Guidelines for Hospital Compliance with the National Incident Management System (NIMS)

Revision Date: September 22, 2009

It is important to remember that NIMS is a system of incident management. It is more a culture and a process about how your hospital manages an incident rather than a checklist of actions. Some of the following compliance checklists are tangible and measurable; others are a reflection of your hospitals preparedness processes and culture. The Assistance Secretary of Preparedness and Response (ASPR) requires that hospitals recertify each ASPR fiscal year that the hospital is in compliance with the following 14 NIMS elements. Adoption of NIMS Element 1 - Adoption of NIMS at all organizational levels Adopt NIMS throughout the healthcare organization, including all appropriate departments and business units. An example of compliance with Element #1, a statement in the hospitals Emergency Operations Plan regarding how the hospital has adopted NIMS in all appropriate departments and business units is sufficient. Element 2 Ensure Federal Preparedness awards support NIMS implementation (in accordance with the eligibility and allowable use of awards) This is a leadership responsibility. The Leadership Group along with Regional Hospital Preparedness Boards will ensure that all projects funded by the Assistance Secretary of Preparedness and Response Cooperative Agreements help the hospital and other funded entity to support the implementation of NIMS. An example of compliance with Element #2, the hospital participates as appropriate in projects funded by the Hospital Preparedness Program that support the implementation of NIMS. Preparedness: Planning Element 3- Revise and update plans 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.

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Hospitals are to update their Emergency Operations Plan, based on their After Action Reports, completed after each exercise. Once corrective actions are taken, plans should be exercised so as to determine if corrective actions taken are effective. An example of compliance with Element #3, the hospital completes an After Action Report for each exercise and then prioritizes and follows up on these prioritized Corrective Actions and tests those Corrective Actions in a subsequent exercise and then up-dates the Emergency Operations Plan as necessary. Element 4- Participate in interagency mutual aid and/or assistance agreements to include agreements with public and private sector and nongovernmental organizations. Hospitals are to establish mutual-aid agreements with hospitals and with other emergency responders, vendors, etc., as appropriate and necessary. An example of compliance with Element #4, the hospital has completed the Memorandum of Understanding with other hospitals in its region and with other emergency response partners, as appropriate and necessary. Preparedness Training Element 5: Identify the appropriate personnel to complete ICS 100 HC, ICS 200 HC and IS 700 or equivalent courses. For compliance with Element #5, the appropriate persons at the hospital have been identified and have completed this training. Element 6: Identify the appropriate personnel to complete IS 800 or equivalent course Examples of compliance with Element #6, the appropriate persons at the hospital have been identified and have completed this training. Element 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 exercise. Hospitals are to include NIMS and ICS policies and practices into internal and external training and exercises. An example of compliance with Element #7, the hospital has a method to train and educate staff, according to their level of responsibility, about NIMS and ICS

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Communication and Information Management Element 8 Promote and ensure that equipment, communication and data interoperability are incorporated into the healthcare organizations acquisition programs. Hospitals are to implement the recommendations of the State Expert Panel on Communication so as to ensure that there are four levels of telecommunications redundancy and interoperability. An example of compliance with Element #8, the hospital, to the extent possible, plans for the purchase of telecommunications equipment and information technology so that it can communicate with other hospitals and other emergency responders. Element 9 - Apply common and consistent terminology as promoted in NIMS, including the establishment of plain language communication standards. Although the use of plain English codes within the facility is strongly encouraged (it should not be assumed that patients and visitor scan interpret these codes, especially codes that may affect them), this Element does not prohibit the use of in-house hospital emergency codes to communicate within the facility. However, when communicating with entities outside the hospital, plain English is to be used in place of acronyms and internal emergency codes (e.g. Dr. Red is internal to a hospital. If a hospital is reporting a fire to the Incident Commander, the hospital should simply state that it has a fire. An example of compliance with Element #9, the hospitals Emergency Operations Plan or policies reflect the use of plain English by staff during emergencies, when communicating with outside entities. Element 10 Utilize systems, tools and processes that facilitate the collection and distribution of consistent and accurate information during an incident. According to the Incident Command System, the hospital identifies the person/position, who will serve as the Public Information Officer (PIO), responsible for media and public information. The designated PIO is to establish working relationships, prior to an incident, with local media outlets, emergency management, law enforcement, public health, emergency medical services, etc. An example of compliance with Element #10, as part of its Incident Command System, the hospital designates a person/position to serve as the PIO (if necessary) and to work through the Emergency Operations Center and/or the Joint Information Center (JIC), if these entities are activated. The hospital PIO uses the ICS forms as appropriate.

