Onx After Action Report Draft ONX System s1

April 20, 2012

AFTER ACTION REPORT / IMPROVEMENT PLAN

State of Washington Region 2 Healthcare Preparedness Network After Action Report / Improvement Plan Operation Acorn Drop Functional Exercise

ADMINISTRATIVE HANDLING INSTRUCTIONS

1. The title of this document is The "Operation Acorn Drop - A Healthcare Earthquake Exercise" After Action Report. 2. The information gathered in this AAR/IP is classified as For Official Use Only (FOUO) and should be handled as sensitive information not to be disclosed. This document should be safeguarded, handled, transmitted, and stored in accordance with appropriate security directives. 3. At a minimum, the attached materials will be disseminated only on a need-to-know basis and when unattended, will be stored in a locked container or area offering sufficient protection against theft, compromise, inadvertent access, and unauthorized disclosure. 4. Points of Contact:

Hospital:

Laura Jull Harrison Medical Center (Office) 360-744-6426 (E-Mail) [email protected]

Exercise Director:

Jessica Guidry Kitsap Public Health District (Office) 360-337-5267 (E-Mail) [email protected]

DRCG LLC – www.drc-group.com 2 | Page After Action Report / Improvement Plan Operation Acorn Drop Functional Exercise

CONTENTS

ADMINISTRATIVE HANDLING INSTRUCTIONS...... 2 CONTENTS...... 3 EXECUTIVE SUMMARY...... 4 SECTION 1: EXERCISE OVERVIEW...... 5 Exercise Details...... 5 Participant Information...... 6 SECTION 2: EXERCISE DESIGN SUMMARY...... 7 Exercise Purpose and Design...... 7 Exercise Objectives, Capabilities and Activities...... 7 Scenario Summary...... 8 SECTION 3: ANALYSIS OF CAPABILITIES...... 9 SECTION 4: CONCLUSION...... 47 APPENDIX A: IMPROVEMENT PLAN...... 49 APPENDIX B: PARTICIPANT FEEDBACK (3 THUMBS UP – 3 THUMBS DOWN). .50 APPENDIX C: ACRONYMS...... 63

EXECUTIVE SUMMARY

Operation Acorn Drop - A Healthcare Earthquake Exercise was designed and facilitated to provide participants with an opportunity to evaluate current response concepts, plans, and capabilities for a medical / health response to an earthquake in Region 2 (Clallam, Jefferson, and Kitsap Counties). The exercise focused on emergency operations coordination, medical surge, patient evacuation, regional coordination and communication.

The purpose of this report is to analyze exercise results, identify strengths to be maintained and built upon, identify potential areas for further improvement, and support development of corrective actions.

Incorporated in Section 3: Analysis of Capabilities of this After Action Report is a comprehensive listing of each Target Capability with its associated Major Strengths, Primary Areas for Improvement and Improvement Recommendations

SECTION 1: EXERCISE OVERVIEW

Exercise Details

Exercise Name: Operation Acorn Drop - A Healthcare Earthquake Exercise

Type of Exercise: Tabletop

Exercise Start Date: April 20, 2012

Duration: Three Hours

Location: Clallam, Jefferson and Kitsap Counties Washington

Sponsor: Region 2 Healthcare Preparedness Network

Program: Exercise design objectives focused on improving understanding of a response concept, identifying opportunities or problems, and achieving a change in attitude. This exercise focused on the following design objectives selected by the Exercise Planning Team: 1. Situation Assessment. Identify processes for accounting for patients, staff, and visitors at facilities. Discuss process for conducting damage assessments at facilities to determine whether relocation is necessary. 2. Incident Command. Review plans and triggers for activating incident command. Implement activation procedures and notify partners of activation. Identify key response priorities. Review triggers for deactivation of incident command. 3. Resource Coordination. Discuss processes for ensuring access to key resources, including staff, for response activities or ongoing operations. 4. Communications. Review available communications systems that can be used in emergency response. Test communications systems. Ensure that contact lists are accessible. Discuss internal and external notification procedures. 5. Medical Surge. Assess resources available to handle an influx of patients at your facilities (hospitals / clinics) or to act as potential first aid stations in your facilities (public health agencies). 6. Medical Evacuation. Discuss plans for medical evacuation, especially regarding requesting or providing evacuation assistance. Identify steps in packaging patients and communicating evacuating patients to families.

Purpose: The purpose of this exercise is to provide participants with an opportunity to evaluate current response concepts, plans, and capabilities for a medical / health

response to an earthquake in Region 2 (Clallam, Jefferson, and Kitsap Counties). The exercise focused on emergency operations coordination, medical surge, patient evacuation, regional coordination and communication.

Mission: To emphasize the role of local healthcare responders in response to an earthquake.

Scenario Type: Earthquake

Participant Information

Participant Location

Clallam County Division of Emergency Management

Clallam County Health and Human Services

Harrison Medical Center

Harrison Medical Center - Silverdale

Jefferson County Public Health

Jefferson Healthcare

Kitsap County Department of Emergency Management

Kitsap Public Health District

Lower Elwha Klallam Tribe

Makah Tribe

Naval Hospital Bremerton

Olympic Medical Center

Peninsula Community Health Services

Washington Veterans Home

Number of Participants 80

SECTION 2: EXERCISE DESIGN SUMMARY

Exercise Purpose and Design

The purpose of this exercise is to provide participants with an opportunity to evaluate current response concepts, plans, and capabilities for a medical/health response to an earthquake in Region 2 (Clallam, Jefferson, and Kitsap Counties). The exercise will focus on emergency operations coordination, medical surge, patient evacuation, regional coordination and communication.

Exercise Objectives, Capabilities and Activities

Capabilities-based planning allows for the exercise planning team to develop exercise objectives and observe exercise outcomes through a framework of specific action items that were derived from the Target Capabilities List (TCL). The capabilities listed below form the foundation for the organization of all objectives and observations in this exercise. Additionally, each capability is linked to several corresponding activities and tasks to provide additional detail.

Based upon the identified exercise objectives below, the exercise planning team decided to demonstrate the following capabilities during this exercise:

Communications

Activity Target Capability

Provide Incident Command / First Responder / First Receiver / Interoperable # 1 Communications

Medical Surge

# 1 Activate Medical Surge

# 2 Implement Surge Patient Transfer Procedures

# 3 Implement Surge Staffing Procedures

# 4 Receive and Treat Surge Casualties

# 5 Demobilize Medical Surge

On-Site Incident Management

# 1 Direct On-Site Incident Management

# 2 Implement On-Site Incident Management

# 3 Establish Full On-Site Incident Command

# 4 Conduct Resource Management

Patient Evacuation and Shelter-In-Place

# 1 Direct Evacuation and / or In-Place Protection Tactical Operations

# 2 Activate Evacuation and / or In-Place Protection

Scenario Summary

Residents throughout the region begin to feel the ground roll and shake. Initial seismic reports indicate that a 6.3 magnitude earthquake has occurred along the Seattle Fault.

SECTION 3: ANALYSIS OF CAPABILITIES

Communications

Performance Target Capability

Activity # 1: Provide Incident Command / First Responder / First Adequate Receiver / Interoperable Communications

Associated Critical Tasks

Task # 1.1: Communicate Incident Response Information.

Strong Evaluator # 1

 Incident Command immediately identified who needed to be communicated with. First communicated in house with staff, then Observations began communications out of house to: County EOC (DEM), Public Health, Region 2 Hospital partners, WaTrac.

 House Supervisors need additional functionality on the phones Recommendation they carry. It is reported calls drop and cell coverage spotty. s Texting would be a benefit during an event. Relocate portable Satellite phone to communications room.

Adequate Evaluator # 2

Observations  Used amateur radio to communicate with county EOC

Recommendation  Had problems with phone line access with county EOC. Develop s satellite phone communication

 This was an excellent opportunity for the new administrator and the associate administrator to complete a practical application of current emergency procedures. Using the Emergency Observations Preparedness plan as a guide to walk through the exercise the facility discovered both strengths and weaknesses of the procedures.

