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Role of exercises and drills in the evaluation of public health in emergency

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Article  in  Prehospital and disaster medicine: the official journal of the National Association of EMS Physicians and the World Association for Emergency and Disaster Medicine in
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Role of Exercises and Drills in the Evaluation
of Public Health in Emergency Response
Kristine M. Gebbie, DrPH, RN;1 Joan Valas, MS, RN;1 Jacqueline Merrill, MPH RN;1
Stephen Morse, PhD2
1. Center for Health Policy, Columbia
University School of Nursing, New York,
New York USA
2. National Center for Disaster
Preparedness, Mailman School of Public
Health, Columbia University, New York,
New York USA
Correspondence:
Joan Valas, MS, RN
Columbia University School of Nursing
Center for Health Policy
630 West 168th Street-Mail Code 6
New York, NY 10032 USA
E-mail: jv16@columbia.edu
Keywords: agency; criteria; emergency
response; evaluation; event; exercises; drills;
performance; public health; readiness;
standards
Abbreviations:
CDC = Centers for Disease Control and
Prevention
DHS = (US) Department of Homeland
Security
FEMA = (US) Federal Emergency
Management Agency
IAP = incident action plan
IC = incident command
ICS = incident command system
JIC = jurisdiction-wide information center
NACCHO = (US) National Association of
County and City Health Officials
PIO = public information officer
PPE = personal protective equipment
SOCO = single overriding communication
objective
UTL = universal task list
Received: 22 June 2005
Accepted: 19 July 2005
Revised: 02 August 2005
Web publication: 21 June 2006
May – June 2006
ORIGINAL RESEARCH
Abstract
Introduction: Public health agencies have been participating in emergency
preparedness exercises for many years. A poorly designed or executed exercise,
or an unevaluated or inadequately evaluated plan, may do more harm than
good if it leads to a false sense of security, and results in poor performance
during an actual emergency. At the time this project began, there were no
specific standards for the public health aspects of exercises and drills, and no
defined criteria for the evaluation of agency performance in public health.
Objective: The objective of this study was to develop defined criteria for the
evaluation of agency performance.
Method: A Delphi panel of 26 experts in the field participated in developing
criteria to assist in the evaluation of emergency exercise performance, and
facilitate measuring improvement over time. Candidate criteria were based on
the usual parts of an emergency plan and three other frameworks used else-
where in public health or emergency response.
Results: The response rate from the expert panel for Delphi Round I was
74%, and for Delphi Round II was 55%. This final menu included 46 public
health-agency level criteria grouped into nine categories for use in evaluating
an emergency drill or exercise at the local public health level.
Conclusion: Use of the public health-specific criteria developed through this
process will allow for specific assessment and planning for measurable
improvement in a health agency over time.
Gebbie KM, Valas J, Merrill J, Morse S: Role of exercises and drills in the
evaluation of public health in emergency response. Prehosp Disast Med
2006;21(3):173–182.
Introduction
The roles of exercises and drills as a mechanisms for education, experience,
and evaluation of emergency response have increasingly become important
for all response partners, including the public health system.1–3 The ability of
the public health community to perform exercises, drills, and emergency sim-
ulations for both internal and external evaluation of plan effectiveness has
been improving, and includes greater involvement and more ties to other
components of the response system. The objectives of the research are: (1) to
clearly describe the levels of exercises and drills appropriate to levels of pre-
paredness, the purpose of the drill (management and leadership, operational
performance or systems performance), and the size of the agency and com-
munity served; and (2) to develop a standardized set of criteria for use by local
public health agencies or others to evaluate an agency’s response during a
drill, exercise, actual emergency event, or after-exercise evaluation are
described in this report. In addition, a subsequent phase of the same project
was undertaken to develop a standardized method for recording a drill or
exercise experience that can be used for the evaluation and documentation of
public health readiness.
The emergency response readiness of the public health system increasing-
ly has been an important topic for research, development, and action in the
http://pdm.medicine.wisc.edu Prehospital and Disaster Medicine
174
United States since 1996, with the events of 11 September
2001 providing even more stimulus.4–6 This research
included:
1. the development of competencies in emergency pre-
paredness for individual public health workers;2
2. training for public health agency staff and their com-
munity partners;4,7
3. improved electronic and other communication
capacities at all levels of public health practice;8,9
4. federal guidance to state public health agencies (and
through state agencies to local public health agen-
cies) on critical agency capacities needed for emer-
gency response;3
5. strengthened planning for emergency response
throughout the public health community;10 and
6. the creation of Project Public Health Ready, a system
