course material

1. PowerPoint Presentations: PPT Presentations of 15-20 slides ( HealthCare
Emergency Management )
Accreditation Program: Hospital Emergency Management Pre-Publication Version © 2008
The Joint Commission on Accreditation of Healthcare Organizations Accreditation Program:
Hospital Chapter: Emergency Management Standard EM.01.01.01 The [organization]
engages in planning activities prior to developing its written Emergency Operations Plan.
Note: An emergency is an unexpected or sudden event that significantly disrupts the
organization’s ability to provide care, or the environment of care itself, or that results in a
sudden, significantly changed or increased demand for the organization’s services.
Emergencies can be either human-made or natural (such as an electrical system failure or a
tornado), or a combination of both, and they exist on a continuum of severity. A disaster is a
type of emergency that, due to its complexity, scope, or duration, threatens the
organization’s capabilities and requires outside assistance to sustain [patient] care, safety,
or security functions. Rationale for EM.01.01.01 An emergency in a health care organization
can suddenly and significantly affect demand for its services or its ability to provide those
services. Therefore, the organization needs to engage in planning activities that prepare it to
form its Emergency Operations Plan. These activities include identifying risks, prioritizing
likely emergencies, attempting to mitigate them when possible, and considering its
potential emergencies in developing strategies for preparedness. Because some
emergencies that impact an organization originate in the community, the organization
needs to take advantage of opportunities where possible to collaborate with relevant
parties in the community. Elements of Performance for EM.01.01.01 1. The hospital’s
leaders, including leaders of the medical staff, participate in planning activities prior to
developing an Emergency Operations Plan. A 2. The hospital conducts a hazard vulnerability
analysis (HVA) to identify potential emergencies that could affect demand for the hospital’s
services or its ability to provide those services, the likelihood of those events occurring, and
the consequences of those events. The findings of this analysis are documented. (See also
EM.03.01.01, EP 1) Note: Hospitals have flexibility in creating either a single HVA that
accurately reflects all sites of the hospital, or multiple HVAs. Some remote sites may be
significantly different from the main site (for example, in terms of hazards, location, and
population served); in such situations a separate HVA is appropriate. Footnote: If the
hospital identifies a surge in infectious patients as a potential emergency, this issue is
addressed in the “Infection Prevention and Control” (IC) chapter. (See also IC.01.06.01, EP

2. 4) A 3. The hospital, together with its community partners, prioritizes the potential
emergencies identified in its hazard vulnerability analysis (HVA) and documents these
priorities. Note: The hospital determines which community partners are critical to helping
define priorities in its HVA. Community partners may include other health care
organizations, the public health department, vendors, community organizations, public
safety and public works officials, representatives of local municipalities, and other
government agencies. A 4. The hospital communicates its needs and vulnerabilities to
community emergency response agencies and identifies the community’s capability to meet
its needs. This communication and identification occur at the time of the hospital’s annual
review of its Emergency Operations Plan and whenever its needs or vulnerabilities change.
(See also EM.03.01.01, EP 1) A Page 2 of 19 Pre-Publication Version © 2008 The Joint
Commission on Accreditation of Healthcare Organizations Accreditation Program: Hospital
Chapter: Emergency Management 5. The hospital uses its hazard vulnerability analysis as a
basis for defining mitigation activities (that is, activities designed to reduce the risk of and
potential damage from an emergency). Note: Mitigation, preparedness, response, and
recovery are the four phases of emergency management. They occur over time: mitigation
and preparedness generally occur before an emergency, and response and recovery occur
during and after an emergency. A 6. The hospital uses its hazard vulnerability analysis as a
basis for defining the preparedness activities that will organize and mobilize essential
resources. (See also IM.01.01.03, EPs 1-4) A 7. The hospital’s incident command structure is
integrated into and consistent with its community’s command structure. Note: The incident
command structure used by the hospital should provide for a scalable response to different
types of emergencies. Footnote: The National Incident Management System (NIMS) is one of
many models for an incident command structure available to health care organizations.
NIMS provides guidelines for common functions and terminology to support clear
communications and effective collaboration in an emergency situation. NIMS is required of
hospitals receiving certain federal funds for emergency preparedness. A 8. The hospital
keeps a documented inventory of the resources and assets it has on site that may be needed
during an emergency, including, but not limited to, personal protective equipment, water,
fuel, and medical, surgical, and medication-related resources and assets. (See also
EM.02.02.03, EP 6) A Page 3 of 19 Pre-Publication Version © 2008 The Joint Commission on
Accreditation of Healthcare Organizations Chapter: Emergency Management The hospital
develops and maintains a written Emergency Operations Plan that describes the response
procedures to follow when emergencies occur. (See also EM.03.01.03, EP 5) Note: The
response procedures address the prioritized emergencies, but can also be adapted to other
emergencies that the hospital may experience. Response procedures could include the
following: – Maintaining or expanding services – Conserving resources – Curtailing services
– Supplementing resources from outside the local community – Closing the hospital to new
patients – Staged evacuation – Total evacuation The Emergency Operations Plan identifies
the hospital’s capabilities and establishes response procedures for when the hospital cannot
be supported by the local community in the hospital’s efforts to provide communications,
resources and assets, security and safety, staff, utilities, or patient care for at least 96 hours.
Note: Hospitals are not required to stockpile supplies to last for 96 hours of operation. The

3. hospital develops and maintains a written Emergency Operations Plan that describes the
recovery strategies and actions designed to help restore the systems that are critical to
providing care, treatment, and services after an emergency. 2. 3. 4. A A A A Page 4 of 19 Pre-
Publication Version © 2008 The Joint Commission on Accreditation of Healthcare
Organizations The hospital’s leaders, including leaders of the medical staff, participate in
the development of the Emergency Operations Plan. 1. Elements of Performance for
EM.02.01.01 Rationale for EM.02.01.01 A successful response effort relies on a
comprehensive and flexible Emergency Operations Plan that guides decision-making at the
onset of an emergency and as an emergency evolves. Although the Emergency Operations
Plan can be formatted in a variety of ways, it must address response procedures that are
both applicable to the [organization]’s likely emergencies and adaptable in supporting key
areas (such as communications and patient care) that might be affected by emergencies of
different causes. The [organization] has an Emergency Operations Plan. Note: The
[organization]’s Emergency Operations Plan is designed to coordinate its communications,
resources and assets, safety and security, staff responsibilities, utilities, and [patient]
clinical and support activities during an emergency (refer to EM.02.02.01, EM.02.02.03,
EM.02.02.05, EM.02.02.07, EM.02.02.09, and EM.02.02.11). Although emergencies have
many causes, the effects on these areas of the organization and the required response effort
may be similar. This “all hazards” approach supports a general response capability that is
sufficiently nimble to address a range of emergencies of different duration, scale, and cause.
For this reason, the Plan’s response procedures address the prioritized emergencies, but are
also adaptable to other emergencies that the organization may experience. Standard
EM.02.01.01 Accreditation Program: Hospital The Emergency Operations Plan identifies the
individual(s) who has the authority to activate the response and recovery phases of the
emergency response. The Emergency Operations Plan identifies alternative sites for care,
treatment, and services that meet the needs of its patients during emergencies. If the
hospital experiences an actual emergency, the hospital implements its response procedures
related to care, treatment, and services for its patients. 6. 7. 8. A A A A Page 5 of 19 Pre-
Publication Version © 2008 The Joint Commission on Accreditation of Healthcare
Organizations The Emergency Operations Plan describes the processes for initiating and
terminating the hospital’s response and recovery phases of an emergency, including under
what circumstances these phases are activated. Note: Mitigation, preparedness, response,
and recovery are the four phases of emergency management. They occur over time:
mitigation and preparedness generally occur before an emergency, and response and
recovery occur during and after an emergency. Chapter: Emergency Management 5.
Accreditation Program: Hospital Chapter: Emergency Management The Emergency
Operations Plan describes the following: How the hospital will communicate information
and instructions to its staff and licensed independent practitioners during an emergency.
The Emergency Operations Plan describes the following: How the hospital will notify
external authorities that emergency response measures have been initiated. The Emergency
Operations Plan describes the following: How the hospital will communicate with external
authorities during an emergency. The Emergency Operations Plan describes the following:
How the hospital will communicate with patients and their families, including how it will

