SCPS Public Safety Webinar 01 | Mandala Collections

Hello everyone and welcome to the University of Virginia's Master of

Public Safety program webinar series on active shooter incidents in the

healthcare setting. This webinar is brought to you by the school of

continuing and professional studies. The title of this webinar is active shooter

incidents in the healthcare setting - collaborative planning. I'm Meghan

Stepanek and I'll be your presenter today. This is the first of three webinars. We

hope you take a look at each one to see the full scope of the content. In the

first webinar will discuss collaborative planning for active shooter incidents

and healthcare facilities with an emphasis on the requirements applicable

to response stakeholders, coordination of crisis communications and training, and

the second webinar will discuss the operational considerations for first

responders including what they need to know about the healthcare context and

the third webinar will discuss the operational considerations for

healthcare facility responders. An active shooter incident is an emergency you

hope would never happen anywhere and especially not in the communities you

serve and protect as first responders emergency managers and health care

workers. Nationally the increase in shooter incidents makes the scenario a

growing threat and a priority to address. It's a threat type that's hard to assess

before an actual incident happens - preparedness through collaborative

planning for active shooter incidents is the best way to build confidence and

response. Preparedness ensures people know what they need to do quickly to

implement plans that can save lives and mitigate damage. Health care facilities

are often a centerpiece of communities first responder agencies especially law

enforcement however new focus on community and stakeholder engagement as

reflected in the 21st century policing task force final report to the president

from May 2015. Leaders as well as line officers are

expected to be trained and ready to respond to new challenges such as

international and domestic terrorism, evolving technologies, and the growing

mental health crisis. Collaborative planning with healthcare entities for

active shooter incidents is a way to sharpen situational decision

making, public communication strategies, and crisis intervention capabilities.

This webinar will discuss how the planning problem is characterized. At the

conclusion of the session learners will be able to (one) identify emergency plan

frameworks and requirements applicable to healthcare entities, emergency

management, and first responder agencies to more effectively engage stakeholders

for plan development. (Two) identify strategies for the coordination of

crisis communications and public messaging and planning. and (three) discuss use

of the Homeland Security exercise an evaluation program or HCP framework to

Train test and exercise interagency actor shooter response plans for ongoing

improvement. Our first segment we'll begin by characterizing the planning

problem for active shooter incidents healthcare settings have long been

recognized by the Department of Labor Occupational Safety and Health

Administration or OSHA as experiencing higher rates of workplace violence than

other industries. For this reason the Joint Commission, an accreditation

organization for many healthcare entities encourages the tracking and

analysis of occurrences of violence to inform policies and prevention efforts.

In a survey conducted by the American Nurses Association 43% of nurses and

nursing students reported having been verbally and/or physically threatened by

patient or a family member of a patient. Health care workers in the emergency

department are frequent victims of violence perpetrated by visitors and

patients resulting in injuries, acute stress, and lost productivity. All forms

of workplace violence have negative consequences on workers ability to

perform their duties. In studies of nurses about workplace violence patient

related factors most commonly reported include mental health issues, anger

related to the patient's situation or condition, frustration with delays or

unfilled needs, pain, delirium, intoxication, and anger at staff members

related to enforcement of hospital policies. For violence

perpetrated by employees identifying the potential in advance to prevent an

incident may be difficult. Employee behaviors that are cause for concern

related to risk of an act of violence include depression or withdrawal,

repeated violations of company policies, explosive outbursts of anger or rage

without provocation, behavior that may suggest paranoia, talk of severe

financial problems, or talk of previous incidents of violence. As part of the

Department of Homeland Security's nationwide suspicious activity reporting

or SAR initiative public health and health care professionals are encouraged

to report potential criminal or non criminal activities that have a

potential terrorism nexus. While not all violence including active

shooter incidents are part of a systemic coordinated campaign some may be and

reports of suspicious activity may enable law enforcement to thwart an attack. In a

study by researchers Guralnik and Malls about threats of violence and

perceptions of health care, their findings indicated that more than half

of the public and professional respondents surveyed believed that

doctors and nurses have a special duty to protect patients. This perception of duty

is similar to that of police officers and firefighters to protect the public.

