INTRODUCTION TO THE
HOSPITAL EMERGENCY INCIDENT COMMAND SYSTEM
The Hospital Emergency Incident Command System (HEICS) was developed to assist the operation of a medical facility in a time of crisis. The second edition of the HEICS manual is significantly more comprehensive than the original version developed in 1991. This third edition remains essentially unchanged from its May, 1993 predecessor. Some of the additions made to the second edition included introductory text dealing with implementation of the HEICS program into a medical facility. The organizational chart was revised to include a subsection addressing the care of the hospital's in-patients. The Job Action Sheets were reformatted for easier reading. Lesson plans were added to facilitate instruction of the hospital staff and the training of other instructors. Each chapter has an introduction to explain the purpose and use of the material. Chapter introductions, added in the second edition of HEICS, were originally intended to be instructional and self-prompting. Experience over the years has pointed to the reality that a certain degree of outside support may be necessary to integrate HEICS into a medical facility's culture. An experienced instructor or tour of a facility using HEICS may be necessary to assist a hospital's transition to the incident command style of management.
This third edition of the HEICS manual is the joint property of the State Emergency Medical Services Authority and the San Mateo County Emergency Medical Services Agency. All material is provided to institutions for their private use and adaptation within each facility/facilities. Institutions are encouraged to make full use of the material provided in this manual, so long as it is used for that specific facility or facilities managed by the same parent organization. This includes the direct use or adaptation or copying of any Job Action Sheet, lesson plan or other information contained in this manuscript. Any other use or publication of this material must have the written permission of the State EMS Authority. You are asked that when using this material credit be given to the State of California Emergency Medical Services Authority.
HISTORY OF THE HOSPITAL EMERGENCY INCIDENT COMMAND SYSTEM
In the 1980's an inter-agency (local, State and Federal) cooperative effort was formed to develop a common organizational system which fire protection agencies could use in response to a very large incident, as well as smaller day-to-day operations. The cooperative plan known as FIRESCOPE, directed by the National Inter-Agency Incident Management System, produced a management system which has become a standard operating procedure for fire departments across the United States. The process, known as the Incident Command System (ICS), is utilized by most every fire department in the State of California. It is finding acceptance in fire departments across the United States and Canada and is now being integrated into other civil service areas and the private sector.
In 1987, the Hospital Council of Northern California completed work on an adaptation of the ICS to hospital emergency response functions in a publication entitled Earthquake Preparedness Guidelines for Hospitals. That document served as a corner stone in the development of the original Hospital Emergency Incident Command System (HEICS) written by Orange County Emergency Medical Services in 1991 with a grant from the State of California Emergency Medical Services Authority. In 1992 Orange County EMS began work on the second edition of the HEICS, again, with a funding provided by the State EMS Authority. This major rewriting of the HEICS was done with the intention of making the original document easier to use and implement within the hospital environment. The second edition attempted to retain those same characteristics that made the original ICS-based plan so appealing. This third edition of HEICS is produced by the County of San Mateo Emergency Medical Services Agency; again, with a grant from the State EMS Authority. The Project began in the fall of 1996 with the intention of gathering data regarding the usage of HEICS. From this input, a revised edition of HEICS would be recreated. However, a survey of California acute care hospitals in the spring of 1997 revealed no major concerns regarding the currently used HEICS plan. What was discovered was that there needed to be a better understanding regarding the adaptability and flexibility of HEICS to facilities of all sizes and emergencies of all types. The original attributes remain as before. They include the following:
- Responsibility oriented chain of command
This is an organizational structure which provides for the addressing of many facets of an emergency. It provides a manageable scope of supervision for all functions/positions.
- Wide acceptance through commonality of mission and language
Through the use of a broadly accepted organizational chart and generic position titles, the ICS system has found expanding acceptance in both public and private based management circles.
- Prioritization of duties with the use of Job Action Sheets
The Job Action Sheets are position job descriptions which have a prioritized list of emergency response tasks. The Job Action Sheets also serve as reminders of the lines of reporting and promote the documentation of the incident.