4. notify families when patients are relocated to alternative care sites. The Emergency
Operations Plan describes the following: How the hospital will communicate with the
community or the media during an emergency. The Emergency Operations Plan describes
the following: How the hospital will communicate with purveyors of essential supplies,
services, and equipment during an emergency. The Emergency Operations Plan describes
the following: How the hospital will communicate with other health care organizations in its
contiguous geographic area regarding the essential elements of their respective command
structures, including the names and roles of individuals in their command structures and
their command center telephone numbers. The Emergency Operations Plan describes the
following: How the hospital will communicate with other health care organizations in its
contiguous geographic area regarding the essential elements of their respective command
centers for emergency response. The Emergency Operations Plan describes the following:
How the hospital will communicate with other health care organizations in its contiguous
geographic area regarding the resources and assets that could be shared in an emergency
response. 2. 3. 4. 5. 6. 7. 8. 9. 10. A A A A A A A A A A Page 6 of 19 Pre-Publication Version ©
2008 The Joint Commission on Accreditation of Healthcare Organizations The Emergency
Operations Plan describes the following: How staff will be notified that emergency response
procedures have been initiated. 1. Elements of Performance for EM.02.02.01 Rationale for
EM.02.02.01 The [organization] maintains reliable communications capabilities for the
purpose of communicating response efforts to staff, [patient]s, and external organizations.
The [organization] establishes backup communications processes and technologies (for
example, cell phones, landlines, bulletin boards, fax machines, satellite phones, Amateur
Radio, text messages) to communicate essential information if primary communications
systems fail. As part of its Emergency Operations Plan, the [organization] prepares for how
it will communicate during emergencies. Standard EM.02.02.01 Accreditation Program:
Hospital The Emergency Operations Plan describes the following: How, and under what
circumstances, the hospital will communicate information about patients to third parties
(such as other health care organizations, the state health department, police, the FBI). The
Emergency Operations Plan describes the following: How the hospital will communicate
with identified alternative care sites. The hospital establishes backup systems and
technologies for the communication activities identified in EM.02.02.01, EPs 1 – 13. The
hospital implements the components of its Emergency Operations Plan that require
advance preparation to support communications during an emergency. 12. 13. 14. 17. A A A
A A Page 7 of 19 Pre-Publication Version © 2008 The Joint Commission on Accreditation of
Healthcare Organizations The Emergency Operations Plan describes the following: How and
under what circumstances the hospital will communicate the names of patients and the
deceased with other health care organizations in its contiguous geographic area. Chapter:
Emergency Management 11. Accreditation Program: Hospital Chapter: Emergency
Management The Emergency Operations Plan describes the following: How the hospital will
obtain and replenish medical supplies that will be required throughout the response and
recovery phases of an emergency, including personal protective equipment where required.
The Emergency Operations Plan describes the following: How the hospital will obtain and
replenish non-medical supplies that will be required throughout the response and recovery

5. phases of an emergency. The Emergency Operations Plan describes the following: How the
hospital will share resources and assets with other health care organizations within the
community, if necessary. Note: Examples of resources and assets that might be shared
include beds, transportation, linens, fuel, personal protective equipment, medical
equipment, and supplies. The Emergency Operations Plan describes the following: How the
hospital will share resources and assets with other health care organizations outside the
community, if necessary, in the event of a regional or prolonged disaster. Note: Examples of
resources and assets that might be shared include beds, transportation, linens, fuel,
personal protective equipment, medical equipment, and supplies. The Emergency
Operations Plan describes the following: How the hospital will monitor quantities of its
resources and assets during an emergency. (See also EM.01.01.01, EP 8) The Emergency
Operations Plan describes the following: The hospital’s arrangements for transporting some
or all patients, their medications, supplies, equipment, and staff to an alternative care site(s)
when the environment cannot support care, treatment, and services. (See also EM.02.02.11,
EP 3) 2. 3. 4. 5. 6. 9. A A A A A A A Page 8 of 19 Pre-Publication Version © 2008 The Joint
Commission on Accreditation of Healthcare Organizations The Emergency Operations Plan
describes the following: How the hospital will obtain and replenish medications and related
supplies that will be required throughout the response and recovery phases of an
emergency, including access to and distribution of caches that may be stockpiled by the
hospital, its affiliates, or local, state, or federal sources. 1. Elements of Performance for
EM.02.02.03 Rationale for EM.02.02.03 The [organization] that continues to provide care,
treatment, and services to its [patient]s during emergencies needs to determine how
resources and assets (that is, supplies, equipment, and facilities) will be managed internally
and, when necessary, solicited and acquired from external sources such as vendors,
neighboring health care providers, other community organizations, state affiliates, or a
regional parent company. The [organization] should also recognize the risk that some
resources may not be available from planned sources, particularly in emergencies of long
duration or broad geographic scope, and that contingency plans will be necessary for
critical supplies. This situation may occur when multiple [organization]s are vying for a
limited supply from the same vendor. As part of its Emergency Operations Plan, the
[organization] prepares for how it will manage resources and assets during emergencies.
Standard EM.02.02.03 Accreditation Program: Hospital The hospital implements the
components of its Emergency Operations Plan that require advance preparation to provide
for resources and assets during an emergency. 12. The Emergency Operations Plan
describes the following: The roles that community security agencies (for example, police,
sheriff, national guard) will have in the event of an emergency. The Emergency Operations
Plan describes the following: How the hospital will coordinate security activities with
community security agencies (for example, police, sheriff, national guard). The Emergency
Operations Plan describes the following: How the hospital will manage hazardous materials
and waste. The Emergency Operations Plan describes the following: How the hospital will
provide for radioactive, biological, and chemical isolation and decontamination. The
Emergency Operations Plan describes the following: How the hospital will control entrance
into and out of the health care facility during an emergency. The Emergency Operations

6. Plan describes the following: How the hospital will control the movement of individuals
within the health care facility during an emergency. The Emergency Operations Plan
describes the following: The hospital’s arrangements for controlling vehicles that access the
health care facility during an emergency. The hospital implements the components of its
Emergency Operations Plan that require advance preparation to support security and safety
during an emergency. 2. 3. 4. 5. 7. 8. 9. 10. A A A A A A A A A A A Page 9 of 19 Pre-Publication
Version © 2008 The Joint Commission on Accreditation of Healthcare Organizations The
Emergency Operations Plan describes the following: The hospital’s arrangements for
internal security and safety. 1. Elements of Performance for EM.02.02.05 As part of its
Emergency Operations Plan, the [organization] prepares for how it will manage security
and safety during an emergency. Standard EM.02.02.05 The Emergency Operations Plan
describes the following: The hospital’s arrangements for transferring pertinent information,
including essential clinical and medication-related information, with patients moving to
alternative care sites. (See also EM.02.02.11, EP 3) Chapter: Emergency Management 10.
Accreditation Program: Hospital Chapter: Emergency Management The Emergency
Operations Plan describes the following: The process for assigning staff to all essential staff
functions. The Emergency Operations Plan identifies the individual(s) to whom staff report
in the hospital’s incident command structure. The Emergency Operations Plan describes
how the hospital will manage staff support needs (for example, housing, transportation,
incident stress debriefing). The Emergency Operations Plan describes how the hospital will
manage the family support needs of staff (for example, child care, elder care,
communication). The hospital trains staff for their assigned emergency response roles. The
hospital communicates in writing with each of its licensed independent practitioners
regarding his or her role(s) in emergency response and to whom he or she reports during
an emergency. The Emergency Operations Plan describes how the hospital will identify
licensed independent practitioners, staff, and authorized volunteers during emergencies.
(See also EM.02.02.13, EP 3; EM.02.02.15, EP 3) Note: This identification could include
identification cards, wrist bands, vests, hats, or badges. The hospital implements the
components of its Emergency Operations Plan that require advance preparation to manage
staff during an emergency. 3. 4. 5. 6. 7. 8. 9. 10. A A C C A A A A A Page 10 of 19 Pre-
Publication Version © 2008 The Joint Commission on Accreditation of Healthcare
Organizations The Emergency Operations Plan describes the following: The roles and
responsibilities of staff for communications, resources and assets, safety and security,
utilities, and patient management during an emergency. 2. Elements of Performance for
EM.02.02.07 Rationale for EM.02.02.07 To provide safe and effective [patient] care during
an emergency, staff roles are well defined in advance, and staff are oriented in their
assigned responsibilities. Staff roles and responsibilities may be documented in the Plan
using a variety of formats (for example, job action sheets, checklists, flow charts). Due to the
dynamic nature of emergencies, effective training prepares staff to adjust to changes in
[patient] volume or acuity, work procedures or conditions, and response partners within
and outside the [organization]. As part of its Emergency Operations Plan, the [organization]
prepares for how it will manage staff during an emergency. Standard EM.02.02.07
Accreditation Program: Hospital Chapter: Emergency Management As part of its Emergency