that certifies that a local public health agency has a
staff competent in emergency response, a plan for
emergency response, and has tested its preparedness
through exercises or drills.11
Need for Exercises
Public health agencies have been participating in at least
some emergency preparedness exercises for many years,
(e.g., the participation of local public health agencies in
emergency drills in the area surrounding nuclear power
plants).12 Many jurisdictions have regular experiences with
emergencies caused by weather.6 However, a poorly designed
or executed exercise, or an unevaluated or inadequately
evaluated plan, may do more harm than good if it leads to
a false sense of security, resulting in poor performance dur-
ing an actual emergency. Also, the public may be put at risk
and confidence in the public health system undermined.
The National Association of County and City Health
Officials (NACCHO) has provided a useful tool, Bt
Create, that guides an agency through the development of
a locally relevant exercise or drill.13 However, at the time
this project began, public health had not developed its own
specific standards for the public health aspects of exercises
and drills, and no defined criteria for the evaluation of
agency performance existed.
Because exercises and drills are expected to provide a
simulation of actual emergency experiences, the format for
assessing response during a drill or exercise should be the
template for evaluation of an actual response.8,12 Evaluating
the degree to which the exercise and its results are used for
ongoing organizational development also is crucial. There
currently are no published guidelines for assessing public
health emergency response. General guidelines developed
by the US Department of Homeland Security (DHS) have
been developed, but are not specific for the public health
agency role, both at the state and local levels.19 It is essen-
tial that the evaluation of emergency response at the local
level be consistent with expectations of emergency
response at the state public health agency level, thus assur-
ing that critical elements of response are developed in a
consistent manner. Since this project began, several US
organizations started initiatives that increase contribution
from public health within the emergency response sector.
Prehospital and Disaster Medicine http://pdm.medicine.wisc.edu
Role of Exercise and Drills
One major challenge to this project was that public
health agencies already had been conducting or participat-
ing in exercises and drills, using a wide range of resources
and working with US national, state, and local emergency
preparedness organizations, the national network of
Academic Centers for Public Health Preparedness, and pri-
vate consulting firms. This resulted in a lack of standardiza-
tion that produced different vocabularies, expectations, and
thus, different approaches in exercise assessment in the US.
The purpose of this study was to describe the levels of exer-
cises and drills appropriate to levels of preparedness and the
purpose of these drills, and to develop a standardized set of
criteria for use by local public health agencies to evaluate an
agency’s response during an exercise.
Methods
To develop criteria using expert opinions, this Delphi study
was conducted at the Center of Health Policy at the
Columbia University School of Nursing. The study was
determined to be exempt from Institutional Research
Board approval on 02 January 2004.
The first step in this study was to define the types and
levels of exercises based on critical review of existing
national standard language developed by the DHS.21 This
review resulted in a document that was circulated in the
public health community for feedback and comment.
Subsequently, it was made available in its final form via the
project Website, and is summarized in Table 1.20
The second step was to identify criteria for evaluating
local public health emergency exercises. This was achieved
through a two-round Delphi survey utilizing a 26-member
expert panel to gain insight and consensus to the develop-
ment of public health agency criteria for the evaluation of
emergency exercises. The experts for this panel were select-
ed based on experience and expertise from representative
public health professional associations (boards of health,
local and state health officials), local and state public health
agencies, the Centers for Disease Control and Prevention
(CDC), the DHS, and the Federal Emergency Management
Agency (FEMA). Special attention also was given to select-
ing a panel that included representatives from each of the
ten geographic regions of the country. The composition of
the panel is summarized in Table 2.
Delphi Survey Round I
Project staff reviewed an extensive range of materials from
the DHS, the FEMA, the Centers for Public Health
Preparedness (funded by the CDC), and local public health
departments. In developing the Round I Delphi instru-
ment, it was decided to present criteria for the evaluation
of public health exercises in a manner consistent with and
understandable to those working in the broader emergency
management area. For that reason, the researchers chose to
organize the document in categories identified by the
major components of a public health agency emergency
management plan as described by NACCHO, which is a
format consistent with more general emergency plans.
However, because other ways of describing public health
performance or emergency response are in use, each of the
Vol. 21, No. 3
Gebbie, Valas, Merrill, et al 175