- Applicability to varying types and magnitudes of emergency events
The HEICS is a flexible program which can be expanded or scaled back to meet the particular needs of a specific crisis.
- Thorough documentation of actions taken in response to the emergency.
The Job Action Sheets and the associated forms promote vigorous documentation of both personnel and overall facility response to the crisis. This comprehensive documentation may improve recovery of financial expenditures, while it decreases liabilities.
- Expeditious transfer of resources (mutual aid) within a particular system or
from one facility to another
The idea of sharing material and human resources in time of need is not new to hospitals. Mutual aid among medical institutions will be facilitated which a common system of management and terms.
- Flexibility in implementation of individual sections or branches of the HEICS
Activation of the HEICS based plan can be customized to meet the needs of a particular crisis.
- Minimal disruption to existing hospital departments by virtue of parallel job qualifications/duties
The HEICS Organizational Chart and Job Action Sheets are designed to mitigate a crisis affecting the medical facility. However, it is readily apparent that there are many individuals within the day-to-day management structure whose jobs closely match those of the HEICS.
The HEICS Organizational Chart shows a chain of command which incorporates four sections under the overall leadership of an Emergency Incident Commander (IC). Each of the four sections: Logistics, Planning, Finance and Operations, has a Chief appointed by the IC responsible for their section. The Chiefs in turn designate directors and unit leaders to subfunctions, with supervisors and officers filling other crucial roles. This structure limits the span of control of each manager in the attempt to distribute the work. It also provides for a system of documenting and reporting all emergency response activities. It is hoped that this will lessen liability and promote the recovery of financial expenditures.
Each one of the forty-nine positions found on the organizational chart has a prioritized Job Action Sheets written to describe the important duties of each particular role. Every Job Action Sheet begins with the job title, the supervising officer where the location of the section operations center is and a mission statement to define the position responsibility. The duties listed on the Job Action Sheet are put into categories of "Immediate", "Intermediate" and "Extended". A line to the left of the particular action is provided for the recording of the time when the duty was accomplished or last completed.
Where it is necessary to revise particular job descriptions, caution should be used to retain the intent of the Job Action Sheet's mission. Changing the Job Action Sheet title, or position title is not recommended, as there will be a loss of common nomenclature. Changing titles will only inhibit communication when dealing with outside agencies. Moving positions to other sections or locations will defeat commonality of structure. The organizational structure should remain as pictured in the organizational chart. Standardization of language and chain of command is essential to promote communication and mission achievement both inside the hospital and with outside entities.
IMPLEMENTATION OF HEICS
In 1991 the administrative staff of the pilot hospitals were introduced to the original HIECS program, trained and tested the plan in a full functional exercise. This was all accomplished within a three month time span with very positive results. While 90 days may be rushing it for some institutions, the length of the implementation/ transition program for each medical facility will depend upon a variety of factors. The size of the institution, the number of people committed to the project, the funds available to promote the project and the strength of management's support are just some of the factors that will need consideration in the implementation program design. The information and tools contained in this second edition will significantly help this process, but the actual implementation time is the decision of management and the HEICS implementation team.
IMPLEMENTATION PROGRAM OUTLINE
The following is an outline of the suggested phases which may be necessary to implement the Hospital Emergency Incident Command System (HEICS) Program into a medical facility.
HEICS Concept Briefing
Someone experienced in the HEICS program briefs interested hospital administrators and emergency planners. The person conducting the briefing may be an employee of the hospital who has attended an educational offering on the HEICS; or someone in public health, emergency services or from another hospital which has already instituted the system. Utilizing experience and information found in the HEICS lesson plans, the presenter will provide a general description of the program and the benefits of adapting the facility's emergency response plan to an incident command style of operation. As much detail as possible should be given to Administration regarding the estimated cost of implementation and maintenance of the HEICS plan. The session should conclude with a question and answer session. References should be made available if there is the desire to contact an individual at another facility which has adopted the HEICS program.
