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Hospital Preparedness Pocket Guide

This resource was developed by AHRQ as part of its Public Health Emergency Preparedness program, which was discontinued on June 30, 2011. Many of AHRQ's PHEP materials and activities will be supported by other Federal agencies. Notice of transfer to another agency will be posted on this site.

This information is for reference purposes only. It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work. Persons with disabilities having difficulty accessing this information should contact us at: Let us know the nature of the problem, the Web address of what you want, and your contact information.

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This Pocket Guide is meant to be a quick reference for those planning, conducting, and evaluating hospital preparedness exercises. For additional information on the materials presented in this Pocket Guide, please reference the Hospital Preparedness Exercises Guidebook. For a complete listing of resources and tools related to hospital preparedness exercises, please go to the Hospital Preparedness Exercises Atlas of Resources and Tools.

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Hospital Preparedness Exercises

A hospital preparedness exercise is a means for a hospital to test and evaluate its capabilities of preventing, preparing for, protecting from, responding to, and/or recovering from an event that puts a significant strain on a hospital's patient care or operating systems. Exercises are a component of a hospital's emergency management program, which also may include emergency operations plans and an incident command system.

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Types of Exercises

Two main categories of exercises are discussion-based exercises, which concentrate on strategic issues related to plans, policies, agreements, or procedures, and operations-based exercises, which test and evaluate certain capabilities, procedures, and functions.

Discussion-Based Exercises Types

Type of Exercise Exercise Scale Definition and 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 walk through incident response under simulated emergency settings.
Game Small-Medium Adapts to actions of participants; and consequences of decisions and actions during exercise play.
Model/Simulation Small Used to visualize and quantify a scenario and consequences of specific decisions.

Operations-Based Exercise Types

Type of Exercise Exercise Scale Definition and Purpose
Drill1 Small-Medium Small scale way of testing a specific function of an organization (e.g. fire evacuation drill) and are 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 Exercise21 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

1In certain publications, 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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Exercise Requirements

Hospital preparedness exercises serve to prepare the hospital to respond to an emergency incident. Exercises may be required by certain government agencies or accreditation organizations. Some of the important groups that have specific exercise requirements are:

The Joint Commission—go to the chapter on Emergency Management in the accreditation manual.

The American Osteopathic Association —See the Disaster Drills Standards in the Healthcare Facilities Accreditation Program standards.

Det Norske Veritas—See Environment of Care Standards in the National Integrated Accreditation for Healthcare Organizations standards.

National Hospital Preparedness Program—Check with your State or local Jurisdiction for potential deliverables required of your hospital.

Other State and Local Jurisdiction Requirements

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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 Review 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.
After Action Reports/Improvement Plans Show existing strengths, weaknesses, and recent improvements in the system.
Emergency Operations Plan Outlines the hospital's plans and protocols for emergency events.
Accreditation Standards Important if one of the exercise goals is to meet accreditation requirements.
Federal/ State/ Local Jurisdiction Requirements, 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 Guide (EEG) Evaluators, Controllers Used to help evaluate an exercise; identifies tasks linked to certain capabilities.
Situation Manual (SitMan) Exercise Participants, Evaluators, Controllers Ideally the primary source of documentation for a discussion based-exercise —a textual exercise playbook.
Multimedia Presentation Exercise Participants Used to supplement the SitMan; provides a degree of realism to a discussion-based exercise.

Documentation to be Created/Modified Operations-Based Exercises

Name User Purpose
Exercise Evaluation Guide (EEG) Evaluators, Controllers Used to help evaluate an exercise; Identifies tasks linked to capabilities.
Exercise Plan (ExPlan) Exercise Participants Similar to a SitMan, but has no scenario information; includes summary of objectives, exercise scope, roles and responsibilities, duties for a planning team.
Controller and Evaluator (C/E) Handbook Controllers and Evaluators Explains roles and responsibilities during the exercise; greater scenario detail 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 to evaluators immediately prior to the start of an exercise; packets contain information on their duties (e.g. relevant EEGs).
Media/Public Information Documents Media, Community Can be in the form of a press release or public announcement

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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 points for maximizing efficacy and efficiency are listed here.


An exercise can only effectively test what the participants know. It is essential that the participants are 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, meetings can be shortened and the number of staff needed for exercise planning can be reduced. They 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 seeking 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 only a single entity, so it is important to do exercises that involve the community. Some accreditation organizations such as Joint Commission require involvement of community partners such as local police, fire, and public health departments. 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 available.

Additionally, 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.

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HSEEP Exercise Methodology

The Homeland Security Exercise and Evaluation Program (HSEEP) has an exercise methodology that consists of five phases:

  • Foundation
  • Design & Development
  • Conduct
  • Evaluation

Improvement Planning

These phases are meant to be a cycle, with the next exercise being based on lessons learned and improvements made from previous exercises. This is meant to strengthen the overall emergency management program of the hospital. The following checklists outline each phase and include essential tasks to be completed in each phase. The lists are not exhaustive of all tasks that need to be completed, nor do they ensure full HSEEP compliance.

Checklist: Foundation

The following are some of the essential steps in the Foundation phase:

Developing a Support Base

  • Identify key stakeholders.
  • Involve key stakeholders in exercise planning (form an emergency management committee).