7. Operations Plan, the hospital identifies alternative means of providing the following: Water
needed for consumption and essential care activities. As part of its Emergency Operations
Plan, the hospital identifies alternative means of providing the following: Water needed for
equipment and sanitary purposes. As part of its Emergency Operations Plan, the hospital
identifies alternative means of providing the following: Fuel required for building
operations, generators, and essential transport services that the hospital would typically
provide. As part of its Emergency Operations Plan, the hospital identifies alternative means
of providing the following: Medical gas/vacuum systems. As part of its Emergency
Operations Plan, the hospital identifies alternative means of providing the following: Utility
systems that the hospital defines as essential (for example, vertical and horizontal
transport, heating and cooling systems, and steam for sterilization). The hospital
implements the components of its Emergency Operations Plan that require advance
preparation to provide for utilities during an emergency. 3. 4. 5. 6. 7. 8. A A A A A A A Page
11 of 19 Pre-Publication Version © 2008 The Joint Commission on Accreditation of
Healthcare Organizations As part of its Emergency Operations Plan, the hospital identifies
alternative means of providing the following: Electricity. 2. Elements of Performance for
EM.02.02.09 Rationale for EM.02.02.09 Different types of emergencies can have the same
detrimental impact on an organization’s utility systems. For example, brush fires, ice
storms, and industrial accidents can all result in a loss of utilities required for care,
treatment, services, and building operations. Organizations, therefore, must have
alternative means of providing for essential utilities (for example, alternative equipment at
the [organization], negotiated relationships with the primary suppliers, provision through a
parent entity, Memoranda of Understanding (MOU) with other organizations in the
community). Organizations should determine how long they expect to remain open to care
for [patient]s and plan for their utilities accordingly. Because some emergencies may be
regional in scope or of long duration, organizations should not rely solely on single source
providers in the community. Where possible, organizations should identify other suppliers
outside of the local community in case the communities’ infrastructure is severely
compromised and unable to support the organization. As part of its Emergency Operations
Plan, the [organization] prepares for how it will manage utilities during an emergency.
Standard EM.02.02.09 Accreditation Program: Hospital Chapter: Emergency Management
The Emergency Operations Plan describes the following: How the hospital will evacuate
(from one section or floor to another within the building, or, completely outside the
building) when the environment cannot support care, treatment, and services. (See also
EM.02.02.03, EPs 9 and 10) The Emergency Operations Plan describes the following: How
the hospital will manage a potential increase in demand for clinical services for vulnerable
populations served by the hospital, such as patients who are pediatric, geriatric, disabled, or
have serious chronic conditions or addictions. The Emergency Operations Plan describes
the following: How the hospital will manage the personal hygiene and sanitation needs of its
patients. The Emergency Operations Plan describes the following: How the hospital will
manage the mental health service needs of its patients that occur during the emergency. The
Emergency Operations Plan describes the following: How the hospital will manage
mortuary services. The Emergency Operations Plan describes the following: How the

8. hospital will document and track patients’ clinical information. The hospital implements the
components of its Emergency Operations Plan that require advance preparation to manage
patients during an emergency. 3. 4. 5. 6. 7. 8. 11. A A A A A A A A Page 12 of 19 Pre-
Publication Version © 2008 The Joint Commission on Accreditation of Healthcare
Organizations The Emergency Operations Plan describes the following: How the hospital
will manage the activities required as part of patient scheduling, triage, assessment,
treatment, admission, transfer, and discharge. 2. Elements of Performance for EM.02.02.11
The emergency triage process will typically result in [patient]s being quickly treated and
discharged, admitted for a longer stay, or transferred to a more appropriate source of care.
A disaster may result in the decision to keep all [patient]s on the premises in the interest of
safety or, conversely, in the decision to evacuate all [patient]s because the facility is no
longer safe. Planning for clinical services must address these situations accordingly,
particularly in the face of escalating events or in potentially austere care conditions.
Rationale for EM.02.02.11 The fundamental goal of emergency management planning is to
protect life and prevent disability. The manner in which care, treatment, and services are
provided may vary by type of emergency. However, certain activities are so fundamental to
patient safety (this can include decisions to modify or discontinue services, make referrals,
or transport patients) that the organization should take a proactive approach in considering
how they might be accomplished. As part of its Emergency Operations Plan, the
[organization] prepares for how it will manage [patient]s during emergencies. Standard
EM.02.02.11 Accreditation Program: Hospital Chapter: Emergency Management The
medical staff identifies, in its bylaws, those individuals responsible for granting disaster
privileges to volunteer licensed independent practitioners. The hospital determines how it
will distinguish volunteer licensed independent practitioners from other licensed
independent practitioners. (See also EM.02.02.07, EP 9) The medical staff describes, in
writing, how it will oversee the performance of volunteer licensed independent
practitioners who are granted disaster privileges (for example, by direct observation,
mentoring, or medical record review). Before a volunteer practitioner is considered eligible
to function as a volunteer licensed independent practitioner, the hospital obtains his or her
valid government-issued photo identification (for example, a driver’s license or passport)
and at least one of the following: – A current picture identification card from a health care
organization that clearly identifies professional designation – A current license to practice –
Primary source verification of licensure – Identification indicating that the individual is a
member of a Disaster Medical Assistance Team (DMAT), the Medical Reserve Corps (MRC),
the Emergency System for Advance Registration of Volunteer Health Professionals (ESAR-
VHP), or other recognized state or federal response organization or group – Identification
indicating that the individual has been granted authority by a government entity to provide
patient care, treatment, or services in disaster circumstances – Confirmation by a licensed
independent practitioner currently privileged by the hospital or by a staff member with
personal knowledge of the volunteer practitioner’s ability to act as a licensed independent
practitioner during a disaster During a disaster, the medical staff oversees the performance
of each volunteer licensed independent practitioner. Based on its oversight of each
volunteer licensed independent practitioner, the hospital determines within 72 hours of the

9. practitioner’s arrival if granted disaster privileges should continue. 2. 3. 4. 5. 6. 7. C A A A A
A A Page 13 of 19 Pre-Publication Version © 2008 The Joint Commission on Accreditation of
Healthcare Organizations The hospital grants disaster privileges to volunteer licensed
independent practitioners only when the Emergency Operations Plan has been activated in
response to a disaster and the hospital is unable to meet immediate patient needs. 1.
Elements of Performance for EM.02.02.13 During disasters, the [organization] may grant
disaster privileges to volunteer licensed independent practitioners. Note: A disaster is an
emergency that, due to its complexity, scope, or duration, threatens the organization’s
capabilities and requires outside assistance to sustain [patient] care, safety, or security
functions. Standard EM.02.02.13 Accreditation Program: Hospital Accreditation Program:
Hospital Chapter: Emergency Management 8. Primary source verification of licensure
occurs as soon as the immediate emergency situation is under control or within 72 hours
from the time the volunteer licensed independent practitioner presents him- or herself to
the hospital, whichever comes first. If primary source verification of a volunteer licensed
independent practitioner’s licensure cannot be completed within 72 hours of the
practitioner’s arrival due to extraordinary circumstances, the hospital documents all of the
following: – Reason(s) it could not be performed within 72 hours of the practitioner’s
arrival – Evidence of the licensed independent practitioner’s demonstrated ability to
continue to provide adequate care, treatment, and services – Evidence of the hospital’s
attempt to perform primary source verification as soon as possible C 9. If, due to
extraordinary circumstances, primary source verification of licensure of the volunteer
licensed independent practitioner cannot be completed within 72 hours of the practitioner’s
arrival, it is performed as soon as possible. Note: Primary source verification of licensure is
not required if the volunteer licensed independent practitioner has not provided care,
treatment, or services under the disaster privileges. C Page 14 of 19 Pre-Publication Version
© 2008 The Joint Commission on Accreditation of Healthcare Organizations Chapter:
Emergency Management The hospital identifies, in writing, those individuals responsible
for assigning disaster responsibilities to volunteer practitioners who are not licensed
independent practitioners. The hospital determines how it will distinguish volunteer
practitioners who are not licensed independent practitioners from its staff. (See also
EM.02.02.07, EP 9) The hospital describes, in writing, how it will oversee the performance
of volunteer practitioners who are not licensed independent practitioners who are assigned
disaster responsibilities (for example, by direct observation, mentoring, or medical record
review). Before a volunteer practitioner who is not a licensed independent practitioner is
considered eligible to function as a practitioner, the hospital obtains his or her valid
government-issued photo identification (for example, a driver’s license or passport) and
one of the following: – A current picture identification card from a health care organization
that clearly identifies professional designation – A current license, certification, or
registration – Primary source verification of licensure, certification, or registration (if
required by law and regulation in order to practice) – Identification indicating that the
individual is a member of a Disaster Medical Assistance Team (DMAT), the Medical Reserve
Corps (MRC), the Emergency System for Advance Registration of Volunteer Health
Professionals (ESAR-VHP), or other recognized state or federal response organization or