Recommendation  Update emergency preparedness procedures. s

Observations  Conversation among players flowed easily. Problems with our

communication system was identified and solutions discussed. There is no system in place to communicate with all staff in the event of an actual emergency.

Recommendation  All managers should have all staff phone numbers in the event of s an emergency and a phone tree system put in place.

 Many of NHB's communications rely on the strong possibility that Observations communications will be non-existent. Many units self-dispatch and activate rapid damage assessment or mass casualty plans.

Recommendation  Not so sure I would change too much of that... s

Observations  JCPH Incident Command staff initiated communication within the facility immediately after the earthquake meeting with staff in the designated "safe meeting area" outside the building. JCPH IC staff discussed that the reception staff will take the "check-in / check-out" notebooks with them to the "safe meeting area" and identify any staff that might be missing and those who might be off or working outside the office. (According to JCPH "Hazards and Threats Plan" and "JCPH Safety Plan.) 1. Communication with JCPH staff: Trying to reach staff out of the office could be a challenge. Receptionist have current copy of "Emergency phone Tree list" in the "check-in / check-out" notebook so staff phone numbers are easily available when staff evacuate building after earthquakes. JCPH IC staff initiated communication with Jefferson County Administration and Jefferson County DEM. JCPH IC would send at least one JCPH staff to be Public Health Liaison to the Jefferson County EOC.  Communication within Jefferson County Departments; JCPH Incident Command Staff identified the need for a building inspector to inspect building before re-entry. JCPH is in the same building with Jefferson County Department of Community Development (DCD) who employ building inspectors so communication would be in person to DCD. JCPH staff attempted to call Jefferson Healthcare (JHC) multiple times using mangers IPhones and land line. #254-381-8156 would not go through. # 254-244-3573 rang but no answer.  JCPH IC staff considered trying to call JHC mangers office phone number. In a real event JCPH staff could walk across the street to communicate in person. Plus, JCPH IC called from JCPH Satellite phone and was able to reach JCPH Deputy Director's

IPhone.

 Admin staff will put copy of "emergency phone tree list" in the glove compartments of all the cars next to the car cell phones. Admin staff will program JCPH Manager Cell phone/I phone numbers into the Cell phones in the cars. Add to "Hazards and Threats" plan that "Building Sweepers" will pick up County Car keys from the Key boxes as they leave the building after Recommendation earthquake. s  JCPH Management will review with new DCD Manager cooperative agreement to get facility inspected after earthquake to be able to reenter building as quickly as possible.  JCPH Management will work with Jefferson Healthcare to establish multiple ways of communicating with each other via landlines, cellphone / iPhone and in person meetings

 Exercise questions were clear and progressed well. Question Observations response time was adequate.

Recommendation  None s

 Sophie Trettevik Indian Health Clinic (STIHC) upon the cessation of shaking the Clinic Director would announce a CODE BROWN over the intercom which initiate an evacuation of the clinic due to Observations the risk of tsunami. Once staff and clients arrived at the assembly area the Clinic staff would send a liaison to the Diaht Hill Incident Command Post. A Disaster First Aid Station would be established to treat any injured.

 Landline telephone is the main communication system which Recommendation could be destroyed or overloaded during an event. Other s secondary means of communication should be tested on a regular basis.

 Participants all demonstrated the ability to communicate Observations effectively throughout the exercise. Command Center well organized with equipment. Drop Cover and Hold was announced.

 Participants advised to self-report to Board Room following initial Recommendation assessment of their unit. Managers or designee to bring patient s and staff census to the Command Center.

 The KPHD Emergency Coordination Center (ECC) activated and immediately identified need to communicate to County Emergency Operations Center (EOC) that activation of the ECC Observations had taken place. Established successful connectivity with Harrison Medical Center via satellite phone. The command staff quickly reviewed plan checklists as well.

Recommendation  The designated ECC staff should drill more with the various s communications modes - texting, ham radio, etc.

Task # 1.2: Establish and maintain response communications systems on-site.

 Incident Command recognized there would need to be assessed and reassess of Physical Structure, staffing and supplies. A loop Observations of communication would be needed. Radios in all departments monitoring for updates.

Recommendation  Phone upgrades to House Supervisors. s

 Amateur radio, CERT if cell phones down. Our area still had Observations texting capabilities so this was not seen as a problem

Unsure Evaluator # 3

 Really had an opportunity. Our satellite communications were Observations lacking.

Recommendation  Work on this capability. s

Observations  None

 If there is a landline/IT loss, we can fall back on our UHF talk Observations group radios.

Recommendation  Need to do some more training on radio usage. s

 JCPH IC staff identified multiple ways to communicate with Incident Command staff in ECC and with other staff. If cell phones and computer network were available managers will use them to inform staff of situation, identify needs and areas that Observations need staffing. JCPH Liaison to Jefferson County Department of Emergency Management EOC will continue to communicate with JCPH ECC regarding assessment of the situation and identified needs.

 Remind staff of JCPH "Hazards and Threats" and Safety Plans. It is critical that staff follow JCPH policies and constantly inform Recommendation receptionists of their location if working outside the facility. s  Orient new Environment Health Director to Jefferson County Department of Emergency Management EOC to be back-up Public Health Liaison to the County EOC.

Observations  The system worked well.

Not Applicable Evaluator # 8

 Facility was evacuated due to tsunami risk. Response Observations communications were mainly focused on evacuation.

 Priority of actions was discussed and participants were able to set priorities. New procedures for facility control and damage Observations assessment were discussed. Use of alternative communication systems were applied.

Recommendation  The need for damage assessment training for the Security Officer s in Silverdale.

 Command staff identified quickly that all KPHD staff needed to be notified of ECC activation and to direct to forward inquiries to the ECC. After the group determined command roles, etc., identified Observations need to prepare and share SitRep and info release with the EOC. Again, staff reviewed plan checklist to ensure completion of tasks.

 Exercising internal communications systems more through drills Recommendation would be useful in the future. Staff alert and warning system s capabilities and limitations need to be better understood.

Evaluator Evaluator Name Number # 1 Kelly O’Connell # 2 Hollie Kaufman # 3 Brian Schaefer # 4 Jaima Hardman # 5 Terry Lerma # 6 Julia Danskin # 7 Zena Kinne # 8 Andrew Winck # 9 Susie Rankin # 10 Ruth Westergaard

Medical Surge

Adequate Activity # 1: Activate Medical Surge

Task # 1.1: Activate medical surge plans, procedures, and protocols to ensure medical treatment for populations requiring specialized assistance.

Observations  Our clinic had trained for this as an overflow facility for the local

hospital, we have child care workers and educators who are with our CERT program and also with our medical reserve corp to assist with special population needs

 We have no medical surge plan in place and discussed what our Observations role would be in the event of a medical surge. The decision was that we would only play a support role in this event.

 We discussed our role as the region Frail Patient Location, and Observations we would implement it.

Recommendation  More exercising of the plan. s

 Surge plan activated by House Supervisor, discussion lead by House Supervisor, CNO, COO. Review of Swing Bed, Inpatient Observations Census, and Surgery Schedule to determine who could be discharged to home or alternate care in anticipation of Surge. 18 available rooms.

Recommendation  Verify actual 'beds' on site at hospital. s

 We practice our MasCat plan at least twice a year. Many Observations personnel are well trained on how to activate and the process of patient surges.

Recommendation  Keep practicing with inclusion of Harrison for receipt of trauma s patients from NHB.

Recommendation  None

 The number of surge patients was not adequate to, in reality, activate our surge plan. The group answered the questions as if Observations 50 and not 12 patients were coming to the primary care clinic. This allowed for testing of our surge plan and identified several gaps to work on.

 Medical surge questions appeared to be geared to hospitals and Recommendation not the worried well patients that no doubt will come to a s community health center.