Type of Exercise Definition Examples

The starting points in a building block

Discussion-Based Exercises
approach to exercises. Primarily used
to familiarize agency and staff with Seminar Workshop
existing plans and capabilities. Led by Tabletop
facilitators and presenters to keep Games
participants on track in meeting the
objectives of the exercise.

Used for the purpose of assessing and

validating emergency preparedness
polices, plans, and procedures. They
Drill
include drills, functional exercises, and
Operation-Based Exercises Functional Exercise
full-scale exercises. There is an actual
Full-Scale Exercise (FSE)
response and a mobilization of
personnel and apparatus over a
designated, extended period of time.

Gebbie © 2006 Prehospital and Disaster Medicine

Table 1—Summary of definitions

Expert Panel Respondents (n = 26) Range of Representation

State or Local Public Health Official/Practitioner 14 State and Local Public Health Agencies

DHS/FEMA Regions I, II, III, IV, V, VII, VII, IX, X

National Response Agencies Centers for Disease Control, FEMA, DHS

Association for State and Territorial Health Officials, National

Association of City and County Health Officials, National
Public Health Professional Organizations
Association of National Boards of Health, National
Environmental Health Association

Public Health Practice, Risk Communication, Disaster

Public Health Disaster Specialists/Academia
Management
Gebbie © 2006 Prehospital and Disaster Medicine
Table 2—Professions represented in the expert panel composition (DHS = Department of Homeland Security;
FEMA = Federal Emergency Management Agency; n = number)

plan components was also compared to components of
three other frameworks: (1) components used by general
emergency management;21–23 (2) Public Health in America’s
essential services of public health;24 and (3) the focus plan-
ning areas of the CDC state emergency plan guidance in
use at the time.25 The comparative framework was includ-
ed in Round I for the purpose of explaining and grouping
potential criteria the research team selected for considera-
tion by the experts.
For each category, the project team generated potential
criteria that could measure actions likely to be taken by
public health agencies during an emergency or a disaster.
For example, under the category “Initial Response
Command and Control” an initial draft criterion was:
health department internal incident commander is identi-
fied immediately on notification that emergency manage-
ment will be used in response to an incident. A total of 50
potential agency level criteria corresponding to 10 separate
categories were originally sent out. In Round I of the
Delphi survey, panel members were asked to read each
potential criterion and respond whether it should be
retained, modified, or eliminated. Additionally, they were
asked to comment on the proposed criteria and suggest
additional criteria. The Round I instrument was pilot-test-
ed by four public health experts familiar with emergency
response and emergency plan design, and slight adjustments
in wording and format were made based on their feedback.
The survey was administered by mail and electronically
(reflecting panelist preferences). Suggested modifications
focused on adjusting the agency response times stipulated
in the potential criteria. Other suggested modifications
primarily were to clarify language. Reasons for proposing
rejection of criteria centered on redundant language, or
panelists’ knowledge of a particular health department’s
non-participation in a specific activity, related to a criteri-
on. Only four criteria were not retained by the panel.
Delphi Survey Round II
Based on the results of Round I, the Round II survey
instrument grouped 46 potential criteria into nine cate-

