Session 14 Tabletop Exercise Design By Myra Socher

Session 14 Tabletop Exercise Design By Myra Socher 1

Objectives • Demonstrate an understanding of the Homeland Security Exercise Evaluation Program (HSEEP). • Demonstrate an understanding of the need for conducting Tabletop Exercises (TTX) and their role in the exercise continuum. • Demonstrate the ability to design, conduct and evaluate a TTX. • Discuss the different formats that can be used when developing a TTX and the accompanying benefits and pitfalls. Session 14: Catastrophe Readiness and Response Course 2

HSEEP • Department of Homeland Security (DHS) was directed by HSPD-8 to coordinate with other Federal departments and agencies to establish a “national program and multiyear planning system to conduct homeland security preparedness-related exercises. ” • The Homeland Security Exercise and Evaluation Program (HSEEP) is a capabilities and performancebased exercise program that provides a standardized methodology and terminology for exercise design, development, conduct, evaluation, and improvement planning. 1 It constitutes a national standard for exercises. Session 14: Catastrophe Readiness and Response Course 3

We must apply the elements of HSPD-5 • To enhance the ability of the United States to manage domestic incidents by establishing a single, comprehensive national incident management system (NIMS). • Ensure that all levels of government have the capability to work efficiently and effectively together. • Cooperate in an acronym-free environment where we all talk the same language. Session 14: Catastrophe Readiness and Response Course 4

Preparedness Cycle • This is defined as “planning, training, equipping, exercising, evaluating, and taking action to correct and mitigate. ” • The plan, train, exercise & evaluate formula will use the after action report to update Emergency Operation Plans (EOP)s; modify training plans; and prepare for the next exercise or all hazards incident response. Session 14: Catastrophe Readiness and Response Course 5

Exercise Phases Session 14: Catastrophe Readiness and Response Course 6

Why have exercises? • Well-designed and well-executed exercises are the most effective means of: – assessing and validating policies, plans, procedures, training, equipment, assumptions, and interagency agreements; – clarifying roles and responsibilities; – improving interagency coordination and communications; – identifying gaps in resources; – measuring performance; and – identifying opportunities for improvement. Session 14: Catastrophe Readiness and Response Course 7

Exercise Types • Discussion-Based Exercises – – Seminars Workshops Tabletop Exercises Games • Operations-Based Exercises – Drills – Functional Exercises – Full Scale Exercises Session 14: Catastrophe Readiness and Response Course 8

Building Block Approach Crawl-Walk-Run Session 14: Catastrophe Readiness and Response Course 9

More Intense Pressure for Catastrophe Scenarios • Ensure that in the framework of a catastrophe, the players are overwhelmed and under extreme pressure • This can be achieved by: – – An initial long period of little or no response; No rapidly available mutual aid; Creating a sense of isolation; The loss of many colleagues - first responders and coordinating personnel; – Resultant issues of concerns about one’s own family and the families of responders and emergency management personnel; – Applying mental health stressors to both casualties and responders alike. Session 14: Catastrophe Readiness and Response Course 10

Exercise Components • Planning Conferences • Design and Development – – Capabilities, Tasks, and Objectives Scenario Documentation Logistics • Exercise Conduct Session 14: Catastrophe Readiness and Response Course 11

Exercise components (2) • Evaluation – Hot Wash and Debrief – After Action Report / Improvement Plan • Improvement Planning – Improvement Plan – Improvement Tracking and Planning • Lessons Learned and Best Practices – https: //www. llis. dhs. gov/ Session 14: Catastrophe Readiness and Response Course 12

Exercise Planning Team • Determine objectives and what a scenario should cover. • Develop the scenario and accompanying documentation. • Team should be a manageable size with each member having a manageable span of control for their area of responsibility. • Structure along ICS principles – Command role – Team leader – Planning, Logistics, Finance & Admin, Operations • Define roles and responsibilities. • These are “trusted agents” so cannot be players too. Session 14: Catastrophe Readiness and Response Course 13

