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1
Standards and Guidelines for Healthcare Surge
During Emergencies
Volume I Hospitals
2
Learning Objectives
Upon completion of this session, you should be
able to

• Define key concepts including surge, surge
  capacity, standards of care and others as used in
  the context of the Standards and Guidelines for
  Healthcare Surge During Emergencies project
• Recognize the issues pertaining to the scope of
  practice and liability protection in an event of
  a healthcare surge
• Become familiar with the Surge Planning concepts
  and operational tools available to
• Expand the clinical and non-clinical workforce
• Maximize sustainable resources surrounding
  supplies equipment in the event of a healthcare
  surge
• Address administration and patient care issues

3
Learning Objectives
Upon completion of this session, you should be
able to

• Become familiar with the Surge Planning concepts
  and operational tools available to
• Identify reimbursement planning strategies for
  hospitals
• Identify and review the healthcare surge planning
  template
• Understand the elements and tactics to engage in
  community planning for Surge.

4
Hospital Volume Purpose

• The purpose of the Hospital Volume is to
• Assist healthcare facilities develop a more
  robust healthcare surge plan to guide their
  response and build surge capacity when a
  catastrophic emergency occurs.
• List essential elements that facilities need to
  address in order to plan and prepare for
  healthcare surge
• Create a scaleable and adaptable plan for
  different facility types
• Engage healthcare facilities in community
  planning which is critical to the overall
  planning and response to a healthcare surge.
• Identify community planning roles for government,
  public and private resources that will be called
  upon during a healthcare surge.

5

• Review of Foundational Knowledge Key Concepts
• Foundational Knowledge - Section 1, p. 4-10
  Section 9, p. 84-126

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Review of Foundational Knowledge Key Concepts

• Individual based care will shift to population
  based care during a surge challenging
  professional, legal, regulatory and ethical
  paradigms.
• The standard of care during a surge is defined as
  the utilization of skills, diligence and
  reasonable judgment to optimize population
  outcomes that a reasonably prudent person with
  comparable training would use under similar
  circumstances.
• Executive standby orders issued by the Governor
  following his/her declaration of an emergency may
  result in specific suspensions that allow for
  flexibility.

7
Review of Foundational Knowledge Key Concepts

• The manuals do not attempt to solve the current
  challenges of the healthcare system, but rather
  how to operate within it.
• The materials will help you to enhance existing
  hospital emergency plans and engage your
  respective communities in healthcare surge
  planning.

8
Regulatory Flexibility for Hospitals

• As we learned in Foundational Knowledge,
• the types of flexibility of State and federal
  laws during a healthcare surge include
• Administrative Flexibility provides waivers for
  regulatory requirements (i.e. CDPH Licensing and
  Certification provides waivers to regulatory
  requirements for hospitals)
• Immunities for Emergencies becomes effective
  upon declaration of a local or state emergency
• Waivers for Emergencies allows regulatory
  flexibility under declared local or State
  emergencies
• Suspensions of Regulatory Statutes and State
  Regulations can be ordered by the
  Governor/designee under a State emergency
• Emergency Regulations Changing Standards can
  only be ordered by the Governor under a State
  emergency

9
Regulatory Flexibility for Hospitals

• Information on the flexibility of state and
  federal laws during a healthcare surge can be
  found in Foundational Knowledge and the Reference
  Manual.
• Refer to Pages 85 to 126 of Foundational
  Knowledge for a summary of statute/regulation
  flexibility that can be achieved. A more detailed
  analysis is provide in Section 3 of the Reference
  Manual.
• For example
• Disease Reporting Requirements
• Clinical Staff Requirements
• Occupational Health and Safety Requirements
• Department of Managed Healthcare Requirements

10
Review of Foundational Knowledge Key Concepts

• Operational Tools from Foundational Knowledge
  Volume
• Community Planning Participants Checklist,
  Section 9, p.80-81
• Surge Monitoring Guidelines, Section 9, p. 82-83
• Tables of Specific State and Federal Laws and
  Regulations and their Emergency Provisions during
  a Healthcare Surge, Section 9, p. 84-100
• Statutory and Regulatory Flexibility under
  Emergency Declarations Table, Section 9, p.101-126

