1. Develop the checklist to address the specific needs of the process.  Does the checklist need to be performed in a certain order so the process is performed correctly or does it just need to confirm that everything has been addressed and/or completed?
2. Keep it simple.  Checklists should only include the critical and important steps needed in a complex process and/ or address issues that have the most impact on the outcomes you desire.
3. Align with strategic initiatives.  Don’t use checklists just to have a checklist. Carefully select the areas within your hospital or practice that you will gain the most value towards meeting your overall goal, or in problematic areas where performance is less than desired.  The utilization of a checklist should be determined based on factors involving safety risks, quality of patient care and financial impact.
4. Implement, monitor and enhance.  Monitor the performance of implementing each checklist to verify that they are providing the desired outcome.  If they seem to be effective, continue to fine tune the checklist overtime to enhance performance. Share the positive results to increase their adoption and encourage continued use among staff that utilizes these routine checklists.

With the recent anniversary of 9/11, we are reminded of the imminent threats we face, both natural and man-made.  However, Hurricane Katrina in 2005 also reminded us of the dangers of focusing too much on particular hazards, vulnerabilities, and threats as incident needs overwhelmed response management and coordination mechanisms during this catastrophic disaster.

The lesson in both of these events, regardless of incident type, is that common capabilities can be better identified and prioritized by extending our risk assessments to include a consequence matrix.  The matrix helps define both the common and unique impacts or effects to your organization or community as well as prioritize the capabilities needed based on impact severity and number of incidents in which the capability is needed.

Similar to an risk index, a consequence/impact matrix and index will help you apply quantitative measures to your disaster preparedness program and clearly identify where resources and funding should be prioritized, especially given the current economic and Federal grants landscape.

Brandon Greenberg

The events surrounding the oil spill in the Gulf of Mexico this past summer highlighted, among other issues, the problems with executing incident command with organizations and individuals who are not familiar with Incident Command System (ICS).  However, this is just the beginning of external problems that can occur when other issues impact unified command such as the protection of proprietary information.  This is especially true when federal regulators are monitoring the response in an effort to determine the cause of the event.

At the root of the problem is a recent buzz phrase: “public-private partnerships”.  Unified command requires disparate and sometimes unknown groups to be the active participants in a response situation.  When a significant amount of time during the response is spent training the individuals on the procedures of incident command, the benefits of using the ICS structure are negated.  With the Gulf oil spill, individuals who were never expected to be in a response situation were suddenly thrust into incident command positions.

Additionally, the primary private sector company at the center of the incident had to take into consideration the careful examination of the response being conducted by federal authorities as part of their all encompassing investigation into the cause of the spill.  This could result in limiting important information in an effort to protect a corporation’s interests, ultimately impeding the progress of the responders even further.  Similarly, private citizens must also be protected from legal action if the measures they take in good faith have negative results.

In addition to considering the potential legal and fiduciary responsibilities private sector entities may face, facilitation of the process of immediate implementation of incident command must be addressed.  As we have discovered as a nation, those who may be thrust into the position to be first responders simply because they happen to be present when an unexpected event occurs are not always ‘traditional’ first responders.  Being able to activate those private citizens while providing legal protection for both private corporations and private citizens must be taken into consideration when planning and exercising response.

Sheri Donahue, DisastersNet

1)      Evaluate your Resources: Ask questions like: Have there been changes to the staff? If so, which roles in the disaster plan need to be reassigned? Has the budget changed? If so, can you afford to eliminate more risks? Are there new technologies available that would improve your current system?

2)      Keep Emergency Management a high priority: Preach throughout the organization the importance of emergency preparedness. It should be something that is constantly top of mind and part of your hospital’s overall mission.

3)      Build your Emergency Management Committee: Committee should be comprised of decision makers from the following departments; Administration, Safety/Emergency Management, Risk Management, Infection Control, Emergency Department, Nursing, Medical Staff, Security, Plant Operations, Environmental Services, Human Resources, Dietary and Pharmacy. This committee should be chaired by a C-Level executive.

4)      Evaluate your Emergency Management Committee: Check and balance the team. Make sure everyone is handling their responsibilities. Clearly redefine responsibilities as needed to improve the team.

5)      Identify a member of the Medical Staff that will be a champion on this committee: Without an active member of the medical staff, this committee will always be limited.

6)      Continue to educate: Make sure your orientation and continuing education process establishes the importance of Emergency Management.

7)      Set Measurable Emergency Management Goals: Set realistic goals for your team with deadlines and measurable results. Hold team members responsible for completing them.

