NIMS COMPLIANCE TRACKING TEMPLATE In September 2006 ...

NIMS COMPLIANCE TRACKING TEMPLATE
In September 2006, the National Incident Management System (NIMS) Integration
Center, along with the Department of Health and Human Services, outlined 17 elements
of compliance as implementation activities for Hospitals and Healthcare. Four of the
seventeen elements were required to be eligible for Federal Preparedness Grant
Funding in FY2007. The following document was originally created to provide a
template for healthcare organizations to track NIMS Implementation activities internally.
It has now been modified to assist healthcare organizations in tracking compliance
activities.
In May 2008, NIMS Implementation Activities for Healthcare and Hospitals were
updated and 14 of the original 17 elements were identified as most applicable to
healthcare organizations for compliance objectives in FY2008. Hospitals and healthcare
organizations were expected to complete all 14 elements by September 30, 2009.
Activities from previous years to the 2008/2009 requirements are compared in the
Crosswalk of the 2007 & 2008/2009 NIMS Healthcare Activities/Objectives, dated
11/2008, available on the NIMS Integration Center website.
The following template outlines each of the activities required for compliance to meet
the 14 elements for healthcare. It begins with a directive acknowledging that the
organization has adopted NIMS and continues with sections that outline the 14
compliance activities. Examples of activities within each section are provided to assist
with filling out the template and are highlighted in yellow. The template provides a
mechanism for the NIMS requirements to be tracked internally to validate compliance.
As NIMS compliance activities expand, the template will be updated. Please contact
Danica Mann at Danica.mann@overlakehospital.org with any questions about NIMS
implementation activities.
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NIMS IMPLEMENTATION DIRECTIVE
In February 2003, in Homeland Security Directive-5, the President directed the
Secretary of the Department of Homeland Security to develop and administer a National
Incident Management System (NIMS). The goal of NIMS is to provide a consistent
nationwide approach for federal, state, local, and tribal governments to work together
more effectively and efficiently to prevent, prepare for, respond to, and recover from
disasters, regardless of cause, size, or complexity. Ultimately, the implementation of the
activities required by the NIMS are designed to strengthen the relationship between
hospitals, local public health and other emergency response agencies.
, in cooperation with Public Health Seattle and King County, the
King County Healthcare Coalition, local emergency management and other response
partners, will develop a program to integrate the National Incident Management System,
to the extent appropriate, into our emergency management program. National Incident
Management System compliance activities, as outlined in the NIMS Alert 202-646-3850,
“NIMS Implementation Activities for Hospitals and Healthcare”, will be addressed in the
. The hospital emergency manager will
identify any statutes or regulations that need to be modified to facilitate implementation
of the NIMS and will track implementation annually as part of the emergency
management program.
will report on the status of NIMS compliance activities as
directed by the Washington State Department of Health.
Implementation activities will proceed as outlined in the following NIMS Implementation
Strategy.
__________________________________ ______________________
(Name of Signing Authority)
(Date)
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NIMS IMPLEMENTATION STRATEGY
I. Purpose
This document establishes that is compliant with the elements
of NIMS outlined for healthcare to ensure compliance with HSPD-5, Management of
Domestic Incidents. HSPD-5 requires all Federal Departments and agencies to adopt
the NIMS and requires all state and local jurisdictions to implement the NIMS to receive
federal preparedness funding. This plan illustrates that the required elements of NIMS
for healthcare are met and maintained by plans and training
programs.
II.
Responsibilities
a.
Position Title
Point of
Contact
Office
Telephone
Responsibilities to Ensure
Full Adoption of the NIMS
III.
NIMS Implementation Objectives
NIMS requirements are outlined in 5 sections throughout this document. These
sections are outlined in the NIMS Implementation Objectives for Healthcare
Organizations dated 6/08. The first section addresses NIMS Adoption, which will include
a list of which departments / business units are appropriate to include in the NIMS
activities (i.e. laboratory, emergency department, security, etc). The second section
addresses planning, which covers emergency operations plans (EOPs), standard
operating procedures (SOPs) as well as mutual aid agreements (MAAs). Section 3
outlines training and exercises. It will cover who is responsible for the completion of
which courses, listed by job title, as well as verify that NIMS principles are demonstrated
in exercises.
Section 4 addresses communications and information management. Common
terminology, interoperable communications equipment, and information management
are covered in this section. The last section outlines all the command and management
activities, such as managing incidents using ICS (or HICS), applying an Incident Action
Plan (IAP), and adopting Public Information strategies consistent with partners in a
response.
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Section 1 Adoption
1. Adopt NIMS throughout the healthcare organization including all appropriate
departments and business units Preparedness Exercises - Incorporate NIMS/ICS into
all training and exercises
2. Ensure Federal Preparedness awards support NIMS Implementation (in accordance
with the eligibility and allowable uses of the awards)
Section 2 Planning
3. Revise and update emergency operations plans (EOPs), standard operating
procedures (SOPs), and standard operating guidelines (SOGs) to incorporate NIMS
and National Response Framework (NRF) components, principles and policies, to
include planning, training, response, exercises, equipment, evaluation, and corrective
actions. Emergency response plans, including those that fulfill Emergency Support
Functions under the NRP and internal response plans, such as COOP Plans and
EOPs, must be modified to adopt NIMS principles and language.
4. Participate in interagency mutual aid and/or assistance agreements, to include
agreements with public and private sector and nongovernmental organizations.
