CHAOS

Comprehensive Hazard Analysis of  Organization Sustainability

CHAOS Workbook Instruction Guide 

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CHAOS Workbook Instruction Guide

The Comprehensive Hazard Analysis of Organization Sustainability (CHAOS) workbook was designed to provide a clearer picture of an organization’s emergency preparedness program. Many regulating bodies and accreditation programs recognize the importance of an emergency preparedness program, and require that an annual hazard vulnerability assessment (HVA) be performed as the basis of a program. Kaiser Permanente developed and shared an HVA that is widely used across the nation. While this HVA is objective in quantifying risk, it is subjective when quantifying an organization’s readiness levels. CHAOS is a work in progress that addresses readiness levels based on national standards. This first version relies heavily on the standards put forth by The Joint Commission, which are largely based on The National Fire Protection Association Code 1600, National Preparedness Standard. The workbook is divided into several sections indicated by tab color. Gold colored tabs provide the overall picture of the program, and include: Program Maintenance, a listing of personnel assigned responsibility for specific sections of the emergency management program, including their contact information; CHAOS Dashboard, the report that lists scores of plan components, mitigation, probability, magnitude, risk and severity for each hazard event; and 96 Hour Report, a graphic representation of the organization’s resource sustainability by hours. Blue colored tabs are the HVA section of the workbook. Both risks and mitigation levels are analyzed at the community and organization level, followed by a priorities report that shows where planning and mitigation efforts should be concentrated. Green colored tabs evaluate sections of the organization’s plan. Teal tabs (blue-green) provide a means of comparing sections of the plan and developing a means to correct deficiencies. Orange tabs are focused on resources, including partners, exercise schedule, inventory and agreements for assistance. This instruction guide will walk you through each worksheet of CHAOS, providing instruction and suggestion for completing each section.

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Program Maintenance The Program Maintenance worksheet lists each tab of the CHAOS workbook and provides a means of tracking who is responsible for each of them. Because the program needs to involve leadership and members from departments across the organization it is easy to lose sight of who is responsible for specific objectives. Also, change is constant, so an objective may be inadvertently dropped because an individual has moved on or been reassigned. This worksheet provides an overview of the assignments, making it easier to keep track of them, and reassigning program elements when necessary. Assignments on this page should be made by leadership. 1. Contact Name: a. Decide who by title is responsible for management and review of each tab of the CHAOS workbook. b. Include contact information for each tab. 2. Last Review Date: a. Decide on the frequency of review for each tab in the workbook. b. Document the date of each section as it is reviewed or updated.

Community HVA Risk Analysis There are two tables on this worksheet, Magnitude of Impact to Community, and Community Mitigation. Meet with local, county and state Emergency Management Agency representatives, if available, to complete the Community HVA Risk Analysis. Since many of these events impact a region, you might consider working with other healthcare organizations on this section as well. Results from the Magnitude table will be displayed on the Community HVA Priorities report. Items from Magnitude and Mitigation tables transfer into the Internal HVA Risk Analysis worksheet. 1. Magnitude of Impact to a Community Table a. Probability i. Hazard probability is the likelihood that an event may occur in your community. Probability for an event can be determined by the existence of conditions that are required for an event to occur combined with historical data. For example, in a plains area, a landslide is unlikely, however tornados may occur every summer. If your organization has employees, then a labor action is possible even though it has not 3   

happened yet. Use existing data and the scoring guideline to estimate the probability of each listed event. Enter the score in the white boxes under each event. ii. Scoring Guideline: 1. Very Low a. Conditions do not exist for this type of event (wildfire and ice storm are not likely in a desert, rogue wave will not happen in a non-coastal state) b. The event has never happened 2. Low a. Conditions exist for this type of event b. However the event has not happened yet or in the last 50 years 3. Moderate a. Conditions exist for this type of event b. The event has happened in the last 20 years 4. High a. Conditions promote the event b. And/or the event has happened in the last 10 years ( ice storm is likely in northern states, a nearby forested state park is susceptible to wildfire) 5. Very High a. Conditions promote the event b. And the event has happened in the last 5 years (Infectious disease outbreaks and mass casualty incidents are likely in any population, coastal areas will see a tropical storm or hurricane) iii. Enter the scale for each event using the drop down arrows. iv. Use the provided criteria in the scoring guideline to determine the probability scale. Do not consider how an event impacts your organization when considering likelihood of an event, as the impact is calculated separately. b. Warning & Duration i. Advance notice and event duration dramatically affect the impact on an organization. Advance warning helps communities develop a response plan, while little warning makes it difficult for responders to catch up to the crisis. Duration of an event impacts the ability of a community to sustain a response. Use the scoring guideline to estimate the Warning & Duration scale of each event. ii. Scoring Guideline 1. More than 24 hours advance notice and less than 24 hours of event duration 2. Either: a. More than 24 hour notice and more than 24 hour duration b. Less than 24 hour notice and less than 24 hour duration 3. Less than 24 hour advance notice and more than 24 hours of event duration iii. Enter the scale for each event using the drop down arrows.