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Resource Management There are no implementation objectives for healthcare facilities under this category. Command and Management Element 11 - Manage all emergency incidents, exercises and pre-planned (recurring/special) events in accordance with ICS organizational structures, doctrines, as defined by NIMS. This is very straight-forward. The hospital uses the Incident Command System to manage incidents. An example of compliance with Element #11, the hospital has adopted the Incident Command System as the means by which to manage incidents, exercises and preplanned events. This is evidenced by reference to Incident Command in the Emergency Operations Plan. It is recommended that healthcare facilities use the Incident Command System for day-to-day projects as a learning tool and an effective tool to manage projects. Element 12 ICS implementation must include the consistent application of Incident Action Planning (IAP) and common communications plans, as appropriate. The hospital has trained its staff to produce Incident Action Plans as part of ICS along with the communications that go through the ICS chain-of-command. An example of compliance with Element #12, the hospital has Incident Action Plans for all incidents and exercises along with the plans to communicate through the ICS chain-of-command. Element 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. The hospital has adopted the role of the Public Information Officer and coordination with the Joint Information Center (JIC) in its Emergency Management Plan. An example of compliance with Element 13, the hospital has a reference in its Emergency Operations Plan to role of the hospital Public Information Officer and coordination with the incident PIO at the Emergency Operations Center and/or the Joint Information Center (JIC).

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Element 14 Ensure that Public Information procedures and processes gather, verify, coordinate and disseminate information during an incident or an event. The hospital has trained its staff on how communications are managed under ICS and that to ensure consistency of messaging, the hospital Public Information Officer coordinates all messages with the Joint Information Center. An example of compliance with Element #14, the hospital has a person assigned to serve as the Public Information Officer and this person has been trained and knows how to coordinate messages with the Joint Information Center (JIC). The following are only recommendations on what a hospital may do in order to be in compliance with Elements 5 and 6: Preparedness Training. It is the responsibility of each hospital to determine what staff needs to be trained in which courses in order to be in compliance with these Elements. Example of compliance for IS1 100HC and IS 200HC: 1. The hospitals training records track completion of IS 100HC and IS 200HC by personnel, who are likely to assume the functions of the top eight Incident Command positions (Incident Commander, Safety and Security Officer, Public Information Officer, Liaison Officer, Operations Chief, Planning Chief, Logistics Chief, Finance Chief). 2. In addition, the hospitals training records track completion of IS 100HC and IS 200HC by members of the Emergency Management Committee. Example of compliance for IS-700: NIMS: An Introduction: The hospitals training records track completion of IS 700 by personnel, who are likely to assume the functions of the top eight Incident Command positions (Incident Commander, Safety and Security Officer, Public Information Officer, Liaison Officer, Operations Chief, Planning Chief, Logistics Chief, Finance Chief). Example of compliance for IS-800: NRP: An Introduction: The hospitals training records track completion of IS 800 by individual(s) responsible for the hospitals emergency management program. This should be a member of the Emergency Management Committee, preferably the Chairperson or the person, who has responsibility for writing the hospital emergency managements plan.

IS means Independent Study

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The following is an example of a Letter of NIMS Compliance and should be placed on your hospital letterhead and sent to your Regional Project Coordinator prior to requesting reimbursement for any ASPR funded project.
The (name) hospital understands that, in order to continue to receive federal preparedness funding, the (name) hospital must be in compliance with the National Incident Management System. This is to certify that (name) hospital is in full compliance with the 14 Elements of the National Incident Management System. Documentation to support this compliance is available to state or federal auditors, upon request. Sincerely, (hospital)

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