Healthcare

Virtual Exercises: They're the Real Thing!

by Joseph Cahill
By Joseph Cahill, jcahill@domprep.com

The Oxford English Dictionary defines a system as “a set of things working together as a mechanism or interconnecting network.” There are many such systems in the public health world, and throughout the nation’s private sector in general.

To begin with, there are entire groups of hospitals – sometimes within the same geographic area, sometimes not – bound together by a common ownership. Similarly, there are numerous schools – primary schools, middle schools, and high schools – within the same school district. The typical county or city government has a number of different agencies, headquartered at and/or working out of different locations, that are bound together primarily by the fact they are all working for the same constituency of citizens.

For a number of reasons, including but not limited to “ownership” (however that term is defined), matters affecting many if not all of the system components or facilities (e.g. hospitals, schools, government facilities, and the like) in the same group require common planning and, frequently, common use of the same emergency resources. This of course adds another level of complexity to any program of drills and training exercises that might be planned to deal with domestic-preparedness or other emergencies. It goes without saying that each individual school or facility must exercise its own emergency plans. In addition, the entire system – of schools, agencies, hospitals, etc. – also should be exercising as a group.

At a minimum, all of these exercises, and the emergency plans they are testing, and sometimes challenging, should help determine how the individual components of the system communicate and connect with one another. Or, of perhaps greater importance, how they do not communicate and connect. Such exercises, frequently if not always, are not only complicated but also rather expensive.

Connectivity and Continuity Traditionally, there has been a clear dividing line between full-scale exercises and what are called tabletop exercises. The latter are valuable as a development or teaching tool, and can be used, by representatives of the agencies involved in the plan, to run a draft plan through its paces.

A virtual tabletop is an exercise that is designed and run as a tabletop, with many if not all of the participants at different locations, however – but closely connected by the miracles of modern communications.

The principal value of this type of exercise is in testing the connectivity between system components. Instead of simply saying that a message will be sent to another component of the same system, that message really is sent. This approach tests the actual communications technologies – and the operator’s knowledge of them – rather than just the written plan itself.

One example of how this would work would be when a hospital system decides to test a written emergency plan – more specifically, a plan that involves both the communications system and the business-continuity response teams. One option would be to carry out an extensive (and costly) functional exercise that takes emergency-team personnel from their day-to-day tasks and requires them to assume the roles they would play in a real emergency. Doing this would mean that the vacancies thus created would have to be backfilled with overtime staff. This has a great deal of value, but may not be practical at all times, and testing these aspects of the emergency plan may not always be desirable.

Another possible option would be to carry out a traditional tabletop exercise in which the participants gather in the same room and run through a scenario. In this simulation, the participants would be provided an introductory story line and then asked what they would do in response. Additional information would be provided by the moderator from time to time as and when needed, and various components of the plan would be verbally activated. This interplay could continue back and forth for a considerable period of time, moving through an entire plan.

A Realistic Scenario and Credible Time Line In today’s era of tight budgets and rising populations hospital administrators are more and more reluctant to take staff off-line even for something as important – and, frankly, as mandated both by law and by common sense – as emergency planning and training.

This brings up yet a third option – namely, to schedule an exercise that straddles the two extremes previously discussed. This option is particularly well suited for a system in which there are a number of separate facilities run as independent entities, but operating under a common upper-level management structure. The common denominators here are the multiple locations, with distinct command structures for each facility in the system, and a common upper level of management that typically carries out most of its management tasks through a middle management layer.

Rather than requiring the managers of each facility to gather in a central location for a tabletop exercise, a virtual tabletop can be used –at least to test the communications plan for the system. This would require the development of a realistic scenario, preferably created by the members of an experienced development team (often referred to as trusted agents) who are familiar with the system emergency plan.

In addition to knowledge of the plan, the trusted agents must possess a broad enough base of knowledge to foresee the impact of various events in the scenario. In the example cited, it would help if at least one of the trusted agents knows which communications pathways would or would not work during a power outage, and what backup power is available. The trusted agents should not take part in the exercise, because they already know what is coming next. However, they may be useful as evaluators/controllers.

The scenario should include not only the initial status quo but also a credible time line that provides the testing of “injects” of various types at some if not all of the facilities participating.

This virtual scenario structure does not vary substantially from that of the traditional tabletop. It provides, however, a simpler and less costly method for conducting the actual exercise. The participants would report to the same work locations they do in a normal workweek.

Ideally, the beginning scenario should start in one of the facilities that, according to the story line, are dealing with a deviation from its normal workday operation – perhaps an increased patient flow, or a local crisis, such as a power outage at one of three facilities in the system being tested. In this example, the exercise controller(s) would provide information about the initial scenario by phoning a participant, from an appropriate level of management, who represents the affected facility.

Again, more specifically: In the example cited, the scenario would start with a call to the administrator of the hospital directly affected. It is important to stress in all messages that “this is a drill” and make this clear to all who hear or read it. Although a power outage would be readily apparent to the manager if it were really occurring, many other types of emergencies would not be quite so apparent. The last thing that an emergency manager needs is to start a panic similar to that caused by Orson Welles in his famous but fictitious 1938 “War of the Worlds” radio broadcast.

The Strength of a Well-Scripted Scenario Equally important is that the controller tells the manager who is first contacted the scope and extent of play that has been established for the exercise – including, for example, the levels of management involved, theentities of the other players, and the instructions they have been given. The most important instruction, however, is that they should use any type of communications that are available to them. It is imperative that this part of the scenario be well scripted and delivered so that the managers participating know that they are not expected to be going it alone.

The controller should continue stating, “This is a drill” – and also should continue to explain that the facility has lost power. This is the point where the real strength of this type of exercise becomes apparent. The first critical action that must be evaluated is how the information that there has been a loss of power is conveyed, and to whom. Here there are several questions that must be answered, including but not limited to the following: Does the first manager who was given the initial scenario contact upper-management decision makers? Do they in turn call the system’s emergency team together? Or, perhaps, do they try to solve the entire crisis by themselves? More generally, do they take the notification actions that have been prescribed in the plan being tested? How do they react to communications failures?

The fact that they are in their normal work facilities and have been expressly instructed to use the forms of communications available to them forces them to test those means of communications. This situation might be compared to what a manager might do sitting at his or her desk and dealing with a crisis by contacting others. Phones that are assumed to be available may not be; or they may not work. Such information would be invisible in the traditional tabletop exercise, but readily apparent in the virtual tabletop.

As various injects present problems to the players, they should pass information and requests for action to other players to solve the problem rather than giving their responses to the controllers. In this way the action progresses in much the same way it would during a real crisis – i.e., over the phone. In this example, the end result would be that the affected facility either restores power or moves its patients to a safe location.

As play progresses the scenario injects may be presented to any of the participating managers. This distribution of tests and challenges would allow the play to progress as the action probably would in reality, and would permit as much of the communications infrastructure to be tested as possible.

This type of exercise is particularly relevant to the flow of communications. Its strength is that the participants cannot rely on one another’s reactions to gauge the correctness of their own actions, nor can they overhear information that they would not actually know in a real emergency. The fog of war becomes a real player in this type of exercise. The only way that information can or should flow in this type of exercise is when the participants move it through a viable channel.

Finally, because the system’s real communications routes are forced into use, their real effectiveness is shown. If they do not actually work, or if –for any of a number of other reasons – it is not possible to use them, the information stays put, and this becomes painfully evident to all involved.

That, of course, should lead to remedial action as soon as possible – which validates the requirement for the exercise and makes the final outcome not a partial failure but an actual success.