Stakeholder Participation • Identify a wide range of stakeholders to create a useful exercise : – representatives from all first responder disciplines – representatives from volunteer or non-governmental organizations, such as Citizen Corps Councils and the American Red Cross – representatives from important private sector entities – Federal, state, local, and tribal officials. • Buy-in is essential for coordinated response. Session 14: Catastrophe Readiness and Response Course 14

Planning Timelines • Establish timeframes for exercise milestones to include: – – – Planning conferences Training Exercise conduct After action reporting Improvement planning. • Needs to be consistent with Multi-Year Training and Exercise Plan. Session 14: Catastrophe Readiness and Response Course 15

TABLETOP EXERCISE PLANNING TIMELINE Planning Description Conferences Concept and Objective Meeting Prior to the Exercise Identifies the type, scope, objectives and Prior to or purpose of the exercise concurrently (C&O) with the Initial Is typically attended by the sponsoring Planning agency, lead exercise planner and senior Conference officials Initial Planning Conference (IPC) Lays the foundation for exercise Three Months development Gathers input from the exercise planning team on the scope, design, objectives, scenario, exercise location, schedule, duration and other details required to develop exercise documentation Assigns responsibility to planning team members Final Planning Conference (FPC) Uses a forum to review the process and Six Weeks procedures for exercise conduct, final drafts or exercise material and logistical requirements Ensures no major changes made to design or scope of the exercise or to any supporting documentation Session 14: Catastrophe Readiness and Response Course 16

Design & Development • Capabilities, tasks, and objectives are the core components of design and development. • Each capability has specific tasks associated with it that should be identified and validated during the exercise. • These capabilities and tasks are derived from the Target Capabilities List (TCL) and Universal Task List (UTL). • We use them to formulate the exercise objectives, which will reflect the special needs of the organization. Session 14: Catastrophe Readiness and Response Course 17

Design & Development (2) • Well-defined objectives provide a framework for scenario development. • Use objectives that are (SMART) simple, measurable, achievable, realistic, and taskoriented. • Exercises designed for a catastrophic event will stress the players far more than those designed for a disaster. Session 14: Catastrophe Readiness and Response Course 18

The Scenario • This provides the backdrop and storyline that drives the exercise – think of it as the “spine” around which the “body” is built. • Identify the hazard to be used – suggest using the 15 national planning scenarios as a guide. • Realism is critical to engaging the participants. • Tailor the exercise to the community where it is being held. Session 14: Catastrophe Readiness and Response Course 19

Documentation • Situation Manual – SITMAN • Exercise Evaluation Guide • Participant Feedback Form Session 14: Catastrophe Readiness and Response Course 20

SITMAN • Provides background information. • Contains the scenario information. • Allows participants to read along during the multimedia/facilitator presentations. • All participants and observers should receive a SITMAN prior to STARTEX. Session 14: Catastrophe Readiness and Response Course 21

SITMAN (2) • Introduction gives exercise overview: – – – – Scope Capabilities Tasks and objectives Structure Policies Rules Exercise Conduct Agenda. • Next section is scenario. Session 14: Catastrophe Readiness and Response Course 22

SITMAN (3) • Scenario is divided into modules. • Chronologically sequenced. • Each module represents a specific time segment e. g. – – Warning or intelligence Notification Response Recovery • Exercise evaluation guides – Each linked to a target capability. – Enable evaluators to collect exercise observations – Provide the information used to complete the After Action Report and Improvement Plan (AAR/IP). Session 14: Catastrophe Readiness and Response Course 23

Logistics • Often overlooked but very important – can make or break an exercise: – – – Appropriate size meeting room with sufficient seating Food and refreshments Audiovisual equipment Supplies for note-taking and facilitation Registration table with sign-in, name tags. • It’s important that all participants wear some form of identification. Session 14: Catastrophe Readiness and Response Course 24

Evaluation Process 1. Exercise evaluation guides – sometimes called evaluation plans – are a tool to provide information for the After Action Report/Improvement Plan (AAR/IP). 2. Hot Wash – allows participants to provide immediate feedback for input to AAR/IP and can occur in functional break-out groups, plenary group or both. 3. Debrief – more formal forum for planners, facilitators, controllers and evaluators to provide feedback. 4. AAR/IP – documents following HSEEP format, provided to whoever conducted the exercise. Session 14: Catastrophe Readiness and Response Course 25

