EIIP Virtual Forum Presentation — September 12, 2007

NIMS Compliance for Hospitals
and Healthcare Systems

K. Joanne McGlown, R.N., M.H.H.A., F.A.C.H.E., Ph.D.
Adj. Professor, School of Health Related Professions, University of Alabama at Birmingham (AL)
CEO, McGlown-Self Consulting, LLC and Southern Legal Nurse Group, LLC
Sr. Healthcare and Emergency Systems Analyst, Argonne National Laboratory; Chicago, IL

James M. Mullikin
Chief - Compliance and Technical Assistance Branch
National Integration Center
Federal Emergency Management Agency
Department of Homeland Security

Amy Sebring
EIIP Moderator

The following version of the transcript has been edited for easier reading and comprehension. A raw, unedited transcript is available from our archives. See our home page at http://www.emforum.org

[Welcome / Introduction]

Amy Sebring: Good morning/afternoon everyone. Thank you for joining us today. On behalf of Avagene and myself, welcome to the EIIP Virtual Forum! Our topic today is "NIMS Compliance for Hospitals and Healthcare Systems."

We expect by now that most of you are familiar with NIMS, especially those in the public sector that have been working on the annual requirements for a number of years. For those of you who may not be familiar with the hospital-specific requirements, the link to the related materials is included on today's Background Page at: http://www.emforum.org/vforum/070912.htm. There you will find the original NIMS Alert, issued a year ago, as well as the implementation activities, summary, Fact Sheet and FAQ. 17 elements were identified including:

  • Adoption of NIMS
  • Incident Command System (ICS)
  • Multi-agency Coordination System (MACS)
  • Public Information System (PIS)
  • NIMS Implementation Tracking
  • Preparedness Funding
  • Revise and Update Plans (Required Activity in FY2007)
  • Mutual-Aid Agreements
  • IS 700 NIMS (Required Activity in FY2007)
  • IS 800 NRP (Required Activity in FY2007)
  • ICS 100 and 200 (Required Activity in FY2007)
  • Training and Exercises
  • All Hazard Exercise Program
  • Corrective Actions
  • Response Inventory
  • Resource Acquisition
  • Standard and Consistent Terminology

As noted above, four of the elements are required to be completed this year, and the remaining are to be completed next year.

Now it is my pleasure to introduce Dr. Joanne McGlown, an independent consultant currently engaged in assisting State Public Health Departments, hospital associations and other clients with medical aspects of emergency and disaster preparedness. In addition to her extensive experience in pre-hospital EMS, nursing, and healthcare administration, Dr. McGlown has broad teaching experience in her specialty areas of EMS, emergency and disaster management, and healthcare delivery issues in emergency and disaster environments. She is a noted speaker on the topic of hospital preparedness for disasters and terrorism for the American College of Healthcare Executives, and is editor of the book, Terrorism and Disaster Management: Preparing Healthcare Leaders for Our New Reality - a top-five best seller and 2004 publication of Health Administration Press (Chicago, IL).

We are also extremely pleased to welcome Mr. James M. Mullikin, Chief of the Compliance and Technical Assistance Branch of FEMA's National Integration Center, which is charged with developing and implementing National Incident Management System (NIMS) compliance policy. Prior to this assignment Jim worked at the DHS Office for Domestic Preparedness serving as the Program Manager for the States of Maine, New Hampshire and Vermont where he facilitated the development of their State Homeland Security Strategies and coordinated, administered and managed their State Homeland Security Grant Program Grants. Additionally, Jim has had extensive experience working for the Department of the Army (DA) as the DA Liaison to the US Health and Human Services (HHS) Agency for Toxic Substances and Disease Registry (ATSDR).

If you have not already done so, please review our Background Page for further biographical details, as well as links to materials related to today's topic. We expect that many who are working to achieve NIMS compliance will have a number of questions, and Jim will assist in responding to them during our Q&A.

Welcome to both of you and thank you for taking time to be with us today. Joanne, I now turn the floor over to you to start us off please.


Joanne McGlown: Good morning everyone. It is a pleasure to have you with us in the Virtual Forum for this very important update on NIMS and what is expected of hospitals and the healthcare industry as we work toward compliance by this time next year.

We are honored to be joined at the 12th hour (my fault, not his) by Mr. James Mullikin; Chief of the Compliance and Technical Assistance Branch of the NIC. As your interest in this topic became evident, we wanted you to have access to the individuals who could best answer your questions, and are thankful to Mr. Mullikin for joining us today.

