Not Ready: The Need for a Training Standard in Healthcare Emergency Preparedness

Abstract

Natural and human-induced disasters are increasing, which affects public health and safety in many ways including disruption of healthcare. Emergency preparedness mitigates the impacts of these disasters and training improves preparedness. However, no standard for training emergency managers exists. This study aimed to explore the state of US healthcare preparedness and the impact of training on preparedness and proposes a training standard for healthcare emergency managers. Mixed methods research was conducted to understand different aspects of training, inform the design of a training standard, and explore potential barriers. The first phase included a quantitative survey with 67 participants who responded to questions about training topics, quantity, and delivery format. In the second qualitative phase, 5 focus groups with 29 participants were conducted to deepen the understanding of survey results and collect information about training topics, barriers to adopting a standard, and recommendations for overcoming barriers. Ten training topics, for a quantity of 11 hours or more per topic, were identified in the quantitative phase and reinforced in the qualitative phase. In-person training was preferred for all but 3 topics, where online synchronous delivery was preferred. Other aspects of training were further explored, and the concept of a basic versus advanced training standard emerged as a major theme. Barriers to training included financial support and time to attend training as well as gaps in leadership knowledge and support. While training is key to improved healthcare emergency preparedness, variation in training exists. This study recommends a standard in healthcare emergency manager training.

Introduction

Impacts to public health from disasters are evident and well documented. Disasters can cause physical and mental injuries, death, increase in disease, loss of personal and public shelter, and loss of facilities and services. Both natural and human-induced disasters are on the rise, which makes mitigating their impacts even more critical.^1,2 Disasters can affect healthcare in many ways, for example, by creating less predictable and higher patient volumes and complexity, understaffing, shortages of equipment and supplies, disruption in utilities, and temporary or long-term facility closure.³

One way to reduce the effect of disasters is to invest in emergency preparedness practices. The International Federation of Red Cross and Red Crescent Societies (IFRC) promotes preparedness with the priority to “save lives, reduce suffering, and uphold human dignity.”⁴ Further, the IFRC highlights the importance of improving response capacity and preparedness to reduce the impacts of disasters on communities.

US federal regulations outline emergency preparedness requirements for healthcare providers participating in Medicare and Medicaid programs (eg, for hospitals, 42 CFR §482.15 [2023]⁵). These regulations include training as a core requirement and mandate healthcare entities to provide and document initial and ongoing training; however, no specifics are provided on what the training should include.

Even with these regulatory mandates, the level of preparedness across the US healthcare system is highly variable and, in many cases, lacking.³ In the American Hospital Association CLEAR Field Guide for Emergency Preparedness, the authors address this level of variability: “it is clear that emergency preparedness is uneven across the country.”⁶ In a large-scale literature review, Melnychuk et al⁷ concluded that “the disaster literature shows that hospitals, health systems, EDs [emergency departments] and staff around the world are not prepared for disaster, adequate disaster plans are not in place, plans already in place are highly variable, and the current level of disaster-related education is inadequate for health care workers.”

Training is a critical component of healthcare emergency preparedness; however, a standard for training emergency managers does not exist. Standards are designed to find and adopt best practice and eliminate variation. In a comprehensive literature review of disaster preparedness in healthcare by Gowing et al,⁸ a theme that emerged was that the “most effective content and methods for disaster preparedness is unknown.” The authors went on to highlight an urgent need for “high-quality research to evaluate the best content and methods of disaster preparedness.” This article describes the current state of US healthcare preparedness, details the impact of training on preparedness, and proposes a training standard for healthcare emergency managers.

Methods

We conducted a mixed methods explanatory sequential study involving a survey (Phase 1) and focus groups (Phase 2). The survey and focus group questions are provided in Supplemental Materials: Appendixes A and B, respectively (all Supplemental Materials can be found at www.liebertpub.com/doi/suppl/10.1089/hs.2024.0086). This study was reviewed by the University of Nebraska Medical Center Institutional Review Board and was determined to be exempt.

Study Participants

Study participants were emergency preparedness professionals from US healthcare organizations including individuals with a wide range of exposure and experience in healthcare emergency preparedness. They were sourced from attendees of the 2023 National Healthcare Coalition Preparedness Conference and the Association of Healthcare Emergency Preparedness Professionals membership by an open call to participate. The criteria for participation in the study were a minimum of 1 year of experience in acute healthcare emergency response and willingness to participate in either the survey or interview component of the study. Participation was strictly voluntary, and participants could withdraw from the study at any time.

