Hospital Incident Command System (HICS)

How Hospitals Respond to Disasters

In This Article

During floods, fires, hurricanes, earthquakes, man-made emergencies, threats, or even planned events, hospitals have to respond in a way that meets the needs of patients, staff, and visitors. Hospital Incident Command System (HICS) gives them a framework on which to build a response quickly and scale it to fit the magnitude of the situation. It's important because managing a large scale incident is not something most nurses, doctors, or administrators do on a day-to-day basis.

What is HICS?

HICS is simply a standardized approach to managing complex incidents. Each hospital that adopts this process is agreeing to follow common principles and use standardized terminology in the event of a large-scale emergency or event. The principles of HICS come from the Incident Command System (ICS) developed for managing wildland fires in California in the 1970s. Wildland fires use resources from many different organizations, and those folks didn't all do things the same way. ICS standardized the response to fires, which made everyone more efficient and safer.

Even within a single hospital, each department might do things differently. Just like during a wildfire, HICS allows the hospital to standardize its approach to an event globally, even if each department does things their own way during normal operations. In the fire service, adopting ICS led to a lot of command structure standardization across individual fire departments, which is also beginning to happen in the hospital industry. This is good; people understand HICS concepts better if they are using them all the time.

ICS has been around since the 1970s. HICS became popular about 20 years later, mostly in areas familiar with wildland fires and comfortable with the use of ICS. After the 9/11 attacks, the federal government implemented the National Incident Management System (NIMS), which incorporates ICS. Since then, HICS has become much more common across the nation and worldwide.

The Benefits of HICS

HICS has five main elements that work together and allows a hospital to effectively manage an incident:

  1. Develop a command structure that eliminates duplication, can be scaled to fit the needs of the incident, and follows a reasonable span of control (bigger incidents need more leaders)
  2. Integrate people from different parts of the hospital and from outside agencies into the command structure
  3. Identify needs and establish objectives to resolve the incident
  4. Develop strategies to achieve the objectives
  5. Provide support and direction to those responsible for carrying out the objectives (the tactical response)

Best practices to make HICS work start with planning. Someone should be named as the Emergency Program Manager to plan and guide the Emergency Operations Plan (EOP). There should also be a space in the hospital dedicated for use as a Hospital Command Center (HCC) in the case of an incident requiring a HICS response. Ideally, the HCC will have multiple, dedicated phone lines and internet connectivity. In a modern facility, the HCC should have redundancies to ensure that it can continue to operate even if the facility loses power.

Manageable Span of Control

HICS encourages the use of a manageable span of control, meaning that no one person should have too many direct reports. Usually, the recommendation is to keep teams between three to seven people. In other words, if the task can be done with five people, one leader should do it. If the task takes 14 people, there should be at least two teams, each with its own leader to direct the work.

This is one of the most important tenets of ICS and HICS. During day-to-day operations at almost any business, leaders often oversee teams much larger than seven people. That works because workers and team members are typically experts at the tasks they perform on a routine basis. Oversight in this situation is limited to extraordinary circumstances and most workers are capable of completing tasks without intervention by a team leader.

An emergency incident or special event is different. This is a unique situation in which people are going to be asked to perform tasks they don't usually do. Some tasks could be similar to what they do every day, but often those come with a slew of questions that need to be answered as an incident progresses. It's important not to burden leaders with unmanageably large teams.

HICS addresses span of control through a flexible organizational command structure. For example, if a medical gas leak in a single part of the hospital required a department to evacuate until maintenance could turn it off, the hospital might activate HICS with an Incident Commander (see below) and a couple of command staff members to direct the department on how to respond. If the leak grows to the point where there are multiple departments evacuating, now the number of leaders increases to a point that one Incident Commander can't effectively keep track of everything that's happening. So, the Incident Commander can appoint someone as the Operations Chief and someone else as the Logistics Chief. Those two people are then able to direct their own teams and respond to the incident, freeing up the Incident Commander to address other things such as public information messaging and notification of additional hospital leadership.

HICS Command Structure

One basic tenet of ICS is the clear chain of command, consisting of the Incident Commander and four sections: Operations, Planning, Logistics, and Finance/Administration. Depending on how complex the incident is, each HICS section can be further divided into branches, units, and teams, led by branch directors, unit or team leaders. The title of "manager" is reserved for tasks that might cross multiple other divisions, such as a staging manager or a patient tracking manager. In traditional ICS, there are additional subdivisions that are not typically used in HICS.

One of the ways that leaders in HICS are identified is by wearing color-coded vests with their titles clearly visible. The colors associated with each section are included below.

Incident Command Staff (White Vests)

The Incident Commander (IC) is responsible for everything that happens when he or she is in charge of the incident. The IC will guide and support the four section chiefs to set objectives and meet them. In the event of confusion or disagreement, the Incident Commander makes the final decision. The IC may have additional staff if necessary, such as a Public Information Officer or a Safety Officer. The size of the Incident Commander's staff is driven by the size and complexity of the incident.

