After Action Report Improvement Plan Infirmary Intimidation A Workplace Violence Response Tabletop Exercise November 18, 2015 Bert Fish Medical Center 1 Page
ADMINISTRATIVE HANDLING INSTRUCTIONS 1. The title of this document is The "Infirmary Intimidation - A Workplace Violence Response Tabletop Exercise" After Action Report. 2. The information gathered in this AAR/IP is classified as For Official Use Only (FOUO) and should be handled as sensitive information not to be disclosed. This document should be safeguarded, handled, transmitted, and stored in accordance with appropriate security directives. 3. At a minimum, the attached materials will be disseminated only on a need-to-know basis and when unattended, will be stored in a locked container or area offering sufficient protection against theft, compromise, inadvertent access, and unauthorized disclosure. 4. Points of Contact: Bert Fish Medical Center: Karen Duncan Bert Fish Medical Center (Office) 386-547-9815 (E-Mail) karen.duncan@bertfish.com Dawn Myers Bert Fish Medical Center (Office) 386-871-4165 (E-Mail) dawn.myers@bertfish.com Exercise Director: Chris Floyd Disaster Resistant Communities Group LLC (Office) 850-241-3565 (E-Mail) chrisfloyd@drc-group.com 2 Page
CONTENTS ADMINISTRATIVE HANDLING INSTRUCTIONS... 2 CONTENTS... 3 EXECUTIVE SUMMARY... 4 SECTION 1: EXERCISE OVERVIEW... 5 Exercise Details... 5 Participant Information... 5 SECTION 2: EXERCISE DESIGN SUMMARY... 6 Exercise Purpose and Design... 6 Exercise Objectives, Capabilities and Activities... 6 Scenario Summary... 6 SECTION 3: ANALYSIS OF CAPABILITIES... 7 SECTION 4: CONCLUSION... 10 APPENDIX A: IMPROVEMENT PLAN... 11 APPENDIX B: PARTICIPANT FEEDBACK (Strengths Areas for Improvement)... 13 APPENDIX C: ACRONYMS... 16 3 Page
EXECUTIVE SUMMARY Infirmary Intimidation - A Workplace Violence Response Tabletop Exercise was designed and facilitated to provide Bert Fish Medical Center employees with the opportunity to assess current plans while gaining additional knowledge as to how to recognize and prevent workplace violence. The purpose of this report is to analyze exercise results, identify strengths to be maintained and built upon, identify potential areas for further improvement, and support development of corrective actions. Incorporated in Section 3: Analysis of Capabilities of this After Action Report is a comprehensive listing of each Core Capability with its associated Major Strengths, Primary Areas for Improvement and Improvement Recommendations 4 Page
Exercise Details SECTION 1: EXERCISE OVERVIEW Exercise Name: Type of Exercise: Infirmary Intimidation - A Workplace Violence Response Tabletop Exercise Tabletop Exercise Start Date: November 18, 2015 Duration: Location: Sponsor: Three Hours New Smyrna Beach Florida Volusia County Emergency Management Department Purpose: The purpose of the exercise was to provide Bert Fish Medical Center employees with the opportunity to assess current plans while gaining additional knowledge as to how to recognize and prevent workplace violence. Scenario Type: Patient Stalking Potential Active Shooter Threatening Individual Hospital Employee Firing Participant Information Participant Agency / Organization Number of Participants 46 Bert Fish Medical Center Volusia County Emergency Management Department 5 Page
SECTION 2: EXERCISE DESIGN SUMMARY Exercise Purpose and Design The purpose of the exercise was to provide Bert Fish Medical Center employees with the opportunity to assess current plans while gaining additional knowledge as to how to recognize and prevent workplace violence. Exercise Objectives, Capabilities and Activities Capabilities-based planning allows for the exercise planning team to develop exercise objectives and observe exercise outcomes through a framework of specific action items that were derived from the Core Capabilities List. The capabilities listed below form the foundation for the organization of all objectives and observations in this exercise. Additionally, each capability is linked to several corresponding activities and tasks to provide additional detail. Based upon the identified exercise objectives below, the exercise planning team decided to demonstrate the following capabilities during this exercise: Hospital Security Workforce Safety Activity Core Capability # 1 Workforce Security and Safety # 2 Initiate and Manage Protective Measures Operations Scenario Summary The exercise consisted of the following four scenario vignettes. Vignette # 1 Patient Stalking Vignette # 2 Potential Active Shooter Vignette # 3 Threatening Individual Vignette # 4 Employee Firing 6 Page
SECTION 3: ANALYSIS OF CAPABILITIES Hospital Security Workforce Safety Performance Adequate Core Capability Activity # 1: Workforce Security and Safety Associated Critical Tasks Task # 1.1: Initiate and maintain Workplace Security and Workforce Protection. Adequate Evaluator # 1 Observations Recommendations During the exercise only one person had a copy of appropriate plans and procedures. However many knew of their existence and where to find them. Some participants knew the details of the various plans and procedures. Make sure more hospital employees have knowledge of and access to appropriate plans and procedures. Task # 1.2: All employees have a thorough working knowledge of current security and workforce protection procedures and guidelines. Adequate Evaluator # 1 Observations During the exercise only one person had a copy of appropriate plans and procedures. However many knew of their existence and where to find them. Some participants knew the details of the various plans and procedures. Recommendations More training on and exercising of plans and procedures. Performance Core Capability Needs Improvement Activity # 2: Initiate and Manage Protective Measures Operations Associated Critical Tasks 7 Page