 Medical Surge plans were not activated due to the immediate evacuation of STIHC. Additionally, no casualties were reported Observations and Medical Surge Plans are not activated unless there are 5 or more patients. A Disaster First Aid Station was established by clinic staff at the Diaht Hill Assembly Area.

Recommendation  Update Makah CEMP to reflect the STIHC plans and the new s emergency facility available for use on Diaht Hill.

 All victims seeking medical care are directed through the funnel Observations point in the ED. Traffic pattern flows East on Hickory Street. Entrances to the Medical Center are not secured.

 The plan should address those injured victims self-presenting at alternative entrances due to the fact there will gridlock on Hickory Recommendation with emergency traffic and the public with seek other means of s entry. A process for vetting care providers to go to alternate facilities when roads prevent travel to Medical Center.

Adequate Activity # 2: Implement Surge Patient Transfer Procedures

Task # 2.1: Provide knowledge or visibility of available destination medical care facilities / services and tracking for mass movement of patients, ensuring patients are matched with transportation and destinations that provide appropriate levels

of medical care.

 Use of Coast Guard reviewed, triage and documentation of Observations patients.

Recommendation  Improved paperwork to stay with patient until moved to another s facility.

 Facility did discuss this, but we understand the movements will Observations be directed by Kitsap County Emergency Management Office.

Recommendation  Attend more Region 2 meetings to work more closely with Kitsap s County Emergency Management Office.

 HS and clinical staff defined what an 'appropriate patient' would Observations be for JH to transfer in.

Weak Evaluator # 5

 We know how to evacuate from one military hospital to another Observations military hospital as we do it every week.

 We need to work out an exercise to evacuate patients to a civilian Recommendation hospital to see what paperwork or equipment failure we might s encounter.

 The players could easily identify the local hospital and believed that in a disaster, they could call the hospital up business as usual. Verbal cues were needed to remind the group of the Observations importance of coordinating the transfer of patients with the emergency management lead organization and that they could not just call the charge nurse at the local emergency room.

Recommendation  More exercising will be beneficial. s

 No casualties reported or needed transport to alternative Observations facilities.

 EMTALA procedures during disaster discussed. Ability of other facilities to receive patients in transfer was discussed. The need Observations for evacuation and how it would be implemented had a very good discussion. Getting ahold of relatives to pick up those that can be discharged was discussed.

 A discharge unit or area for those no longer requiring Recommendation hospitalization should be defined in plan and identified how it s would be staffed and what entrance the discharges would take place.

Adequate Activity # 3: Implement Surge Staffing Procedures

Task # 3.1: Assess initial and ongoing need for staff and augment as needed.

Observations  Medical Reserve Corps activation.

Recommendation  Better phone communication, texting or email as possible s alternative means of contacting staff.

 Excellent communication through Facility Notification Tree. Observations Alternate vehicle notification plan.

Recommendation  Practice s

 Staffing Coordinator and Department directors initiate call plans. Schedule augmented to prepare for Surge. Relief shift scheduled. Staff reminded to bring medications and any personal items they Observations may need for extended shift. A question: Would Harrison be sending any staff who live in PT / Jefferson County with transferred patients?

Recommendation  List of local RN's who work out of county added to call up list. s Verification of MOU for Child care.

 Logistics and staff support are strong as we prepare for the Observations potential to stand alone for up to 30 days.

Recommendation  Keep exercising these contingencies. s

 Verbal cues were need for the incident commander to think about pulling staff from another site to staff the site experiencing the Observations surge. No policy existed for acceptance of volunteer staff and under what scenarios the center's insurance would cover the volunteer clinical staff.

Recommendation  The player organization needs to develop a plan for accepting

medical volunteers and be more knowledgeable about their s insurance coverage and under what scenarios.

 Clinic staff gather at Diaht Hill Assembly Area and are assigned Observations to pre-determined roles at the Disaster First Aid Station.

 Different units are using many different methods for contacting Observations staff to report. This is a very time consuming function.

 Technology could be universally utilized by all units and Recommendation departments to activate staff with specific instructions which s would assist in providing on-going staff levels as the days and hours progress in the disaster.

Adequate Activity # 4: Receive and Treat Surge Casualties

Task # 4.1: Ensure adequacy of medical equipment and supplies in support of immediate medical response operations and for restocking supplies / equipment requested.

 Medical supplies for emergency use stored at the bunker for Observations restocking of clinic supplies.

 Need more IV's, pharmacy supply access besides hospital, Recommendation Possible statement of intent from pharmacies to supply in case of s emergency.

Observations  Not in our current plan, but have capability.

 Adequate inventory on hand for current situation and at least 96 hours. Emergency supply plan activated in Materials department, Observations verified communication with Prime distributor. A question: How would House Supervisors gain access to the 'Mother Omni' if no Pharmacists available?

Recommendation  Verify Pharmacy emergency supply plan. s

 We do Mass Casualties well, but with the high rate of turnover of Observations military staff, we need to keep practicing.

Recommendation  Keep practicing Mass Casualty exercises. s

 The player organization had good stocks of medical resources to treat the surge outlined in the exercise. The exercise had the Observations medical surge going to the clinic site that also housed the medical supplies for the player organization.

Recommendation  Plan into the exercise the need to obtain additional supplies that s would not be housed at the clinic site.

 Discussed how and where STIHC would be able to procure Observations supplies during a region wide event.

Recommendation  Ensure that written agreement is developed between clinic and

s medical supply vendor.

Adequate Evaluator #9

 Many different Department Managers relayed how they would Observations obtain further supplies in the event of the depletion during the disaster. Some had alternative storage areas.

 The Command Center should have a written summary of these Recommendation department specific plans in the event the manager is unavailable s at the time. This would include food, pharmaceuticals, and medical supplies.

Adequate Activity # 5: Demobilize Medical Surge

Task # 5.1: Transition from surge to normal operations.

 No extra equipment needed for this drill, personnel were Observations adequate for situation.

Observations  Reasonable transition plan.

Recommendation  Exercise the plan more regularly. s

 Followed recovery plan. A question: Liaison officer for EOC, how Observations long do they stay? Who decides?

Recommendation  Include trigger for closing Incident Command in recovery plan. s

 Most of the time, we just throw stuff back in the bags or storage Observations area and sort it out later.

Recommendation  We need to practice demobilization further to track our equipment s and supply usage properly.

Weak Evaluator # 7

 The players were not immediately aware of who was authorized to close down the EOC and under what conditions. The Observations organizational plan did address this and was used as a resource for the players to answer the questions.

 Reviewed STIHC SOP that gives clear direction for Observations demobilization of medical surge activities.

 Staff were well versed in the process that they would implement Observations when the situation is returning to normal. Gradually reducing the Command Center staff was implemented.

Evaluator Evaluator Name Number # 1 Hollie Kaufman

# 2 Jaima Hardman # 3 Brian Schaefer # 4 Kelly O’Connell # 5 Terry Lerma # 6 Julia Danskin # 7 Zena Kinne # 8 Andrew Winck # 9 Susie Rankin

Strong Activity # 1: Direct On-Site Incident Management

Task # 1.1: Establish and maintain communications with the Emergency Operations Center (EOC), dispatch center and responding units.

 Lower Elwha EOC was activated. Radio communication with Observations Clallam county EOC.

Weak Evaluator # 2

 The ECC was unaware that EMD was locating at OMC therefore Observations breaking down our communications with EMD.

Recommendation  Better communications with EMD prior to exercise. s

Observations  Had no communication during this exercise.

Recommendation  Plan to communicate in future exercises. s

Observations  SitRep sent to EOC, per plan.

 The CDOs and OODs are all trained on HCC activation, and the Observations IMT staff knows their main jobs well.

Recommendation  Keep practicing and rotate in alternate staff for training. s

 JCPH Management staff simulated sending Public Health Liaison to Jefferson County Department of Emergency Management Observations Emergency Operations Center. PH Liaison would be under Operations at the EOC

Recommendation  Orient additional JCPH staff to Jefferson County EOC for s additional staffing back-up to Public Health Liaison to EOC.