The Incident Commander is likely to be a high-ranking hospital administrator, such as the CEO, COO, Chief Medical Officer (CMO), or Chief Nursing Officer (CNO). Some hospitals will use the Emergency Program Manager, which is likely going to be the person with the best working knowledge of HICS. Since incidents happen at all hours, day or night, it is also quite reasonable to assume that a nursing supervisor or an on-call administrator might need to fill the role until a higher-ranking administrator can get there.

In many cases, there will be multiple people with responsibility for the overall response to an incident (fires, violence, or natural disasters, for example). In these cases, representatives from each agency with responsibility for the incident will collaborate in what is known as Unified Command. From this Unified Command group, someone will be designated to act as Incident Commander.

Operations Section Staff (Red Vests)

The Operations Section is where the bulk of the work gets done. All of the tactical decisions to achieve the incident objectives are made by the Operations Section Chief (Ops Chief) who reports to the Incident Commander. This position requires a high degree of technical knowledge on hospital operations and therefore it will draw from the same group of candidates as the Incident Commander. Remember that nursing supervisor who had to be Incident Commander when the incident began at 3:00 in the morning? She's the best person for the job of Ops Chief as soon as the CEO shows up to take over as IC.

Most of the additional branches and units will appear under in the Operations Section as an incident grows and becomes more complex. it's really important for the Ops Chief to use branches to maintain a manageable span of control.

  • The Medical Care Branch Director will report to the Ops Chief and will oversee all aspects of patient care. Under the Medical Care Branch Director, there could be an Inpatient Unit Leader, an Outpatient Unit Leader, a Casualty Care Unit Leader, a Behavioral Health Unit Leader, a Clinical Support Unit Leader, and a Patient Registration Unit Leader.
  • The Infrastructure Branch Director is responsible for the facility. In most hospitals, this would be the maintenance staff. Under the Infrastructure Branch Director, there could be a Power/Lighting Unit Leader, a Water/Sewer Unit Leader, an HVAC Unit Leader, a Building/Grounds Unit Leader, or a Medical Gases Unit Leader.
  • The Security Branch Director is pretty self-explanatory and could oversee an Access Control Unit Leader, a Crowd Control Unit Leader, a Traffic Control Unit Leader, a Search Unit Leader, and a Law Enforcement Interface Unit Leader.
  • The HazMat Branch Director is responsible for any decontamination of patients or facility and for responding to any spills. Units under the HazMat Branch include Detection and Monitoring, Spill Response, Victim Decontamination, and Facility/Equipment Decontamination.
  • The Business Continuity Branch Director is the one who keeps the computers running. This is usually an IT leadership position. Under the Business Continuity Branch would be the IT Systems and Application Unit, the Services Continuity Unit, and the Records Management Unit.
  • The Patient Family Assistance Branch Director oversees two vital roles: the Social Services Unit and the Family Reunification Unit. Depending on the type of incident, these units will be two of the busiest. While it seems like a small branch, it could have the most impact on the public's perception of how well an incident was handled.

Planning Section (Blue Vests)

The Planning Section Chief reports to the Incident Commander and is responsible for tracking the incident and the resources. The Planning Section Chief doesn't actually plan but is responsible for writing the plan and collecting and disseminating information. People who are capable of being the Planning Section Chief include anyone from above, as well as a human resources director, nursing supervisor, or facilities director.

The Planning Section is much smaller than the Operations Section with four units: Resources, Situation, Documentation, and Demobilization. On small incidents, the Planning Section Chief might handle all the responsibilities of this section alone.

Logistics Section (Yellow Vests)

The Logistics Section Chief reports to the Incident Commander and is responsible for getting all supplies, personnel, equipment, and other resources necessary to get the job done. The Logistics Chief could be the hospital's Chief Procurement Officer, a support services director, COO, facilities director, or warehouse director. The Logistics Section is second in size only to the Operations Section. There are two branches:

  • The Service Branch takes care of keeping everyone talking and fed. The Service Branch Director oversees the Communications Unit Leader, the Food Services Unit Leader, and the IT/IS Equipment Unit Leader.
  • The Support Branch Director makes sure the Operations Section Chief has everything she needs. The Support Branch has as many as five units: Supply, Labor Pool and Credentialing, Employee Health and Well-Being, Transportation, and Employee Family Care.

Finance/Administration Section (Green Vests)

It is probably not a coincidence that the Finance Section staff wears green vests. The Finance Section Chief (can also be called the Admin Section Chief) keeps track of costs and processes payments. If the Logistics Section requisitions something, the Finance Section procures (buys) it. The Finance Section is about the same size as the Planning Section and like its organizational sibling, the Finance Section Chief might act solo in the case of smaller incidents. Good candidates for Finance Chief are the hospital's Chief Financial Officer (CFO) or other finance executive, business services director, Chief Information Officer (CIO), comptroller/controller, or administrative VP.

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Article Sources

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