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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 6. Design and Development

This section provides an overview of the Design and Development phase of a hospital preparedness exercise in the following sections:

  • Overview: Design and Development.
  • Defining Capabilities, Tasks, and Objectives.
  • Scenario.
  • Exercise Documentation.
  • Exercise Logistics.
  • Evaluation Planning.
  • Checklist: Design and Development.
  • Useful Resources and Tools.

Overview: Design and Development

According to HSEEP, designing and developing an exercise involves:

  • Defining objectives.
  • Developing scenarios.
  • Deciding on the logistics of an exercise.
  • Documenting activities.
  • Planning how the exercise will be conducted.
  • Deciding on the evaluation and improvement planning program.
    This phase occurs along with the planning conferences mentioned in the Foundation phase (go to Chapter 5).

Defining Capabilities, Tasks, and Objectives

Capabilities are competencies in which a health care organization needs to be proficient to perform critical tasks in an emergency situation. Capabilities may be derived from the Target Capabilities List (TCL). The TCL is a list that describes the capabilities as deemed by the Federal Emergency Management Agency (FEMA) necessary for any organization to prevent, protect from, respond to, and recover from an emergency. The list includes items such as handling a "medical surge."

Capabilities have specific related tasks, which are various activities that need to be performed to achieve a given outcome. Tasks may be derived from the Universal Task List (UTL), a list also created by FEMA that describes critical tasks related to the capabilities listed in the TCL. The UTL includes items such as, "Activate the healthcare incident command system." Tasks may also come from the hospital's Emergency Operations Plan, which should be reviewed when designing an exercise.

Objectives are the goals of an exercise and are used as performance measures. Objectives should be Simple, Measurable, Achievable, Realistic, and Task-oriented (SMART); and should be formulated using the capabilities and tasks identified as necessary for emergency operations. It is also important to examine documents, such as Improvement Plans, from prior exercises to help shape the objectives of the current exercise.

Tip: Reviewing your hospital's most recent Hazard Vulnerability Analysis (HVA) may be useful during this phase. A hospital may choose to identify their capabilities, tasks, and objectives by evaluating the top hazards found in the HVA. Although this is not part of HSEEP methodology, most hospitals use the HVA as a starting point for exercise design and development because it is a requirement of accreditation organizations, such as the Joint Commission. Using the HVA is important because exercises should test responses to hazards that a hospital is likely to encounter. The HVA allows the exercise planning team to develop exercises that test certain capabilities based on hazards their hospital has a high probability of encountering.


According to HSEEP, a scenario is a description of a series of actions and events taking place during an exercise. A scenario has three basic elements:

  1. Context of the exercise or a story describing the situation
    • This may include injects—information provided by controllers that prompts players to implement plans that the exercise is meant to test.
  2. Conditions in which the exercise players can demonstrate their fitness in meeting certain capabilities, tasks, and objectives.
  3. Technical aspects to portray scenario conditions and events.

Key Additional Factors to Consider When Developing a Scenario

According to HSEEP, when developing a scenario, the following factors also need to be considered:

  • Threat/Hazard: Exercises may focus on a specific type of threat/hazard. Possible threats/hazards should come from the hospital's Hazard Vulnerability Analysis.
  • Venue: If the exercise is taking place at a hospital, the area needs to be properly sectioned off to prevent alarming those passing by and to prevent interruption of normal patient care. Many hospital operations-based exercises take place in the emergency department and surrounding area. Discussion-based exercises often take place in the hospital's Emergency Operations Center or conference room.
  • Weather: If there is inclement weather and the exercise is taking place outdoors, plans should include whether the exercise should proceed as planned or be rescheduled.
  • Date and Time: Healthcare organizations are largely shift-based, so careful scheduling of the date and time of the exercise is critical. It is important to make sure exercises cover a variety of dates and times to allow all staff to be involved.
Tip: It is useful to have some exercises that extend beyond the emergency department to other key areas of the hospital to test patient flow and tracking, detect potential bottlenecks (e.g., radiology during mass casualty incidents), and examine the overall response of key support departments.

Exercise Documentation

Exercise Documentation includes documents that will be used or reviewed by exercise participants, exercise evaluators, exercise controllers, and exercise observers. These documents are developed by the exercise planning team.