Commitment to Adopt the HEICS Plan
An anticipated result of the above briefing will be the hospital's decision to either accept or reject a plan to implement the HEICS program within the facility. If there is a commitment to go ahead with the HEICS program then a transition team should be appointed. This team should be composed of as many upper level managers as possible. The hospital's Disaster Coordinator should guide the team; but other institutions have experienced great success when a vice-president and department head have also been appointed to serve on the HEICS Implementation Team. Needless to say, all who sit on this team should be actively supportive of the concept and mission. These individuals should have the ability to devote at least five to ten hours per week for one to three months in order to effect the transition. Above all, top level management must make the decision to stand visibly behind the program. If hospital management and staff are convinced of the CEO and/or Board's determination to enhance the hospital's disaster response the chances of a smooth and successful transition will be greatly increased.
The remainder of this document assumes that there has been a decision to proceed with the implementation of the HEICS.
Establishment of the HEICS Implementation Committee
The HEICS Implementation Committee should be larger that the Implementation Team. It should be composed of a number of hospital employees of various management levels and from various departments. These employees may be currently serving on the facility's Disaster or Safety Committee. The charge of the Implementation Committee is to put together a comprehensive program to integrate the HEICS into the facility. Some of the duties of the committee are:
- Develop an agenda and time line for the implementation project
- Revise the current disaster/emergency plan to incorporate the HEICS
- Develop a training schedule and pool of instructors
- Ensure the inclusion of HEICS training in the annual employee inservice training program
- Develop a pre-training employee awareness and "public relations" programs
- Establish an employee disaster preparedness resource center
- Requisition the HEICS vests, storage equipment and any other materials related to emergency management
There may be other projects that the committee may involve themselves with which will promote a positive attitude toward the hospital's revised emergency response plan.
A presentation is made to all administrators, department heads and managers regarding the implementation of the HEICS program into the facility's emergency response plan will help solidify support in all areas of the hospital. It is very important that this briefing is co-sponsored by the HIECS Implementation Team and CEO/Board representative.
This program should be a combination of education and public relations. Managers should be made to feel that they are all an integral part of the new system. Interested managers can be recruited to become part of a train-the-trainer class.
Revision of the Hospital's Disaster/Emergency Plan
The hospital's current disaster plan will need to be configured so that the Incident Command System becomes the "standard operating procedure" when an the plan is activated. It is important to understand that the HEICS is not the entire disaster plan; but rather the method by which a hospital will operate when an emergency is declared. The revision of the facility's emergency plan may be initiated at any point in the implementation program, however, the sooner this process is completed the more cohesive the overall plan will appear to involved personnel. This may become a important, positive selling point during the general introductory phase.
The HIECS Job Action Sheets and forms might be viewed as the center of a disaster/emergency plan. Surrounding the Job Action Sheets are supporting policies and procedures which augment the HEICS and make it work. The following is a short list of some typical P & P which are instrumental in a complete emergency plan:
- Pre-disaster departmental readiness checklists
- Policy for activation of the hospital's disaster plan
- Policy for termination of the hospital disaster plan
- Personnel recall procedures
- Security/lock-down policy
- Decision to evacuate policy
- Evacuation procedure
- Volunteer credentialing policy
- Policy regarding standing orders for patient care during a disaster
- Policy allowing for rapid patient discharge during a disaster
Some facilities have developed annexes, or subsections of the disaster plan, to deal with specific emergencies such as hazardous material releases, earthquakes, utility outage, severe weather, bomb/security threat and other conditions which may potentially occur.
The completed disaster manual will above all be simple. The plan requiring volumes of memorization will eventually collect dust on a shelf. Some of the most effective hospital disaster plans are surprisingly brief and simple to read. A well indexed text, with brevity as its hallmark, will be considered "user friendly" by those who depend upon it.