 The players were aware of the lead organization and identified an Observations information officer for outside communications.

 STIHC EOC was established at the evacuation assembly area in Observations order to lead the medical response.

 Communication with county and state EOC may be challenging if Recommendation phone lines are not usable. Alternate forms of communication s should be developed.

 There is a designated Incident Management Team that has received and continues to receive specific training in the Observations management of the Command Center and how it interfaces with the County EOC.

 I think this is the most valuable component of response when Recommendation individuals understand the "big picture" and how the medical s center functions within a larger system. Having these individuals observe how the County EOC operates will be very helpful.

 KPHD ECC staff understood to establish immediate communications with the County EOC and to notify them of the Observations ECC activation. The successfully made connection via satellite phone with EOC partner (Harrison Medical Center) to ensure system connectivity.

 Practice / drills using more modes of communication - texting, Recommendation ham, etc. - would help to ensure ease with using quickly and s effectively if needed.

Adequate Activity # 2: Implement On-Site Incident Management

Task # 2.1: Conduct initial assessment (size-up) (first arriving units).

 Reviewed information, made recommendation for personnel and Observations EOC set up, directed police to make initial evaluations also employed CERT teams for this.

Recommendation  Need better written plan for who takes what responsibilities, s needs review and exercise to test

Observations  ICS roles were assigned quickly.

Observations  As a Tabletop exercise it appeared that we had this sown up.

Recommendation  Exercise this plan more in the future. s

 Incident commanders and department directors followed Observations Emergency plan with Department status reports.

Recommendation  Emergency management plan review and revise at EOC by next s review date of 5/23/2012.

 We do rapid damage assessment well. We need to further Observations improve our auto-report or automatic damage assessments at the work center level.

Recommendation  Work with Facilities on the damage assessment training. s

 JCPH Management staff reviewed that an initial assessment Observations would be done and information would be communicated to the County EOC.

 The players had ICS vests, clip boards, community health center Observations specific job action sheets, and many necessary forms.

 Clinic Director assessed situation and activated a CODE BROWN Observations to evacuate the facility.

 As stated in previous question. This is a valuable asset to the Observations response teams.

 KPHD staff immediately understand to drop, cover and hold and evacuate when directed to pre-designated rendezvous point. Staff are to be immediately accounted for. A situational assessment will be conducted of damage, threats, casualties, structural damage, public utilities, reports and visible damage. Command staff reviewed the ERP section on activation criteria and protocol for confirmation of process. Command staff Observations identified trained staff to conduct first aid to customers and staff. The operations section would triage injured to appropriate facilities. Various means of transporting would be employed depending on how ambulatory the injured are and whether other facilities are able to handle (PCHS, e.g.) The GHC damage assessment would be completed by the building superintendent (not KPHD staff) plus 2-3 others trained.

 KPHD staff – custodial – need to be trained in damage assessment and should have ready copies of checklists and forms to conduct the assessment. A problem of inconsistencies in how and who staff contact regarding their location and status was identified. Follow-up is needed to consider various notification modes such as texting, email via I-Phone, severe weather system, Comcast The question was asked about how to determine how many customers are in the reception area and Recommendation how to account for them. The recommendation was to make sure s that floor monitors understand to verify that everyone - not just staff and clients/customers they are immediately working with - are alive and out of the building. Also, make sure floor monitors are individuals who are consistently in the office. The question was also raised about assisting injured, disabled down stairs. The recommendation is to follow up with Community Development regarding access to their lift chair and then train appropriate staff (floor monitors) in how to use it.

Task # 2.2: Initiate and implement the ICS.

 When some team members were unavailable, other personnel Observations were available to fill in, however they were not familiar with the process and had difficulty with understanding the exercise goals.

Recommendation  Training of more people with the ICS system, more exercises. s

Observations  Good leadership. Staff were comfortable with their roles.

Observations  We activated before the exercise began.

Recommendation  Delay implementation during future exercises. s

 Incident command was missing two of its standard members. Observations Their positions were filled by others. Good job!

Recommendation  Additional Incident Command training has been requested by this s team.

 Military personnel know chain of command very well; adopting Observations ICS is a natural for them.

Recommendation  Keep practicing so they know the ICS terminology. s

 JCPH Managers initiated ICS with the Director became the Incident Commander. Assessment of needs and resources including available staff was initiated. Deputy Director became Observations Logistics and Financial lead. Fiscal accounting was initiated with specific code for disaster. JCPH IC simulated notifying EOC that it was open and sending SitRep.

Observations  Did not have a method for widespread communication to the staff that the EOC was implemented. Did not have a mechanism that requested senior leaders to report to the EOC if able. Training to employees across the organization is underdeveloped on incident command. The players in the room had recently completed NIMS

training and there was varying understanding of the system.

Recommendation  Provide widespread employee training on ICS. Provide more s exercise opportunities.

 Clinic Director was established as the Incident Commander and Observations ordered an immediate evacuation.

 The members of the IC Team were able to guide those present. Observations Command Center was set up per the plan.

 One of the four directors would order activation of the KPHD ECC. Pre-assigned staff (managers) know to report to the ECC. All staff would be notified of ECC activation and directed to forward inquiries to the ECC. EOC notified of activation. EOC would notify media. Priorities identified were identified – set up, assignments, responsibilities. Command staff reviewed ERP and Observations identified protocols. Deactivation would commence when Incident Command deems that the event could be handled within normal operating scope, e.g. cessation of requests for assistance, reports from partners reporting return to normal activity. Deactivation would be communicated to all hands, the EOC, and media. A KPHD representative would remain at the EOC if still activated.

 The question was raised about what would happen if none of the directors were available when an even occurred. While this is Recommendation unlikely, it is recommended that appropriate managers be given s the authority to direct activation of the ECC, e.g. EH manager if it was an EH event, CD manager if it was a CD event. The ERP should be modified to include this recommendation.

Adequate Activity # 3: Establish Full On-Site Incident Command

Task # 3.1: Establish Incident Command.

 Incident commander assumed role after feeling more comfortable Observations with the team; all members contributed knowledge of particular areas to facilitate best response.

Recommendation  Better identification of ICS roles. s

Observations  Was utilized to direct operations during this exercise.

Recommendation  Further exercises will allow better utilization of this group. s

 Only four managers and the Communicable Disease lead Observations participated in the Exercise. Incident Commander simulated filling all the positions.

 The players in the room worked well together and were fully Observations engaged. Roles were well understood.

No response Evaluator # 8

 Once at the Assembly Area STIHC staff would establish a Observations Disaster First Aid Station and report to the Diaht Hill Incident Command Post.

No response Evaluator #9

Strong Evaluator #10

 KPHD command staff recognized immediate need for all staff to be notified of ECC activation and to direct staff to forward inquiries to the ECC. Simultaneously, they recognized priority of County Emergency Operations Center (EOC) notification of ECC activation. EOC would, they noted, notify media. Command staff identified priorities such as set up, assignments, responsibilities. The staff reviewed the plan and noted relevant protocols. The Observations staff discussed that deactivation would commences when Incident Command deems that the event can be handled within normal operating scope, e.g. cessation of requests for assistance, reports from partners reporting return to normal activity. Communication of deactivation would be transmitted to all hands, EOC, and to the media. A KPHD representative would remain at EOC if still activated.

Task # 3.2: Establish communications with EOC.

 Local ARES member worked closely with tribal ham radio operator to ensure proper protocols were followed, phone Observations communication did not work well (had to leave a message). Tribal EOC communication with police department ok, and ham radio operators needed more involvement.

 Training with local emergency radio group to improve tribal ham Recommendation radios operators use proper protocol for EOC communications. s Explore alternative communication resources.

Weak Evaluator # 2

 EOC was not on site, breaking down communication between Observations ECC and EOC.

Observations  Not exercised during this exercise.

