Why We Support More Detailed Exercise Standards

Currently, almost every provider type is required to participate in two exercises per year. One “should be” a “community full-scale exercise” while the other can be a tabletop. The original version of the current exercise standards was clearly written without input from anyone with Homeland Security exercise expertise, and they’re finding this out now.
By “full-scale” they meant “operations based” which translates into “real-time, realistic scenario, higher pressure” exercise. Now they realize they’d be happy with a “functional” exercise, which is operations based, but without actually moving staff or patients. Typically, the incident command team of a facility comes together to face a scenario and make decisions. An exercise controller gives them inputs including available resources and what impact the command team’s resources have on the emergency.
The proposed rule clarifies the exercise requirements and for most facilities, gives more flexibility. Here is the proposed text for hospitals, which also applies to most in-patient facilities:
(2) Testing. The hospital must conduct exercises to test the emergency plan at least twice per year. The hospital must do all of the following:
(i) Participate in an annual full-scale exercise that is community-based or when a community-based exercise is not accessible, an individual, facility-based functional exercise annually. If the hospital experiences an actual natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full-scale community-based exercise or individual, facility-based functional exercise following the onset of the actual event.
(ii) Conduct an additional exercise at least annually that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that includes a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the hospital’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the hospital’s emergency plan, as needed.
For outpatient facilities like home health and home-bound hospice, only one exercise per year is required. Every other year, they must participate in a community-based full-scale or facility-based functional exercise, and in the off years, any exercise from column ii: a second full-scale or functional, a “mock drill” or a tabletop or workshop.
The big differences are:
  1. Clarity in the first exercise requirement. A functional exercise will suffice.
  2. More choices in the second exercise. A “workshop” counts as an exercise, but it is really a session that seeks to produce a particular document, like a training and exercise plan, or a new policy or procedure. Workshops are important, but they do not demonstrate capability in emergency performance.
  3. For outpatient facilities, only one exercise per year would be required.
We believe in regular exercises. We prefer to see smaller scale exercises, with limited objectives, testing a handful of core capabilities like incident command, communications, and shelter in place. Make it simple, get a realistic and honest after-action report and improvement plan out quickly, make the suggested changes, and then test the capabilities again, to see what difference they made. In our view, grandiose “community-based full-scale exercises” yield little value to individual facilities. You are a bit player in a large chess game. They may be important for global community strategy, but at best, you end up with a drill out of it.
Leave your comments on the federal register and let us know what you think!

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Categories: CMS Compliance | Healthcare

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