10. group – Identification indicating that the individual has been granted authority by a
government entity to provide patient care, treatment, or services in disaster circumstances
– Confirmation by hospital staff with personal knowledge of the volunteer practitioner’s
ability to act as a qualified practitioner during a disaster During a disaster, the hospital
oversees the performance of each volunteer practitioner who is not a licensed independent
practitioner. Based on its oversight of each volunteer practitioner who is not a licensed
independent practitioner, the hospital determines within 72 hours after the practitioner’s
arrival whether assigned disaster responsibilities should continue. 2. 3. 4. 5. 6. 7. C A A A A A
A Page 15 of 19 Pre-Publication Version © 2008 The Joint Commission on Accreditation of
Healthcare Organizations The hospital assigns disaster responsibilities to volunteer
practitioners who are not licensed independent practitioners only when the Emergency
Operations Plan has been activated in response to a disaster and the hospital is unable to
meet immediate patient needs. 1. Elements of Performance for EM.02.02.15 During
disasters, the [organization] may assign disaster responsibilities to volunteer practitioners
who are not licensed independent practitioners, but who are required by law and regulation
to have a license, certification, or registration. Note: While this standard allows for a method
to streamline the process for verifying identification and licensure, certification, or
registration, the elements of performance are intended to safeguard against inadequate care
in an emergency situation. Standard EM.02.02.15 Accreditation Program: Hospital If, due to
extraordinary circumstances, primary source verification of licensure of the volunteer
practitioner cannot be completed within 72 hours of the practitioner’s arrival, it is
performed as soon as possible. Note: Primary source verification of licensure, certification,
or registration is not required if the volunteer practitioner has not provided care, treatment,
or services under his or her assigned disaster responsibilities. 9. The hospital conducts an
annual review of the objectives and scope of its Emergency Operations Plan. The findings of
this review are documented. The hospital conducts an annual review of its inventory
process. The findings of this review are documented. 2. 3. A A A C C Page 16 of 19 Pre-
Publication Version © 2008 The Joint Commission on Accreditation of Healthcare
Organizations The hospital conducts an annual review of its risks, hazards, and potential
emergencies as defined in its hazard vulnerability analysis (HVA). The findings of this
review are documented. (See also EM.01.01.01, EPs 2 and 4) 1. Elements of Performance for
EM.03.01.01 Rationale for EM.03.01.01 The risks and hazards facing an organization or an
area of the organization may change over time. The scope or goals of the [organization]’s
planning activities may evolve in response to changes in the organization, its structure,
patient population, community planning partners, or a number of other factors. Such
changes can have an impact on the [organization]’s response capabilities, including
decisions about its inventory of resources and assets needed during an emergency. The
[organization] conducts an annual review of its planning activities to identify such changes
and support decision-making regarding how the [organization] responds to emergencies.
The [organization] evaluates the effectiveness of its emergency management planning
activities. Standard EM.03.01.01 Primary source verification of licensure, certification, or
registration (if required by law and regulation in order to practice) of volunteer
practitioners who are not licensed independent practitioners occurs as soon as the

11. immediate emergency situation is under control or within 72 hours from the time the
volunteer practitioner presents him- or herself to the hospital, whichever comes first. If
primary source verification of licensure, certification, or registration (if required by law and
regulation in order to practice) for a volunteer practitioner who is not a licensed
independent practitioner cannot be completed within 72 hours due to extraordinary
circumstances, the hospital documents all of the following: – Reason(s) it could not be
performed within 72 hours of the practitioner’s arrival – Evidence of the volunteer
practitioner’s demonstrated ability to continue to provide adequate care, treatment, or
services – Evidence of the hospital’s attempt to perform primary source verification as soon
as possible Chapter: Emergency Management 8. Accreditation Program: Hospital Chapter:
Emergency Management For each site of the hospital that offers emergency services or is a
community-designated disaster receiving station, at least one of the hospital’s two
emergency response exercises includes an influx of simulated patients. Note 1: Tabletop
sessions, though useful, cannot serve for this portion of the exercise. Note 2: This portion of
the emergency response exercise can be conducted separately or in conjunction with
EM.03.01.03, EPs 3 and 4. For each site of the hospital that offers emergency services or is a
community-designated disaster receiving station, at least one of the hospital’s two
emergency response exercises includes an escalating event in which the local community is
unable to support the hospital. Note 1: This portion of the emergency response exercise can
be conducted separately or in conjunction with EM.03.01.03, EPs 2 and 4. Note 2: Tabletop
sessions are acceptable in meeting the community portion of this exercise. For each site of
the hospital with a defined role in its community’s response plan, at least one of the two
exercises includes participation in a community-wide exercise. Note 1: This portion of the
emergency response exercise can be conducted separately or in conjunction with
EM.03.01.03, EPs 2 and 3. Note 2: Tabletop sessions are acceptable in meeting the
community portion of this exercise. 2. 3. 4. A A A A Page 17 of 19 Pre-Publication Version ©
2008 The Joint Commission on Accreditation of Healthcare Organizations As an emergency
response exercise, the hospital activates its Emergency Operations Plan twice a year at each
site included in the plan. Note 1: If the hospital activates its Emergency Operations Plan in
response to one or more actual emergencies, these emergencies can serve in place of
emergency response exercises. Note 2: Staff in freestanding buildings classified as a
business occupancy (as defined by the Life Safety Code) that do not offer emergency
services nor are community designated as disaster-receiving stations need to conduct only
one emergency management exercise annually. Note 3: Tabletop sessions, though useful,
are not acceptable substitutes for these exercises. Footnote: The Life Safety Code is
published by the National Fire Protection Association. Refer to NFPA 101-2000 for
occupancy classifications. 1. Elements of Performance for EM.03.01.03 Rationale for
EM.03.01.03 The organization conducts exercises to assess the Emergency Operations
Plan’s appropriateness; adequacy; and the effectiveness of logistics, human resources,
training, policies, procedures, and protocols. Exercises should stress the limits of the plan to
support assessment of the organization’s preparedness and performance. The design of the
exercise should reflect likely disasters but should test the organization’s ability to respond
to the effects of emergencies on its capabilities to provide care, treatment, and services. The

12. [organization] evaluates the effectiveness of its Emergency Operations Plan. Standard
EM.03.01.03 Accreditation Program: Hospital Accreditation Program: Hospital Chapter:
Emergency Management 5. Emergency response exercises incorporate likely disaster
scenarios that allow the hospital to evaluate its handling of communications, resources and
assets, security, staff, utilities, and patients. (See also EM.02.01.01, EP 2) A 6. The hospital
designates an individual(s) whose sole responsibility during emergency response exercises
is to monitor performance and document opportunities for improvement. Note 1: This
person is knowledgeable in the goals and expectations of the exercise and may be a staff
member of the hospital. Note 2: If the response to an actual emergency is used as one of the
required exercises, it is understood that it may not be possible to have an individual whose
sole responsibility is to monitor performance. Hospitals may use observations of those who
were involved in the command structure as well as the input of those providing services
during the emergency. A 7. During emergency response exercises, the hospital monitors the
effectiveness of internal communication and the effectiveness of communication with
outside entities such as local government leadership, police, fire, public health officials, and
other health care organizations. A 8. During emergency response exercises, the hospital
monitors resource mobilization and asset allocation, including equipment, supplies,
personal protective equipment, and transportation. A 9. During emergency response
exercises, the hospital monitors its management of the following: safety and security. A 10.
During emergency response exercises, the hospital monitors its management of the
following: staff roles and responsibilities. A 11. During emergency response exercises, the
hospital monitors its management of the following: utility systems. A 12. During emergency
response exercises, the hospital monitors its management of the following: patient clinical
and support care activities. A 13. Based on all monitoring activities and observations, the
hospital evaluates all emergency response exercises and all responses to actual
emergencies using a multidisciplinary process (which includes licensed independent
practitioners). A 14. The evaluation of all emergency response exercises and all responses
to actual emergencies includes the identification of deficiencies and opportunities for
improvement. This evaluation is documented. A 15. The deficiencies and opportunities for
improvement, identified in the evaluation of all emergency response exercises and all
responses to actual emergencies, are communicated to the improvement team responsible
for monitoring environment of care issues. (See also EC.04.01.05, EP 3) A 16. The hospital
modifies its Emergency Operations Plan based on its evaluations of emergency response
exercises and responses to actual emergencies. Note: When modifications requiring
substantive resources cannot be accomplished by the next emergency response exercise,
interim measures are put in place until final modifications can be made. A Page 18 of 19
Pre-Publication Version © 2008 The Joint Commission on Accreditation of Healthcare
Organizations 17. Chapter: Emergency Management A Page 19 of 19 Pre-Publication
Version © 2008 The Joint Commission on Accreditation of Healthcare Organizations
Subsequent emergency response exercises reflect modifications and interim measures as
described in the modified Emergency Operations Plan. Accreditation Program: Hospital
Indian Journal of Science and Technology, Vol 10(28), DOI:
10.17485/ijst/2017/v10i28/115466, July 2017 ISSN (Print) : 0974-6846 ISSN (Online) :