It is appropriate that we address this topic today, as it was exactly one year ago today that the NIMS Integration Center released the NIMS ALERT: NIMS Implementation Activities for Hospitals and Healthcare Systems. Perhaps you were an early adopter; if not, the past year has been a whirlwind of activity--in many instances, simply trying to help CEOs and management team members understand the importance of NIMS, and why the healthcare sector should/must be full and willing participants.

I will speak to what we know, and what the NIC may THINK we know. So, let's get started.

We KNOW much about NIMS. We know it evolved from HSPD-5 in early 2003. We also know it was a rather unknown element to our industry until this day last year. We know how it is defined, the core concepts, purposes, and its strengths: flexibility, standardization and (ideally) full interoperability with the community.

We know the 17 Elements and what is expected this year versus next September. Hospitals and healthcare organizations have been struggling to reach compliance goals, but many have faced a difficult time. Despite best efforts, NIMS guidance is not crystal clear for all hospitals and healthcare organization, and much seems left to independent or local interpretation. This may be necessary and the best approach, but is problematic.

We have heard the discussions of who must be compliant, and certain sectors in our industry stating that they are the 'exception'. The question instead should ask why they would want to be an exception? I have long been a supporter of the Joint Commission, NFPA and the EMAC program for providing the 'early encouragement' for our industry to take emergency and disaster preparedness seriously. Without their leadership, we would not be where we are today.

NIMS is the first real effort of our federal government to bring healthcare organizations into the "interoperability loop" with other community agencies. As a healthcare administrator, we should embrace the challenge and step up to the plate. The program may not be perfect, but is a step in the right direction for our patients, employees, staff and our industry.

Ric Skinner (Baystate Health/Baystate Medical Center, MA) and his colleagues Jennifer Davey (Children's Hospital and Regional Medical Center ) of Seattle, WA and Angela Devlen, an emergency manager at Caritas Christi Healthcare (Boston, MA) recently completed a survey under the sponsorship of the Business Continuity Planning Workgroup for Healthcare Organizations. With over 1100 responses representing over 1500 facilities, two questions about NIMS Compliance were asked:

First, "Does your facility or system meet minimum NIMS requirements for Incident Command System (ICS)?" Of the 922 responding to this question, 64.8% replied "Yes"; 12.3% replied "No"; 16.8% stated they "didn't know", and 6.2% replied "not applicable." And, when asked if 'your facility or system meets minimal NIMS requirements for training (e.g., IS 100, IS-700 courses)' 59% replied "Yes"; 17.9% "No"; 16.4% "don't know"; and 6.3% replied "not applicable." There were greater than 100 additional comments to each question. These numbers seem in line with what I am hearing from the facilities I encounter and others with whom I have discussed this topic.

There is much debate as to the expectations of various sectors of the healthcare industry: are for-profit facilities held to the same compliance expectations as public facilities? What role does funding play in compliance? If you didn't receive funds of any sort, did NIMS even relate to you? These questions and more are addressed in documents posted for all to see.

There are many valuable articles on the NIMS website, and one that I find very interesting and helpful is "NIMS Implementation Activities for Hospital and Healthcare Systems Implementation FAQs", originally posted 4/13/07. This document defines "hospital and healthcare systems" as 'all facilities that receive medical and trauma emergency patients on a daily basis' and does not include non-hospital receivers and specialty hospitals, and raises questions about compliance in relation to CMS and Joint Commission. In addition, I urge you to view the "Fact Sheet: Private Sector NIMS Implementation Activities" (from 11/30/06) that reviews the 12 activities for the private sector that support NIMS implementation.

As hospitals address the "simple" 2007 requirements, most have identified a way to address the training elements (#9, #10 and #11) - and quite a few found they were not so "simple" after all. However, Element #7 is the real eye-opener. Many hospitals have Emergency Operations Plans (EOP's) written in the 1970's with segmental updates performed only when required by the State, the industry, or Joint Commission (JC). The result is a very disjointed EOP that includes some, but not all, of the required aspects of NIMS Compliance - but, the Plan is so jumbled it is difficult, even impossible, to navigate. Implementing NIMS does force a natural flow to the planning process - but will require a rigorous revisit and rewrite of the EOP on the part of many hospitals. And, as many of you are aware, this does not happen quickly.

Hospitals work by committee, and this is one instance where committee input is crucial. Even if deadlines are not met, the process of planning may benefit the hospital and its leaders much more than the plan itself. Like the saying, "it isn't the destination, but the journey" that is of value; the journey through a structured planning process pays dividends to the facility rather quickly and continuously. The NIMS challenge offers us a rare opportunity to revisit our plans, and develop a new, current EOP that better serves our facility, our employees and our community. If you need direction and guidance in leading your facility through this process - get it. This is a very important task and not one that should be done by a single individual or rushed through for the sake of a deadline (NOTE: there IS a deadline, unfortunately).