Documentation to Be Reviewed by Exercise Planning Team

Name Purpose
Hazard Vulnerability Analysis (HVA)* Identifies and analyzes potential hazards of a system a hospital is likely to encounter. Useful for identifying exercise objectives and an exercise scenario. Conducted prior to exercise planning in connection with the development of the EOP.
After Action Reports/ Improvement Plans Show existing strengths, weaknesses, and recent improvements in the system that may need to be addressed in the current exercise and in future exercises.
Emergency Operations Plan Outlines the hospital's plans and protocols for emergency events. Tasks and scenarios can be developed to test these plans
Accreditation Standards Important if one of the exercise goals is to meet accreditation requirements.
Federal/State/ Local Jurisdiction Requirements and Deliverables Important if one of the exercise goals is to meet Federal funding requirements or State/local jurisdiction requirements.

Documentation to be Created/Modified
Discussion-Based Exercises

Name User Purpose
Exercise Evaluation Guides (EEGs) Evaluators, Controllers Used to help evaluate an exercise. Identifies tasks linked to certain capabilities. Can help in creating exercise objectives and a scenario.
Situation Manuals (SitMans) Exercise Participants, Evaluators, Controllers Ideally the primary source of documentation for a discussion based-exercise. Textual exercise playbook that participants can follow while watching the multimedia presentation.
Multimedia Presentation Exercise Participants Used to supplement the SitMan. Adds a degree of realism to a discussion-based exercise by using visual and audio elements of a threat/hazard.

Operations-Based Exercises

Name User Purpose
Exercise Evaluation Guides (EEGs) Evaluators, Controllers Used to help evaluate an exercise. Identifies tasks linked to certain capabilities, can help in creating exercise objectives and a scenario
Exercise Plan (ExPlan) Exercise Participants Similar to a SitMan, but does not include scenario information. Includes summary of objectives, exercise scope, roles and responsibilities for exercise participants, duties for an exercise planning team, safety issues, rules of conduct, security, communication, schedule, and maps.
Controller and Evaluator (C/E) Handbook Controllers and Evaluators Distributed prior to an exercise to give ample time for review of material. Explains roles and responsibilities during the exercise. Contains greater detail about the scenario than ExPlan.
Controller Packets Controllers Distributed prior to the start of an exercise to controllers. Packets contain controller information respective to their duties (e.g., MSEL).
Evaluator Packets Evaluators Distributed immediately prior to the start of an exercise to evaluators. Packets contain evaluator information respective to their duties (e.g., relevant EEGs).
Media/Public Information Documentation Media, Community Can be in the form of a press release or public announcement. Can be distributed prior to an exercise and/or post-exercise.

Exercise Logistics

Exercise Logistics involve resources, tasks, and personnel needed to implement the exercise. Logistics differ for discussion-based exercises and operations-based exercises.

Discussion-Based Exercises

For Discussion-Based Exercises, key items that need to be considered are:

  • Participants: Identification of exercise participants, notification about the exercise, and essential exercise information.
  • Evaluators: Need to be recruited and trained prior to the exercise.
  • Facility: The hospital or another location.
  • Room: Often take place at an emergency operations center or conference room.
  • Room Layout: What groups/staff at each of the tables represent and seating assignments.
  • Multimedia Capabilities: Whether projectors, screens, computers, whiteboards, etc., are needed.

Other items that need to be considered include:

  • Accommodating People With Disabilities.
  • Providing Food.
  • Restrooms.
  • Registration Procedures.
  • Name Tags and Table Tents.

Operations-Based Exercises

For Operations-Based Exercises, the same factors need to be considered as for Discussion-Based Exercises, except with greater detail. Key items that need to be considered are:

  • Location(s): The physical location of the exercise, which varies depending on the objective, scope, and magnitude of exercise.
  • Assembly Area: The staging location for deployable resources prior to an exercise.
  • Response Route (if applicable): The path where emergency units travel during the exercise (e.g., when there is more than one exercise location).
  • Operations Area: The location for exercise play/tactical operations.
  • Observer/Media Area: The location for observers and media to safely watch the exercise and not interfere with exercise play.
  • Simulation Cell (SimCell): The area for simulating agencies not participating in an exercise, often represented as a call center that participants contact in lieu of contacting the actual agencies.
  • Multimedia Capabilities: Needed depending on the exercise.
  • Videotaping: Used for documenting the exercise and identifying areas of improvement. May be challenging if real patients are present, due to Health Insurance Portability and Accountability Act regulations.
  • Communications: How information sharing will take place during an exercise. Best to use a form that would most likely be used during an incident, e.g., radio or telephone. All communications should start and end with, "This is an exercise."
  • Safety: Ensuring that the safety of exercise participants is maintained and that actual patient care is not interrupted.
  • Actors: If actors are being used, the following items should be considered: waivers of liability, actor instructions, symptomology cards, moulage (e.g., cosmetics, fake blood).