13. 0974-5645 Challenges of Hospital Incident Command System (HICS) from Experts’
Perspectives: A Qualitative Research Shirin Abbasi1, Shahin Shooshtari2* and Shahram
Tofighi3 Candidate in Health Management in Disaster, Isfahan University of Medical
Sciences, Isfahan, Iran; shirinabbassi2000@yahoo.com 2 Department of Community Health
Sciences, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of
Manitoba, Canada; Shahin.Shooshtari@umanitoba.ca 3 Health Management Research
Center, Baqiyatallah University of Medical Sciences, Tehran, Iran; sh.tofighi@aut.ac.ir 1
Abstract Background: Hospital Incident Command System (HICS) is one of the most valid
incident command systems for preparing and increasing efficiency of hospitals. With regard
to hospitals’ key roles in Medical Incident Management, the present study aims at obtaining
experts’ ideas for investigating challenges of establishment of HICS in Iran’s hospitals.
Methodology: The present study is qualitative one conducted via the semi-structured
interviewing method. Interviews were conducted on 23 experts selected from HICS in the
Medical University, Red Crescent Society and Social Security Organization in 2016 so that
after recording each interview, they were transcribed and, then, the raw data were reduced
and organized via the content analysis technique. Results: According to findings of the
present study, since the HICS is established based on the principles that ensure the effective
deployment of resources on one hand and decrease the disorder in policy making and the
operations of responding organizations, on the other hand, the point of view of most
participants in this study showed that the HICS in Iran is not implemented properly. The
studies showed that consistency of this system with existing management structure in
hospitals cause internal and external barriers to its implementation. Conclusion: Based on
the present results, the most important cases causing inefficiency of HICS in Iran are as
follows: complete lack of understanding of HICS’s components and features, lack of
adequate training of the staff, and lack of localization HICS in Iran. Thus, appropriate
planning, necessary intra-and inter-organizational coordination in incidents, reinforcement
of forces by appropriately organizing them, supply of required training, suggestion of long-
term strategies, and finally design of a HICS by applying components of the Quality
Management System with regard to conditions in Iran seem necessary. Keywords:
Challenges, Hospital Incident Command System (HICS), Qualitative Research, Semi-
Structured Interview 1. Introduction Unexpected events have always threatened human
societies. During the past decade, the need for preparedness in cases crisis and emergency
has been as one of the main issues of public opinion1,2. In 2014, according to international
statistics, 324 natural disasters occurred which killed more than 7823 people. Meanwhile,
Asia has the largest number of incidents (44.4%) and the highest numbers of victims were
(69.5%)3. About 1.828 million people have been affected by natural disasters in the last six
years in Iran4. What happens after these incidents is an unpredictable chaos and the
hospitals are involved in reception of the injured after accidents5. In fact, the damage
caused *Author for correspondence by disasters harm to society. Therefore, hospitals
should be the first reference of the health care system which is fully prepared for disasters6.
It is important to note that hospitals dysfunction does not take place only as a result of
physical damage. On the other hand, lack of preparedness of medical center scan lead to
consequences including the loss of capabilities and resources of the society to manage and

14. cope with incidents7, and likelihood of confusion, poor service delivery and ultimately,
failure to meet the needs of victims8. Hospital destruction would lead to sense of insecurity
in the absence of alternative standards and facilities. This requires effective management in
disasters including planning and preparedness before the occurrence of Challenges of
Hospital Incident Command System (HICS) from Experts’ Perspectives: A Qualitative
Research events as well as effectiveresponse9,10. Hospital Incident Command System is one
of the most reliable Unexpected Situations Command Systems to prepare and increase the
efficiency of hospitals11. In the late 1980s, the principles of the Incident Command System
were recognized for hospitals with nearly 25 years of experience in using the Hospital
Incident Command System in America and other countries, and its revision process became
possible in 2014 12. HICS can provide response to all events regardless of scope,
geographical conditions and structure and the system strengthens coordination and
communication between various health organizations and offer health during the crisis13.
The system should prepare the hospital staff to manage the events inside and outside the
hospital, and to facilitate the intra- and inter-sectoral collaboration with other
institutions14. The most important objectives of applying HICS include timely response to
the incident, security of the responders, management of incidents, and ensuring the efficient
and optimal use of resources15. In the study of Schoenthal entitled “a case study in
identification of critical criteria in successful application of HICS” the results of the review
showed that the existence of teamwork, as the main component in this system, is the reason
for success in the system (11). Study of Djalali et al. entitled “Hospital incident command
system performance in Iran” showed that application of the modified model enhanced the
performance of hospitals in disaster management16,17. Studies conducted on the
preparedness of hospitals to respond incidents in order to deploy Unexpected Disaster
Command System revealed that none of the hospitals of the university had fully deployed
the system, and the activities carried out in this regard were incomplete (10). Large-scale
damage caused by natural disasters and incidents in the world led to carrying out applied-
executive researches in the field of crisis management and application of Incident Command
System. Given that the area of health which is considered as the first and most important
place among all elements involved in Disaster Management requires proper functioning of
the Hospital Incident Command System, proper planning, training, identifying capabilities
and limitations contained in it is of significant importance; in this respect, identifying and
applying standards of Command System plays a major role. For this purpose, in this study,
the effect of Incident Command System in the health care system (hospitals)was examined
from experts’ opinions. 2 Vol 10 (28) | July 2017 | www.indjst.org 2. Methodology 2.1 Study
Design and Research Population This study aims to achieve experts’ opinions on the impact
of deployment of HICS. For this purpose, qualitative method was adopted using content
analysis method in a nine-month period in 2016. The information source populations in this
study were selected from knowledgeable individuals in medical universities, Baqiyatallah,
Red Crescent Society, Emergency Center and Social Security Organization. 2.2 Selection and
Description of Participants There were 23 participants from different cities in Tehran,
Isfahan, Qom, and Kerman in Iran, who met the inclusion criteria. The individuals in the
above cities were selected according to management and work experience in this regard,

15. experience of occurrence of unexpected disasters, rich information on this topic, interest in
the provision of information and experiences. Exclusion criteria included lack of willingness
to cooperate at every stage of research, or altered responses. In this study, target-based
sampling began according to the importance of deep examination of the experiences of
knowledgeable individuals, and the other individuals were then added by the snowball
method. Then, sampling continued by confirmatory and rebutter samples method rule to
the individuals’ saturation stage (17). 2.3 Data collection The data in this study were
gathered semi-structured and individual in-depth interviews based on open-ended
questions, including demographic characteristics form, interview questions, and informed
consent form. For this purpose, one of the informants was the first person who was
interviewed as pilot in Kerman, and he was present in the Bam earthquake, in order to
extract the possible flaws. Then, minor changes were made in the interview questions based
on the results, and the interview was done with 15 questions. The interview process was
conducted through a formal interview with the prior agreement in the participants’ working
environment; the interviews were recorded with their consent, and then typed word by
word by a member of the research group. The average duration of the interview was about
44.5 minutes. Indian Journal of Science and Technology Shirin Abbasi, Shahin Shooshtari
and Shahram Tofighi 2.4 Data Analysis 3.1 Deployment of HICS In order to analyze
qualitative data in this study, the researcher used the conventional qualitative content
analysis method inductively to gain a rich understanding and describe the phenomenon.
The qualitative data analysis steps included determination of analysis content in which all
interviews were conducted in accordance with the objectives and the question of the
research. The next step was definition of analysis and coding unit where the researcher
converted the data obtained from the expressions to manageable sections as primary codes.
Then, the researcher compared and grouped them into two or more classes. Then,
comparing the codes, similarities and differences in the concepts were extracted and a kind
of integration was created on similar topics. In this way, themes were extracted and main
classes were formed. In the last step, in order to form the theme of the obtained data, a
consensus was reached. Then, the main themes were extracted. Written informed consent
was taken from the participants to observe the moral considerations. In order to ensure the
reliability of findings, after the individual interview and verification of the results, the typed
information was sent to five of the participants and their opinions were reviewed again and
necessary changes were made in the interviews. In addition, the interviews were
terminated through reviewing manuscripts and ensuring the completeness of the text in
terms of content by the participants in this study. In this way, the credibility and
acceptability of the data were increased. For verifiability, the codes were aggregated, and
were sent to two faculty members of medical universities who were thoroughly familiar
with qualitative research. Finally, the members achieved an agreement respecting
impartiality on codes and classes, as well as examining the extracted codes and classes. One
of the main classes extracted from findings of the implementation of HICS was the way of
deployment of the system. According to the experiences and views of a small number of
participants, “the model simulation was possible by changing some modules in hospital, and
their experiences were acceptable only in two hospitals of Tehran and Ahvaz” (P21). One of