Yet, revisiting and revising your plans are only ONE component of Element #7. I have worked with individuals who felt this simple element should be almost an instant "sign-off" for hospitals, and they proceeded to read the 7 items that follow: "to include planning, training, response, exercises, equipment, evaluation, and corrective actions." These SEVEN primary aspects must be addressed. Each requires time and attention to be adequately described and integrated into your EOP.

Just take "exercises" as an example. Do you have an exercise program? What policies or procedures exist for your exercise program, or do they need to be written? If written, do they need to be approved higher in your facility? (Many items in the NIMS Elements may need to go before your governing Board for approval.) Are your exercises based on a valid Hazard Vulnerability Analysis (HVA)? Another challenge many hospitals face.

Is there a qualified exercise leader (Master Exercise Practitioner, MEP) in your facility or contracted to your State Hospital Association or State Department of Health to assist you in developing, exercising and evaluating the exercise - validating the effort? How will they be evaluated? What forms will be used and how will the information be used in your facility? Are your exercises fully integrated with the community? Asking similar questions in each of these 7 areas helps reveal the weaknesses that must be addressed in your compliance activities.

For 2008, many of the Elements are straightforward and should be easy to implement. Others require approvals very high in the organization, with CEO involvement as a "champion" in the facility and community.

NIMS Compliance requirements have ushered in a new era for hospitals and healthcare preparedness. We have our work cut out for us - but it is healthy work and will certainly strengthen the medical/healthcare response in disasters. There are many questions concerning the expectations of hospitals and changes that may be coming in the future. I'm sure our guests will welcome your questions on these topics. We will be happy to try to answer your questions and will turn the session back over to our Moderator.

Amy Sebring: Thank you very much Joanne. Now, to proceed to your questions or comments. We are also interested in hearing about your own experiences and challenges.

[Audience Questions & Answers]

Ric Skinner: Many of the issues you've addresses -- exercise plans, HVA, EOPs, -- we've addressed in our survey. We expect to have a report in 6 weeks and have submitted a presentation proposal to the National EM Summit in Feb. Also, we plan to publish portions of our results and analysis.

Amy Sebring: Thanks Ric. That may pre-empt some questions on your results.

Vickie Maywald: Are most truly interpreting the requirement as ALL hospital employees needing NIMS training in the end?

Jim Mullikin: Fundamentally the only people who need the required training are those that are expected to respond in the event of an incident. So, there is no requirement for all hospital employees to take NIMS training.

Joanne McGlown: The problem I am seeing with rural facilities is that they are completely new to HICS and ICS. Also, there is limited computer capability -- perhaps not even one computer available for training. Thus, educational level and equipment / resources ARE an issue for the majority of US hospitals.

Lloyd Colston: The big issue in local government is funding. Guidance from HS here is that money coming out will be 20% match. Does this apply to health? Also, can't we continue with 100% funding for the percentage of folks that ARE NIMS compliant?

[At this point in the session there was a general disruption of the chat service for about 3 minutes. The session subsequently resumed.]

Amy Sebring: Jim, you were addressing Lloyd's question re grant funding when we were cut off, and the last we saw was that you are not a grant making body.

Jim Mullikin: No problem. We work with HHS, specifically HRSA, and they are responsible for establishing grant guidance for hospitals, so we will have to defer to them on issues of funding.

David Kondrup: Thank you With regards to NIMS HICS compliance training: ICS 100, 200, 700 (NIMS Intro) 800 (NRP) - are most people taking them online, or is training being offered in the hospital or by colleges or through County City, State or HS training facilities? How is compliance (9/30/07 date) and will scheduled training be considered being in compliance?

Joanne McGlown: I see that most of the larger facilities are offering classes in-house to try to get the masses through. However, volumes also are taking the courses online. Those who can afford it are bringing in consultants to handle the crushing work load (many of you know what I mean). Colleges and universities are lagging behind. FEMA has done a fabulous job of providing this online, but it is a very slow read.

Jim Mullikin: As of right now, compliance determinations are made by the grant maker based on the NIMS Implementation Activities, established collaboratively with HHS. In the future, we will be providing an online web based self-assessment tool called NIMSCAST that will allow facilities to report compliance on-line. This report can shared with HHS and other grant makers. The NIMSCAST is currently being used by State and local government to report compliance. Please note that the module used by State and locals is not the same module that the Health sector will use. Another module is under development for the Health sector.