May – June 2006 http://pdm.medicine.wisc.edu Prehospital and Disaster Medicine

176
Figure 1—Exercise flow chart
gories: (1) initial response command and control; (2) com-
munication; (3) early recognition/surveillance and epi-
demiology; (4) sample testing; (5) evidence management;
(6) mass prophylaxis, immunization, and pharmaceutical
stockpiles; (7) mass-patient care; (8) mass-fatality manage-
ment; and (9) environmental surety. All non-conflicting
editorial suggestions from Round I were included. Where
there were conflicting responses from the panel, changes
suggested by the majority of panelists were included.
Where there was no clear consensus, the research team
decided on the best alternative for inclusion. The instru-
ment also provided feedback to the expert panel consisting
of: (1) the individual panelist’s scores for each item in
Round I; and (2) the range of scores for each criterion in all
10 categories of plan response.
In response to questions asked by panelists, the research
team developed a flow chart (Figure 1) to illustrate where
in the process of developing a drill or exercise one or more
criteria from the Round II menu of criteria could be select-
ed for use in exercise evaluation.
The Round II survey was pilot tested again with four
public health experts, and minor adjustments were made
before distribution. Again, the expert panelists were asked to
review the criteria as they did in Round I. Round II also was
administered by mail and e-mail. Suggested modifications
were based primarily on language clarification and disputed
response times. Criteria were rejected for similar reasons as
in Round I, and once again, few criteria were rejected.
Results
The response rate for Delphi Survey Round I was 74% and
55% for Round II. Based on Round I responses, criteria
were eliminated, reused, or others were suggested by the
Prehospital and Disaster Medicine http://pdm.medicine.wisc.edu
Role of Exercise and Drills
Gebbie © 2006 Prehospital and Disaster Medicine
respondents, resulting in 46 potential criteria. These 46 cri-
teria served as the basis for Round II. In Round II, >80%
of respondents were in agreement with retaining all 46 cri-
teria presented. Eighty percent of respondents agreed with
retaining the potential criteria as written. The response rate
for Delphi Survey Round II was 74%.
In the last step of this research, the results of Round II
were used as the basis for a final menu of criteria for use in
evaluating an emergency drill or exercise at the local public
health level. The research team selected the final criteria
based on the majority opinion of the response panel. For
purpose of clarity, the team separated criteria that con-
tained composite actions, so that each resulting criterion
had only one action verb and was stated in an observable
format. This final document was circulated to the expert
panel for a final round of comments. The final set of crite-
ria is shown in Table 3.
Discussion
The US Homeland Security Exercise Evaluation Program
provides exercise evaluation guidelines for conducting and
observing exercise activities.21–23 Within that document,
the guidelines for public health lacked detail when this
project began. Once validated, use of the public health-spe-
cific criteria that were developed through this research
would allow for specific assessment and planning for mea-
surable improvement over time in a health agency. The
researchers plan to integrate these criteria into a format
that can be used by exercise observers to record the events
that take place in an exercise, and to use these observations
in an analysis of agency performance. Preliminary applica-
tion in a limited number of exercises suggests that using
structured criteria minimizes subjective interpretation.
Vol. 21, No. 3
Gebbie, Valas, Merrill, et al 177

I. Initial Response Command and Control

1. Health department internal incident commander is identified immediately on notification that emergency management will be
used in response to an incident.

2. All health department internal ICS positions (PIO, Liaison, Safety Officer, needed section chiefs) are identified and activated*
within 30 minutes regardless of time of day.

3. All initial, available, relevant information centralized to the agency’s ICS Planning Section using a situation board or
equivalent within 15 minutes.

4. Establish an IAP describing primary objectives and overall strategy to be accomplished by the health department in the first
24 hours within 30 minutes after the establishment of the department’s EOC.

5. Activate appropriate ICS General Staff Sections within 60 minutes of initial activation of internal incident commander.

6. Portions of state/local public health law/code relevant to the specific emergency retrieved and available to ICS Command
Staff.

7. Activate plan for operating/closing routine health department operations within 30 minutes of initial activation of internal
incident commander

II. Communication

1. Establish liaison with JIC within 15 minutes of notifying the incident commander that the JIC is operational.

2. Draft and approve public information for anticipated phases of response within two hours. Draft and approve public
information for anticipated phases of response within two hours of establishment of agency’s EOC.

3. Identify critical partners (e.g., other health jurisdictions, law enforcement, hospitals, etc.) and convey initial public health
information to them immediately upon approval of information and no later than one hour after approval of information by
agency JIC.

4. Establish a schedule to update partners regularly.

5. Test back-up communication procedures.

6. Identify a public health spokesperson appropriate to the emergency (e.g., Health Director, Epidemiologist).

7. SOCO developed, conveyed through ICS structure.

8. SOCO updated and distributed (e.g., posted to Situation Boards) as needed, but at least every four hours (maximum).

Gebbie © 2006 Prehospital and Disaster Medicine

Table 3—Menu of criteria for evaluation of local public health emergency drills and exercises (EOC = emergency
operations center; IAP = incident action plan; ICS = incident command system; JIC = jurisdiction-wide
information center; PIO = public information officer; SOCO = single overriding communications objective)
*activated = notified and in communication, not necessarily on-site continued

May – June 2006 http://pdm.medicine.wisc.edu Prehospital and Disaster Medicine

178 Role of Exercise and Drills

III. Early Recognition/Surveillance and Epidemology

1. Event/incident specific surveillance is established within 60 minutes of establishing the EOC.

2. Establish a preliminary case definition.

3. Adjustments to surveillance communicated as needed to and from the internal health public health IC.

4. Changes/enhancements in surveillance implemented within one hour of approval by the internal public health IC.

5. Epidemiology investigation plan including tools and forms completed within two hours of establishing the agency’s EOC.

