted for future planning.
16 As mentioned earlier, the NHPP requirements and capabilities listed in this document are for State and Local Jurisdiction applicants, and are not direct requirements for hospitals. However, States and local jurisdictions use these requirements and capabilities to develop the deliverable requirements for hospitals to receive NHPP funds, so hospital emergency managers may want to familiarize themselves with them.
17 This is a draft document; a final version was not available at the time of publication.

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