Recommendation  More practice in different scenarios. s

Observations  SitRep sent per policy.

Recommendation  Liaison officer needs to be identified. s

 We communicate well with our Host Command and higher Observations headquarter authorities.

Recommendation  We need to work on our communications with civilian hospital s and healthcare organizations.

 JCPH IC staff simulated sending a Public Health Liaison to the Observations EOC and sending SitRep.

 Understood the role of the liaison and information officer. Observations Understood the role of the lead coordinating agency.

 The Diaht Hill Incident Command Post would establish Observations communication with the Makah EOC. Clinic staff would communicate to Makah EOC through Diaht Hill ICP.

 The Kitsap County EOC was contacted within a very short time of Observations activating the Command Center.

 KPHD command staff recognized immediate need to connect with and notify EOC of ECC activation as well as for all staff to be notified of ECC activation and to direct staff to forward inquiries to Observations the ECC. Communication of deactivation would be transmitted to all hands, EOC, and to the media. A KPHD representative would remain at EOC if still activated.

Task # 3.3: Coordinate operations with specialized emergency response teams (e.g., special weapons and tactics [SWAT] / tactical, bomb squad / explosives, hazardous materials [HazMat], land-based search and rescue).

Observations  Not exercised during this exercise

 Facilities and 2 medical personnel are trained in Earthquake Observations search procedures.

Recommendation  Consider training additional staff. s

 Environmental Health Director reviewed the new Environmental Health Appendix to Region 2 Public Health Emergency response Observations plan. JCPH IC staff discussed how EH staff would assess the situation and depending on available EH staff would offer resources to the EOC - Operations and Logistics

Recommendation  Orient new Environmental Health Director to Jefferson County s Department of Emergency Management EOC.

Weak Evaluator # 7

 The player organization did not have a ready list of staff that would be at an affected clinic site. There was a good Observations understanding of evacuation until the building assessment was completed.

Adequate Activity # 4: Conduct Resource Management

Task # 4.1: Implement processes to order, track, assign and release incident resources.

Observations  No observed need for additional resources for clinic use.

 Not really exercised during this exercise. Expendable supplies Observations were discussed.

Recommendation  More practice in different scenarios.

 HICS 255 master patient evacuation tracking form used for Observations equipment tracking from facility to facility. Supply issue tracked from Inventory distribution.

Recommendation  Incorporate the tracking tool in Evacuation policy. s

 We do well afterwards to track supplies used, but need to work Observations on actual report from the work center on disaster supplies used.

Recommendation  Work with Materiel management on improving this aspect of our s logistics.

 JCPH IC staff tried to initiate contact / communication with Jefferson Healthcare to assess needs for supplies. JCPH IC staff simulated contacting Jefferson County EOC to collect information Observations on needed medical supplies. JCPH staff would follow Region 2 Public Health Emergency Response plan Appendix 7, Emergency Medical Resources Coordination.

 JCPH Management will work with Jefferson Healthcare to identify Recommendation ways of communicating resource and medical supply needs s during disasters

Weak Evaluator # 7

 Had forms for the tracking of patients and personnel. No simple intake form for patients and did not have patient tags. Did not Observations discuss how supplies would be reordered in a prolonged disaster. Each site does have six weeks of supplies for normal operations.

 Development of a patient intake form that includes billing Recommendation information. Develop a process for ordering and tracking release s of incident resources.

 No universal system was utilized to notify staff of reporting Observations instructions.

 Offsite human resource site is being transitioned to assist in staff Recommendation deployment. This type of system could well involve all s departments which would then assist in tracking resources.

Task # 4.2: Monitor / measure performance of assigned resources, and request additional resources as needed.

Observations  Not exercised during this exercise.

 Contact with JH Primary Medical Supply distributor verified per Observations plan.

Recommendation  Verify Pharmaceutical supply. s

 JCPH IC staff discussed the possible need for food / supplies during a disaster within the building, examples of needing food for Observations staff who are working long hours and unable to leave building, and also first aid supplies.

 Fiscal staff will submit an ongoing "Food and Beverage" request to Jefferson County Administration to be used in case of a disaster and the need to support staff working long hours. Recommendation  JCPH Building Safety Committee will evaluate the current First s Aid Resources in the building and identify needed additional supplies. JCPH Management will evaluate possible budget for First Aid supplies.

 Understood the process of ordering resources centrally from the Observations lead response organization, if PCHS needed assistance.

Task # 4.3: Request additional resources as necessary for operations and onsite incident management.

 IC suggested use of coast guard for delivery of supplies if needed Observations and roads unusable, also local airstrip.

Weak Evaluator # 3

 Discussed what we would do if we needed assistance through Observations the Kitsap County Emergency Management, such as diesel for heating and electricity.

 We communicate with our host Installation and higher Observations headquarters well; we should practice this type of scenario to see how it would work for additional logistics.

 Discussed how to request additional supplies from Portland Observations Indian Health Services Office and from private vendor.

 The offsite Human Recourse Department is to be trained in this Observations function.

Recommendation  Continue the implementation of offsite staffing coordination. s

Not Applicable Evaluator #10

Evaluator Evaluator Name Number # 1 Hollie Kaufman # 2 Jaima Hardman # 3 Brian Schaefer # 4 Kelly O’Connell # 5 Terry Lerma # 6 Julia Danskin # 7 Zena Kinne # 8 Andrew Winck # 9 Susie Rankin # 10 Ruth Westergaard

Activity # 1: Direct Evacuation and / or In-Place Protection Tactical Adequate Operations

Task # 1.1: Identify patients and locations to be evacuated or sheltered in place.

 This tribe has a facility set up for sheltering tribal members, no real current evacuation plan for elders, childcare. Shelter is at 125' elevation with no easy access except one road into Observations reservation. Some members of team were knowledgeable about elders in certain houses that would need to be evacuated but does not seem to be a solid plan for this.

 Evacuation plan update, planning for vertical evacuation towers, Recommendation tribal meeting to educate members about necessity for planning, s sheltering, water, and other emergency necessities

Observations  Followed printed plan. Appeared to be relevant.

Recommendation  Try a more hands on exercise. s

 Incident Command utilized Earthquake response plan. There was Observations discussion about the 'Triangle of Life' shelter. Confusion among staff.

Recommendation  Intentional training of staff to the Drop, cover and hold on per s Earthquake plan.

 We have on site safe / refuge points and evacuation points; we Observations need to work on the actual evacuation of patients from higher floor locations more often.

Recommendation  Practice an evacuation drill. s

 Understood evacuation but has opportunities related to shelter-in- Observations place. Organization has supplies of blankets and water.

Recommendation  Stronger exercise attention to sheltering in place. s

 STIHC CEMP / SOP has specific plans for evacuation due to local tsunami. Staff have designated areas that they will make Observations sure are clear. Staff will evacuate with patients and visitors at Assembly Area. Once at assembly area then people will be accounted for.

Recommendation  Develop written plan to designate that specific staff positions s clear certain areas of the facility.

Task # 1.2: Identify appropriate decision making authority responsible for deciding a course of action to address the incident.

 Tribal members in position on the council were identified as those Observations who could be included in decision making as well as director of emergency management, tribal CEO, facilities director.

Recommendation  Written plan and assignment of responsibilities. s

 Decisions were decisive. Leadership was sure. Command and Observations control was apparent. Leadership team showed a sense of urgency.

 Consensus: House Supervisor or Administrator on Call would be Observations authority.

 We have an EM Working Group we can share the finding with Observations and they can make recommendations for the After Action Reports.

 Understood the role of the incident commander and coordination Observations with the CEO.

 Clinic Director will be the decision making authority and decided Observations to evacuate immediately.

Task # 1.3: Determine appropriate course of action to address the incident.

 All participants involved in good discussion of appropriate action. Observations At times hard to keep focused on incident at hand

Observations  Well organized. Utilized printed plan.

Recommendation  Plan is old and is in need of updating, but it did work for this s exercise.