AAR/IP (continued) • AAR provides feedback to the participating entities on overall performance and capabilities. • It summarizes exercise events and analyzes performance of critical tasks that are pre-determined. • Evaluates achievement of exercise objectives. • The IP provides corrective actions for improvement with timelines for implementation and assignment to responsible people. • The IP converts lessons learned into concrete measurable steps to improve response capability. Session 14: Catastrophe Readiness and Response Course 26

Tabletop Formats • Can use: – Breakout groups (usually according to function e. g. fire, medical, law enforcement) – Plenary sessions – Combination of both. • Pros and cons to both • Sometimes physical space will drive format – are there areas to “break-out”? Session 14: Catastrophe Readiness and Response Course 27

Facilitation • A plenary group requires one or two very strong facilitators who can control a large group. • The pitfall is that some participants may be “take charge” while others are reticent. A good facilitator will overcome this and draw out the shy ones while not offending the stronger players. Session 14: Catastrophe Readiness and Response Course 28

Facilitation (2) • Break-out groups will require a larger number of facilitators skilled in the various disciplines. • Once the groups re-convene to report back on their findings the plenary group format will be followed. • Plenary groups allow for more cross-fertilization of ideas. Session 14: Catastrophe Readiness and Response Course 29

Common Features • Group problem-solving • Critical issues related to senior officials’ responsibilities • Group message interpretation is examined. • Participants share information within functional areas and between groups. Session 14: Catastrophe Readiness and Response Course 30

The Discussion Questions • While the scenario is the “spine”, the questions used by the facilitators to drive the discussion constitute the “cerebral cortex. ” • The appropriate selection of questions is critical for: – Drawing out the participants – Achieving the end product. Session 14: Catastrophe Readiness and Response Course 31

The End Product • Evaluation is the cornerstone of exercises. • It will provide an indicator of the overall level of preparedness – what works, what doesn’t and how to fix it. • Lessons learned will provide mechanisms for improving existing plans. • The early interaction between participants creates relationships which will be critical to a coordinated response during a real event. Session 14: Catastrophe Readiness and Response Course 32

Exercise Tips • A good exercise is like a Broadway show: – It’s well choreographed with something for everyone. – You walk out of it feeling better than when you went in. – It leaves you with food for thought. • Humor is an essential component: – An exercise is a dry run. – Most of us only get one shot at a catastrophic event. – We need to do it right the first time! Session 14: Catastrophe Readiness and Response Course 33

Exercise Tips (2) • Exercises are like Lego for Adults – Planning, dialogue and integration are key components. – Block by block we have to build the essential components of the response initiative. – All the pieces need to fit to make it work well. – It’s a game with serious implications. Session 14: Catastrophe Readiness and Response Course 34

What constitutes a beneficial tabletop exercise? • A scenario which realistically sets the scene & provides appropriate discussion points • Providing a forum to get to know one’s partners & develop relationships. • Integrating the different disciplines and uniting the military with the civilian communities, both private and public sectors. • Allowing the participants to problem solve and to identify strengths & areas for improvement. Session 14: Catastrophe Readiness and Response Course 35

An example of what constitutes a questionable/dangerous exercise • A county commission meeting was interrupted by three men and a woman with guns drawn and claiming to take hostages. • One man threatened to detonate a bomb with the device he was holding and another fired a shot (turned out to be a blank). • As the meeting dissolved – the director of EMA announced that it was “only a drill”. • The city police were not aware of the drill and responded to what they thought was a real hostage situation – could have had a serious outcome. Session 14: Catastrophe Readiness and Response Course 36

Anthrax Tabletop Exercise Session 14: Catastrophe Readiness and Response Course 37

Participant Introductions • Moderator and facilitators • Federal partners • State partners • Local agencies: – – – Public health Hospitals Fire, rescue Law enforcement NGOs • Observers Session 14: Catastrophe Readiness and Response Course 38