11

• Workforce and Staffing
• Volume 1 Hospitals - Sections 6-9, p. 90-149

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12
Workforce and Staffing

• Scope of Practice Objectives
• Flexibility in scope of practice of healthcare
  professionals to expand the capacity of the
  healthcare delivery system in a surge
• Liability protection for healthcare professionals
  and facilities that act outside their normal
  scope of practice to mitigate the impact of the
  emergency
• Reimbursement for healthcare services provided

13
Workforce and Staffing

• Government Code Section 8659. Any physician or
  surgeon (whether licensed in this state or any
  other state), hospital, pharmacist, nurse, or
  dentist who renders services during any state of
  war emergency, a state of emergency, or a local
  emergency at the express or implied request of
  any responsible state or local official or agency
  shall have no liability for any injury sustained
  by any person by reason of such services,
  regardless of how or under what circumstances or
  by what cause such injuries are sustained
  provided, however, that the immunity herein
  granted shall not apply in the event of a willful
  act or omission.

14
Workforce and Staffing

• Solution for Scope of Practice
• Executive Order issued by Governor which balances
  professional judgment and the appropriate
  authority for flexing scopes of practice
• State health officer identifies which healthcare
  professionals will need to expand their scope of
  practice to mitigate the needs of the emergency
• Local health officers and/or chief medical
  officers at a hospital direct healthcare
  providers under their authority to mitigate the
  medical needs caused by the emergency
• Creating a flow of authority from the Governor,
  to the local operation person, to the actual
  healthcare provider will link the action to the
  protections of the Emergency Services Act

15
Workforce and Staffing

• Scope of Practice Standby OrderIt is hereby
  ordered that in the area proclaimed to be in a
  State of Emergency and/or that specific area(s)
  designated by the State Public Health Officer
  outside of the proclaimed area(s) but which is
  (are) essential to the relief and aid of the
  medical and health needs of the people within the
  proclaimed area, those rules that regulate the
  practice of licensed health care providers,
  including but not limited to ___________ ,
  ___________, shall be waived or amended as
  directed by the State Public Health Officer in
  order to increase the availability of acute
  medical care. Pursuant to the State Public
  Health Officer's actions, the local health
  officer, or chief medical officer at a hospital,
  shall direct health care providers under their
  authority to mitigate the medical needs caused by
  the emergency.

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Workforce and Staffing

• During a healthcare surge, how do you
• Increase clinical staff? Page 90
• Non-clinical staff? Page 133
• Options to consider
• Inventory and modify existing staff roles and
  responsibilities to accommodate the specific
  clinical and administrative staff needs resulting
  from the surge. Page 90-91
• Prioritize staffing needs and request additional
  resources through the Operational Area process
  described in your county emergency plans. Page
  98-101

17
Workforce and Staffing

• Develop a process for identifying,
  pre-registering, and credentialing clinical and
  non-clinical staff who may be utilized during a
  surge event. Page 107 - 109
• Develop a plan for maintaining occupational
  health and safety for the workforce. Page 138
• Develop a plan to flex the scope of practice of
  clinical staff for when the governor issues a
  standby order. Page 110-111

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Workforce and Staffing

• Plan to manage nurse-to-patient ratios and focus
  on maintaining the best use of nursing skills
  during extraordinary emergencies.
• In developing nursing staffing strategies during
  a healthcare surge hospitals should consider such
  issues as
• Facilitation of patient and caregiver safety
• Mitigation of nursing fatigue
• Nursing availability and training Page 115
• The transition back to normal nurse-to-patient
  ratios as recovery from the emergency occurs
• Use of volunteers Page 124-128
• Credentialing log Page 131-132