16. the participants said “this Command System is a set of organizational structures, programs,
guidelines and resources” (p7). In contrast to these people, the views of the most
participants showed that the HICS does not have proper functionality. Of the most
important causes are the “credit limit” (P10) and “lack of national package approved by the
Ministry of Health” (P3). One of the participants said “validation guidelines and standards
focus on this matter, however, HICS is not fully implemented in Iran” (p4). 3. Results
Findings showed that the average age of the participants in the study was 45.13 years and
that about 91% of them were male. About 61% of participants were studying at PhD course
and only about 22% had a bachelor’s degree. In terms of administrative records, 30.5% of
the respondents had management experiences and nature of 83% of their works was
therapeutic. In Table 1, themes, main classes and sub-classes are displayed. Accordingly,
subclasses were made in the form of 24 classes. The number of primary classes were 9, and
5 themes were created at last. Vol 10 (28) | July 2017 | www.indjst.org 3.2 Meeting the
requirements of HICS Based on the participants’ experiences, there are regulations in
hospitals in order to meet the requirements of HICS including requirements for validation.
In this regard, one of the participants expressed that “the model we use now is based on
model validation” (P4). In fact, our framework is a validation that is obliged by the ministry
for hospitals; and hospital activities has an axis that reviews the crisis management”(P5).
According to the participants, meeting the requirements of the system can be conducted
through modeling from organizational guidelines or books” (P20). 3.3 Design and
Development of HICS based on Standard Structure This class focuses on the conditions that
determine the fulfillment of expectations in design and development based on structure,
processes and outcome. One of the sub-classes is process standard which includes care,
service, or management. Participants stated that “hospital crisis management processes are
designed and developed, and systems, processes and flowcharts are specified” (p12).
Another participant said “in this section, we analyze the risk through contingency planning,
and select the prioritized cases, then, preventive strategies will be identified” (p19). The
second sub-class in this category is related to structural standards. These standards are the
cases which Indian Journal of Science and Technology 3 Challenges of Hospital Incident
Command System (HICS) from Experts’ Perspectives: A Qualitative Research Table 1.
Themes, main classes, and sub-classes extracted from the qualitative part of the study
Theme Achievements 1. resulting from the implementation of HICS Dimensions influenced
2. by HICS Main classes Sub-classes Deployment of HICS 1. 1. Presence of HICS Meeting the
requirements of 2. HICS 3. Organizational requirements Design and development of 3. HICS
based on the standard structure Process standards 5. 4. Crisis management cycle in HICS 8.
Phases of risk reduction and prevention Lack of implementation of the HICS 2. Modeling
from books and instructions 4. Structural standards 6. Consequential standards 7.
Preparation phases 9. 10. The phases of response and evaluation 11. Recovery phases
Characteristics of HICS 5. 12. The benefits of utilizing the HICS 13. Defects in application of
HICS 14. Barriers to preventing the establishment Strategies and priorities 3. 6.
Vulnerability assessment based 15. Functional dimension on hospitals safety index 16.
Structural elements 17. Non-structural elements Importance and necessity of 7. HICS 18.
Training and preparation 19. Command and control 20. Localization The models of quality

17. 4. improvement in health centers Qualitative elements of 8. the QMS resulting from
establishment of QMS 21. The positive achievements of the establishment of QMS 5. Suitable
pattern of HICS 9. Process management and quality improvement 23. Using QMS
components and the relationship between them enable service delivery such as human,
financial and physical resources. According to the views of the participants, the most
important changes in the “design of crisis management structure at the university and
hospital” (P14) can be “call for manpower, building organizational structure in the hospital,
training personnel and material resources (P1). The last sub-class in this section is outcome
standard. This standard reflects the results of the work that we do with the resources
available. Based on the experiences of most of the participants “in many cases, the
consequential standards at this stage did not cause significant changes in the results” (P10).
Despite the change in knowledge and skills of personnel, no change has been made in their
attitudes”(P21). 4 Vol 10 (28) | July 2017 | www.indjst.org 22. Limitations resulting from
the establishment of QMS 24. The relationship between HICA and QMS models 3.4 Crisis
Management Cycle in HICS This class consists of four sub-classes including risk reduction
and prevention, preparedness, response and assessment and finally, recovery phases. One
participant described the situation of risk reductions follows: “we can use different
methods, such as risk assessment methods in crisis management, as a tool for the
prevention of accidents before they occur” (P12). The most important points mentioned by
the participants were risk identification and assessment. In the preparedness phases, the
most important concepts were: “staff empowerment” (P2), “codified and mandating
programs, creating operation system structure and human resource management” (P3). At
these phases, participants introduced concepts Indian Journal of Science and Technology
Shirin Abbasi, Shahin Shooshtari and Shahram Tofighi such as understanding tasks,
planning and regulation as parts of the preparedness phase. The third phase after collecting
the participants’ views was the phase of response. Concepts derived from the experts’
opinions at these phases were “continuing care services, taking the necessary measures in
time of the incident, accountability and coordination inside and outside the organization”
(P18). According to the views of a handful of participants who had experience of presence in
incidents, the concepts extracted in recovery phases included: Coordination with some
related institutions, providing emergency accommodation, welfare and safety of staff and
patients. “One participant stated: after Bam earthquake, hospitals were not ready, when
patients were discharged, there were no shelter for them, tired staff needed to strengthen
their mental power, there were no alternative forces, we did not know where to transfer the
patients after partial recovery. We used the experience we got in Bam earthquake.” (P1) 3.5
Characteristics of HICS Statements of the participants about the characteristics of the HICS
showed that there were three characteristics including the benefits, drawbacks and barriers
to the implementation of HICS. According to the participants, benefits of use of the system
were “increasing the level of preparedness in the incidents based on the assessments
carried out, determining the place and role of individuals and preventing the stop of
services when the incident occurs” (P9), modifying processes, regulating the affairs and
creating a written task description” (P16). However, according to experts, there were some
shortcomings in the implementation of the HICS in Iran. The most deficiencies examined

18. from the perspective of participants which lead to lack of full implementation of the system,
were “lack of Standard Command System at the community level, lack of managers’
awareness, defect in the chart created, and absence of comprehensive, complete education
and incompleteness of duties description” (P11). In this regard, one of the participants
contended “we have deficiencies in implementation of HICS, including structure, simulation
and discussion of consequences, plans, and instructions as well as skilled workers that are
the deficiencies of the work” (P23). Based on the experts,’ opinions, barriers to
establishment of a HICS were lack of prediction of enough credit for crisis management, lack
of resources and facilities, changes in senior managers, overlapping of administrative and
financial rules and lack of Vol 10 (28) | July 2017 | www.indjst.org information record
system”(P22). One of the participants believed that “major inconsistencies that exist
between the system and the state of our hospitals is attributed to non-compliance of rules
and regulations in systems and social, bureaucracy and administrative culture.” (P13) 3.6
Vulnerability Assessment based on Hospital Safety Index Functional dimensions, structural
and non-structural elements of the groups under study rein this class. Functional dimension
shows the primary measures of safety assessment, to enable hospitals which would have
quick response when coping with crises. The majority of participants believed that
“Hospital vulnerability assessment in this dimension is proper when compared with the
crisis, and less measures have been taken in two structural and non-structural dimensions”
(P17). However, based on the point’s accumulated from structural elements, in this axis,
majority of the participants believed that hospitals did not have suitable activities in this
area. One of the participants stated “Given that there are some changes in hospital structure,
and according to experts, although some problems are solved, some are added to the
structural problems and this can create accident and crisis for you” (P5). Accordingly, the
major measures in the non-structural elements were: strengthening operations,
immunizing equipment” (P15). 3.7 Importance and Necessity of HICS According to the
participants’ statements based on their experiences, the class is divided into sub-axes
including training and preparation, command and control and localization. The most
important participants’ points of view regarding preparedness and training were training
concepts and repetition, maneuver, use of scientific and specialist experts and exercise. “I
think we work well on the staff preparedness, the staff are trained and are faced with real
situations”(P6). However, one of the participants believed that “there is no appropriate
training courses for this” (P20).With regard group command and control, some experts
believed that the implementation of system requires leadership, command and control in
the hospital: “each organization has a crisis management for itself, but there is a real need
for leadership and management, and it should be focused”(P9). About localization of the
HICS, the major- Indian Journal of Science and Technology 5 Challenges of Hospital Incident
Command System (HICS) from Experts’ Perspectives: A Qualitative Research ity of
participants believed that “ using other patterns without regard to the country’s needs do
not have the necessary effects.” (P11) 3.8 Qualitative Elements of the Quality Management
System Resulting from System Establishment This main class was aggregated based on the
views of participants, and it examined the achievements and limitations of the
establishment of quality models selected in health centers. Some positive achievements of