Agenda Registration Welcome and Overview Introduction Module 1 Module 2 Working Lunch Module 3 Hotwash Session 14: Catastrophe Readiness and Response Course 39

Primary Objectives • Create a quality learning environment. • Identify key essentials for an integrated response. • Evaluate effectiveness of incident command system, policies, procedures and roles and responsibilities. • Provide a forum for discussing response issues. • Identify strengths and areas for improvement. Session 14: Catastrophe Readiness and Response Course 40

Rules for Players • Relax – you are in a no-fault, low stress environment. • Respond based on your current capability. • Interact with other breakout groups (if used). • Allow for artificialities of the scenario – it’s a tool and not the primary focus. • Feel free to improvise – think outside the box. Session 14: Catastrophe Readiness and Response Course 41

Two Options are presented for an Anthrax Scenario • The first focuses on the Bio. Watch program where filters are collected daily and assayed for certain pathogens – this will alert to an attack within a reduced time frame. • http: //www. cidrap. umn. edu/cidrap/content/bt/bioprep/new s/biowatch. html • The second is much more covert with symptomatic patients presenting to doctors offices and hospitals – more of a puzzle and more challenging to the participants who must identify the agent. • Select the option most suited to the sophistication level of the players. Session 14: Catastrophe Readiness and Response Course 42

Commonalities • Both scenarios will involve the prophylaxis and treatment of large numbers of patients. • There will be activation of the Strategic National Stockpile and other federal assets to assist state and local entities. • Resources will be scarce due to the overwhelming numbers of people descending on hospital emergency departments and doctors’ offices. • Additionally there will not be enough critical care beds and ventilators. • Mass fatality management will be needed. Session 14: Catastrophe Readiness and Response Course 43

Commonalities (2) • Adjustments to standard of care will be needed and necessary legal authorities will need to provide oversight to ensure maximum care with limited resources is available to as large a sector of the population as possible – triage will become critical. • Activation of federal teams – DMATs, DMORTs, etc will be needed and decisions will need to be made at the federal level on how best to apportion these. • At the local & regional levels the Metropolitan Medical Reserve Systems, Medical Reserve Corps and Citizen Emergency Response Teams will be activated. Session 14: Catastrophe Readiness and Response Course 44

What is the CRI Program? • The Cities Readiness Initiative (CRI) is a federally funded effort to prepare major US cities and metropolitan areas to effectively respond to a large scale bioterrorist event by dispensing antibiotics to their entire identified population within 48 hours of the decision to do so. • It focuses on a covert outdoor release of aerosolized anthrax covering a large geographic region. • It was a pilot program started in 2004 with 21 cities that has grown to 72 cities – at least one for each state. Session 14: Catastrophe Readiness and Response Course 45

Scenario One • On Day One the Bio. Watch filters in Los Angeles, the District of Columbia, New York City and Chicago are picked up and sent for analysis. • That evening the Centers for Disease Control schedule multiple conference calls to contact all four area city and state labs. • A “PCR verified positive for Anthrax” of multiple filters collected across the four city areas is declared. • The National Operations Center is notified and the CDC sets up a bridge conference call for H+2 (two hours after initial notification) to discuss the dispatch of the SNS to affected areas. • The cities affected will implement their CRI plans Session 14: Catastrophe Readiness and Response Course 46

How did this Happen? • The previous day (Day 0) specially fitted flat-bed trucks enter the cities in question towards the end of morning rush hour. • A concealed spraying device aerosolizes a Bacillus anthracis slurry • This potentially exposes upwards of 330, 000 individuals (in each location) which is likely to result in approximately 13, 000 cases per city of inhalational anthrax Session 14: Catastrophe Readiness and Response Course 47

Scenario 2 • Instead of Bio. Watch filters quickly being used to identify the existence of anthrax in the communities, use the following model based on the same release in four major cities on Day 0: – Emergency departments and doctors’ offices are experiencing a large upsurge in patients with fever and respiratory complaints (would occur between 2 - 10 days after exposure). – Some patients are initially hospitalized with pneumonia diagnosis. – Businesses are experiencing increased call-in of sick employees. – Schools and universities also have increased absenteeism. – Rapid flu tests are negative. – Sentinel physician reporting system for influenza-like illness identifies increase in respiratory illness and absenteeism. Session 14: Catastrophe Readiness and Response Course 48