Data Collection

In Phase 1, we conducted an in-person survey at the 2023 National Healthcare Coalition Preparedness Conference that included questions about training topics, quantity of training (in hours), and delivery formats experienced. A total of 72 individuals participated in the survey.

Phase 2 consisted of virtual (online) focus groups using research questions designed following an initial analysis of the survey’s data to better understand and explain the information collected. This qualitative phase also helped to gain a better understanding of respondents’ ideas and opinions on training impacts on healthcare emergency preparedness and perceived barriers in adopting a training standard. To improve reliability and validity, a single interviewer conducted all interviews using the same set of questions. With the participants’ consent, all interviews were recorded and transcribed to ensure accuracy and facilitate quantitative data analysis. Focus groups were structured to include a minimum of 4 participants and a maximum of 8. There were 5 focus groups with a total of 29 participants.

Analysis

Survey data (quantitative) analysis included reviewing the data and preparing descriptive statistics tables showing response percentages for each question. Focus group data (qualitative) analysis included a review of the interviews to identify themes and use of MAXQDA qualitative analysis software (VERBI GmbH, Berlin, Germany) to develop and finalize themes. Mentions of specific words and themes were coded and quantified using MAXQDA.

The quantitative and qualitative data were combined by applying the themes that emerged from the qualitative phase to the quantitative data findings. Interpretation of the data included highlighting findings from both phases and outlining areas of convergence between the qualitative and quantitative results.

Results

Survey Findings

A total of 72 people completed the survey. Of these, 67 (93%) stated they had accountability for emergency preparedness in hospitals. Those who did not report they were responsible for emergency preparedness were excluded from the analysis. If a participant reported zero hours of training in a topic category, no other questions in that training topic category would apply. Fifteen (22%) participants indicated multiple responses for 1 or more of the training topic categories when responding to the question on delivery format taken and 18 (27%) respondents selected multiple formats for 1 or more of the training topic categories when responding to the question on format preferred. To accurately represent multiple responses from a respondent, a numerical value of 1 was given for each response.

With regard to the quantity of training (measured in number of hours) in the last year, 30% of respondents reported they received between 1 to 5 hours. Table 1 shows the percentage of respondents by total number of training hours reported in the last year. The majority (65%) of respondents reported that 1 to 5 hours of training on a given topic was insufficient, whereas 5% reported that 16 or more hours of training on a given topic was insufficient (Table 2).

Table 1.

Percentage of Survey Responses on Training Hours Taken on Topics in the Last Year

Number of Training Hoursin the Last Year	Percentage of Responses
0	14%
1 to 5	30%
6 to 10	24%
11 to 15	8%
16 or more	24%

Table 2.

Percentage of Survey Responses on Insufficiency of Training Hours on Topics

Training Quantity Insufficient	Percentage of Responses
1 to 5 hours	65%
6 to 10 hours	23%
11 to 15 hours	6%
16 or more hours	5%

The format of training received varied by topic, but 50% of respondents reported a preference for in-person training, followed by online synchronous at 42% and online asynchronous at 8% (synchronous training occurs together at the same time, whereas asynchronous training occurs independently and at different times). Topic-specific data on the training format are shown in Table 3, including data on the preferred format. In-person training was preferred overall, but an online synchronous format was sometimes preferred by respondents, depending on the topic.

Table 3.

Percentage of Survey Responses on Training Formats Taken and Preferred for Each Topic

Delivery Format	Incident Command Systems	Hazard Vulnerability Analysis	EP Plan Writing	Exercise Design/ Exercising	Risk Communication	Facilitation/ Collaboration	Healthcare Surge	Healthcare Evacuation	Business Continuity	Other Response Types
Format taken
In person	44%	38%	38%	58%	37%	64%	61%	58%	52%	51%
Online synchronous	39%	50%	44%	33%	59%	36%	36%	42%	41%	40%
Online asynchronous	17%	12%	18%	8%	4%	0%	3%	0%	7%	9%
Format preferred
In person	46%	50%	24%	58%	58%	77%	77%	78%	38%	40%
Online synchronous	35%	42%	45%	25%	42%	23%	23%	22%	58%	47%
Online asynchronous	19%	8%	31%	17%	0%	0%	0%	0%	4%	13%

Abbreviation: EP, emergency preparedness.