8)      Always have Emergency management as an agenda item in your Executive Committee or Quality Council meetings.

9)      Implement and maintain a continuous improvement process. Identify opportunities to improve, develop and implement actions plans. Educate your staff and monitor their effectiveness through exercises. 

The community served by a hospital depends on hospitals the most when disaster strikes. Remember, even the most prepared hospitals will experience many challenges during a disaster. The hospital that has prepared carefully will deliver far better outcomes than the hospital that has not taken the time to evaluate and prepare. Make sure preparedness is a priority in your organization and don’t just assume the risk.

The Chief Executive Officer of a hospital has a vast array of responsibilities to the patients, visitors, staff and the community. In order to fulfill these responsibilities healthcare organizations identify vulnerabilities and determine measures that should be taken to minimize risks to operations and the safety of patients, visitors and staff.  The foundation of a well prepared hospital starts with top management placing emergency preparedness as an essential element of patient safety/quality in the organization’s strategic initiatives. The majority of hospitals that place emergency preparedness as a top priority find it vital to include the Chief Operating Officer or an executive member of the management team as an active member of a committee that coordinates emergency management efforts and activities. The direct involvement of upper management in this process provides the essential insight into the point at which the scale tips from reasonable measures of mitigation and preparedness to the financially impractical. At some point all hospitals are forced to assume a certain level of risk by determining what appropriate cost effective measures are. There is a fine line between doing all that you can reasonably do to be prepared and being negligent in addressing known risks. At what point can we sleep comfortably at night knowing that your hospital has done everything within reason to be prepared when a disaster strikes?

The logical first step hospitals take is performing a Hazard Vulnerability Analysis (HVA). The HVA is a process that allows hospitals to identify their known risks compared to their level of preparedness.  While this is a great first step in identifying your vulnerabilities and risks, it generally lacks the depth necessary to adequately evaluate your emergency operational plans and methods of implementation. Although an HVA can be a painful experience for those ultimately responsible, identifying these vulnerabilities is an essential part of preparing for emergencies that your management culture should embrace. It is better to know the organization’s weaknesses before something happens than to discover those weaknesses when lives are at stake. 

Being prepared and staying prepared is continuous process.  So what steps should you take to assure that your organization is prepared and stays prepared?  Emergency preparedness is a moving target and in a constant state of change. As a result, developing the structure to manage the process should be the first step in improving and sustaining a hospital’s preparedness efforts:

1)      Evaluate the resources your organization has dedicated to emergency management.  While this is everyone’s responsibility, having a competent person to oversee the process is imperative.

2)      Clearly state that Emergency Management is a priority for your organization;

3)      Evaluate the committee that is charged with Emergency Management responsibilities.  It is recommended that an Emergency Management Committee be established if your organization is sharing this responsibility with another committee;

4)      Appoint a member of your Executive Team to chair this committee.  This responsibility is typically placed on the Safety Officer or Emergency Management Coordinator.  These position(s) should serve as the subject matter expert, but unfortunately they don’t usually have the authority to manage the process effectively across departmental lines;

5)      Evaluate the membership of your Emergency Management Committee to make sure it is comprised of decision makers from the following departments; Administration, Safety/Emergency Management, Risk Management, Infection Control, Emergency Department, Nursing, Medical Staff, Security, Plant Operations, Environmental Services, Human Resources, Dietary and Pharmacy.

6)      Identify a member of the Medical Staff who will be a champion on this committee. Without an active member of the Medical Staff this committee will always be limited and the role of Emergency Management as a part of clinical care will be diluted.

7)      Make sure your orientation and continuing education process establishes the importance of Emergency Management in your organization.

8)      Incorporate measurable Emergency Management goals into your overall performance improvement process and cascade these goals throughout your organization.

9)      Always have Emergency Management as a standing agenda item in your Executive Committee or Quality Council meetings.

10)  Implement and maintain a continuous improvement process. Identify opportunities to improve, develop and implement actions plans, educate your staff and monitor their effectiveness through exercises. 

DisastersNet recommends the following cycle for preparedness:

1)      Annual identification of risk using a Hazard Vulnerability Analysis (HVA);

2)      Implementing mitigation measures to minimize risks;

3)      Assessing, developing or redesigning Emergency Operations Plans;

4)      Educating staff on response procedures and providing monthly communication to reinforce preparedness;

5)      Conducting quarterly exercises to test and evaluate emergency operational plans and staff response.  Plans that set on the shelf are nothing, but good dust collectors. Exercises are the single most important aspect of emergency preparedness.