Section 3 Training and Exercise
5. Identify the appropriate personnel to complete ICS 100, ICS 200 and IS 700, or
equivalent courses.
6. Identify the appropriate personnel to complete IS 800 or an equivalent course.ICS 100
– Introduction to Incident Command System
7. Promote NIMS concepts and principles into all organization-related training and
exercises. Demonstrate the use of NIMS principles and ICS Management structure in
training and exercises.
Section 4 Communications and Information Management
8. Promote and ensure that equipment, communication, and data interoperability are
incorporated into the healthcare organization’s acquisition program.
9. Apply common and consistent terminology as promoted in NIMS, including the
establishment of plain language communications standards.
10. Utilize systems, tools, and processes that facilitate the collection and distribution of
consistent and accurate information during an incident or event.
Section 5 Command and Management
11. Manage all emergency incidents, exercises, and preplanned (recurring/special) events
in accordance with ICS organizational structures, doctrine, and procedures, as defined
in NIMS.Resource Management – Maintain an inventory of organizational response
assets
12. ICS implementation must include the consistent application of Incident Action
Planning (IAP) and common communications plans, as appropriate.Corrective Actions
– Incorporate corrective actions into preparedness and response plans and
procedures
13. Adopt the principle of Public Information, facilitated by the use of the Joint Information
System (JIS) and Joint Information Center (JIC) during an incident or event.
14. Ensure that Public Information procedures and processes gather, verify, coordinate,
and disseminate information during an incident or event.
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IV.
NIMS Compliance Activities
Section 1 - Adoption
NIMS Compliance Activity Completed Notes Examples
Adopt NIMS throughout the healthcare
organization including all appropriate
departments and business units
Ensure Federal Preparedness awards
support NIMS Implementation (in
accordance with the eligibility and
allowable uses of the awards)
The directive at the
beginning of this
document assists
with documenting this
activity
Utilizing ASPR
training and exercise
funding for ICS
training and
participation in
exercises achieves
this requirement
Section 2 - Planning
NIMS Compliance Activity Completed Notes Examples
Revise and update emergency
operations plans (EOPs), standard
operating procedures (SOPs), and
standard operating guidelines (SOGs) to
incorporate NIMS and National
Response Framework (NRF)
components, principles and policies, to
include planning, training, response,
exercises, equipment, evaluation, and
corrective actions.
Participate in interagency mutual aid
and/or assistance agreements, to include
agreements with public and private
sector and nongovernmental
organizations.
Plans, procedures,
guidelines associated
with this activity are
listed in a table
below.
Mutual Aid
agreements
associated with this
activity are outlined in
a table below
Plan, Procedure,
or Policy
Example: Emergency Operations
Plan (EOP)
Strategy for NIMS
Implementation
Update to include Incident
Command language, training plans
and exercise requirements are
defined by NIMS Integration Center
Adoption Date
September 30, 2007
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Mutual Aid
Agreement
Capacity
Addressed
Internal Point of
Contact
Contact Information
Example: Linen
Agreement
Linens
Section 3 – Training and Exercises
NIMS Compliance Activity
Identify the appropriate personnel to
complete ICS 100, ICS 200 and IS 700,
or equivalent courses.
Identify the appropriate personnel to
complete IS 800 or an equivalent course.
Promote NIMS concepts and principles
into all organization-related training and
exercises. Demonstrate the use of NIMS
principles and ICS Management
structure in training and exercises.
Completed Notes Examples
Training
requirements are
outlined in the table
below
All regional training
and exercises, and
templates provided
by the King County
Healthcare Coalition
assist in achieving
this requirement.
Training Course Required Staff Completion Date
Example: IS-700 National Incident
Management System
All EOC Staff September 30, 2007
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Section 4 – Communications and Information Management
NIMS Compliance Activity
Promote and ensure that equipment,
communication, and data interoperability
are incorporated into the healthcare
organization’s acquisition program.
Apply common and consistent
terminology as promoted in NIMS,
including the establishment of plain
language communications standards.
Utilize systems, tools, and processes
that facilitate the collection and
distribution of consistent and accurate
information during an incident or event.
Completed Notes Examples
WSHA ensures this
process is followed
with all ASPR
equipment purchases
Adoption of the new
proposed hospital
codes is one
example of applying
common terminology
in a healthcare
setting.
Connecting with
Health and Medical
Area Command by
email, phone, or
WATrac is one way
to facilitate this
requirement.
Section 5 – Command and Management
NIMS Compliance Activity
Manage all emergency incidents,
exercises, and preplanned
(recurring/special) events in accordance
with ICS organizational structures,
doctrine, and procedures, as defined in
NIMS.
ICS implementation must include the
consistent application of Incident Action
Planning (IAP) and common
communications plans, as appropriate.
Adopt the principle of Public Information,
facilitated by the use of the Joint
Information System (JIS) and Joint
Information Center (JIC) during an
incident or event.
Ensure that Public Information
procedures and processes gather, verify,
coordinate, and disseminate information
during an incident or event.
Completed Notes Examples
Ensure your
organization is
following ICS by
outlining it in
response procedures
and training staff
regularly
Complete an IAP for
every exercise or real
event that requires
activation of your
Healthcare
Command Center
Ensure your
organization is
connected with the
Communications
Team at PHSKC, as
well as with local
emergency
management
Outline these
processes in your
EOP and test them
during exercises
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