19. QMS establishment in health centers, according to participants, were “training employees,
paying attention to the society, creating a process approach, action plans, paying attention
to innovation and putting emphasis on performance management” (P17). “Paying attention
to the centrality of patient safety in hospitals, creating an incentive mechanism and
managing the risk and error, consistency with the risk management system and
occupational safety” (p8). However, according to another participant, “it increases
documentation that is not consistent with our culture”(p15). The cost of its establishment is
high, lack of organization in the hospitals, competitiveness of the certificate and rising
expectations of employees and customers are of its limitations.” (P14). 3.9 Process
Management and Quality Improvement The most important themes in this class included
“the use of components of the QMS, strategic plan, training along with effectiveness, training
needs assessment, monitoring and analysis of key indicators (P20), preparation through the
maneuver, using registration system, documentation control system” (P16). In this regard,
the experts stated that “assessment of the HICS in our country is not clear, it is not
mandatory and it has a minor score in the accreditation (P18). “It is important that we have
a review on the external audits and systems to promote the preparedness” (P11). The
relationship between HICS and quality management models was evaluated at the last class
of this group based on the views of the participants. Based on the views of a limited number
of participants, “using the QMS in Incident Command System was identified as the
confounders in hospitals which led to failure to fully understand each of the systems, more
attention to satisfaction of employees and customers, and less attention to 6 Vol 10 (28) |
July 2017 | www.indjst.org the consequences of the crisis” (P19). In this regard, most
experts believed that QMS and incident command system had overlaps with some of the
main elements and that both move in the same direction. According to these people, “QMS
will reinforce the Incident Command System through the use of qualitative elements and
implementation of the system”(P2). 4. Discussion The outcome of this study is obtaining five
main themes including achievements resulting from the implementation of HICS, the
dimensions influenced by HICS, strategies and priorities, models improving quality in health
centers and appropriate pattern of HICS. The HICS is established based on the principles
that ensure the effective deployment of resources, on one hand, and decrease the disorder
in policy making and the operations of responding organizations (12), on the other hand. In
this sense, the point of view of most of the participants in this study showed that the HICS in
Iran is not implemented properly. The analyses showed that consistency of this system with
existing management structure in hospitals caused internal and external barriers to its
implementation (10). Further more comfort in his study stated the failure to understand the
system objectives and the soul governing it, inflexibility and difficulty of activation as
factors that lead to failure of proper implementation of the system18. Findings of some
other studies which have so far been conducted are consistent with those of the present
study in terms of implementation of HICS. One of the reasons for failure to meet the
requirements of the HICS in Iran is the lack of planning for incident management in
hospitals (16). In this regard, proper planning is one of the requirements for Incident
Command System19. Results of two recent studies are consistent with those obtained in the
current study in terms of meeting the system requirements. According to the statements of

20. interviewed people and themes, design and development of HICS are possible based on
structural, process and outcome and standard. In this regard, in order to assess, control, and
improve the quality of health care systems, Donabedian approach is proposed and it
includes three dimensions of structure, process and outcome20. Studied conducted by
Roger et al. also showed that quality assessment in hospitals will be inefficient with- Indian
Journal of Science and Technology Shirin Abbasi, Shahin Shooshtari and Shahram Tofighi
out the use of standards of process, consequence and structure21. This study is consistent
in terms of creation of the nature of the standard in the model according to Donabedian
model. In this study, the experts believed that the crisis management cycle should be
completed in the phases of risk reduction and prevention, preparedness, response and
recovery. Most studies conducted in Iran have been done on the preparedness of hospitals
when coping with disasters and incidents. Salari examined the preparedness against natural
disasters in fifteen hospitals in Iran. Results showed that there was an average
preparedness in hospitals and there was no significant relationship between the type of
hospital and disaster preparedness22. In a study in Romania, a comprehensive model was
presented for crisis management including a decision-making system. It focused on the
preventive measures, improvement opportunities, risk reduction and risk assessment; in
this regard, it is consistent with that of the current study23. The results of the research
conducted on the benefits of the use of HICS showed that the system created preparedness
in medical facilities, communications and resource sharing between organizations and
health care institutions (11) and teamwork increased the preparedness of manpower
against disaster24. Moreover, other studies on the administrative barriers and constraints
showed that high cost of implementation, lack of legal requirements, different needs of
hospital users in international levels with different economic and social dimensions (10)
and lack of accepted methodology to evaluate the system25. This system was unable to
operate all the practical measures and the necessary plans for assisting wounded people in
the response phases. In a study related to vulnerability assessment, Bajow paid attention to
prevention of structural and non-structural dimensions as a preventive measure (6). This
study is also consistent with current study in terms of insufficient attention to structural
and non-structural dimensions. The studies conducted on the performance evaluation
showed that there is no international standard and accepted methodology in Incident
Command System for evaluating the performance. This weakens the performance of
evaluation of the services provided in disasters26. This study is not consistent with the
present study in terms of attention to the functional dimensions. Such studies concerned the
importance and necessity of HICS valuated in training, command and control and
localization of the model. Vol 10 (28) | July 2017 | www.indjst.org According to the studies
conducted, attention to organizational knowledge and training courses are repeatedly
expressed in studies. The main findings of the study were the need to changes in staff ’s
attitudes through effective operational training and exercises and creation of required
maneuvers27. Zane also stated the presence of proper knowledge and understanding of the
Incident Command System as the requirement of the system establishment. In this regard,
we can refer to the suggestions including providing necessary trainings, simulations and
measures such as maneuver and training the members of the crisis committee19 and

21. conducting a research to state a deeper knowledge and view at the system in the future.
However, the results of the studies have investigated the training and awareness at all
levels necessary for the creation of a common language and culture. Therefore, the need for
training programs in the field of crisis management and consistent and effective
implementation of them should be considered as a priority. The importance of leadership,
command and control in the system is considered as a provider when responding to
incidents11, 16. However, what seems essential is the importance of the role of
management and leadership as an integral part of one another. According to the literature
on Incident Command System in which the interviews were done with senior executives in
some cases28 and, attention to the leadership role in the hospital management in disasters
25, and leadership commitment as the main parts of HICS were examined for successful
implementation of this model11. Some other studies have shown that attention to the role
of leadership and management as two inseparable parts is necessary to establish Incident
Command System, and the studies conducted are consistent with the current study.
According to the findings of the research, creating a specific and native model in Iran is one
of the ways to meet the requirements of the system10. Other researchers conducted also
considered it necessary to createa modified model to increase the functionality of hospital
when disasters occur. From the participants’ perspective, the proposed models of quality
improvement in health care system had positive achievements and limitations. The
possibility of establishing new standards of assessment process, outcome and structure
instead of the traditional standards in hospitals29 are of the studies on the positive
achievements. It is a method to measure the performance of evaluation Indian Journal of
Science and Technology 7 Challenges of Hospital Incident Command System (HICS) from
Experts’ Perspectives: A Qualitative Research possibility and self-assessment approaches in
the health sector30 and 31. However, a study in Netherlands reported that despite the
development of quality improvement activities cycle in hospitals under study, only a small
number of hospitals implemented the qualitative management system32. Given that most
researches showed an increase in satisfaction, performance, and efficiency of the
organizational learning, it is essential to note that implementation of quality models should
enhance the quality of the treatment, management and support processes. Based on general
views of the participants, the relationship between HICS and quality improvement models
would be possible through the implementation of quality management components. The
study conducted by Djalali on the modification of organizational chart of HICS including the
addition of quality control officer to command group and integration of the planning
department with administrative/financial unit (16)is among the studies which is associated
with the use of components of the quality management system, as well as the need to train
managers and their staff awareness, providing indexes related to Incident Command System
and planning (10), and providing a specific process for the system and consistent
implementation of them as a priority (11). 5. Conclusion According to the theoretical
fundamentals and literature, outcome of all the studies conducted so far showed that
preparedness of hospitals in Iran against disasters was not desirable, and so, reviews and
actions taken regarding the Incident Command System were sporadic and unorganized. In
most of the researches conducted in Iran, limitations of the study were not considered; the

22. most important cases that caused in efficiency of this system in Iran were: the focus of
hospitals intended in crisis management in unexpected events on the guidelines and
documentations of the unexpected events organization system, lack of full understanding of
the system components and features and stages of execution, lack of adequate training for
staff, lack of employee’s motivation and involvement, lack of native Incident Command
System in Iran, lack of expert force familiar with crisis management in the health centers,
and the lack of strong organizational requirements. However, most of the studies were
related to pre-crisis conditions in Iran and prepared- 8 Vol 10 (28) | July 2017 |
www.indjst.org ness level. As a result of these problems and numerous other defects,
incidents and disasters of all types and sizes were often not well-managed, leading to the
imposition of multiple damages in the area of health, unnecessary harms, ineffective
resource management, and economic losses. Therefore, necessity of proper planning,
prioritization of policies and activities, creation of the necessary coordination inside and
outside the organization at events, reinforcement of forces with proper organization,
providing the necessary trainings, long-term strategies, and finally, designing the Hospital
Incident Command System were considered necessary for the current situation in Iran.
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Science and Technology 9 Appendix C – Healthcare Emergency Management Competencies
Appendix C Healthcare Emergency Management Competencies: Competency Framework
Final Report 1 Joseph A. Barbera, MD, Anthony G. Macintyre, MD, Greg Shaw, DSc, Valerie
Seefried, MPH, Lissa Westerman, RN, Sergio de Cosmo, MS Institute for Crisis, Disaster, and
Risk Management The George Washington University October 11, 2007 Introduction In
December 2004, the Veterans Health Administration (VHA) Emergency Management
Strategic Healthcare Group awarded the Institute for Crisis Disaster & Risk Management
(ICDRM) a contract to participate in establishing innovative training and personal
development curricula for the VHA Emergency Management Academy (VHA-EMA). The
objective of the project was to develop a nationally peer-reviewed, National Incident
Management System (NIMS) compliant, competency-based instructional outline and
curriculum content upon which to base education and training courses. The curriculum is
intended to educate VHA personnel for response and recovery in healthcare emergencies
and disasters, to provide a resource for future VHA training programs, and to be placed in
the public domain for use by other healthcare personnel. The initial phase of the EMA
project consisted of developing a competency framework (competency definition, structure
and format, and critical elements) followed by development of peer-reviewed emergency
response and recovery competencies for VHAselected healthcare system job groups. The
competencies describe knowledge, skills, and abilities essential for adequate job
performance during the emergency response and recovery phases of an incident. Peer
review was accomplished through a web-based survey of the proposed competencies,
which was distributed to a select, nationwide sampling of emergency management
personnel who were identified as having extensive experience or advanced expertise in
healthcare emergency response. The survey process was designed to obtain a balanced
expert opinion as to whether the project team’s written competencies were valid, and to
assess the appropriate level of proficiency for each primary competency (i.e., awareness,
operations, or expert). The competencies developed during this initial phase were then used
to guide the development of learning objectives for the instructional curriculum. 1 This
report was supported by Department of Veterans Affairs, Veterans Health Administration
contract “Emergency Management Academy Development,” CCN20350A. The report is the
work of the authors and does not represent the views of the Department of Veterans Affairs
or any of its employees. Institute for Crisis, Disaster and Risk Management The George
Washington University 33 Appendix C – Healthcare Emergency Management Competencies
An extensive research effort was conducted to understand the historical use of
competencies, and to establish objective criteria for competency development. Historical
development of competencies Competency modeling originated in business management
research, and has evolved extensively over the past 25 years as other disciplines began
adopting the practice. 2 The original intent of competency development was to enhance the
then common “job analysis” by relating a position’s requisite knowledge, skills and abilities
to the overall objectives of the organization in which the position existed. This approach
aligns the objectives (i.e., desired outputs) of individual jobs with the overall objectives of
the organization, such that organizational objectives are achieved through effective