Dawn Rougeux: Given that we are just realizing the complexity of Element 7, will there be a deadline extension for that element? Also, folks are in need of some truly concrete examples of what implementation of Element 7 looks like. (Sorry, but the example given seems like gobbledygook to me!)

Jim Mullikin: There are no planned extensions at this time, but we will raise the issue with HRSA to further consider your question.

Russ Robinson: Jim, my question is does every member of a hospital response team need a certain level of NIMS training, i.e. labor pool staff, or is this geared towards the leadership positions, and what, if any certifications are need for "in house" instructors to teach the ICS classes.

Jim Mullikin: We have identified in the NIMS Standard Training Curriculum Guidance who should take what courses based their roles and responsibilities as part of an emergency management team. These are currently available on our web site. As to the certifications for training, the Emergency Management Institute establishes requirement/competencies. Since the ICS 100. 200, 700, and 800 are delivered online, we would refer you to the HICS for their train-the-trainer requirements. Please note that the HICS courses are not necessarily compatible with the EMI offered training. Hospitals may create their own courses, provided they meet the objectives found in the NIMS Training Development Guidance issued in March 2007. This is also available on the NIMS Web Site.

Joanne McGlown: I approach this as 'if you have a role in response in your organization, you must be trained to respond appropriately and in concert with the HICS or HICS-type organization under which you activate.' This takes the benefit of training much below the senior management level, especially as we are expected to staff the Command Center roles three deep (advised). Just consider what is truly needed in your facility, and on each unit, to respond effectively to an event. The activity truly occurs further down the organization and that approach is what I advise hospitals to address in their training.

Vickie Maywald: So am I interpreting your comments correctly, that FEMA may not have specific requirements related to ALL hospital employee requirements, but some of the individual HRSA grant regulators might have stricter guidelines? We are getting conflicting statements here in Texas and really need to clarify that specific question. Most of us tend to agree with your earlier statement that only those responding within the command structure truly need it, but that is not completely clear.

Jim Mullikin: HRSA can have stricter guidelines.

Brian d'Angona: Joanne - Are there any attempts to integrate community-based care givers (health care providers, pharmacists), the private sector (insurers, retailers) and the public sector (government) into a coordinated local response to maintain continuity of care for persons with chronic illness who may not be affected acutely by the disaster event?

Joanne McGlown: Yes, I see much of this activity happening here in my local area, and I hope you do, as well. The Home Health organizations, hospice and other support agencies are not "NIMS" savvy, but are getting the word that there is much else afoot. We must bring them to the table. They don't know how to get there by themselves. Invite them, and plan in concert with them. I hope you will find them willing and eager to participate.

Garrett Doering: Thank you for taking my question. If there is a dispute over what constitutes NIMS compliance, who is the final arbiter? For example, if I believe our CEMP is NIMS compliant and our Department of Health does not, then what?

Jim Mullikin: If you are receiving a HRSA grant, for example, the recipient compliance determination is made by HRSA.

Kay Gordon: Joanne, you talked about MEP's and are they available to help plan exercises. Since there are not lots of MEP's out there what are your recommendations?

Joanne McGlown: Inquire at your State EMA or local, if very engaged, and get recommendations of those with experience. Then check references!!! I can't stress that enough. Validate that the exercise consultant you have selected has credentials, has had appropriate training and education, and will be qualified to assist you. I have, unfortunately, been a reviewer on some truly horrible exercise experiences. Buyer beware!

David Kondrup: Are exercises being incorporated into some training, or do they have to be scheduled as a separate event? In ICS 200 300 and 400 you break participants into groups and do a simulated exercise; in others there are tabletops and functional exercises.

Joanne McGlown: Exercises (usually tabletops) are an excellent way to bring home teaching points, but your "exercise program" for your facility needs to be more comprehensively planned and integrated.

Amy Sebring: David, do you mean what will be required to be compliant in the exercise area?

David Kondrup: Do hospitals understand their need for separate exercises? Yes, compliance. Exercises separate from training.

Jim Mullikin: Well, if you mean would the course exercises be considered as compliance activities, then no.

Joanne McGlown: I believe they do, but also believe this is still very new to the majority of hospitals. Mr. Mullikin, if you can encourage an extension for hospitals for Element #7, I know the entire Rural Health contingent would be very appreciative!

Kari Isaak: I work for a Community Health Center (CHC) and so far we have been told at Regional Planning meetings that CHCs are not required to be NIMS Compliant currently. Is there a compliance timeline put together for CHCs like the hospitals to start the implementation process for CHCs? If so where can I find it?