Focus Group Findings

The analysis included responses from 5 focus groups, each with a minimum of 4 and a maximum of 8 participants. Where we share participant quotes, we do not use identifiers to distinguish between individual participants in order maintain their anonymity.

Training Topics

Overall, the need for a training standard emerged as a strong theme across all focus groups and was mentioned a total of 64 times. Example quotes include these:

I’m still fairly new to hospital emergency management and received no training.

There is never enough training, and we can never stop training.

I know it’s extremely difficult in healthcare, but I put everything on training, everything.

When participants were asked to make suggestions for additional regular training topics, they discussed incident command operations, with a focus on the operational aspects of incident command. Participants indicated a need for broader understanding about how command centers should collaborate, communicate, and operate. Participants believed traditional incident command system (ICS) training highlights structure and job roles, but does not provide sufficient training on these operational aspects. Themes about ICS and ICS operations were mentioned 28 times. Participants further stated that ICS training needs to be healthcare specific because much of the ICS training available is taught from a government or public health lens.

The need for more options for training on healthcare specific topics for emergency preparedness in general was a theme across groups, with quotes like “healthcare emergency preparedness is a whole field in and of itself,” and was mentioned 17 times.

The participants also highlighted the importance of including interactive training as part of incident command and mentioned including running scenarios where incident command is initiated and operated for several hours as part of the scenario. The importance of hands-on, interactive training was also a theme across groups and questions and was mentioned 42 times. Hands-on training includes being able to physically practice skills, such as patient evacuation, which is difficult to simulate in online delivery formats.

Quantity of Training

Focus group participants were asked about the quantity of training identified as sufficient by survey respondents. Focus group participants indicated the amount of training needed might vary by topic and level of experience, but that 11 hours per training topic category was an appropriate starting point for most topics. This led to a top theme across groups that there should be an “entry-level” or basic amount of training for new healthcare emergency managers as well as a certain number of hours per year for experienced healthcare emergency managers to maintain competency. The recommendation to delineate between basic versus advanced requirements emerged across groups and across questions and was mentioned a total of 42 times.

Participants stated that 11 hours per training topic category was an appropriate starting point. However, some participants clarified that training exercises (mentioned 28 times) require more hours, such as 40 or more, to gain basic competency: “When you get to exercises […] you’re talking […] 40 hours minimum.”

Delivery Format

A common theme across all focus groups, which aligned with the survey findings, was that in-person training was the preferred delivery format.

In-person collaboration really can’t be replicated.

All of our clinicians, they have mandatory required in-person trainings, which elevates […] the importance of the training. […] So emergency management really shouldn’t be different.

In-person training was mentioned across all groups a total of 26 times and interactive training was mentioned across all groups a total of 42 times. A related concept across groups was that in-person and synchronous online training allow for interaction with other participants. One participant said that interaction with other participants “is just as if not more important than interacting with the instructors.” Some participants expressed that online asynchronous training was not preferred because it was not interactive. For example, a participant said it “is just a check-the-box activity.”

Other Factors in Training

The importance of interaction between participants was reinforced in responses to questions about other factors that should be considered in a training standard. Participants indicated that participatory components and opportunities for interaction with others enrolled in the course were the most valuable and engaging aspects.

Networking and learning from others is such an important part.

Every adult learns differently […] the demonstrating, the actually doing, that’s where I learned the most.

Training Frequency

When asked how often training for the 10 topics should be required, focus group participants most often indicated 3 years (mentioned 7 times) and reiterated the recommendation for different training standards based on the level of experience.

Three years [to complete training] but we need to have a basic versus advanced [standard].

Across groups, participants agreed that new healthcare emergency managers would benefit from training in the 10 topics listed, for a minimum of 11 hours, with the exception that the topic of exercises need more than 11 hours in a basic training standard.

A corresponding clarification on the idea of different training standards emerged with this recommendation, which was that experienced healthcare emergency managers should not complete the same training repeatedly. Instead, participants stated that experienced managers should have options for advanced topics, which they defined as topics with evolving information including regulatory standards and leadership skills development, as well as more in-depth training on healthcare-specific topics, such as ICS operations and patient evacuation.

When asked whether some topics should be covered more frequently than other topics, participants stated that ICS and training exercises should be completed annually, at a minimum.

Barriers and Overcoming Barriers

Focus group participants were asked about barriers to adopting a training standard for healthcare emergency managers. Themes across all groups included financial barriers (mentioned 18 times), time to attend training, and leadership knowledge barriers.