Introductory Lesson for All Hospital Employees
All employees of the facility are instructed on the HEICS plan. This is done utilizing the Introduction to the Hospital Emergency Incident Command System Lesson Plan. It is recommend that all levels and areas of service should attend these general education session. The programs are estimated to run approximately one hour. Participants at this training session are made aware of the HEICS plan and how it will affect their disaster response. They should be advised that some of them will be invited back to participate in a table top exercise. Ultimately all personnel will be involved when the hospital tests the new plan in a future disaster exercise.
This inservice may be an opportunity to create some positive employee - employer relations by promoting employee family/home disaster preparedness. Some hospitals have found this to be quite successful in promoting employee loyalty.
Staff Table Top Exercise
The HEICS Table Top Exercise is a paper drill intended to demonstrate the working and communication relationships of functions found within the HEICS organizational plan. The exercise is intended primarily for the administrators, managers and personnel who could conceivably be placed into an officer's position upon activation of the disaster plan. The exercise itself will take two to two and a half hours to complete.
Full-Functional Exercise of the HEICS Plan
The new HEICS disaster response plan may be tested when the facility conducts a general disaster exercise. This will involve the activation and simulated activity of all sections of the Incident Command System. Other medical facilities have received a highly positive response from employees who have been involved in their first, fully-functional exercise of the HEICS. In three hospitals of 200 beds or more, greater than 80% of participating employees felt that the hospital's disaster exercise performance was more organized than before the implementation of the HEICS program. These same hospitals have devoted an adequate amount of pre-training to all employees.
Continuing Staff Education
These periodic sessions are intended to meet licensing/accreditation standards, but also to keep all hospital responders committed to disaster preparedness and proficient in emergency operating procedures. The expertise of top management in regards the HEICS plan is a priority. The leadership team composed of managers who could potentially fill the of roles of Incident Commander, Administrative officers and section chiefs must be always ready and always aware of how the facility's disaster plan works; as well as the responsibilities associated with the most critical job positions.
Educational offerings may be centered on paper or functional exercises, introduction of new disaster-related topics and review of the MASICS plan. Home and family emergency preparedness should always be stressed at each educational session. General employee classes are usually done at the employee's anniversary or prior to a scheduled disaster exercise. Smaller educational sessions may be held within department inservices or as part of a facility-wide safety program. The chapter dealing with lesson plans has additional suggestions regarding staff education.
It is believed that the material in this manual is comprehensive enough to allow institutions and individuals to begin the integration of an incident command system into a hospital's disaster plan. Those who worked on the revision of this document trust that those individuals who are able to grasp the key ideas in this text will be able to initiate a program like the one outlined here. It is important to keep in mind that the HEICS is a tool to facilitate accomplishing a task. The HEICS identifies critical management functions in order for the hospital to develop and implement an emergency action plan. In the end, it is people who are truly the most important element of any emergency plan. There is no Job Action Sheet or form or Action Plan which can substitute for the well trained employee; including the Medical Staff. Training and exercise of the disaster plan builds the confidence of the entire staff. Honest critiquing will illuminate those areas which are in need of further revision or retraining. Those officers with a working knowledge of the facility disaster plan will be better able to exercise a command and control presence over those areas assigned to their care. Confidence in management is an essential component of the plan which no hospital administrator should overlook. People who believe in leadership will give their loyalty, as well as their skill.
Finally, there are two types of people who believe in emergency plans. Those who know they are necessary for accreditation and licensing; and those who believe that they will eventually someday be used. People who develop plans for licensing purposes solely will probably not read this. There is really no other driving force other than to meet a code. For their purposes, any reasonable plan will suffice. The individual who believes that real emergencies do happen is usually committed to a preparedness philosophy which promotes emergency planning at work, home or where ever a person may be. Employee personal disaster preparedness is a deserving venture for the medical facility for a number of reasons. Some of these reasons are practical, such as the employee who is better prepared at home will be better able to report to work if called. The employer who has devoted energy to creating a comprehensive emergency plan in the workplace; and has also committed some resource towards preparing the worker for an emergency away from the job, is clearly telling the employee "You are a valuable resource - a most important part of this facility's disaster plan." The employee's attitude toward the hospital will be one of loyalty and commitment to recovery.