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c. Magnitude of Impact i. Work with your Local Emergency Planning Committee to determine the impact an event, if it were to occur, would have in your community. ii. Committee members should represent all areas of your region: emergency management and public safety, health care, government, utilities, academia and private businesses. iii. Scoring Guideline: use the provided matrix to help determine the impact to the community iv. Enter the scale for each event using the drop down arrows.

Community Impact Matrix Human

0

1

2

3

4

No injuries

Minor injuries or psychological trauma

Severe injuries and psychological trauma

Property

No damage, minor cleanup, brief interruption of utilities

Minor damage, repairs and restoration of utilities may take days to weeks

Minor injuries, limited major trauma, psychological trauma Moderate damage, repairs may require weeks to months

Infrastructure

Utilities not affected

Utilities interrupted for short duration. Services restored within a day.

Utilities lost for several days. Repairs are possible. Back up services are required.

Severe damage to a section of the facility, repairs prolonged for more than a month Services are lost for weeks, back up or replacement services are required.

Fatalities, severe injuries and psychological trauma Damaged facilities must be permanently closed or relocated

Business/Services

Businesses able to continue at full capacity, accommodate a surge without stressing existing resources

Business stress, Some services are delayed, services still provided

Most businesses remain open, some services are cancelled and referred outside the community, delay in supplies delivery or availability

Some service lines can no longer be offered and are referred outside the community, interruption in supplies, interruption in product distribution

Services must be entirely replaced.

Businesses are forced to relocate or close for good.

d. Magnitude Total is calculated automatically as a sum of Warning & Duration and Community Impact. e. Risk is the product of Probability times Magnitude Total 2. Community Mitigation a. Community mitigation is scored on the completeness of each of the following components: 5   

i. Human Resources – may include trained professionals and a means to manage volunteers, either organized in a function team or ad hoc ii. Space – may include an incident command center, field hospitals and other spaces large enough to accommodate a response iii. Equipment & Supplies – an inventoried list of assets that are maintained for the purpose of a response or easily converted for use in a response iv. Plans – are response plans thought out for functions or for likely scenarios v. Integration with Community Response – are the response plans written to integrate with other response agencies and do these groups train and exercise together b. Score the components for each event using the following scoring guideline: 1. Plan is complete 2. Plan is in progress 3. Planning is scheduled 4. Planning is not yet scheduled 5. Will not implement planning for this component c. The Mitigation Total score transfers to the Community Mitigation Score on the CHAOS Dashboard.

Community HVA Priorities Report The Community HVA Priorities Report is a series of pivot tables that organize events by their risk scores. National standards state that emergency planning, mitigation and exercises should be based on the highest risk events. These tables show the scores in an easy to read format. You will see separate tables for each type of event, and a larger table showing all events. Since events in the Community HVA may score differently than events on the Internal HVA, these tables should be used for planning community-wide exercises and training. Internal HVA Risk Analysis 1. Magnitude of Impact table a. Probability i. Hazard probability is the likelihood that an event may occur in your community. Probability for an event can be determined by the existence of conditions that are required for an event to occur combined with historical data. For example, in a plains area, a landslide is unlikely, however tornados may occur every summer. If your organization has employees, then a labor action is possible even though it has not happened yet. Use existing data and the scoring guideline to estimate the probability of each listed event. Enter the score in the white boxes under each event. 6   

ii. Scoring Guideline: 1. Very Low a. Conditions do not exist for this type of event (wildfire and ice storm are not likely in a desert, rogue wave will not happen in a non-coastal state) b. The event has never happened 2. Low a. Conditions exist for this type of event b. However the event has not happened yet or in the last 50 years 3. Moderate a. Conditions exist for this type of event b. The event has happened in the last 20 years 4. High a. Conditions promote the event b. And/or the event has happened in the last 10 years ( ice storm is likely in northern states, a nearby forested state park is susceptible to wildfire) 5. Very High a. Conditions promote the event b. And the event has happened in the last 5 years (Infectious disease outbreaks and mass casualty incidents are likely in any population, coastal areas will see a tropical storm or hurricane) iii. Enter the scale for each event using the drop down arrows. iv. Use the provided criteria in the scoring guideline to determine the probability scale. Do not consider how an event impacts your organization when considering likelihood of an event, as the impact is calculated separately. b. Warning & Duration i. Advance notice and event duration dramatically affect the impact on an organization. Advance warning helps communities develop a response plan, while little warning makes it difficult for responders to catch up to the crisis. Duration of an event impacts the ability of a community to sustain a response. Use the scoring guideline to estimate the Warning & Duration scale of each event. ii. Scoring Guideline 1. More than 24 hours advance notice and less than 24 hours of event duration 2. Either: a. More than 24 hour notice and more than 24 hour duration b. Less than 24 hour notice and less than 24 hour duration 3. Less than 24 hour advance notice and more than 24 hours of event duration iii. Enter the scale for each event using the drop down arrows. c. Magnitude of Impact i. Work with your organization’s emergency management committee to determine the impact an event, if it were to occur, would have on your organization. ii. Magnitude Total will be calculated as the sum of magnitude of Impact in each of the listed categories iii. Committee members should represent all areas of your organization, from human resources and facilities, to finance and clinical staff 7   