Other items that need to be considered (if applicable) include:

  • Accommodating People With Disabilities.
  • Providing Food and Refreshments.
  • Supplies (e.g., HazMat Suits, Personal Protective Equipment).
  • Badges and Identification.
  • Registration Procedures.
  • Props and Devices.
  • Site Security (Including Weapons and Safety Policy).
  • Restrooms.

Evaluation Planning

The Design and Development phase takes place simultaneously with the Evaluation (Go to Chapter 8) phase. The capabilities, tasks, and objectives of an exercise need to be clearly defined because they are the basis of what will be evaluated. Evaluation documentation, such as Exercise Evaluation Guides (EEGs), along with the evaluation procedures and tasks of the evaluators, are designed prior to conducting the exercises. Planning the placement of the evaluators in the operations area is also an important planning consideration. Evaluators should be located where they can directly observe exercise activities, but they should not interfere with operations. Evaluators should also be able to move freely so that they may follow the action of key players as they complete tasks.

Evaluation planning is important early in the exercise planning process because the means of making a critical assessment of the exercise are necessary to determine strengths, weaknesses, and areas of improvement to build a stronger emergency management program.

Checklist: Design and Development

The following are some of the essential steps in the Design and Development phase:

Defining Capabilities, Tasks, and Objectives

  • Determine necessary capabilities and tasks.
  • Review the most recent hazard vulnerability analysis (HVA), Emergency Operations Plan (EOP) and previous After Action Reports/Improvement Plans.
  • Review necessary requirements/standards.
  • Define exercise objectives based on the HVA and capabilities and tasks to be tested.


  • Develop narrative context of the scenario.
  • Develop conditions to test plans and objectives.
  • Determine technical aspects of portraying the scenario.


  • Discussion-based Exercises
    • Exercise Evaluation Guides (EEGs).
    • Situation Manual (SitMan).
    • Multimedia Presentation.
    • Media/Public Announcement.
  • Operations-based Exercises
    • Exercise Evaluation Guides (EEGs).
    • Exercise Plan (ExPlan).
    • Controller/Evaluator (C&E) Handbook and Packets.
    • Media/Public Announcement.


  • Discussion-based Exercises
    • Participants: facilitators, controllers, evaluators.
    • Setting: location, room setup, restrooms.
    • Supplies: multimedia technology, table tents, name tags, food.
  • Operations-based Exercises
    • Participants: actors, controllers, evaluators.
    • Setting: assigning areas for assembly, operations, observation, SimCell and response routes.
    • Supplies: multimedia technology, communications technology, food, badges.
    • Safety: security, weapons and safety policy.

Evaluation Planning

  • Develop evaluation documentation (Exercise Evaluation Guides, Evaluation forms, etc.)
  • Recruit and train evaluators.
  • Plan the placement of evaluators at the exercise site.

Useful Resources and Tools

Below is a list of useful resources and tools for exercise design and development.


Defining Capabilities, Tasks, and Objectives

Hazard Vulnerability Analysis (HVA)

  • The following are templates for HVAs that assess the probability and severity of hazards and threats to the hospital.
  • Kaiser Permanente HVA Exit Disclaimer (Kaiser Permanente)


Exercise Documentation

  • Discussion-Based Exercises
    • Situation Manual (SitMan) (HSEEP Vol. IV, See under Design and Development > Documentation).
  • Operations-Based Exercises
    • Exercise Plan (ExPlan) (HSEEP Vol. IV, See under Design and Development > Documentation).
    • Controller & Evaluator (C&E) Handbook (HSEEP Vol. IV, See under Design and Development > Documentation).

Exercise Logistics

  • Discussion-Based Exercises
    • Media/Public Announcement (HSEEP Vol. IV, see under Design and Development).
  • Operations-Based Exercises
    • Media/Public Announcement (HSEEP Vol. IV, see under Design and Development > Actors).
    • Actor Waiver Form (HSEEP Vol. IV, see under Design and Development > Actors).

Evaluation Planning

  • Exercise Evaluation Guides
    This Web site has a library of EEG templates developed by HSEEP that correspond to capabilities in the Target Capabilities List. They include guides for medical surge, mass prophylaxis, medical supplies management and distribution, among others that are related to hospitals. (HSEEP)
  • Evaluation of Hospital Disaster Drills: A Module-Based Approach
    This resource provides valuable information and forms for evaluating hospital exercises, including scenarios related to decontamination, biological incidents, radiation incidents, and triage. (AHRQ)

*Note: The HVA is not a form of HSEEP documentation.

**Note: These can be found as part of the HSEEP Volume IV Library: Sample Exercise Materials under Exercise Planning.

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