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Workforce and Staffing

• Operational Tools
• The Acceptance and Assignment of Augmented Staff
  During Healthcare Surge Process Flow, Section
  6.1, p. 91-92
• The List of Potential Staffing Sources during
  Healthcare Surge - Background and Activation
  Information, Section 6.4, p. 98-101
• The Skills and Abilities Assessment Tool, Section
  7.1.2, p. 107-109
• The Basic Plan for Augmenting Registered Nurse
  Staffing During Healthcare Surge, Section 7.2, p.
  115
• The Volunteer Application for Clinical Staff,
  Section 7.4.3, p. 124-128
• The Credentialing Log for Licensed Healthcare
  Professionals, Section 7.4.5, p. 131-132
• The Volunteer Application for Non-Clinical Staff,
  Section 8.1, p. 133-136

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• Supplies, Pharmaceuticals and Equipment
• Volume I Hospitals - Section 10, p. 150-179

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Supplies, Pharmaceuticals and Equipment

• Hospitals should plan to maximize their own
  sustainability by
• Becoming self sufficient for 72 hours at a
  minimum with a goal of 96 hours
• The Joint Commission E.C. 4.12 identify the
  capability to sustain operations for at least 96
  hours
• Using Memorandum of Understanding with retailers
  
• Considering the type of inventory to be stockpiled

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Supplies, Pharmaceuticals and Equipment

• A challenging aspect of acquiring pharmaceuticals
  is determining which pharmaceuticals are needed
  and in what quantity. Page 152-157 with
  checklist on page 154
• The Inventory Based Pharmaceuticals by General
  Classifications List in conjunction with the
  Hazard Vulnerability Assessment Tool should be
  considered when reviewing pharmaceutical supplies
  Page 159 165 is the pharmaceutical checklist

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Supplies, Pharmaceuticals and Equipment

• The California State Board of Pharmacy issued a
  Disaster Response Policy Statement in January
  2007 to state that it will use its authority to
  waive or flex regulations related to
  pharmaceuticals.
• The board expects to use its authority to
  encourage and permit emergency provision of care
  to affected patients and areas.
• In the event the pharmacy waiver is activated,
  the California State Board of Pharmacy will
  communicate this information to the Office of
  Emergency Services to be widely distributed.

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Supplies, Pharmaceuticals and Equipment

• Under California Labor Code Section 6401, every
  employer must Page 166
• Furnish protective equipment
• Use safety devices and safeguards
• Provide training
• The following provides guidance on selecting and
  acquiring personal protective equipment (page
  167)
• Emphasize the use of facial protection and
  prioritize respirator protection
• Utilize the Hazard Vulnerability Analysis
• Use equipment similar to that used by local
  emergency responders to standardize personal
  protective equipment within a community/region
  for interoperability

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Supplies, Pharmaceuticals and Equipment

• Below is a list of factors a hospital should
  consider when selecting a vendor to ensure proper
  storage and maintenance of supplies and equipment
  (page 176)
• Disaster clauses within the contract with the
  vendor to understand what they are responsible
  for during a healthcare surge situation.
• Process for the rotation of stock and inventory
  (control management).
• Vendor lead time for critical supplies,
  pharmaceuticals and equipment.
• Process for material delivery during a healthcare
  surge.

26
Supplies, Pharmaceuticals and Equipment

• Hospitals may require supplies, equipment and
  pharmaceuticals beyond local availability.
• Additional resources must be requested through
  the operational area defined in your county
  emergency plan (Page 177).