More than half of the public respondents also said that they would expect doctors

and nurses to put themselves at risk to try and protect them if they were a

patient unable to get out of harm's way. these respondents described what many

people perceive that a hospital is a place of healing, sanctuary, and comfort

both for those who seek care and those who provide it that must also promise

safety and security An active shooter scenario is a particular type of

violence. FEMA defines an active shooter as an

individual actively engaged in killing or attempting to kill people in a

confined and populated area. The incident is typically over within minutes

typically the perpetrator uses firearms, has unpredictable actions, follows no

pattern or method to their selection of victims, and will

continue to move throughout the building or area until stopped by law enforcement,

suicide, or other intervention. Taking a look at national data on active shooter

incidents, a study was conducted by Johns Hopkins of public reports of various

types of shootings taking place in the acute hospital setting. The study focused

on those shootings in the hospital from the year 2000 to 2011 that had at least

one injured victim. The results identified 154 Hospital related

shootings, with 235 victims injured or killed. The emergency department was the

most common site for a shooting to occur, followed by the parking lot and patient

rooms. Most events involved a shooter motivated by grudge, suicide, euthanizing

an ill relative, or a prisoner escape. This is a chart of FBI data on active

shooter incidents in all settings from 2000 to 2017. During this time period a

total of 250 incidents were reported that resulted in 2,217 people killed

and wounded. An overall trend is that incidents are increasing with only one

reported in 2000, and 30 reported in 2017. Additional information from the FBI

shows that while annual active shooter incident numbers have increased so have

the casualty numbers with only seven noted for 2000 and 720 in 2017. The pie

chart here is also from the FBI study of active shooter incidents in the U.S.

between 2000 and 2017. It shows the statistical breakdown of the location

categories where the 250 active shooter incidents took place. In this time period,

10 incidents occurred in health care facilities. 50 of the active shooter

incidents reported by the FBI as having occurred during the 2016 to 2017

timeframe were perpetrated by single shooters. Four of these 50 incidents

occurred in health care facilities resulting in seven killed and eight

wounded. All four shooter committed suicide before police arrived

at the scene. One incident occurred in a group home in Topeka Kansas. The

perpetrator used a handgun and killed three people. A second incident occurred

at Pine Kirk care center in Kirkersville, Ohio. There the perpetrator used a

shotgun and a handgun to kill two employees after taking two people

hostage and ambushing and killing a police officer. A third incident occurred

at Bronx Lebanon Hospital Center in New York. There a former employee killed and

wounded six others. In the second segment of the webinar we'll identify

emergency plan frameworks and requirements applicable to healthcare

entities, emergency management, and first responder agencies, including tips on

organizing plan development. Knowing the frameworks and requirements of the

stakeholders involved helps for identifying common ground and

understanding what motivates entities to engage in planning. Federal, state and

local government entities are charged with filing the National Incident

Management System or NIMS approach. NIMS is applicable at all jurisdictional

levels and across functional disciplines. NIMS is used in planning for all hazards

in accordance with the National Response framework as required to receive federal

funding assistance. As part of federal requirements jurisdictions across the

country have also organized their emergency plans and response using the

incident command system or ICS structure. ICS is used to identify the common

functional areas of command, operations, planning, logistics, and finance and

administration. The use of common titles as names for roles within these

functional areas is intended to make coordination easier for active shooter

incidents. The framework that local emergency management, police, fire and EMS

and others use is helpful for health care entities to know about in advance.

Emergency plans organized according to the NRF have emergency support functions

or ESF's with more detailed information to support the overall plan. These ESF's

are specific to topic areas for healthcare entities. Knowing what the

ESF's are and which agency is charged as the lead under the function can help in

identifying who needs to be involved in planned development for active shooter

incidents. The ESF's most likely to be relevant include ESF-5: information

and planning, ESF-8: public health and medical services, and ESF-13: public

safety and security. Depending on the incident needs other

ESF's could also be needed such as ESF-4: firefighting, ESF-6: mass care,

emergency assistance, temporary housing, and Human Services, ESF-7: logistics

and ESF-15: external affairs.For healthcare entities ,accreditation

organizations have long required them to adhere to emergency management criteria.

Additionally, in 2016 CMS issued the emergency management

final rule that applies to 17 different healthcare settings. For these healthcare

entity types compliance means the difference of whether they are able to

continue to bill Medicare and Medicaid and critical to their viability. The

following requirements apply under the final rule: development of an All Hazards

emergency plan that includes an assessment of risk, development of

policies and procedures related to the plan, development of a communication plan

that includes Public Health and emergency management as well as training,

and a testing program. OSHA also requires healthcare entity employers to have a

written emergency action plan or EAP. Employees are also required to meet

standards related to exit routes and to the documentation of planned employee

actions. These requirements are relevant to active shooter scenarios in that

they relate to the same issues to be addressed in emergency planning efforts.