Adequate Evaluator #4

Observations  IC followed plan.

Recommendation  Additional training of staff on how to protect themselves. s

Observations  Work on a patient evacuation exercise with local hospital to test

transport and logistics and admin process.

Weak Evaluator # 7

 Identified that if there are transportation issues it may be better Observations for staff to remain at the clinic.

 Clinic Director assessed situation and ordered an immediate Observations evacuation of facility.

No response Evaluator #9

Adequate Activity # 2: Activate Evacuation and / or In-Place Protection

Task # 2.1: Implement systems for tracking evacuees and those who shelter in place.

Non-Existent Evaluator # 1

 No system available for tracking tribal members who evacuate Observations the reservation.

 We have a very good working relationship with all our residents. Observations This type of tracking/sheltering is similar to a Fire Evacuation as we train defend-in-place.

Recommendation  More practice. Improve residents tracking even without an s emergency situation.

 Evacuation order will come from CO; however, we have never Observations done a full evacuation exercise with our facility

Weak Evaluator # 7

Observations  Not really tested in the exercise.

Recommendation  Plan an exercise in the future that will test this capability. s

 Universal tracking sheets with all patients moved or transferred Observations was utilized.

Recommendation  Form was revised as participants identified need for additional s information.

Evaluator Evaluator Name Number # 1 Hollie Kaufman # 2 Jaima Hardman # 3 Brian Schaefer # 4 Kelly O’Connell # 5 Terry Lerma # 6 Julia Daskin # 7 Zena Kinne # 8 Andrew Winck # 9 Susie Rankin

SECTION 4: CONCLUSION

Exercises such as this one allow personnel to validate training and practice strategic and tactical prevention, protection, response and recovery capabilities in a risk-reduced environment. Exercises are the primary tool for assessing preparedness and identifying areas for improvement, while demonstrating community resolve to prepare for major incidents.

Exercises aim to help entities within the community gain objective assessments of their capabilities so that gaps, deficiencies, and vulnerabilities are addressed prior to a real incident.

Exercises are the most effective (and safer) means to:

 Assess and validate policies, plans, procedures, training, equipment, assumptions, and interagency agreements;  Clarify roles and responsibilities;  Improve interagency coordination and communications;  Identify gaps in resources;  Measure performance; and  Identify opportunities for improvement.

This exercise succeeded in addressing all of the above as it provided examples of good to excellent participant knowledge, teamwork, communication and use of plans and procedures while pointing out areas in need of improvement and clarification.

Listed below is a summary of the level of performance the Target Capabilities and Tasks evaluated during the exercise. This summary outlines the areas in which participating healthcare providers and emergency management agencies are strong as well as identifying areas that the departments should invest future planning, training and exercise funds on.

Communications

Activity Target Capability Performance

Provide Incident Command / First Responder / First # 1 Adequate Receiver / Interoperable Communications

Medical Surge

# 1 Activate Medical Surge Adequate

# 2 Implement Surge Patient Transfer Procedures Adequate

# 3 Implement Surge Staffing Procedures Adequate

# 4 Receive and Treat Surge Casualties Adequate

# 5 Demobilize Medical Surge Adequate

# 1 Direct On-Site Incident Management Strong

# 2 Implement On-Site Incident Management Adequate

# 3 Establish Full On-Site Incident Command Adequate

# 4 Conduct Resource Management Adequate

Direct Evacuation and / or In-Place Protection Tactical # 1 Adequate Operations

# 2 Activate Evacuation and / or In-Place Protection Adequate

APPENDIX A: IMPROVEMENT PLAN

This Improvement Plan has been developed specifically for the Region 2 Healthcare Preparedness Network based on the results of Operation Acorn Drop - A Healthcare Earthquake Exercise conducted on April 20, 2012. These recommendations draw on both the After Action Report and the After Action Conference.

Responsible Completion Capability Observation Recommendation Agency Date

Communications

Medical Surge

Patient Evacuation / Shelter In Place

APPENDIX B: PARTICIPANT FEEDBACK (3 THUMBS UP – 3 THUMBS DOWN)

Thumbs Up

Phones worked. Communications successful (OMC, EOC).

All ICS positions were filled.

Liked using online exercise format.

The modules were not too difficult to determine what information was needed.

The scenario was realistic an plausible.

The time allotted for each module was not too difficult to comply with.

STIHC CEMP and SOP provided clear guidance for emergency operations.

We were able to draw off lessons learned from previous exercises which made decision making quicker.

STIHC CEMP is well coordinated with the Makah Tribe's CEMP.

Earthquake Response Plan that we have in place. It was consistent with the exercise.

This computerized interactive format and the diversity of the participants. Scenario was plausible and realistic.

The time allotted was appropriate.

The ONX System is user friendly.

It generated discussion that otherwise wouldn't have clarified aspects of Clallam County EOC and OMC response procedures and expectations.

Concise and educational.

The format was effective.

We’re all responding to the same questions so it will be interesting to see how feedback is compared when we get done.

Using low key and low stress exercise was a good plan. Good to work together and learn about each other's experience and capabilities.

Staff available to step in to various roles - flexibility. Like the online - real time type scenario, yet we can proceed on our own. Accountable only for our EM scenario.

Good having HAM Radio capabilities simultaneously.

Our policies meet incident command needs and gave a good ground work for the disaster.

Team participation had wide diversity of knowledge on operations both in house and surrounding communities.

Organized and well communicated.

A good chance to test out a total system for disaster management.

The policies and procedures that we have in place worked well and provided a good baseline for the drill.

Team worked well. We did not have a lot of the department heads so it was left up to the rest of us to work our way through the scenario.

Communication of information between staff.

Knowledge of policies and procedures of emergency processes.

Organized processes.

Refreshments were served. Well attended and no travel was required.

Stimulated us to discuss needs / gaps in our policies right after disaster occurred.

Increased our communication with each other. We are all comfortable with our plan.

Group participation.

Easy to follow exercise.

Showed areas that we could improve on.

Multidisciplinary team came together and really engaged around the exercise.

The exercise was very relevant and seemed very plausible.

Our team used our Plans and knew where to look for information.

Believable scenario.

All but one of our staff present.

Communication worked including computer linkage.

All designated County HHS staff did participate in the exercise.

All the equipment functioned without any problems.

The exercise was helpful.

The exercise was well constructed and easy to follow.

The facilitator did an excellent job of moving us through the sections.

Strong participation from all.

Thoughtful discussion / planning around issues we could/could not influence in our organization (as part of whole exercise).

Helped indicate areas we could clarify for our organization such as contact/notification of staff as needed.

Good sense of cooperation / communication within our agency team.

Good participation.

Appropriate amount of time allotted to complete each portion of the exercise.

Our Earthquake Preparedness policy was appropriate.

This particular exercise did not involve our agency to any great degree so it was not time or resource intensive. However, it was good to participate and we did have a couple of issues that we were able to identify that we need to address for future.

Our team worked well together.

Our telephones in the ECC worked!

Participation by key stakeholders.

Timeline and opportunity to discuss each portion in detail.

Identification of areas of opportunities.

Good discussions of information provided.

Evaluation of current protocols and determining deficits that need to be addressed.

Flexibility of personnel when original participants were unavailable.

The drill provided a good format for dialogue and brainstorming what needs to be improved in our process.

There was a discussion of potential to lend and receive resources from out hospital neighbors on the Peninsula. It was recognized that in a large event, Harrison campuses could easily be overwhelmed and collaboration would be one method to increase the capacity of care. Use of military hospital was discussed but determined hampered because of clearance for access. We discussed the roles of volunteers, training needs,

DRCG LLC – www.drc-group.com 55 | Page After Action Report / Improvement Plan Operation Acorn Drop Functional Exercise and identification verifications.

How to release information, notify families, and support from Social Services.

Phones worked.

All ICS positions are filled.

Paperless exercise.

Good hands on learning experience for PCHS staff new to emergency response and recovery.