The community served by a hospital depends on hospitals the most when disaster strikes.  Remember, even the most prepared hospitals will experience many challenges during a disaster situation, but the hospital that has prepared carefully will deliver far better outcomes than the hospital that has not taken the time to evaluate its vulnerabilities and prepare. Make sure preparedness is a priority in your organization and don’t just assume the risk.

First, what exactly is an Active Shooter? The Department of Homeland Security defines an Active Shooter as: an individual actively engaged in killing or attempting to kill people in a confined and populated area; in most cases, active shooters use firearms and there is no pattern or method to their selection of victims.

Before continuing on we need to clear up some misconceptions about active shooter scenarios and situations. First, it is not a new phenomenon. Active shooter incidents have been occurring for many years, and in the United States as far back as August 1, 1968 at the University of Texas in which 14 people were killed.  I am excluding other events, and acts of violence to focus solely on active shooter type events.

Second, if we include Europe, the events go back to June 20, 1913 to an event known as the Bremen school shooting, in Bremen, Germany and in Canada as far back as October 10, 1902 in an incident known as the Altona schoolhouse shooting. So, contrary to popular notion these events are not exclusive to the United States.

Third, not all of these events occur at schools, but schools in particular have had quite a history of active shooter incidents and have security vulnerabilities that are likely to make them targets of future incidents.

What is the intention of the active shooter? The active shooter is often acting out of frustration and rage.  They usually see their act as attempting to correct some event they perceive as a wrong that has been committed against them. The active shooter has a desire to kill and usually is not concerned with their own life, safety, or threat of capture. Active shooters will also usually have intended victims and will search them out.  Active shooter will accept targets of opportunity while searching for or even after finding their intended victims.

Another thing to know about active shooters is that the active shooter will often move throughout a building or area until either stopped by law enforcement, they commit suicide, or are stopped by other intervention.

The active shooter situation is highly unpredictable and events involving active shooters unfold very quickly often ending within 10 to 15 minutes. This is typically before law enforcement arrives on scene. It is for these reasons that every business and school should be prepared to confront this issue and make it part of their planning process.

It is something most planners and law enforcement officials dread. The active shooter scenario is by many accounts difficult to plan for and often impossible to predict, especially the who, and when. But it is possible to prepare and train for it and even mitigate some of the potential of it occurring if done properly. Another step in preventing this scenario is dealing with work place violence and threats of violence appropriately from the onset. What are some other things you can do to deter this event from taking place at your hospital, school or business?

1. Have an active and highly visible security force and ensure they are trained and equipped to deal with such an event.
2. Having both concealed and visible security cameras can also act as a deterrent.
3. Have an electronic security system with electronic ID access for employees.
4. Have all visitors, contractors, and guests to your facility sign in.
5. Train employees to recognize trouble or potential issues early.
6. Make counseling services available to those who need it.
7. Have a notification and alerting system, along with procedures for its use during an active shooter situation.
8. Post evacuation routes in hallways and near exits which are also removable so emergency response personnel can utilize them.
9. Include your local law enforcement and other emergency response personnel in your active shooter training exercises.
10. Create a respectful workplace.

What should you do if an active shooter situation does occur? There are a number of ways to handle the situation, the first and often the best choice is to evacuate.

1. Have an escape route plan in mind and use it.
2. Evacuate whether or not other with you agree to follow.
3. Leave all your belongings behind.
4. If possible, help others escape.
5. Try to prevent others from entering an area where the active shooter may be.
6. Keep your hands visible.
7. Follow all instructions from police officers.
8. Do not attempt to move injured or wounded people.
9. When safe to do so, call 911.

If you can’t evacuate, the next best option is to hide in a place where the active shooter is not likely to find you. The place you choose to hide should be out of view of the active shooter, provide protection if shots are fired in your direction and should not trap you or restrict your options for movement. When hiding be sure to do the following.

1. Lock the door.
2. Blockade the door with heavy furniture.
3. Silence your cell phone and/or pager.
4. Turn off any other source of noise such as a radio or television.
5. Hide behind large items.
6. Remain quiet and calm.
7. Call 911 if you can to alert police to the active shooters location.
8. If you cannot speak just leave the line open for the dispatcher to listen in.

Once the police arrive on scene to an active shooter incident they will likely take action using the Immediate Action Rapid Deployment (IARD) so it is possible only one or a small team of police officers may enter the area or building the active shooter is in. In the past it was common for the police to wait for a SWAT team, but these incidents take place so fast, additional action was needed and IARD was developed in response to active shooter situations.

Be aware that police officers arriving on scene will be heavily armed, possibly with rifles and shotguns and may be wearing heavy outer bulletproof vests, helmets, and other tactical equipment. Be prepared for the police to take the following actions.