Forming an Exercise Planning Team

  • Identify team members and assign roles.
  • Creating a Timeline

    • Determine necessary meetings and milestones.
    • Set dates and deadlines for completion.

    Conducting Exercise Planning Conferences

    Discussion-Based Exercises

    • Concept/Objectives Meeting
    • Initial Planning Conference
    • Final Planning Conference

    Operations-Based Exercises

    • Concept/Objectives Meeting
    • Initial Planning Conference
    • Midterm Planning Conference
    • Master Scenario Events List Conference
    • Final Planning Conference

    Checklist: Design & Development

    The following are some of the essential steps in the Design & 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

    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.

    Checklist: Conduct

    The following are some of the essential steps in the Conduct phase:

    Discussion-Based Exercise

    • Room setup
    • General briefing presentation
    • Exercise play — presentation of scenario and discussion
    • Debriefing with exercise planning team
    • Hot wash and/or participant feedback forms

    Operations-Based Exercise

    • Set-up of location
    • Safety briefing for all participants
    • Individual briefings for controllers and evaluators, players, actors, and observers
    • Exercise play
    • Player hot wash
    • Controller & Evaluator debrief

    Checklist: Evaluation

    The following are some of the essential steps for the Evaluation phase:

    Planning and Organizing the Evaluation

    • Assign a lead evaluator.
    • Identify evaluation requirements.
    • Hire and train evaluators.
    • Develop an evaluation plan.
    • Hold a controller and evaluator briefing (just prior to the exercise).

    Observing the Exercise and Collecting Data

    • Data includes:
    • Evaluators' observations from the exercise
    • Exercise Evaluation Guides (EEGs)
    • Hot wash minutes
    • Participant feedback forms

    Analyzing Evaluation Information

    • Condense information into narratives showing exercise strengths and weaknesses.
    • Decide whether objectives were met.
    • Determine root causes for actions and tasks not completed.
    • Develop recommendations for improvement.

    Developing the Draft of the After Action Report/Improvement Plan

    • Write the draft of the AAR/IP.

    Checklist: Improvement Planning

    The following are some of the 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 to be Implemented

    • Determine changes needed to be made to plans, organizational structures, equipment, and additional training needed for staff.
    • Determine time frames and methods of measuring completion of corrective actions.
    • Write corrective actions into the IP.

    Finalize AAR/IP

    • Create final draft of AAR/IP with 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.

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    Useful Web Sites

    These Web sites may be useful for hospital emergency preparedness exercises:

    Agency for Healthcare Research and Quality (AHRQ)

    Center for HICS Education & Training Exit Disclaimer

    Centers for Disease Control & Prevention (CDC)

    Centers for Medicare & Medicaid Services (CMS)

    Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response (ASPR)

    Federal Emergency Management Agency (FEMA)

    Hospital Incident Command System (HICS) Exit Disclaimer

    Homeland Security Exercise and Evaluation Program (HSEEP)

    National Association of County and City Health Officials Exit Disclaimer

    National Incident Management System (NIMS)

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    Commonly-Used Acronyms and Abbreviations

    AAC—After Action Conference
    AAR/IP—After Action Report/Improvement Plan
    ACS—Alternate Care Site
    AHRQ—Agency for Healthcare Research and Quality
    AOA—American Osteopathic Association
    ASPR—Office of the Assistant Secretary for Preparedness and Response of the U.S. Department of Health and Human Services
    C/E—Controllers and Evaluators
    C&O—Concept and Objectives Meeting
    CMS—Centers for Medicare and Medicaid Services
    CoP—Condition of Participation
    DNV—Det Norske Veritas
    EEG—Exercise Evaluation Guide
    EM—Emergency Management
    EOP—Emergency Operations Plan
    ESAR-VHP—Emergency System for Advance Registration of Volunteer Health Professionals
    ExPlan—Exercise Plan
    FEMA—Federal Emergency Management Agency
    FPC—Final Planning Conference
    HAvBED—Hospital Available Beds for Emergencies and Disasters
    HEICS—Hospital Emergency Incident Command System
    HFAP—Healthcare Facilities Accreditation Program
    HHS—U.S. Department of Health and Human Services
    HICS—Hospital Incident Command System
    HPP—Hospital Preparedness Program
    HSEEP—Homeland Security Exercise and Evaluation Program
    HVA—Hazard Vulnerability Analysis
    ICS—Incident Command System
    IPC—Initial Planning Conference
    MOU—Memoranda of Understanding
    MPC—Midterm Planning Conference
    MSEL—Master Scenario Events List
    NFPA—National Fire Protection Association
    NIAHO—National Integrated Accreditation for Healthcare Organizations
    NIMS—National Incident Management System
    OSHA—Occupational Safety and Health Administration
    POC—Point of Contact
    PPE—Personal Protective Equipment
    SitMan—Situation Manual
    TCL—Target Capabilities List
    TTX—Tabletop Exercise
    UTL—Universal Task List

    AHRQ Publication No. 10-0001-3
    Current as of December 2010


    The information on this page is archived and provided for reference purposes only.


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