25. individual job performance. While this was the original intent of competencies, their
definition varied widely as time progressed. Competency definitions range from
emphasizing underlying characteristics of an employee (e.g., a motive, trait, skill, aspects of
one’s self-image, social role, or a body of knowledge) that produce effective and/or superior
performance 3 to performance characteristics (i.e., how an employee conducted their job in
relation to the organization’s objectives). 4 The application of competencies across the
many organizations that use them has also varied widely. The private sector has commonly
employed competencies to define “superior performers” 5 and therefore, as a selection tool
for hiring, promotion, and/or salary enhancement. In other organizations, competencies
have been used for job-specific performance feedback and improvement. Still others have
used competencies to guide future program training and development. Because of this
variation in definition and application, it becomes critically important to address these
vagaries at the outset of any competency development project. This concept was well-
described by one competency research team: “The first step in the implementation of any
competency-based management framework must be the organizational consensus on how
to define ‘competency.’ This agreed upon definition will drive the methodology used to
identify and assess the competencies within the organization.” 6 The GWU-ICDRM project
team strongly agreed with this concept, and started the project by defining how the
competencies within this initiative would be applied: 2 Newsome, Shaun, Victor M Catano,
and Arla L. Day. Leader Competencies: Proposing a Research Framework. 2003. available at
http://www.cleleadership.ca/paper/leader_competenciesproposing_a_research_framework
.pdf 3 Boyatzis, Richard. The Competent Manager: A Model for Effective Performance New
York: Wiley, 1982. 4 US Office of Personnel Management. Executive Core Qualifications
(ECQ’s), accessed at http://www.opm.gov/ses/ecq.asp 5 Klein AL. Validity and Reliability
for Competency-based Systems: Reducing Litigation Risks. Compensation Benefits and
Review, 28, 31-37, 1996. cited in “Newsome, Shaun, Victor M Catano, and Arla L. Day.
Leader Competencies: Proposing a Research Framework. 2003. 6 Newsome, Shaun, Victor
M Catano, and Arla L. Day. Leader Competencies: Proposing a Research Framework. 2003.
available at
http://www.cleleadership.ca/paper/leader_competenciesproposing_a_research_framework
.pdf Institute for Crisis, Disaster and Risk Management The George Washington University
34 Appendix C – Healthcare Emergency Management Competencies The project
competencies are intended to serve as formative tools to guide healthcare system personnel
in developing knowledge, skills and abilities for effective performance during emergency
response and recovery. These competencies are also intended to serve as a guide for
developing preparedness education and training, and therefore, to serve as a basis for the
healthcare emergency management curriculum. Finally, the competencies may be employed
as a tool for assessing the performance of individual healthcare personnel performance
during emergency response and recovery operations. Defining a competency framework
Despite an extensive search of published articles related to competencies, the GWUICDRM
project team determined that no single authoritative source presented a consistent
competency definition and competency framework to adequately support the VHA-EMA
project needs. A framework was therefore developed, analyzed through pilot competency

26. development, refined and completed before establishing the individual emergency response
and recovery competencies for this project. The competency framework was therefore used
to impose a strict methodological consistency when developing and defining all
competencies developed in this program. Central to this framework is the critical
importance of competencies being objective and measurable, internally and externally
consistent, and tightly described within the context of the organization’s specific objectives.
Within this framework, the project team defined a “competency” as a specific knowledge
element, skill, and/or ability that is objective and measurable (i.e., demonstrable) on the job.
It is required for effective performance within the context of a job’s responsibilities, and
leads to achieving the objectives of the organization. Competencies are ideally qualified by
an accompanying proficiency level. 7 The GWU-ICDRM project team recognized the need to
adapt the methods for competency development, since the usual business approach to
establishing competencies is problematic for emergency management. Business
management models establish competencies by observing performance and relating it to
individual and organizational outputs. Because emergencies are rare events, and therefore
emergency response and recovery outputs occur very infrequently, the related competency
framework and definitions for this project are based less upon observed outputs. Instead,
the basis is a healthcare system’s emergency response and recovery objectives, together
with the NIMS-consistent incident command system 8 structure and processes mandated
for use by all emergency response organizations in the U.S. 9,10 7 GWU Institute for Crisis,
Disaster and Risk Management. Emergency Management Glossary of Terms (October 2007)
available at www.gwu.edu/~icdrm/ 8 Fedral Emergency Management Agency. National
Incident Management System (NIMS) (March 1, 2004), available at:
http://www.fema.gov/emergency/nims/index.shtm. 9 Bush GW. Homeland Security
Presidential Directive (HSPD) -5: Management of Domestic Incidents (February 28, 2003)
accessed at http://www.whitehouse.gov/news/releases/2003/02/20030228-9.html
Institute for Crisis, Disaster and Risk Management The George Washington University 35
Appendix C – Healthcare Emergency Management Competencies Response competencies in
systems using the Incident Command System (ICS), therefore, should be based upon the
general incident objectives an organization has during incident response, and upon the
organizational structures, processes, and relationships with other organizations that are
used during response rather than those used during everyday experience. Emergency
competencies are commonly developed without this relationship to a defined response
system, 11 making it difficult to define how scientific or medical knowledge is to be
implemented in an emergency response. In contrast, the GWUICDRM project team
specifically incorporated the NIMS mandate to use ICS by including reference to the
NIMS/Incident Command System structure and processes throughout the project’s
emergency response and recovery project competencies. Because of the anticipated large
number of competencies, the project team also established a “primary versus supporting
competency” hierarchy to categorize the individual competencies as they were developed.
Designating “primary” and “supporting” competencies helps to maintain a priority in the
framework when listing a large number of individual competencies. Supporting
competencies are also a means to more fully define and clarify the primary competencies.

27. Preparedness versus response and recovery competencies Published articles describing
emergency management competencies commonly do not differentiate between
preparedness and response competencies, and list them in an intermixed fashion. 12,13 The
GWU-ICDRM project team sought to maintain a separation between these categories.
Preparedness competencies are commonly based upon everyday organizational objectives,
structure, processes, and relationships to other organizations. Preparedness is
unquestionably important, but for it to be accurate, comprehensive and successful in
establishing an effective emergency response capability, a thorough understanding of the
response system must be established first, and preparedness guided by this. It was
therefore reasoned by the project team that specific competencies for emergency response
should be established and validated first, and then used as the “end state” to guide the
development of valid preparedness competencies. 10 Barbera JA, Macintyre AG, et al.
Emergency Management Principles and Practices for Healthcare Systems, Unit 3, Lesson
3.1.1, accessed at http://www1.va.gov/emshg/page.cfm?pg=122 11 ATPM (Association of
Teachers of Preventive Medicine) in collaboration with Center for Health policy, Columbia
University School of Nursing. Emergency Response Clinician Competencies in Initial
Assessment and Management, 2003, accessed at
http://www.atpm.org/education/Clinical_Compt.html 12 INCMCE (International Nursing
Coalition for Mass Casualty Education). Educational Competencies for Registered Nurses
Responding to Mass Casualty Incidents, 2003. Available at:
http://www.nursing.hs.columbia.edu/institutes-centers/chphsr/hospcomps.pdf 13 ACEP
(American College of Emergency Physicians) and the U.S Department of Health & Human
Services, Office of Emergency Preparedness. Developing Objectives, Content, and
Competencies for the Training of Emergency Medical Technicians, Emergency Physicians,
and Emerge…