I think you’re absolutely right about needing to speak the language of the C-suite. I always think of myself as the emergency management horse whisperer, that I am not in a position of authority, but I can whisper to the people that are in a position of authority. And nudge them in various directions. But unless you’re speaking their language, they won’t hear you.

In discussions about overcoming these barriers, participants mentioned (1) working with healthcare coalitions to help with funding and low- or no-cost training, (2) educating leadership to help garner support for funding and the need for training, and (3) offering hybrid training to minimize the time healthcare emergency managers need to be away from their organization. The option of hybrid training, which the groups defined as a mix of in-person and synchronous online training, was mentioned 20 times.

Discussion

Only 2 (3%) of the survey respondents answered the question about additional training topics. This could indicate that the majority of respondents found the 10 training topics to be comprehensive, which was reinforced by focus group responses. The focus group participants agreed that the 10 training topics were appropriate for a basic training standard, with the recommendation that the ICS topic should also include ICS operations as part of its scope.

Findings from the focus groups clarified and deepened our understanding of the survey data collected and were crucial to the development of the training standard. A major theme in all groups and across several questions was that participants were supportive of a training standard, but they thought there should be a basic or initial standard for entry-level healthcare emergency managers and a different requirement for ongoing training for experienced healthcare emergency managers. This recommendation to focus the training standard on those new to the field was a significant development in the study and a main consideration in developing the training standard.

Survey respondents indicated that 11 or more hours on a given topic would be an appropriate quantity of training at the basic level. Focus group participants felt that exercises in particular require more than 11 hours to gain competency, and that both exercises and ICS—which seemed to be considered the core area of the emergency manager role—should be covered annually. These findings informed the development of the training standard, with ICS operations and exercises recommended for annual training and the other 8 training topics spread over a 3-year period.

In-person training was strongly preferred for most topics among both survey respondents and focus group participants. The focus group participants felt that interactive training was important in order for the training on these topics to be valuable. These delivery format preferences are reflected in the training standard recommendation.

Survey respondents preferred online synchronous training for 3 topics: emergency preparedness plan writing, business continuity, and hazard vulnerability assessments. These recommendations seemed to be supported by the focus groups as well. Focus group participants took it a step further by recommending that those responsible for developing the training should incorporate a hybrid approach to training when possible. Hybrid training was defined by participants as in-person training augmented by online synchronous training. These 3 topics do not usually require an interactive or hands-on aspect, which may be why respondents were more willing to participate online for these training activities.

One challenge of the study related to data collection about the training format was that some survey participants selected multiple answers in the section about preferred formats, which may indicate a willingness to participate in different training formats or even hybrid-style training. This was further clarified in focus groups, which strongly preferred in-person training for most topics but also encouraged a hybrid training approach, as described earlier.

The data also showed that respondents did not prefer asynchronous delivery for training on any of the 10 topics. This aligns with focus group feedback about the importance of interacting with others in emergency preparedness training in order to perceive the training as effective.

Focus group responses about training delivery formats aligned with the data collected from survey respondents and provided more depth as to why in-person, online synchronous, and hybrid trainings were preferred. The interactive nature of these delivery formats was key to participants finding them valuable and applicable.

The responses about barriers to adopting a training standard, while anticipated, helped to frame the discussion around how to overcome said barriers, including the strategy of incorporating hybrid training when possible.

Recommendations

The recommended training standard is shown in guideline format in Appendix C. The proposed training standard is comprehensive, including recommended topics, target audience, delivery format, and time needed to complete the basic requirements. The training standard target audience is individuals who are new to the field of healthcare emergency preparedness working in hospital environments, defined for purposes of this recommendation as those with 0 to 5 years of experience in the field of healthcare emergency preparedness. The training outlined should be completed within 3 years, ideally beginning upon entry into the field. ICS, including ICS operations, and exercises were identified as high-priority topic areas by the focus groups and are recommended to be completed annually for a minimum of 11 hours each, for a total of 22 hours annually at a minimum or 66 hours on these 2 training topics by the end of the 3-year training period. While this is the minimum amount of training recommended, healthcare emergency managers would ideally exceed this amount because the 2 topics are considered by subject matter experts in the focus groups as core to the success of new emergency managers.

In addition to ICS and exercises, other training topics areas that need to be completed in the 3-year period—each for a minimum of 11 hours—are hazard vulnerability analysis; emergency preparedness plan writing; risk communications (internal and external); facilitation (convening partners for collaboration); healthcare surge (trauma-based and ID-based); healthcare evacuation; business continuity; and other specialized responses tailored to the facility and/or role that could include radiation exposure, chemical exposure, and active shooter.