27
Supplies, Pharmaceuticals and Equipment

• Operational Tools
• The Inventory Based Pharmaceuticals by General
  Classification List, Section 10.2.1, p. 152-157
• The Detailed Supplies and Equipment List, Section
  10.3.2, p. 159-165
• The Pharmaceutical Storage Checklist, Section
  10.5.1, p. 172-173
• The Supplies and Equipment Storage Checklist,
  Section 10.5.2, p. 174-175
• The Staging Recommendations Checklist, Section
  10.8, p. 179

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• Administration and Patient Care Issues
• Volume I Hospitals - Section 11, p. 180-211

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Administration and Patient Care Issues

• Patient tracking (Page 180) Although electronic
  tracking systems are preferred, in cases where
  electronic systems are unavailable, the following
  paper-based tracking methods are a viable
  alternative.
• Collect minimum necessary data (Form on page 183)
• Assign patients a unique identifier
• Paper-based tracking is an essential contingency
• Use of internally generated and assigned
  Disaster Incident Numbers
• Patient Intra hospital tracking (Page 187)
• Can also use HICS form for patient evacuation
  tracking

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Administration and Patient Care Issues

• Emergency responders need to share patient
  information in a catastrophic event to provide
  urgent care to an increased number of patients.
  (Page 205)
• HIPAA rules (Page 203) are not intended to
  prevent the delivery of healthcare during an
  emergency.
• Department of Health and Human Services has
  indicated they will not impose HIPAA compliance
  fines on providers during a healthcare surge.

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Administration and Patient Care Issues

• In the event of a healthcare surge, as it relates
  to EMTALA hospitals should
• Develop a community response that designates
  specific entities with the responsibility to
  handle certain categories of patients during
  catastrophic events
• Establish patient transfer or referred sanctions
  in accordance with the community response plan

32
Administration and Patient Care Issues

• Hospital Reporting Requirements (Page 195) may be
  difficult to maintain during a surge. However,
  the following reporting categories remain in
  effect for the purpose of managing resources
• Disease Reporting /Notification
• Birth/Death Reporting
• Reporting of Patient Transfers
• Inventories of Medical Supplies

33
Administration and Patient Care Issues

• Downtime procedures (Page 188) for Registration
  and provision of medical records numbers will
  need to be assigned manually and minimum data set
  collection be put in place.
• Minimum requirements for medical record
  documentation (Page 192) to capture patient
  assessment, diagnosis and treatment will also
  need to be put in place.
• Workers compensation and medical network
  requirements may need flexing during a healthcare
  surge. Page 211

34
Administration and Patient Care Issues

• Operational Tools
• The Patient Tracking Form, Section 11.1.2, p.
  183-186
• The Paper-based Intra-Hospital Patient Tracking
  Process, Section 11.1.3, p. 187
• Sample Paper-based Fact Sheet, Section 11.2.1, p.
  190
• Sample Paper-based Insurance Verification Form,
  Section 11.2.1, p. 191
• Short Form Medical Record, Section 11.2.1, p.
  192-194
• The Decision Making Tool for Disclosure of
  Protected Health Information (PHI), Section
  11.2.3, p. 204-205
• The Workers' Compensation Process Flow, Section
  11.5, p. 211

35

• Reimbursement
• Volume I Hospitals - Section 12, p. 212-254

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Reimbursement

• The following information is provided to initiate
  discussions between providers and payers to
  develop plans to simplify reimbursement and
  access to care (Page 212).
• This information should be brought back to
  hospital administration including functions such
  as
• Payer Contracting
• Finance
• Medical Records
• Registration
• Reimbursement

37
Reimbursement

• Maintenance of existing revenue streams is
  critical to hospitals during a healthcare surge.
  Key concepts surrounding reimbursement during
  surge include
• Advanced planning and collaboration with
  commercial health plan partners
• Acquiring detailed knowledge of the resources
  available to hospitals during surge conditions
• Methods to access additional resources from
  federal and Stated Funded Programs

38
Reimbursement

• Hospitals should consider the following
  activities when working with their health plan
  partners to prepare for a healthcare surge
• Simplifying hospital rate structure, which may
  include negotiating a global acute care rate for
  inpatient care (Page 218)
• Using an expedited claims form with a minimum
  data set (Page 217)
• Negotiating lump sum advance payments to
  facilitate and maintain cash flow
• Negotiating contract language to obtain an
  automatic increase in capitation during a surge,
  when appropriate
• Moving toward a common reimbursement system, such
  as a Medicare Diagnosis-Related Group based
  system, to simplify claims generation and plan
  payment process

