– Executive Summary –


The Hospital Incident Command System (HICS) is a system of incident management that applies the principles of the Incident Command System (ICS) to hospitals. ICS is an organizational and multi-organizational management system developed in the 1970s by California’s FIRESCOPE (Firefighting Resources of California Organized for Potential Emergencies), a working partnership of fire service partners at the local, regional, state and federal level. Both HICS and ICS provide a scalable, flexible organizational structure that allows for common terminology and span of control during incident response and may expand or contract depending on the size of the incident.

Many of the 6,000 hospitals in the United States use a version of HICS for emergency management, and international use continues to increase. HICS is also used by all Navy hospitals. The Orange County Emergency Medical Services Agency developed HICS in 1991 in partnership with the California Emergency Medical Services Authority (EMSA), and EMSA released subsequent versions, each with increasing stakeholder input. The Fifth Edition was released in 2014.

This thesis is a case study in the identification of critical factors leading to the successful implementation of HICS by Stanford Medicine in response to the Asiana plane crash of July 6, 2013, hereafter referred to as Asiana.

Problem Statement

HICS is widely used, yet there is a paucity of research on HICS implementation. No model exists for evaluating HICS implementation or using it as a predictor of success. A study of HICS may benefit hospitals, provide input for future revisions, and add to the body of knowledge about HICS.

The impact of HICS, positive or negative, has not been comprehensively studied, and implementation of the system seems to be limited to anecdotal examples. Before the hospital response to the 2013 Boston Marathon Bombings provided anecdotal support for the value of HICS, the most compelling documentation available on the value and use of HICS in the United States was a survey conducted at Northridge Hospital after the Northridge Earthquake of 1994.

A research endeavor of HICS implementation during an emergency response appears timely, if not overdue.

Research Question

What are the critical factors that lead to the successful implementation of HICS based upon Stanford Medicine’s response to Asiana? For the purposes of this case study, Stanford Medicine refers to Stanford Hospital, Lucile Packard Children’s Hospital, and the Stanford University School of Medicine located in Palo Alto, California.


Although the available literature on HICS implementation was not extensive, four commonalities that support the perceived successful implementation of HICS were identified to build a model for successful implementation.

  • The literature supports that a firm commitment of hospital executive leadership to implement HICS within a culture of preparedness is a critical factor in successful HICS implementation.
  • It appeared that advance planning with community partners that includes training, drills, and exercising are critical variables in successful HICS implementation.
  • An effective communication plan with redundancies for information management to both internal and external partners is another factor identified from the literature review that supports successful HICS implementation.
  • The modification of HICS to the individual hospital’s or health system’s needs appeared to be a critical factor as part of the planning process.

The HICS implementation model proposes that if a hospital implements HICS and embraces the four commonalities, the hospital will then perceive HICS to be successful during an actual incident. Perceived success is measured by staff statements indicating such, e.g., “HICS worked.”

A comprehensive review and analysis of all documentation relative to Stanford’s Emergency Management Program was conducted including an analysis of HICS activations, an average of 29.6 annually, for the five years that preceded Asiana. It was determined that the four commonalities identified for successful HICS implementation are demonstrated at Stanford Medicine. Thus, it was reasonable to hypothesize that Stanford personnel would perceive HICS implementation to be successful in response to Asiana.

A review of extensive after action documentation was conducted to test this hypothesis. In addition to the after action report (AAR), all HICS materials and forms relevant to Asiana were reviewed along with debrief data collection forms and debrief emails. The AAR stated, “The established HICS processes and procedures worked” specifically under the category of communication. It was reasonable to conclude that the tested hypothesis was supported.

In addition to the lessons learned that support the tested hypothesis, the documentation reviewed described highly competent individuals and cohesive teamwork. It was not possible to separate individual and team competence from the tested hypothesis.

Through the analysis conducted at Stanford, it appeared the four commonalities may not be granular enough for future evaluations and may be further delineated for greater specificity in evaluation.


As a result of analyzing the data from Stanford, it is recommended that the four commonalilties or critical factors for further hypothesis testing be subdivided in six areas for further evaluation. This delineation will provide greater specificity for future analysis:

  • Executive and Administrative Support
  • Planning and Tailoring (includes modifying HICS)
  • Training and Retraining
  • HICS Activations and Exercises
  • Communication
  • Coordination with Community/External Partners

These six critical factors comprise a HICS Implementation Model that is provided as an appendix that may be used as an “after action” evaluation tool or as a potential predictor of HICS success prior to an incident.

Recommendations are provided for users of HICS, for future revisions of HICS and for future research. Based upon lessons learned from Stanford, the HICS Implementation Model comprised of the six critical factors for successful HICS implementation is recommended for hospital use, for inclusion in the next edition of HICS, and to be collected to further analyze case studies of HICS implementation and the perceived success of HICS during an actual event.


This case study identified critical factors leading to the successful implementation of HICS based upon Stanford Medicine’s response to Asiana. A hypothesis for successful HICS implementation was developed from a literature review and this hypothesis was tested and supported by Stanford. In addition to the lessons learned that support the tested hypothesis, the documentation reviewed described highly competent individuals and cohesive teamwork. It was not possible to separate individual and team competence from the tested hypothesis.

A HICS Implementation Model was developed that may be used for “after action” evaluations, as a predictor of successful HICS implementation, for inclusion in the next version of HICS, and to analyze future case studies of HICS implementation.

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