Standards and Measures Documentation: Tips for Success: The Meaning and Requirements for Initial Accreditation Measures 5.4.1 and 5.4.2

In this column, PHAB staff share tips for successfully demonstrating conformity with various PHAB Standards and Measures. Here, PHAB Chief Program Officer Robin Wilcox discusses initial accreditation Measures 5.4.1 and 5.4.2. The difference between these measures and their required documentation is sometimes confused.

Measure 5.4.1 is about the process of the development of the overall jurisdictional plan for the management of all types of potential emergencies. This plan will address an array of issues, such as levels of authority, continuity of public utilities, transportation, housing, communications, animal sheltering, as well as public health. This plan will include the roles on many governmental agencies and other organizations, for example, the fire and police departments, public affairs and information technology, hospitals’ emergency departments, and organizations such as the Red Cross. The process for the development of an inclusive jurisdictional plan for the management of emergencies will be led by a government unit that has been designated as the emergency management agency. The process will not, of course, be led by the health department. Public health plays an important role in emergency management and the public health department must be at the table as the overall All Hazards Emergency Operations Plan (EOP) is developed. Therefore, this measure requires that the health department provides evidence that they participated in preparedness meetings. Since emergency plans must be both tested and practiced in order to be effective, this measure also requires that the health department provide evidence that it participated in the testing of the plan through either a real emergency or an exercise. Included in the testing is the review of an After Action Report (AAR). A purpose of an AAR is to make post-exercise recommendations for improvements in the plan. So, the third requirement of this measure is evidence of a process to revise the plan in which the health department participated. Included in this requirement is a copy of the revised plan. The plan that is submitted here may be a totally revised plan or the original plan with an attachment or supplement that is the “improvement plan.” The plan that is submitted here is not a department of health plan; it is a plan that was developed with the participation of the health department. Included in the overall jurisdictional EOP will be the roles and responsibilities of the health department.

Measure 5.4.2 addresses the specifics of the health department’s operational responsibilities for emergency preparedness and response. The health department needs to have a specific public health emergency preparedness plan concerning how it, as the health department, will respond to an emergency and coordinate with others in an emergency. This public health EOP will link to, and coordinate with, the overall jurisdictional EOP. This plan has been developed/adopted by the health department. The public health EOP might be a separate, freestanding document; it might be built into the overall jurisdictional EOP; it might be an appendix or supplement to the overall EOP.

Measure 5.4.2 requires that the public health specific plan be uploaded. First, the plan must have a staff person who is designated as responsible for leading the public health emergency preparedness activities. Also required in the plan is a list of other health department staff and partners who have roles and responsibilities. The plan must also address the health department’s communication plan and/or network with whom the health department coordinates messages. And, of course, the plan must address how the health department manages its continuity of operations during an emergency. The other two requirements for measure 5.4.2 are similar to those for 5.4.1, but are specific to the health department’s public health plan: that is, the testing and AAR of the plan and the revision of the plan, as indicated by the AAR.

Clearly, these two measures are related and the contents of two plans must be coordinated and must support each other. These two measures are two levels of the same issue: (1) all the roles and responsibilities in the community in the event of an emergency and (2) the specific roles and responsibilities of the health department as a member of the community. These measures are about how the health department participates in the development of, fits into, and operationalizes the overall jurisdiction EOP.

If you have questions, please do not hesitate to contact your Accreditation Specialist.