Task # 2.1: Hospital staff take appropriate measures to protect themselves, patients and visitors and when possible to mitigate or deescalate the incident. Adequate Evaluator # 1 Observations Most had excellent de-escalation techniques, especially Emergency Department personnel that were present during the exercise. All knew how to contact hospital security and police, and most knew when to make that contact. Most knew what a Code Silver was and those that didn't immediately looked on their badges to check. Recommendations There was an additional alert used at the hospital for assistance that did not differentiate to staff what exactly was needed-this needs to be redefined as a bunch of nurses running into a possible security problem is less than ideal. Task # 2.2: Implement surge capacity plans to increase on-site security and workforce protection when a threatening situation is observed. Needs Improvement Observations Recommendations Evaluator # 1 There is only one security member on-site at any given time and he / she has other functions in addition to responding to calls from staff. There was nothing in place to call in more security other than the local police or 911. All present knew how to call security, the dispatch desk and / or 911. Not sure as the hospital only wants one security person on-site, and that person is limited by his / her job description as to what he / she can actually do. Hospital security carries no weapons. Task # 2.3: Initiate notification appropriate internal and external notifications. Needs Improvement Observations Evaluator # 1 Only some administrators were on the list to be alerted and the list seemed a bit fluid. There is no plan in place for when administrators are not 8 Page
present (nights, weekends). Staff is often not notified at all during smaller emergencies. There does not seem to be a system in place other than the alerts on the public address system to contact staff. All present did know how to contact security and 911. Recommendations Update plans regarding: notification-who, when and how. Reassess how and who to notify in various situations. Research a better way to make a staff-wide alert. 9 Page
SECTION 4: CONCLUSION Exercises such as this one allow personnel to validate training and practice strategic and tactical prevention, protection, response and recovery capabilities in a risk-reduced environment. Exercises are the primary tool for assessing preparedness and identifying areas for improvement, while demonstrating community resolve to prepare for major incidents. Exercises aim to help entities within the community gain objective assessments of their capabilities so that gaps, deficiencies, and vulnerabilities are addressed prior to a real incident. Exercises are the most effective (and safer) means to: Assess and validate policies, plans, procedures, training, equipment, assumptions, and interagency agreements; Clarify roles and responsibilities; Improve interagency coordination and communications; Identify gaps in resources; Measure performance; and Identify opportunities for improvement. This exercise succeeded in addressing all of the above as it provided examples of good to excellent participant knowledge, teamwork, communication and use of plans and procedures while pointing out areas in need of improvement and clarification. Listed below is a summary of the level of performance the Core Capabilities and Tasks evaluated during the exercise. This summary outlines the areas in which Bert Fish Medical Center is strong as well as identifying areas that the departments should invest future planning, training and exercise funds on. Hospital Security Workforce Safety Activity Core Capability Performance # 1 Workforce Security and Safety Adequate # 2 Initiate and Manage Protective Measures Operations Needs Improvement 10 Page
APPENDIX A: IMPROVEMENT PLAN This Improvement Plan has been developed specifically for Bert Fish Medical Center based on the results of Infirmary Intimidation - A Workplace Violence Response Tabletop Exercise conducted on November 18, 2015. These recommendations draw on both the After Action Report and the After Action Conference. Capability Observation Recommendation Responsible Personnel Completion Date Hospital security and safety plans and procedures were not easily accessible to exercise participants. Place all hospital Emergency Operations Plans and Procedures, including all security and safety plans and procedures, on the hospital s intranet so they can be easily accessed by hospital management and staff. Workforce Security and Safety Place all hospital Emergency Operations Plans and Procedures, including all security and safety plans and procedures, on the on several Flash drives. Then distribute Flash drives to appropriate hospital leadership that have a responsibility to activate said plans and procedures. There was a base understanding of the hospital s security and safety procedures, however only a few individuals fully understood the processes by which the plans and procedures would be implemented. Continue to train and exercise all hospital personnel on the roles they are responsible for implementing during any threatening situation, emergency or disaster. 11 Page
Initiate and Manage Protective Measures Operations Hospital security is limited to one security guard and this individual has many responsibilities that have made the guard un-available at times. While the overhead code procedures appear to be well defined there does not appear to be an effective system in place for notifying hospital leadership of an emergency when they are not at the hospital. Emergency Department (ED) diversion procedures were not fully understood by many exercise participants Review the priorities of security guards. If needed revise the priorities to focus on life safety above all other priorities. Identify an effective multi-faceted (Text, E- Mail, Phone, etc.) emergency notification system. Upon identifying an appropriate emergency notification system budget funds to fully implement the system. Review current diversion procedures and up-date as appropriate. Upon completing a review of the diversion procedures conduct training for ED staff. 12 Page