Some health care facilities receive federal preparedness monies such as

those available through the Department of Health and Human Services, Assistant

Secretary for preparedness response's hospital preparedness program. Like local

government entities they are urged to use a common

framework for response that is analogous to ICS - the healthcare incident command

system - or Hicks. it's important for outside response agencies to know about

this in planning. In response it also helps them to better identify their

counterparts for the appropriate level of interface and clarity on who has

decision-making authority. it's important that healthcare entities understand that

when the threat of an active shooter exists law enforcement is in charge and

serves as the lead decision-maker, however given the many life safety

issues in the healthcare setting the law enforcement incident commander will need

to have clear input from the healthcare entities command depending on the

complexity and the phase of the active shooter incident utilizing an unified

command with more than one incident commander may be necessary. In the third

segment we'll identify strategies for coordination of crisis communications

and public messaging and planning. The joint information system or JIS concept

from FEMA is part of NIMS. It provides a framework for the provision of timely,

accurate, accessible, and consistent messaging across multiple jurisdictions

and disciplines. if feasible based on the incident circumstance,

A JIS can be set

up in a central location as a joint information center or JIC. This

facilitates face-to-face communications to improve messaging coordination. Health

care entities often have a person or a team assigned to communications.

Communications planning as part of the CMS requirements mentioned earlier:

government entity first responders often have a public spokesperson or public

information officer known as a PIO assigned by the agency or under the

local government. the respective PIOs work together with healthcare entity

communication reps in a JIS. Communications plans include messaging

through the media, as well as through various avenues to the public employees

and other response stakeholders for media engagement. It's important to

identify a location for staging and briefing as well as a cycle of when the

briefings will occur. Assigning someone from incident command

to monitor news coverage of the incident helps ensure accuracy of coverage.

Feedback can be immediately provided to media contacts, as corrections can have a

safety consequence. For example, whether clinics remain open or closed, or

information about perimeter control. Members of the public, including family,

colleagues, friends, and others who are displaced during the incident may be at

the scene of the health care facility. These people will need a safe place to

assemble while the incident response is active, and in the recovery phase once a

location is identified. Messaging to this place will need to occur to keep

everyone informed about the incident status. For messaging to employees,

pre-planning how various communication systems will be used helps set

expectations for alerts and notifications. Ongoing communications

with employees, after the initial notifications, ensure that employees have

situational awareness in performing their response roles. Employees will also

need to know how to report information to command that can help control the

incident. All the response communications to stakeholders and healthcare entities

will also be necessary. The incident could have an impact on other sending

and receiving health care facilities accordingly they will also need to

receive an initial alert and ongoing communications. While communicating about

the incident, especially victims, it's important to consider privacy laws. Many

health care entities are subject to the Health Insurance Portability and

Accountability Act, or HIPAA, as well as other state-level laws that govern

medical information privacy. Planning for active shooters should include what

identifying information about patients can be shared with the public and with

law enforcement. Under HIPAA exceptions exist for disclosure of directory

information to the public. Certain other shares are also

permissible when made to law enforcement. Consulting with your legal counsel as

part of pre-planning will help to clarify what data elements can be

lawfully shared. In this final segment we'll discuss the use of

FEMA's homeland security exercise and evaluation program or HSEEP framework to

train, test, and exercise interagency after shooter response plans. Training

employees on emergency plans, testing communications and other equipment, and

exercising is the best way to improve real-world response. The HSEEP cycle

framework can also be helpful for establishing a common approach with

stakeholders. Many HSEEP training tools and templates exist that mesh with the

National Response framework plans and structures. Health care workers involved

in quality improvement will recognize the similarities with the plan, do, study

act ,or PDSA of the Institute for Healthcare Improvement model. Like the

PDSA cycle the HSEEP cycle accelerates advancements through planning corrective

actions, building capabilities, and maintaining readiness. For active shooter-

specific tools, planning guides, and exercise ideas, take a look at these

resources. The references shown on these slides were utilized in developing

the content for this webinar. These sources include those from government,

healthcare, academia, nongovernmental organizations, industry publications, and

news media. We hope this webinar will spark your interests in UVA's Masters of

Public Safety program. We encourage you to take a look at the website to find

out more about the learning opportunities and available resources

from the program, and through the School of Continuing and Professional Studies

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