39
Reimbursement

• Electronic systems used for charge capture may be
  unavailable, therefore you may need to use
  paper-based processes for capturing charges.
• Recommended minimum data elements required for
  charge capture include (Page 221)
• Patient name
• Medical record number
• Date of service
• Capture units/dose/quantity
• Department services provided in
• Service description
• Zip code
• Disaster incident number
• Work related injury Y/N

40
Reimbursement

• Laws and regulations dictate how providers and
  health plans can respond to a catastrophic
  emergency. Major health plan rules/requirements/is
  sues to consider include (Page 241)
• Network requirements
• Pre-authorization
• Pharmaceutical coverage
• Co-pay requirements
• Claims management
• Insurance questions and coverage verification

41
Reimbursement

• Operational Tools
• Sample Charge Capture Form 1, Section 12.2.1, p.
  218-219
• Sample Charge Capture Form 2 (Acuity Charge
  Sheet), Section 12.2.1, p. 219-220
• Advancing and Expediting Payment Table, Section
  12.2.4, p. 224-225
• Graduate Medical Education Reallocation
  Guidelines, Section 12.3.1, p. 226-228
• Graduate Medical Education Transfer Checklist,
  Section 12.3.1, p. 229-230
• Patient Transfer Table, Section 12.3.2, p.
  231-232

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What is the Role of the Health Plan during a
State of Emergency?
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Lessons from Previous Catastrophic EventsHealth
Plan Response Efforts

• How has the Health Insurance Industry Responded
  to Health Plan Members during a Healthcare Surge?
• Examples
• Members received in-network benefits for care out
  of their network in any state
• Provided emergency transportation and treated all
  area hospitals as participating network hospitals
  
• Temporarily modified certain standard claim
  approval requirements including
  pre-certification, referrals and hospital
  admission procedures
• Implement grace periods and flexible payment
  terms for Individual and Small Group customers
• Waived co-payments for prescriptions

44
Mitigating Risk Experienced during Catastrophic
Emergencies

• Health Plans play a key, and distinct role,
  during a catastrophic emergency and have unique
  issues that must be addressed, including
• In a surge event the network model may be
  disrupted
• Pre-authorization requirements limiting provider
  payment for some services
• Administrative complications and deficiencies
• Increased volume of claims putting strain on
  health plan reserves, systems and processes

45
Department of Managed Healthcare
(DMHC)California Authority during a Healthcare
Surge
1
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The Role of the Department of Managed Healthcare
in a Healthcare Surge

• In order to cope proactively with healthcare
  surges, the Department of Managed Healthcare will
  focus on (Page 236)
• Keeping healthcare services available to
  enrollees ensuring access to care
• Keeping the revenue stream flowing to providers
  in order to keep healthcare services available
• Transferring enrollees from plan-to-plan in the
  event of diminished plan capacity to keep
  healthcare services available
• Transferring provider capacity from plan-to-plan
  to mitigate a shortage of healthcare services in
  severely impaired geographic areas

47
The Role of the Department of Managed Healthcare
in a Healthcare Surge (continued)

• The Director of the Department of Managed
  Healthcare will work with the Governors Office
  as indicated by the severity of the emergency to
• Suspend statutes
• Suspend regulations
• Limit healthcare service plan contract provisions
  
• Facilitate mitigation of the healthcare surge

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Facility Operations Recovery

• Recovery is essential for hospitals (page 255)
• Operational recovery returning to baseline
  levels of functioning or a new normal
• Financial recovery re-establishing revenue
  streams and obtaining reimbursement for patient
  care and response costs
• Elements of recovery
• Identifying a starting point for recovery
• Determining the endpoint to recovery
• Return to readiness
• Recovery is a part of a large effort in the
  community, local, regional and state levels

49
Facility Operations Recovery

• Recovery planning activities
• Personnel recovery
• Non-personnel resources
• Business systems recovery
• After-action Reporting/Corrective Action Plans
• Community recovery activities

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Thank You