First time applying the NIMS concepts that we have learned to earthquake response and recovery.

We got to test our Emergency Plan and identified a few gaps in the plan that need tweaking.

I was so impressed at how well this was organized and how well our hospital wants to be involved

The clock ticking down was great as to pull everyone back on target for what needs to be done.

Everything just fell into place very well put together. When can we do this again????

Computerized exercise was a great method to bring our group together for a drill, and the scenario and injects were realistic for our region

Our organization's earthquake preparedness policies are consistent with national standards

Critical systems and processes were tested and this exercise allowed us to discuss them as a group.

Self-paced was good.

Good scenario, fairly realistic and very plausible.

All who were participating arrived on time and were ready to begin.

The willingness of all participating to provide input and information during each part of the exercise. The ability to have open dialog with all present.

The ability to discuss as a group when our current state of preparedness was not adequate, suggestions and ideas to make us better prepared and able to handle crisis when it occurs.

In general, the more exposure I have to this stuff the better I feel. This time the team

DRCG LLC – www.drc-group.com 56 | Page After Action Report / Improvement Plan Operation Acorn Drop Functional Exercise around me was way more involved than last time so I think organizationally, we have had some growth.

I like the method. It is too hard, too costly, too burdensome, to do many "real action" exercises. This was just as productive to help point out issues that may need fixing within our organization.

Exercises like this always improve inter-team relations.

It was a good opportunity for all four managers to review current Emergency Response Plan with new Environmental Health Manager

Participants were very engaged in the discussion. They focused on plan improvement and brought weaknesses to the forefront. People felt comfortable identifying plan shortfalls understanding we are improving processes.

The time-outs on the slides was very helpful to keeping the exercise on track. One person stated that they thought all meetings should have a countdown on agenda items.

Departments asked for specific tabletops to help their people better understand the disaster plans in place at Harrison.

Roles were identified, assigned, and understood early on in the exercise.

Interaction within the group was good and led to identification of gaps within our organizational action plans.

The online exercise tool worked without any issues and kept the group on track.

Organized group of various departments in attendance.

Identified needs and lack of electricity for discharge area.

Everyone understand the objectives of the exercise; have recent event that can relate our activities to.

Brainstorming supplies, resources, availability that are at our disposal and identifying what we may need that hasn't been accommodated.

Identifying that we don't communicate enough and frequently enough to staff about how to stay prepared and what the expectations are during a real emergency.

Building check for damage.... facilities employee recall in place.

Triage plan – security.

Employee / patient count and condition.

The computer system and format. It was easy to use.

The timing of the exercise questions and overall length of the exercise.

Questions were well thought out and tested our plan.

Notification and activation of event was well communicated.

All participants in attendance were well engaged in exercise and presented important issues that were department specific.

The Incident Management Team was able to educate what they have learned in the Command Center and how others can prepare themselves and their staff.

Every department had a representative.

The dialog was begun regarding things that need to happen and what we can do to make it happen.

Within the exercise, each department learned a bit about what happens with the other departments and how things can work together during a disaster.

I feel that my organization was organized and everyone participated.

Our organization was able to test our emergency plan. We looked at each aspect of our emergency plan and illuminated its strengths and weaknesses. We were able to identify deficiencies that we can improve.

The satellite phone test was successful!

The questions were very clearly written and easy for all participants to follow.

Everyone could participate in the answers.

Easy to access and use, I liked the overall format.

I like the user friendly aspect of the overall system.

The timing system worked to keep players on task....curtailed the tangent conversations and eliminated side-bar discussions amongst the group.

The dialog boxes are a must so that discussions are encouraged. This is where I learned the most from what to expect, and what are partners did NOT know about our capabilities and response operations.

Like working through the scenarios with everyone's input.

Ease of use of the system.

Very well organized.

Very appropriate to our situation living on the Olympic Peninsula along the Seattle Fault.

This scenario is very plausible.

Countdown timer and very structured exercise timeline and format.

Good communication and collaboration among group without confrontation.

Good overall discussion that produced actionable items to be integrated into DR plans.

Having all key players at the table together so we could learn the impact of each area's responses and how they impacted another area.

Being able to identify opportunities for improvements in our Disaster plan through the input of others.

Use of a centralized – online – format which all could see and focus on.

Thumbs Down

Official phone tree system and staff phone numbers. Secondary source if not all section heads present.

Exit strategy on 3rd Street building.

County procedures on building evacuations and damage assessment.

We need to work on our notification process and auto-recall procedures better.

Our earthquake procedures are each individual work centers probably need to be reviewed so all staff know what to do immediately AFTER an quake and the muster procedures

Our evacuation procedures and radio communications testing with Madigan on the ELMR UHF talk group.

STIHC staff would benefit from FEMA Damage Assessment training.

Review Prime Vendor contract to determine alternate delivery locations.

Discuss Portland Area Office emergency management plans to support disaster first aid operations.

Communications: satellite phone system did not work. No one responded to the HAM radio calls.

Establish clearer expectations for staff and physicians.

Reassurance that staff are personally prepared for emergencies. Training and education of all staff on Drop, Cover and Hold on.

We should look at our answers to how they should have been (how different from the

DRCG LLC – www.drc-group.com 59 | Page After Action Report / Improvement Plan Operation Acorn Drop Functional Exercise plan).

We need to be realistic about how we can account for staff - we need to realize that we cannot necessarily account for 100%.

PIO and other ICS positions did not get to participate fully in the exercise.

Need more people trained!! Especially TRIBAL MEMBERS residing in the Valley.

Communication with outside agencies.

Better knowledge for staff on drop, cover and hold in place.

Giving staff knowledge on home disaster plans.

Policies and procedures need to be tweaked a bit.

Additional training for staff on "Drop, Cover, and Hold On". Plus training on individual preparedness and when and how to report in for work.

More table top exercises.

Practicing the plan.

Expand involvement to more staff members.

Revision of current emergency manual in place to connect with outside agencies and / or resources.

Our emergency communication plan needs updating between personal cell phones and land lines. Jefferson healthcare triage of clients. We were unable to contact them and we were not contacted by them.

Need official agreement with DCD for building inspection services and work with other county departments within our building.

Update policies to prepare for emergencies (food & beverage request, client roll call, programming county cell phones with other contacts)

Satellite radio.

Staff training.

Awareness of need for more interagency participation.

Communication: Could not find the Portable Sat phone to begin with eventually found after looking.

De-Escalation or closing Incident Command. Need to document the triggers that closes Incident.

Need to verify is Pharmacy has a plan for emergency supply shipments.

Internal policies regarding notifications.

Designating backups for primary ICS positions.

Protocol for internal telephone tree.

Internal communications.

Realized we need to upgrade out phone tree and ensure we have all contacts.

Make sure we all understand the structure for initiating activity and who is expected to participate--including the designation of alternates.

Better communication between EOC and ECC. For example, we did not know ahead that the EOC team was not going to be in the building for this exercise.

Planning for activation / notification of staff to meet demand or in absence of crucial current team members.

Clarity on roles in activities such as search for missing, evaluation of structural damage and related issues beyond the bounds of our work charter.

Alternative activation strategies should our primary center be unavailable / unusable.

Communication with outside organization no HAM radio response received.

Refresher training for all employees regarding drop, cover and hold-on.

It would be nice to have an audio option available with the exercise.

Written process for departmental phone tree (needed to contact staff).

Better communication with our EOC.

Building assessment of B locations.

Joint participation among Harrison B locations and other community B locations

Scenario needed more injects, more problems and incidents to solve specific for our area.

Scenario did not utilize all ICS departments for this tribe, some felt had little to contribute.

Recognized that training is needed at Harrison beyond those present at this drill. Administrative Coordinator and Charge nurse on the Silverdale Campus.