6. Field Staff appropriately prepared and protected prior to deployment.

7. Establish time interval for updating epidemiology investigation plan based on reassessment of information.

IV. Sample Testing

1. Laboratory resources and requirements specific to agent/incident selected.

2. Specific protocols and procedures for collection of samples relevant to the specific emergency available within 60 minutes
of notification of incident by IC.

3. Ensure case investigators appropriately prepared and protected in PPE prior to deployment.

4. Field workers deployed to sites within 60 minutes of final IAP.

5. Samples properly packed and shipped/transported consistent with laboratory requirements.

Gebbie © 2006 Prehospital and Disaster Medicine

Table 3 (continued from page 177)—Menu of criteria for evaluation of local public health emergency drills and exer-
cises (EOC = emergency operations center; IAP = incident action plan; IC = incident command; PPE = personal
protective equipment) continued
When combined with narrative accounts from participants Recent publication of a Universal Task List (UTL) cov-
and observers, the criteria can contribute to the production ering actions to be taken by the various emergency
of a more detailed, robust “After Action Report”. More response sectors has raised questions about the use of the
importantly, because criteria reflect measures of tasks and criteria reported here. The UTL organizes tasks according
activities performed as part of an emergency response plan, to the four US Homeland Security Missions: Prevent,
they are likely to facilitate writing a more precise improve- Protect, Respond, and Recover. The criteria developed by
ment plan and be easily adapted for use in updating emer- this research can provide the metrics by which successful
gency response plans. completion of tasks may be measured. The UTL tasks in

Prehospital and Disaster Medicine http://pdm.medicine.wisc.edu Vol. 21, No. 3

Gebbie, Valas, Merrill, et al 179

V. Evidence Management

1. Evidentiary requirements confirmed with relevant agencies through jurisdiction-wide National Incident Management System
partners, prior to collection of personal or environmental samples.

2. Coordinated arrangements for maintaining chain of evidence in place prior to collection of any samples/specimens.

VI. Mass Prophylaxis and Immunization and Pharmaceutical Stockpiles

1. Generic mass dispensing strategy adapted to specific event within 60 minutes of notification.

2. Dispensing sites are staffed with adequate and appropriately staffed personnel for mass dispensing (including volunteer
surge staff) prior planned to site opening time.
3. Needed “just in time” training including use of PPE identified and requested at least two hours prior to planned opening of
sites.

4. System in place to restock supplies throughout duration of site operation.

5. System in place to rotate or relieve staff during site operation.

6. All needed record keeping supplies prepared and delivered for opening mass dispensing sites prepared and delivered to
site coordinators by opening of site(s).

VII. Mass-Patient Care

1. Generic mass care strategy adapted to specific event within 60 minutes of notification.

2. Mass care sites are staffed with adequate and appropriately staffed personnel (including volunteer surge staff) prior to
opening.
3. Needed “just in time” training including use of PPE identified and requested at least two hours prior to planned opening of
sites.

4. System in place to restock supplies throughout duration of site operation.

5. System in place to rotate or relieve staff during site operation.

6. All needed record keeping supplies prepared and delivered for opening mass dispensing sites prepared and delivered to
site coordinators by opening of site(s).

VIII. Mass-Fatality Management

1. If needed, identify suitable facility prior to dispatch of pick-up vehicles.

2. Develop plan for transport bodies, including routes and expected timeframes prior to dispatch of pick-up vehicles.

IX. Environmental Surety

1. Develop/adapt strategy for control of environment rendered hazardous by this event within 30 minutes of site identification.

2. Identify specific characteristics of affected areas and report to incident commander within 30 minutes of arrival on site.

3. Establish PPE criteria for staff.

Gebbie © 2006 Prehospital and Disaster Medicine

Table 3 (continued from page 178)—Menu of criteria for evaluation of local public health emergency drills and
exercises (PPE = personal protective equipment)

May – June 2006 http://pdm.medicine.wisc.edu Prehospital and Disaster Medicine

180 Role of Exercise and Drills

Function Universal Task List Item Local Public Health Criteria

VI. Mass Prophylaxis & Immunization and

Pharmaceutical Stockpiles

1. Generic mass dispensing strategy adapted to specific

event within 60 minutes of notification.

2. Dispensing sites are staffed with adequate and

#1.1.1.2 Develop plans, procedures,
and protocols to implement
national pharmaceutical stockpile
operations
appropriately staffed personnel for mass dispensing
(including volunteer surge staff) prior to planned site
opening time.
3. Needed “just in time” training, including use of PPE
identifed and requested at least two hours prior to
planned opening of sites.