Jim Mullikin: If the CHC receives a HRSA grant or other federal preparedness grants, then they would be required to demonstrate compliance. However, if they do not receive preparedness funding, and the State or County has determined that they do not have to be NIMS compliant, then it is up to the State/County.

Ric Skinner: Most focus seems to be on hospitals, but what about the other components of healthcare. There are about 6800 hospitals but about 22000 nursing homes and LTCs. Do all healthcare facilities participate in federal funding? Or do some like community hospitals & clinics and nursing homes have other funding sources? If so, what are the other sources?

Jim Mullikin: As far as this question, we don’t really have visibility at this time on the funding issues for other elements of the system. Your best bet would be to check with HRSA on the funding sources.

Joanne McGlown: No, all do not participate. Many do not even qualify. There is very little funding available from other sources - and little that would assist the healthcare industry in emergency and disaster planning. There are some private foundation grants available to 501 (c)(3)'s, but this is very competitive.

Amy Sebring: Jim, do you plan to issue any further guidance regarding the 2008 requirements?

Jim Mullikin: Yes. On August 6, 2007 we co-convened with HHS a Health Care Working Group to develop 2008 NIMS Implementation Activities guidance. The members are made up of Federal Health Care grant making agencies, VA, American Hospital Association, NDMS, and other hospital and health care responders, including State and local Stakeholders.

Scott Thresher: To be a certified instructor for your healthcare facility on HICS, do you have to attend formal training in Emittsburg or by the state? Staff wants to receive CEUs or contact hours for training with an official certificate of training awarded.

Jim Mullikin: HICS training information and requirements is available through the Center for HICS Education and Training.

Joe Nadzady: HICS is also available on the http://www.hicscenter.org website.

Karen Albritton: Does the training need to be complete by 9/30/07 or just a plan implemented? Where are we to report the information? Keep it in-house? Is there a format for NIMS declaration by hospital administration? We are small & rural & often left out of loops of information. No one answered the earlier question about element 7 clarification.

Jim Mullikin: Without speaking for HHS, the requirement outlined is that the training must be completed by 9/30/07. The determination of who must take the courses, and the numbers of students that must take the courses, is determined by the facility based again on roles and responsibilities.

Joanne McGlown: I recommend that hospitals keep copious records. Hold them in-house. Training records should be in the employee file. I also strongly feel the hospital's Board should formally adopt NIMS. It closes the loop and is inclusive of the efforts of the community. I, (personal statement here), do not believe that HHS truly understands the volume of training that they are asking.


Amy Sebring: That is all we have time for today unfortunately. Thank you very much to you both for an excellent job. We hope you enjoyed the experience. I would also like to thank Bob Sullivan at FEMA for assisting with today's session. Joanne/Jim can you put up a contact for questions that were not answered today?

Jim Mullikin: Our pleasure. More information on NIMS Compliance is available at http://www.fema.gov/emergency/nims/compliance. Questions can be sent to [email protected].

Joanne McGlown: Thanks, everyone, for joining us. If you would like to see Mr. Mullikin join us again later, please let us know. I can be contacted at [email protected].

Amy Sebring: Again, the formatted transcript will be available later today. If you are not on our mailing list and would like to get notices of future sessions and availability of transcripts, just go to our home page to Subscribe.

We are pleased to welcome a new partner today, speaking of hospitals! MediSys Health Network -- Emergency Management; URL: http://www.medisyshealth.org; POC: Mark J. Marino, Director, Emergency Management. "MediSys Health Network, Inc. (MediSys) is a New York not-for-profit corporation. MediSys is a supporting organization to Jamaica Hospital Medical Center, Flushing Hospital Medical Center, and Brookdale University Hospital and Medical Center." Welcome Medisys! If your organization is interested in becoming an EIIP Partner, please see the link to Partnership for You from our home page.

Also, Ric would like to make an announcement regarding the survey mentioned during the presentation. Ric please.

Ric Skinner: Joanne was kind enough to reference a survey we're conducting of healthcare preparedness (EM/DM/BCP) at US healthcare facilities. We already have over 1500 facilities represented. The survey was reopened for a week to allow about 100 respondents an opportunity to complete their surveys which they were not able to do due to technical problems. If anyone online today from a US healthcare facility or healthcare system would like to provide input and they haven't already, they can email me for the link. Our target audience is academic medical centers, trauma centers, community hospitals, health clinics, nursing homes, etc. My email is [email protected]. Survey closes at midnight EDT 9/17/07.

Amy Sebring: Excellent. Thanks. Thanks to everyone for participating today. We stand adjourned but before you go, please help me show our appreciation to Joanne and Jim for a fine job.