What’s Wrong with ASPR’s Coalition Surge Test?

Healthcare coalitions are expected to conduct a Coalition Surge Test this year, as promulgated by ASPR. Many coalitions are struggling with this great idea because it is packaged confusingly. Here, our resident Master Exercise Practitioner will unpack the gems and seek to polish them a bit.
First, let’s get the concept clear. The purpose of this exercise is to test plans, policies, and procedures for regional coordination of bed availability and patient transportation among acute and sub-acute care facilities. This is an essential part of healthcare coordination and has applicability in many scenarios. Since hospitals routinely operate very close to capacity, when disaster strikes a hospital or a region, finding available beds of the right type is a challenge. It may require moving patients from one facility to another, especially moving patients to a lower-acuity facility to make room for incoming higher-acuity patients.

It’s a functional exercise.

The Coalition Surge Test is not a tabletop exercise. It is a functional exercise. The difference is significant. In this functional exercise, a scenario is played out in real time, under pressure, and incident command staff are expected to play their roles as they would in a real emergency. Since no field assets are involved – no patients, real or simulated, are actually being moved – it is not a full-scale exercise. A table that outlines exercise types is available on the FEMA website.
Also, see our post on exercise options and components

It must be part of a progression.

Because this is a functional exercise which requires the coordination of plans, policies, and procedures among different facilities, there is little likelihood of it succeeding unless these plans, policies, and procedures have been reviewed in the low-stress environment of a tabletop exercise. In fact, it is highly likely that a tabletop will reveal that some coordination plans or essential elements are missing and must be created in a workshop. For example, a tabletop exercise might reveal that there is no published inventory of regional transportation assets and no process for activating them in this type of emergency. Another common problem with inter-facility transfer is confusion among bed types and lack of the data necessary to find the right bed (and the optimal transportation) for each patient. These essential tools of a healthcare surge may take months to develop, including one or more tabletop exercises, before a functional exercise can test them in real time.
The coalition surge test is not the final step in preparedness, any more than it is the initial step. ASPR wants these conducted annually but gives no guidance on how to build on previous exercises, nor on how to let the Coalition Surge Test help coalitions and facilities meet their other exercise objectives. We are drafting several variations of this exercise so that coalitions can adapt it to meet the needs of their Multi-year Training and Exercise Plan (MYTEP), which should reflect the regional HVA, the needs of the community, and coalitions’ financial, staff, and membership capacity for exercises.

Let’s use HSEEP?

The US Department of Homeland Security Exercise and Evaluation Program (HSEEP) is the standard for designing, conducting, and evaluating readiness exercises in the US. Healthcare coalitions are learning how to understand and use HSEEP in their exercises. Why HSEEP was ignored in the development of the Coalition Surge Test is not an insult to DHS as much as it is confusing to healthcare coalitions and facilities that are struggling to understand its terminology and document format. We are rewriting the Coalition Surge Test into HSEEP-formatted documents and processes, but let us translate some terms here in the furtherance of uniformity and clarity:
  • They’re “evaluators” and not “assessors” – these are the people who observe exercise play and compare it to the expected behavior based on accepted standards.
  • It’s an “exercise” and not a “test.”
  • It’s a “hotwash” and not a “facilitated discussion” – the time spent debriefing an exercise, gathering input from the players on what they learned, and initial critique on how the exercise was designed and conducted.

It’s missing the most important elements.

If the designers of the Coalition Surge Test were using HSEEP, they would have been forced to document the specific capabilities that are being exercised. This is critical because we exercise capabilities, not scenarios. While evacuation and surge are obvious capabilities, other essential capabilities could be exercised and evaluated, each of which would give excellent guidance to the coalition. For example, some coalitions report that communications between facilities is a challenge during this exercise. Indeed, communications are a frequent challenge in exercises and real-world events, and we have designed communications drills for coalitions just to help them reduce this source of friction. But unless capabilities are specifically included in an exercise, the objectives, scenario, and most importantly, the evaluation process, will not be designed to give useful feedback.
ASPR has produced a detailed document of the capabilities it expects of coalitions and members, but that was not referenced in the Coalition Surge Test. We have made some educated guesses about which of these capabilities the test may be included. There are too many for all of them to be successfully exercised and evaluated within the 90-minute time frame of the exercise, so it is important that each coalition choose the ones it deems most important.
Once capabilities are selected for an exercise, great care must be put into designing the Exercise Evaluation Guide, so that the Target Capability (how well should that capability be executed) and Critical Tasks (the essential “molecules” required for success in this capability) are documented. Only then can the scenario be fully developed, so that the right environment is there to allow the players to demonstrate these capabilities.
Yes, the “Assessor’s Tool” spreadsheet has an evaluation tab that helps document the exercise results, but its data has no goals to compare it to. The exercise compiles “how well you did” but not against “how well you hoped to do” and has no way of documenting what specific things went right or wrong. Therefore, there can be no detailed Improvement Plan, which is the most critical element of any exercise.
What have your experiences been with the Coalition Surge Test? Do you want to learn more about a Multi-year Training and Exercise Plan? How can we help?
Categories: Healthcare
Topics: Coalition

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