Exercise Format • This is an interactive facilitated tabletop exercise with three modules – recognition; response and system surge; and recovery. • There are breakout group sessions after the first two modules, which are both followed by a moderator facilitated discussion with each breakout group reporting back on the actions taken. • After the third and final module there is a facilitated plenary discussion with all participants. • A Hot Wash is the final component of the exercise followed by completion of an participant evaluation form. Session 14: Catastrophe Readiness and Response Course 49

Scenario 2 Module One Recognition 50

Day Two at 7: 30 pm • Emergency departments throughout all four cities (New York, Washington DC, Chicago and Los Angeles) have been much busier than usual. • Last week the CDC had announced an early start to the flu season and urged high-risk individuals to get flu shots. • Emergency departments had seen several cases of flu-like illness over the past two weeks. Session 14: Catastrophe Readiness and Response Course 51

Day Three at 11: 00 am • Volume of patients transported by EMS and those presenting to the ED complaining of flu-like symptoms, especially upper respiratory ailments continues to increase. • Hospital staff are starting to call in sick. • They are discussing this abnormally high number of patients, even with the early flu season. • Isolation rooms are full as patients with similar symptoms continue to present to the hospital EDs across the cities. • Patients are lined up on gurneys in the hallways. Session 14: Catastrophe Readiness and Response Course 52

Day Four at 1: 00 pm • All area emergency department and outpatient treatment areas continue to be inundated with persons seeking care and attention. • Security measures have been initiated as waiting patients become more and more unruly. • Patients are being told about the long wait times and that efforts are being made to seek alternative sites for their evaluation and treatment. Session 14: Catastrophe Readiness and Response Course 53

Day Five at 9: 00 am • The health department in Los Angeles is notified by a Hospital X that patients’ blood cultures are growing gram positive rods. • They contact the CDC who immediately puts out an alert on the HAN. • Shortly thereafter the CDC is inundated with calls from hospitals in all four affected cities. Session 14: Catastrophe Readiness and Response Course 54

Day Five at 4: 00 pm • Reports of potential shortages of antibiotics have resulted in hordes of people seeking out their primary care physicians, clinics and emergency departments throughout the area. • There are long lines outside many facilities. • News crews are camped outside all major healthcare facilities with all major local and national news networks broadcasting round-the-clock information. • Subject matter experts are speculating on the type of anthrax and are wondering if this is connected to the 2001 incidents at post offices, Capitol Hill, TV stations, etc. Session 14: Catastrophe Readiness and Response Course 55

Scenario 2 Module Two Response & Surge 56

Response Activities • Asymptomatic patients flood healthcare facilities, further straining medical resources. • Healthcare providers struggle to deal with the sick and worried; mutual aid agreements are enacted. • Law enforcement is dispatched to medical facilities to control the crowds. • Some news commentators question the capacity of local agencies and hospitals to handle the situation. Session 14: Catastrophe Readiness and Response Course 57

Response Activities (2) • EOCs in Los Angeles, Chicago, New York and Washington DC are activated; notifications are made to the State Emergency Management Agencies of all four cities. • Public health and emergency management agencies are working together with hospitals and other nongovernmental organizations to address regional surge capacity needs. • There are frequent mayoral press briefings to address public concerns, provide safety recommendations and minimize impact of the worried well on hospitals. Session 14: Catastrophe Readiness and Response Course 58

Government Agency Response • Local and state health departments declare public health emergencies. • The governors of all four affected states declare a state of emergency and request resources from the Federal Government. • The health departments are maintaining provider and public hotlines, and continuing active case surveillance, regular health alerts and daily hospital conference calls. Session 14: Catastrophe Readiness and Response Course 59