APPENDIX B: PARTICIPANT FEEDBACK (Strengths Areas for Improvement) Strengths Good interdisciplinary interaction and communication. Good education. Revelation of Security s accessibility to New Smyrna Beach Police Department. Good engagement / diversity. Made us aware of the areas that we need to think about such as follow up after the incident. Discussion and feedback of other groups. Facilitators guiding us on things we had not thought about. Code Gray was known very well. Knew that we needed to deescalate the situation. We had excellent group discussion for all the different. We know where to go for policies or resources. We had good dialog and knew what to do, and having the confidence to do the plans. I feel I know my codes fairly well and wouldn t hesitate in a Code Silver. I feel I know how to properly handle a mad family member and try to get the situation under control to help to protect our patients and their care. I fee over all this was a useful scenario to go thru. Calling security was first on the list. Staying calm and being non-threatening. Making no aggressive moves or force the person at any time. The staff at all levels is trained to acknowledge visitors. While being helpful to the visitor, it also allows staff to identify people who might be upset, don t belong in the hospital, or might otherwise become troublesome. Those taking part in the exercise were supervisory or management level and knew the overall policies of the hospital and what their response duties are. Nobody appeared baffled by the circumstances. All took the workshop seriously. Nobody appeared to be texting or holding side conversations. Very much engaged in the discussion. 13 Page
The policy that if something happens in the Emergency Department and you are not requests, stay away! The hospital staff was very engaged in the exercise. Several different hospital departments participated, which allowed for a well-rounded discussion about the policies, procedures and actions the staff would take. Gaps in the policies and procedures were identified. All team members collaborated well and were able to agree on multiple solutions to the challenges faced. Education on specific direct link contact with the New Smyrna Beach Police Department that was not understood. Identified problem areas within the facility itself that need to be addressed. Areas for Improvement Good plans and procedures, better education to all staff at all levels. All new employees are educated using RUN HIDE FIGHT videos. Increase use of technology to educate the staff on policies and procedure. Security is the responsibility of everyone. Communication of secured areas. Understanding of CODE LOCKDOWN. Schildecker and Tower Lobbies need panic buttons to notify the PBX operator. Notification system for all employees versus just leadership. Review of codes in annual net learning, what they mean and daily applicability. Review diversion policy. We need visitor identification, picture I.D.'s. Maybe visitor sticker or badge. Maybe scan driver license. We need to up our security, or relook at our security. At times they say can't leave desk or watching money being counted for example. Not good when we need them. We need to look at what their roles should be. Need to find the immediate threat to life policy. Weren't aware of it. Also need education on the Code Gray tearm so we know who that is. 14 Page
I feel we need a better system for checking people in and out of the hospital. Badges with names and faces and scan license to protect the employees and the patients. I feel our security officers could have more roles then they do. They aren't allowed to touch people nor do they have any sort of protection on them. There is always room for improvement on every aspect in anyone's work environment. I feel chains of commands and know who to call for certain things is something that can always be told again for a refresher. Remaining calm. Care for the others in the area. Better control on visitors, especially after normal business hours. This could include a requirement to sign in and be issued a visitor's badge. Perhaps too much reliance on a security officer, especially in light of the limitations placed on him / her by their contract. Two versions of the "red button" on the security officer's radio. One version says it goes to 911. Another version it goes to the police department. The police department is not staffed 24/7. It should go to 911. Mitigate termination troubles. 1. Notify the police department when multiple people are to be let go on the same day. 2. Identify people who may be troublesome or who have known personal financial issues (spouse recently lost their job, home foreclosed, etc.). 3. Have the security officer near, but not in the HR area. 4. Have the employee s supervisor oversee them collecting their personal belongings. The hospital relies on a texting system to communicate with leadership, however during nights and weekend s majority of leadership is not at the hospital. An extra step is needed to ensure all staff gets the emergency alerts. A general overview of all policies is needed in each department. Engage the hospital staff more often to ensure the safety policies are remembered always followed. Access to the facility is not well monitored. Volunteers, unlocked loading dock doors and minimal security camera placement. Understanding the use of the Code Silver; diversion process and procedure at the facility. Security force is under a contract that actually limits the ability of security to "touch" patient or visitors-other people. 15 Page
APPENDIX C: ACRONYMS Acronym Meaning COMM CONOPS ED EOC ESF IAP HICS IC ICS IMT JIC LOFR MOA MOU NIMS OPS PIO SitRep SOG SOP UC Communications Concept of Operations Emergency Department Emergency Operations Center Emergency Support Function Incident Action Plan Hospital Incident Command Incident Command Incident Command System Incident Management Team Joint Information Center Liaison Officer Memorandum of Agreement Memorandum of Understanding National Incident Management System Operations Public Information Officer Situation Report Standard Operating Guideline Standard Operating Procedure Unified Command 16 Page