iv. Enter the scale for each event using the drop down arrows, using the following matrix: Internal Impact Matrix Human

0

1

2

3

4

No injuries

Minor injuries Or Psychological Trauma

Minor injuries And Psychological Trauma

Severe injuries And Psychological Trauma

Fatalities And Psychological Trauma

No damage, maybe some cleanup, brief interruption of utilities

Minor damage, repairs and restored utilities take a few days or weeks,

Moderate damage, repairs may take up to a month

Severe damage to a section of the facility, repairs take months

Entire facility must be closed and will not reopen for a year

Technology services not affected

Technology services interrupted but not lost, Services restored within a day, back up services may be required,

Services are lost for several weeks, back up services are required, no loss of information

Services must be replaced, Information is lost and cannot be acquired through alternate means

Able to continue at full capacity, accommodate a surge without stressing existing resources

Business stress, Some services are delayed, services still provided

Services are lost for weeks or months, back up or replacement services are required, information is lost but can be acquired through alternate means Some service lines can no longer be offered and are referred outside the facility, interruption in supplies, interruption in product distribution Loans are required to cover cost of repairs, service replacements, fines or legal fees; Revenue streams are lost for up to a year

Loans are not sufficient to cover cost of repairs, service replacements, fines or legal fees; Revenue cannot be resume for over a year

Patients or Staff Physical Health, Psychological Health Property Buildings, Grounds and Parking, Utilities and Systems Infrastructure Technology, Communication, Information Services, Networked medical equipment and telemetry

Business/Services Lines of service provided, Supplies and distribution, Staffing

Financial Expenses Insurance and Service Agreements Loss of Revenue

No expenses, no fines or legal fees; No loss or delay of revenue

Business remains open, some services are cancelled and referred outside the facility for a few weeks or months, delay in supplies, limited product distribution Most expenses Expenses are are covered by covered by insurance or insurance or service service agreements, no agreements, fines or legal fines or legal fees; Revenue is fees are covered by delayed but not insurance ; lost Some revenue is lost for a few weeks or months

Business closes its door

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d. Risk is the product of Probability times Magnitude Total 2. Plan Components Table – weighting the plan a. Consider the importance of each plan component to the response for each type of hazard i. Plan components include the following: 1. Communication 2. Resources 3. Safety & Security 4. Staff Roles & Responsibilities 5. Patient Management 6. Utility Services 7. Technology ii. Weigh the importance of plan components using the following guide: 1. Least Important – may not be used at all 2. Important –will be used during the response 3. Most Important – a critical component to the response b. Plan weighting will be combined with plan scoring, to create a mitigation total for the internal response, which is found on the Organization Mitigation Total of the CHAOS Dashboard. (Plan scoring occurs later in the green tabs of the workbook.)

Internal HVA Priorities Report The Internal HVA Priorities Report is a series of pivot tables that organize events by their risk scores. National standards state that emergency planning, mitigation and exercises should be based on the highest risk events. These tables show the scores in an easy to read format. You will see separate tables for each type of event, and a larger table showing all events. Since events in the Internal HVA may score differently than events on the Community HVA, these tables should be used for planning internal exercises and training. CHAOS Dashboard The CHAOS Dashboard provides a numerical overview of your organization’s preparedness level compared to risk and severity levels for each event. Plan Components Weighted Score is a combination of the plan weighting completed on the Internal HVA Risk Analysis tab, and the individual plan score completed on the green tabs. These scores are averaged to obtain the Organization mitigation level. The Community Mitigation level is from the Community HVA Risk Analysis tab. Total mitigation is the sum of the two mitigation levels.