Federal Government Response • Federal agencies scramble to mobilize resources for deployment to the affected areas. • The National Disaster Medical System is activated. • The SNS is dispatched to the affected areas. • DHHS notifies the World Health Organization of the confirmed inhalational anthrax patients. • DHS and FBI start investigation into the release of the anthrax which is deemed to be an act of terrorism. Session 14: Catastrophe Readiness and Response Course 60

Response Considerations • Exposed population will disperse widely before the incident detected. • Notify airlines, trains and bus transport. • Severity of this many casualties in four major cities meets the criteria for a catastrophic public health emergency. • Traffic control, protection of special populations, protective measures and public information are pivotal. • Although there is a high mortality rate there is no person to person spread. Session 14: Catastrophe Readiness and Response Course 61

Response Considerations (2) • Coordination will have to occur at local, regional, state, federal and international levels. • NIMS must be used to ensure competent incident management. • JIC will coordinate mass notification. • It will be an invaluable tool with so many different sites involved. • Public Health and ESF-8 is lead agency. Session 14: Catastrophe Readiness and Response Course 62

Scenario 2 Module Three Recovery 63

Recovery Issues • Need plans for long-term health monitoring and care – both for signs of anthrax as well as mental health issues. • Memorial services and public observances will be needed in remembrance of the victims of the attack and to bring closure to families. • The economy, already in a downswing, will be heavily impacted by this new blow; many businesses in affected areas will close, and large locally based companies will relocate elsewhere. • Physical and mental health of the survivors, including first responders, will be a major concern. Session 14: Catastrophe Readiness and Response Course 64

Recovery Issues (2) • What are long term environmental effects? • How will this affect future tourism in the four cities? • Will there be an aversion as was seen with the Brentwood Post Office which remained closed for a long period? • EPA will coordinate clean up and site restoration. Session 14: Catastrophe Readiness and Response Course 65

Recovery Issues (3) • City services will be disrupted. • People will fear the outdoors and will either leave or remain in their homes. • What will need to be done to restore the healthcare delivery system? • How long will it take for supplies in the SNS to be replenished? Session 14: Catastrophe Readiness and Response Course 66

Example Facilitator Questions • Need to consider command, control and communication issues: – Vertically; and – Horizontally. • Public Information – notification & messages. • RSS – receipt, storage and stage – warehouse for Strategic National Stockpile assets. • Security (local, state and federal efforts) of inventory & distribution sites. Session 14: Catastrophe Readiness and Response Course 67

Example Facilitator Questions (2) • Establishing Quick Delivery Centers (QDC)s or Points of Dispensing (POD)s to distribute antibiotics with consideration for: – Critical service workers/first responders – Institutional delivery – Special populations. • QDC/POD sub-components to be considered – – Staffing Sites Delivering Forms, signage & interpreters. • How to manage mental health problems. Session 14: Catastrophe Readiness and Response Course 68

Example Facilitator Questions (3) • Delivery of medications: – Institutions – Where hospitals fit in the picture – Postal Plan • How do you handle: – Special needs populations – Homeless – Non-English speaking. • Role of the DOD – JF-HQ request for meds – Military does not always have its own cache. – They will operate either as members of the civilian population or as institutional sites. Session 14: Catastrophe Readiness and Response Course 69

Example Facilitator Questions (4) • How to expand existing bed capability: – Use of Community Care Centers – Use of Alternate Care Facilities – Deployment of Federal Medical Stations. • Treatment Center Coordination • If an announced attack, how does shelter-in-place impact the CRI process? • What decontamination and remediation is needed? • How do you ensure continuity of operations (COOP)? Session 14: Catastrophe Readiness and Response Course 70

Example Facilitator Questions (5) • What kinds of environmental sampling need to be done? • Have we overlooked anything else you would like to discuss? Session 14: Catastrophe Readiness and Response Course 71

Hot Wash • What have you learned during this tabletop exercise? • Name five organizational strengths. • Name five organizational weaknesses / gaps. • What should the next steps in preparedness be? • List and prioritize five short and five long-term actions for follow-up. • Any other things you’d like to add? Session 14: Catastrophe Readiness and Response Course 72