4. System in place to restock supplies throughout

duration of site operation.

5. System in place to rotate or relieve staff during site

operation.

6. All needed record keeping supplies prepared and

delivered for opening mass dispensing sites prepared
and delivered to site coordinator by opening of site(s).

IV. Sample Testing

1. Laboratory resources and requirements specific to

agent/incident selected.

2. Specific protocols and procedures for collection of

samples relevant to the specific emergency available
Misson: Protection within 60 minutes of notification of incident by IC.
#1.1.2 Develop laboratory plans,
(Pro.C.1.) procedures, and protocols
3. Ensure case investigators appropriately prepared and
protected in PPE prior to deployment.

4. Field workers deployed to sites within 60 minutes of

final IAP.

5. Samples properly packed and shipped/transported

consistent with laboratory requirements.

III. Early Recognition/Surveillance and Epidemiology

1. Event/incident specific surveillance is established

within 60 minutes of establishing the EOC.

2. Establish a preliminary case definition.

3. Adjustments to surveillance communicated as needed

to and from the internal health public health IC.

4. Changes/enhancements in surveillance implemented

#1.1.3 Develop plans and within one hour of approval by the internal public
procedures for disease outbreak health IC.
5. Epidemiology investigation plan including tools and
forms completed within 2 hours of establishing the
agency’s EOC.

6. Field Staff appropriately prepared and protected prior

to deployment.

7. Establish time interval for updating epidemiology

investigation plan based on reassessment of
information.
Gebbie © 2006 Prehospital and Disaster Medicine
Table 4—Relationship of universal task list items to exercise evaluation criteria (EOC = emergency operations
center; IAP = incident action plan; IC = incident command; PPE = personal protective equipment) continued

Prehospital and Disaster Medicine http://pdm.medicine.wisc.edu Vol. 21, No. 3

Gebbie, Valas, Merrill, et al
Function Universal Task List Item
#1.1 Develop plans, procedures,
and protocols for the immediate
provision of mass care services
Misson:Response to shelters for disaster victims to
(Res.C.3) include shelter, feeding, basic
first aid, bulk distribution of
needed items, and other related
services
Table 4 (continued from page 180)—Relationship of universal task list items to exercise evaluation criteria
(PPE = personal protective equipment)
two mission areas for which the public health criteria may
be used for measurement are listed in Table 4.
With any Delphi research approach, there is one per-
spective on the topic of interest. The researchers made
every effort to acheive inclusion of those with an interest in
emergency response in the local public health level, with-
out regard to known perspective on the question of criteria.
The range of responses to the first round indicates that this
was accomplished. It is impossible to fully interpret the
lower response rate to the second round. The non-respon-
dents did not represent any one constituency or interest
group, and the researchers’ observation is that this round
coincided with a busy time of grant renewals and other
demands for time from the experts involved with this study.
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May – June 2006 http://pdm.medicine.wisc.edu
181
Local Public Health Criteria
VII. Mass Patient Care
1. Generic mass care strategy adapted to specific event
within 60 minutes of notification.
2. Mass care sites are staffed with adequate and
appropriate personnel (including volunteer surge staff)
prior to opening.
3. Needed “just in time” training including use of PPE
identified and requested at least two hours prior to
planned opening of sites.
4. System in place to restock supplies throughout duration
of site operation.
5. System in place to rotate or relieve staff during site
operation.
6. All needed patient record keeping supplies prepared
and delivered for opening mass care sites prepared and
delivered to site cooordinator by opening of site(s).
Gebbie © 2006 Prehospital and Disaster Medicine
The research team notes that limitations of this research may
be attributed to the 74% response rate from the expert panel.
Conclusion
Public health agencies must be able to measure perfor-
mance and identify areas for improvement. This can be
done through ongoing training and emergency response
exercising, and through the use of response exercises that
include plans for evaluation. The criteria developed
through this research are essential for those purposes.
Preparedness and response are dynamic processes, as
threats change and weaknesses are identified. Capacity is
continuously built through planning, exercising, evaluating,
and improving.
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applications for terrorism response: A report of the 2002 coastal North
Carolina domestic preparedness training exercise. J Am Inform Assoc
2003;10(2):166–176.
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Role of Exercise and Drills
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Vol. 21, No. 3