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Plan Evaluations The various components of your emergency management plan are evaluated for completeness in the green tabs of the workbook. Each type of plan has a listing of plan elements that are integral to the plan. Plan evaluators should have the emergency management plan in hand as they go through the evaluation plan, so that the can effectively score the plans completeness, list the location in the plan that meets the plan element, and determine if corrective action is required. For reference purposes, the corresponding TJC Element of Performance is listed, as well as other national standards. Some plans will have an additional section for scoring how long a specified resource will last, and will be included in the 96 Hour Plan and Sustainability Report. The entire average score is combined with the plan weighting to calculate the Organization Mitigation score on the CHAOS dashboard. 96 Hour Plan and 96 Hour Report Elements from the Sustainability section of each plan evaluation transfer over to the 96 Hour Plan, which lists each element and the hours it is able to last without being replenished through regular channels. This plan is represented in graphical form in the 96 Hour Report. Comprehensive Plan Overview All plan elements transfer to the Comprehensive Plan Overview tab. The plan elements can then be sorted by topic, score or corrective action status. An emergency management committee consisting of hospital leaders in all areas should review this section together to prioritize which elements need to be addressed. Once chosen, these plan elements should be transferred over to the Corrective Action Plan tab. Corrective Action Plan On the Corrective Action Plan, hospital leaders should decide the course of action along with a due date, and assign the item. It is possible that one plan element may have several corrective action items assigned. Each one should be listed on a separate line, to facilitate tracking the status of each. Internal Partners 10   

List the contact information for all members of the emergency management committee and those assigned to carry out corrective action items. Be sure to include the title to facilitate reassigning items when people change positions or leave the organization. Community Partners List the contact information for members of the community that participate in the HVA, in training and exercises, and in responses. Be sure to include the title and organization for each contact to facilitate reaching out to appropriate alternates when required. Exercise Schedule Keep track of exercises and real world events, linking them to the six critical function areas specified by The Joint Commission. Also link the exercises to the components of your plan that are tested during the response. Resources Inventory Inventory assets used for disasters or for training on this tab, and inspect the inventory at least annually. Alternately, your organization may have these supplies in an existing inventory management system. MOUs As you make or accept Memoranda of Understanding or other emergency service agreements, document the agreements on this tab. You may also want to include a hyperlink to the digital document. References References used for development of the CHAOS tool are listed on this tab. You may want to add additional references cited in your emergency management program.

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References Category Emergency Operation Planning Emergency Operation Planning Emergency Operation Planning Hazard Vulnerability Analysis Hazard Vulnerability Analysis Hazard Vulnerability Analysis Hospital Incident Command System Hospital Incident Command System Hospital Incident Command System Hospital Incident Command System Hospital Preparedness Program Hospital Preparedness Program Hospital Preparedness Program Hospital Preparedness Program Hospital Preparedness Program Hospital Preparedness Program Hospital Preparedness Program National Incident Management System National Response Framework Partnering Agency Partnering Agency Partnering Agency Partnering Agency Training Training

Organization California Hospital Association Department of Homeland Security

Web Address http://www.calhospitalprepare.org/hazardvulnerability-analysis

http://www.dhs.gov/ http://www.va.gov/VHAEMERGENCYMANAGEM ENT/Documents/Education_Training/EMPPHS_L Department of Veterans Affairs esson_Four_Handout.pdf Federal Emergency http://training.fema.gov/EMIWeb/downloads/UNT Management Agency ServiceLearning.pdf Kaiser Permanente National Oceanic and Atmospheric Administration California Emergency Medical Services Authority California Hospital Association Center for HICS Education & Training The Center for Preparedness Education Centers for Disease Control and Prevention US Department of Health & Human Services Maine Center for Disease Control & Prevention National Fire Protection Association National Institute for Occupational Safety and Health Occupational Safety & Health Administration The Joint Commission Federal Emergency Management Agency Federal Emergency Management Agency Eastern Maine Medical Center EMHS Maine CDC Maine Emergency Management Agency Center for Domestic Preparedness Emergency Management Institute

Kaiser Permanente HVA Tool http://www.noaa.gov/index.html http://www.emsa.ca.gov/hics/ http://www.calhospitalprepare.org/hics http://www.hicscenter.org/index.php http://www.preped.org/resources/hics-jasforms.htm http://www.cdc.gov/phpr/ http://www.phe.gov/Preparedness/planning/hpp/P ages/default.aspx http://www.maine.gov/dhhs/mecdc/phdata/publichealth-preparedness/uw-services.htm http://www.nfpa.org/aboutthecodes/AboutTheCod es.asp?DocNum=1600&cookie%5Ftest=1

http://www.cdc.gov/niosh/topics/emergency.html http://www.osha.gov/SLTC/emergencypreparedn ess/ http://www.jointcommission.org/standards_inform ation/standards.aspx http://www.fema.gov/nationalpreparedness/national-incident-managementsystem http://www.fema.gov/nationalpreparedness/national-response-framework http://emmc.org/ http://emhs.org/ http://www.maine.gov/dhhs/mecdc/ http://www.maine.gov/mema/ http://cdp.dhs.gov/ http://training.fema.gov/is/ 12 

 

 

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