Other aspects of training, including delivery format, were identified as essential components to consider in addition to quantity. Hands-on, interactive training was highly valued by the subject matter experts surveyed and would be especially important for those new to the field. Interactive training in healthcare emergency preparedness is primarily accomplished through training exercises. Exercises are valuable due to the physical practice of skills, such as patient evacuation, which is difficult to simulate in online delivery formats. Based on the findings from this study, training in the following topic areas should be delivered in person: ICS, hazard vulnerability analysis, exercise design/exercising the plan, risk communications (internal and external), facilitation (convening partners for collaboration), healthcare surge (trauma-based and ID-based), and healthcare evacuation. Training in the following topics can be completed synchronously online or in a hybrid online/in-person format: emergency preparedness plan writing, business continuity, and other specialized responses.

Online asynchronous training can be used to supplement in-person training and is encouraged to prepare new healthcare emergency managers for interactive training components. Ideally, asynchronous training hours should not be included in the recommended total number of training hours, given that it is not a preferred format. As a reference for online asynchronous training, we created a self-study list (provided in Supplemental Materials: Appendix D) that can be used to supplement and prepare for in-person and hybrid training.

Policy Change

Full adoption of the training standard requires action at the national policy level. The Centers for Medicare and Medicaid Services holds the national policymaking role for healthcare entities. We recommend incorporating the training standard into existing regulations for hospitals with a period of 5 years to achieve full compliance specific to this new training requirement. Once included in policy, accrediting bodies in healthcare would assess compliance to the standard. Training could be conducted through existing government entities such as the Federal Emergency Management Agency or through professional organizations such as the Association of Healthcare Emergency Preparedness Professionals.

Areas for Future Research

In addition to expanding the research to include nonacute environments, future areas of research should include healthcare workers and providers who do not have emergency preparedness as a primary part of their role. This need for additional, standardized training for healthcare workers and providers, while out of scope for this study, was highlighted in the focus groups. The standard described in this article can serve as a starting point.

In considering other healthcare workers, it would be remiss to not include healthcare leaders and the specialized training they need in emergency preparedness. The need for training healthcare leaders in emergency preparedness was also expressed in the focus groups and would assist in garnering greater support of healthcare emergency preparedness through education of leadership. Healthcare leaders are in a powerful position to accelerate preparedness and reduce variability in partnership with emergency managers.

Finally, a core tenet of this research and a consideration for future research is how to improve the safety of the public by supporting advancement of the profession of emergency preparedness. Based on the nature of their responsibilities, emergency preparedness professionals are critical thinkers and problem solvers. Their professional focus is the protection of others, and they often do not receive the credit they deserve. Ways to provide that credit include inviting them into decisionmaking, listening carefully to their ideas, advocating for more attention and funding for emergency preparedness, and providing training and financial support for preparedness. Adopting a national training standard for healthcare emergency preparedness would be an excellent first step in this process.

Limitations

This study has limitations and highlights important topics for future additional research. As with all surveys, it is important to note that response bias exists. The named training topic categories were intentionally broad to reflect the foundational knowledge base that all emergency managers must have. More specific training topics may be included in future iterations of the training standard and may call for a higher number of training hours, depending on the topic. The scope of this study was limited to emergency managers with responsibility for acute facilities. Hospitals are only a portion of what should be considered for healthcare emergency preparedness training. Subacute environments, including ambulatory/medical offices, home health, and long-term care, all play important roles, and it is our hope the work shared here can be expanded to nonacute environments.

Conclusion

While training is key to improved healthcare emergency preparedness, variation in training exists and there is no standard for training emergency managers. This study recommends a standard in healthcare emergency preparedness training and includes a leadership approach to incorporate this plan of change at a national policy level. Barriers to implementation of a standard and how barriers may be overcome are considered. Several areas of future research are recommended, such as expanding research to develop a training standard for nonacute environments and for healthcare workers and providers who do not have emergency preparedness as a primary part of their role, as well as supporting advancement of the profession of emergency preparedness.

Footnotes

Acknowledgments

The authors thank the emergency preparedness professionals who contributed to this work through participation in the survey and focus groups. The views expressed in this article are the authors’ and not an official position of the authors' institutions.

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Supplementary Material

Please find the following supplemental material available below.

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