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Date ArticleType
9/5/2018 Regulatory
Making it Count!

Tabletop exercises, full-scale exercises, and real-life emergencies and the required documentation

When participating in a tabletop exercise the facility will need to: 

1)       Be an active participant – Certificate of attendance

2)      Refer to their own Emergency Preparedness plan, if not part of the tabletop exercise

3)      Demonstrate that they have incorporated any necessary improvement, if required

4)      Complete an AAR = (After Action Report) noting any changes, discussions, improvements, etc

5)      Training on changes if necessary

6)      Keep documentation of the AAR and the Action Plan for improvement and give the facility credit in the QAA – QAPI Committee

The following includes a portion of Appendix Z:

Each facility is responsible for documenting their compliance and ensuring that this information is available for review at any time for a period of no less than three (3) year.  Facilities should also document the lessons learned following their tabletop and full-scale exercises and real-life emergencies and demonstrate that they have incorporated any necessary improvements in their emergency preparedness program.  Facilities may complete an after-action review process to help them develop an actionable after-action report (AAR).  The process includes a roundtable discussion that includes leadership, department leads and critical staff who con identify and document lessons learned and necessary improvements in an official AAR.  The AAR, at a minimum, should determine the following:

1) what was supposed to happen;

2) what occurred;

3) what went well;

4) what the facility can do differently or improve upon; and

5) a plan with timelines for incorporating necessary improvement

Lastly, facilities that are a part of a healthcare system, can elect to participate in their system’s integrated and unified emergency preparedness program and exercises.  However, those that do will still be responsible for documenting and demonstrating their individual facility’s compliance with the exercise and training requirements. 

(B) A tabletop exercise that includes a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.  Example - IHCA Active Shooter Workshop

(iii) Analyze the facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the facility’s emergency plan as needed. 

Click here to access the Improvement Plan Template.

Click here to access the After Action Report Template

Please forward questions to ldavenport@ihca.org