Silverdale ED is challenged by resources. As in our drills, triage would most likely be managed by an experienced RN or during certain hours a mid-level provider. The

DRCG LLC – www.drc-group.com 61 | Page After Action Report / Improvement Plan Operation Acorn Drop Functional Exercise physician resources outside the ED would only be immediately available should the event happen during office hours. Silverdale has a limited blood bank. Currently only has 6 units of O negative blood for immediate use. Our lab is covered by one person.

The revised plan for Bremerton needs to be adapted to the Silverdale Campus with full participation of all units.

Phone tree system.

Exit strategy for the 3rd Street building.

County policy to re-enter the building.

Communications between sites.

We identified a few gaps in our Emergency Response Plan

We need to beef up our emergency preparedness supplies a little bit.

At this time I do not know what you could do to improve things. We as a hospital need to have some improvement that will take place after the discussions today.

Thank you! Thank you! Thank you for this chance to play and learn.

Satellite phone did not work. This is a critical system that we will now rectify immediately.

Better training for all staff and physicians regarding the earthquake response process. We know it, but not all staff is as well versed as they need to be.

Improve staff awareness and planning for personal response (at home) during an earthquake.

Need to exercise a patient evacuation and patient transfer process.

Details of carrying out the traffic control plans.

Certain key areas that will need to be utilized during crisis do not have adequate power supplies.

Getting the disaster plan and training out to general staff.

Communication plan - huge deficiencies identified.

Communication during a disaster need to be established / improved with Jefferson Healthcare

Identified actions based around the six critical areas identified by The Joint Commission include: General Updated Mass Casualty Plan Leaders had an opportunity to review and give input to the new revised mass casualty, evacuation, and mass fatality plans.

Comments are due to Emergency Preparedness Office by April 27 if changes are needed. A 90-minute meeting with Nursing Administration needs to be scheduled to review plan and seek input from Nurse Managers. Communications GETS cards Able to articulate use of GETS cards and current location (HCCs) and Emergency Preparedness. Need to identify others who may need card and train to use. Also need one page document that instructs “owners” to test every 6 months. Live Process Proceed with activating notification system. Communications Test An outgoing call using Harrison’s satellite phone did not work to connect to Kitsap Public Health. Approximately 15 minutes later, the health district was able to contact Harrison’s HCC with an incoming call to the same satellite phone. 800# It was noted during the exercise that during past incidents, using the 800 number has been a reliable way to communicate with the hospital when the main switchboard was out of service. Ensure number is available Resources & Assets Staff Sharing Continue working with Kitsap Healthcare Coalition and Region 2 Preparedness Network to develop shared staff plans. Our geography creates a need to plan how staff can report to the nearest medical facility should transportation linkages (bridges, Gorst, other highways) be completely shut down. Plans should include hospitals, major clinics, and long term care facilities. Future planning could take into consideration home health and Hospice patients. Supply resources Request paragraph or two on contingency plans for resources from Warehouse, Dietary, Pharmacy, and EVS for linens. This document should reside in the Resource Guide in the HCC to ensure IMT is aware of mechanisms to access supplies and equipment during a disaster. Safety & Security Traffic Flow Maps Ensure distribution of traffic flow maps to key staff dealing with crowd control. Maps identify traffic flow onto and within Harrison Hospital campuses. Lockdown vs. Screening Continue working with staff on differences between lockdown vs. screening. Work with Security on identifying additional resources for this task since EVS staff will focus on readying patient beds on floors and in Emergency Department. Staff responsibility Labor Pool Had opportunity to discuss new labor pool liaison role with group based on opening of new Harrison Support Services (HSS) Building across town. Liaison position will be stationed at HSS building to ensure staff are sent to campus that requires the most help. Leadership Checklist Participants had an opportunity to review the newly developed Leadership checklist. This checklist was developed based on feedback from the Incident Management Team members that opened the HCC in the Winter Storm. Leaders have one week to submit suggestions for changes to the document before roll-out. ICS Courses The Leadership Checklist reminds leaders that anyone in a leadership position is supposed to have ICS-100HCb and IS700a courses taken within 6 months of employment/promotion. Executive Vice President and Chief Operations Officer will remind Operations Team of this mandate at April 23, 2012 meeting. Continue working with Organizational Development to get classes on Learning Management System. (As of 0932 on 4/23/12, the Ops Team agreed that all leaders need to have this training within first 6 months of employment, with refreshers every 3 years.) Utilities management Discharge Lounge Review red outlets in area designated to be discharge lounge. Identify back-up location. Patient clinical and support activities Funnel Point Create road signage for outside hospital to direct people to funnel point location in ED. Concern is over how many people will try to come in through front door of hospital for care. Road signage may help those in need of care get to the appropriate area of the

DRCG LLC – www.drc-group.com 63 | Page After Action Report / Improvement Plan Operation Acorn Drop Functional Exercise hospital faster. Front door guards need to have clinical resource for anyone arriving at main entrance that needs immediate help and cannot be sent around building to ED entrance. Form 255E Add the following fields to the Evacuation Form. Date of Birth. ID of employees who are transported with patient. Special needs equipment such as a wheelchair or gurney. Departmental tabletops Surgery and other departments have requested departmental tabletop exercises.

Communication medium standards plan with appropriate staff members.

Patient incident transportation protocol.

Clear incident control deactivation triggers and procedures.

More structured activities.

Clarify what outlying clinics should do immediately following an event of a regional disaster (earthquake).

Communication between campuses.

Fine tuning E.D. procedure for current patient transfer.

Communication to the patient families.

Have a list of employees in the building at any time. Our staff currently do not wear name badges. We do have a plan to change that.

We need a formalized communication plan.

Who initiates and completes the damage assessment by site. We have damage assessment forms but they are not located at each site.

The concept of one funnel point is good but expecting that everyone coming to the Medical Center will follow the signs to funnel point is somewhat unrealistic. Dealing with alternative presentations will help if it is addressed ahead of time.

Road barriers should be identified ahead of time.

Alternative access to food, pharmaceuticals, and food should have written plans for the Command Center

Satellite phone was not working.

Staff expectation of the company in an emergency.

Communication to employees.

Patient triage system.

Needed specific injects to get all areas of the command center to be involved.

We needed to have Forks and the Quileute and the Makah Tribes playing to capture our real needs, gaps, and capabilities. I wanted to answer for them in their absence from the scenario as they are always in our communications and response plans.

Being able to see the other players / agencies responses during the event may have prompted more discussion from my agency and thus a more realistic full picture of response.

Would love to see the same thing done for the staff.

Improve our communication system to the outside world. Our satellite phone didn't work and our attempt to contact through the HAM radio was unsuccessful.

Better communication with our staff.

More staff training on drop, cover, and hold.

Need to better identify system dependencies and their status during disasters, and need to better identify action plans for when they are unavailable. For example, voice communications (need for more GETS, WSP, TSP, etc.), KRONOS for employee tracking, need to have Harrison staff practice real scenario drills with HAM operators, etc.

ALL departments need clear immediate action plans and standing orders for disasters (this is not necessarily currently the case for all Harrison departments). For example, evacuation muster stations, reporting responsibilities, etc. Also, we need to positively identify all employees who are military reservists who may be activated in a disaster... so plans can be made for their unavailability.

It was a large group and not everyone could be heard. I would recommend that statements / questions be repeated by the Facilitator or Moderator so all could gain from the discussions and comments.

More focus on communication with Incident Command regarding staff and patients. This was well addressed by cannot be emphasized enough.

APPENDIX C: ACRONYMS

Acronym Meaning

COMM Communications

CONOPS Concept of Operations

EOC Emergency Operations Center

ESF Emergency Support Function

IAP Incident Action Plan

IC Incident Command

ICS Incident Command System

IMT Incident Management Team

JIC Joint Information Center

LOFR Liaison Officer

MOA Memorandum of Agreement

MOU Memorandum of Understanding

NIMS National Incident Management System

OPS Operations

PIO Public Information Officer

SERT State Emergency Response Team

SitRep Situation Report

SOG Standard Operating Guideline

SOP Standard Operating Procedure

UC Unified Command

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