1. The police will likely use pepper spray and or tear gas.
2. Responding officers will be shouting commands, and may push or force people to the ground for their safety.

Here are some things you should do when law enforcement arrives on the scene.

1. Listen for and follow the police officers instructions
2. Put down anything in your hands, including bags, jackets, cell phones and keys.
3. Immediately raise your hands and spread your fingers.
4. Keep your hands visible at all times.
5. Avoid making any quick movements.
6. Avoid grabbing or attempting to hold onto the officers for their safety and yours.
7. Do not make sudden movements towards the officers.
8. Avoid screaming, pointing and yelling.
9. Do not stop to ask officers for help or directions, just proceed in the direction from where the officers came from.
10. Be aware that the initial police officers in the building will not stop to aid injured victims.

If you are able to successfully call 911 and speak with a dispatcher be prepared to answer the following questions.

1. Location of the active shooter.
2. Number of shooters, if more than one is involved.
3. A physical description of the shooter(s).
4. Type and number of weapons the shooter(s) may have.
5. The number of potential victims that are at the location.

This is a fairly long list of things you should be aware of during any active shooting incident, and yet it is only just touching on the issue. One of the most important things is that you prepare, train, and if you can, involve local law enforcement and emergency personnel into your planning.

Keith Erwood, Author

Link to the original article: http://www.disasterpreparednessblog.com/disaster-preparedness-blog/2010/8/9/are-you-prepared-for-an-active-shooter-steps-you-can-take-to.html

• Johns Hopkins’ Medical Center, Baltimore MD – A man who became distraught as he was being briefed on his mother’s condition by a surgeon at Johns Hopkins Hospital pulled a gun and shot and wounded the doctor,  then killed his mother and himself in her room, distraught over his mother’s treatment. 
• Parkview Medical Center, Knoxville TN – A gunman fatally shot a woman and injured two others before killing himself outside a hospital.
• Baton Rouge General Medical Center-Mid City, Baton Rouge LA -  Man shoots estranged wife and boyfriend inside the hospital.

As a former Safety and Security Director for a large health care system I understand the fear and reality of  a  hostage situation from personal experience.  Wishing you had done more to prepare your staff and hoping in the end the loss of life can be prevented constantly races through your mind during the incident.   Unfortunately the fact that hospitals create an environment of emotions that can trigger violence at any time places hospitals at a greater risk that we might imagine. 

The risk of a shooting or hostage situation should always be on your radar for preparedness.  Having an operational plan is important, but conducting exercises to improve your level of preparedness is vital.   Although immediate response to the incident is critical your Incident Command Team will be invaluable in maintaining control of the situation and coordinating response with local law enforcement and the media.

The online survey asked 1,058 adults about their use of social media sites in emergency situations. It found that if they needed help and couldn’t reach 9-1-1, one in five would try to contact responders through a digital means such as e-mail, websites or social media. If web users knew of someone else who needed help, 44 percent would ask other people in their social network to contact authorities, 35 percent would post a request for help directly on a response agency’s Facebook page and 28 percent would send a direct Twitter message to responders.

 Web users also have clear expectations about how first responders should be answering their requests. The survey showed that 69 percent said that emergency responders should be monitoring social media sites in order to quickly send help—and nearly half believe a response agency is probably already responding to any urgent request they might see.

And the survey respondents expected quick response to an online appeal for help—74 percent expected help to come less than an hour after their tweet or Facebook post.

“The first and best choice for anyone in an emergency situation is to call 9-1-1,” said Gail McGovern, American Red Cross president and CEO. “But when phone lines are down or the 9-1-1 system is overwhelmed, we know that people will be persistent in their quest for help and use social media for that purpose.”

The Red Cross commissioned the survey in advance of an Emergency Social Data Summit set for Thursday, August 12, in Washington, D.C. The meeting, convened by the Red Cross, will bring together thought leaders and experts in the government, social media, emergency response and the non-profit sectors to discuss better ways to handle information that flows through the web during disasters.

“The social web is creating a fundamental shift in disaster response—one that will ask emergency managers, government agencies and aid organizations to mix time-honored expertise with real-time input from the public,” McGovern said. “We need to work together to better respond to that shift.”

The Red Cross survey also found that among web users, social media sites are the fourth most popular source for emergency information, just behind television news, radio and online news sites. More web users say they get their emergency information from social media than from a NOAA weather radio, government website or emergency text message system. One in five social media users also report posting eyewitness accounts of emergency events to their accounts.