Introduction

The operational effectiveness as well as the safety, or even survival, of all components of the local, regional, and state medical infrastructure confronted with a large-magnitude natural, manmade, or terrorism-related disaster will largely depend on the quality of the overall incident management. Public safety, public health, emergency management, and health care system officials should be familiar with the rudiments of emergency incident management theory and practice. Nowhere is this more important than in EMS, where the system must interface seamlessly with public safety entities that use the incident command system (ICS) for daily operations, and hospitals, where the administration typically alters its organizational management scheme to an ICS during major emergencies.

It is easy to understand why it is necessary to organize the management of emergency incidents differently than normal business or public administration plans. For example, a bureaucracy is, by definition, the wrong structure through which to manage a low-frequency, high-hazard incident. According to Webster’s Dictionary [1], a bureaucracy is a “government marked by diffusion of authority among numerous offices and adherence to inflexible rules of operation … [or] an administrative system in which the need to follow complex procedures impedes effective action.” In organizational theory, the core features of bureaucratic management include formalization (i.e. enforcement of rigid rules and procedures), specialization, and hierarchy [2]. This form of administration is most effective at handling large-volume, variably complex but routine tasks, in stable environments [3].

Management of unstable situations with potentially catastrophic outcomes requires establishment of high-reliability organizations [4]. Roberts et al. [5] observed that reliability is directly related to flexibility of the organizational structure. Temporary organizations assembled in response to specific challenges may provide such flexibility, and offer an attractive alternative to conventional structures that have not performed well in high-risk, high-hazard environments. Virtual organization represents an increasingly common temporary administrative architecture for corporate and public safety entities operating in crisis mode.

One distinguishing characteristic of virtual organizations is the time-limited assembly of diverse agencies, corporations, or other specialized teams into a task-determined architecture for the purpose of accomplishing an immediate goal. Linkage within the virtual organization is through information pathways. When constituent units are not colocated, they are electronically networked [6]. The relationships among the units can be evanescent, as structural changes are dictated by the demands of the mission. Virtual organizations make good high-reliability organizations, as units having diverse expertise or resources can share previously inculcated health and safety priorities as well as the joint vision of the mission at hand [6]. Their innate adaptability to rapidly changing conditions as well as some intrinsic redundancy also favor the use of virtual organizations for management of complex, high-hazard, or high-consequence incidents.

Several investigators have studied the ICS employed by local emergency responders as a model high-reliability, virtual organization [6,7]. As required by presidential directive [8], state and federal agencies have nominally incorporated ICS into their emergency response plans because of its simple design, and to facilitate integration of their assets into local emergency operations. The National Incident Management System (NIMS) [9] was designed to coordinate multiagency, multijurisdictional responses to large-scale emergencies. For ICS and NIMS to function effectively, the basic premises of ICS must be understood by those implementing it. These principles cannot be compromised without losing the effectiveness and performance for which ICS and NIMS have become so highly regarded.

Incident command systems were first designed for use by civilian emergency responders in the United States in the mid-1970s. An interagency representative group, Firefighting Resources of California Organized for Potential Emergencies (FIRESCOPE), developed the best-known prototype ICS in response to critical management deficiencies associated with the state’s wildland firefighting [10]. Foremost among the problems encountered were ineffective communications, unclear jurisdictional and tactical command authority, inability to account for the geographic location or task assignments of personnel, and difficulty responding effectively and expeditiously to challenges of the dynamic, high-hazard environment. Although FIRESCOPE was originally conceived for wildland settings, the Phoenix Fire Department and others recognized similar deficiencies in structural firefighting and formulated the Fireground Command System (FCS), for use in all fire department emergency incidents involving more than a single-company response [11].

The US Fire Administration and its National Fire Academy endorsed the FIRESCOPE ICS as the preferred management model for application throughout the fire service, and widely disseminated it through published documents and curricular offerings. Throughout the last two decades, a consortium of fire and emergency services representatives has collaborated on a single incident management system (IMS) incorporating the best features of ICS and the FCS [12]. In the following discussion, the terms ICS and IMS will be used interchangeably, as they are in the emergency response communities.