High-Quality Emergency Operations Planning (EOP)

6.3 After-Action Reviews, Corrective Action Planning, and Gap Analysis

The emergency planning process is continuous and cyclical. The district’s EOP and campus emergency plans should evolve as the school and planning team learn lessons, obtain new information and insights, and update priorities. A high-quality school emergency planning process includes development of an after-action review (AAR) process to facilitate this review and evaluation, as applied to all drills, exercises, events, incidents and emergencies. Essentially, the AAR process seeks to identify the following:

The AAR process results in documentation of strengths and of areas for improvement. These documents are applied within a gap analysis to identify resource needs. A corrective action plan (CAP) is used to establish and track the resolution of each identified gap or need. The CAP should be maintained by a single entity, if possible. If a district wishes for each campus to maintain an individual CAP, then the AAR process should address the sharing of progress on a regular and timely basis.

What is an After-Action Review

The AAR summarizes key information related to evaluation of the district EOP and/or the campus emergency plan as an aspect of the Preparedness Cycle. The AAR concentrates on measurement of the core capability and evaluation of the performance of district or campus staff that was involved in the drill or exercise. By recording the information below, district and campus officials can identify gaps and address areas for improvement.

Like the information recorded on a police report or student discipline form, information about the day, time and location are needed to assist reviewers in gap analysis. Information commonly documented but somewhat unique to the AAR includes:

  • Factors that contributed to the incident
  • Identification of the core capabilities and responsibilities needed for best outcomes
  • Notification and communication systems used during the incident or exercise
  • Quality of response (internal staff and external responders)
  • Involvement of media
  • Possible prevention or mitigation techniques not applied
  • Lessons learned
  • Supplies (materials, equipment and/or job aids) that were missing and might have improved outcome if made available
  • Overall impact to students and to the continuity of the educational process
  • Next steps

There is no mandate that determines the format of an AAR document. Templates are available but each district and/or campus emergency planning team should ensure that the format used addresses the specific hazards and needs of the school district. Guidance for conducting an effective AAR are addressed in the Homeland Security Exercise and Evaluation Program (HSEEP).

When should the AAR be completed?

This process should be used after actual incidents or emergencies, especially those that require assistance from response partners outside the campus and/or district. When a response expands to require outside resources, proper documentation will be needed to ensure full recovery afterwards.

Under normal training, drilling and exercising processes, a scheduled testing of the plan must occur before the AAR can be used. Use of drills and exercises allow districts and campuses to test the existing plans for capacity, capabilities and the coordination of the personnel being trained.

What is a Corrective Action Plan (CAP)?

A Corrective Action Plan is utilized to ensure each gap is addressed and processed through a high-quality school emergency planning process. The needs recorded on the CAP may be items such as:

  • An overview of the performance of staff and students as related to written plan and/or exercise objectives
  • Identification of staff with specialized skills (see the Staff Skills Survey Example below)
  • Additional education and training for staff with assigned roles and responsibilities
  • Acquisition of materials or equipment
  • Review and revision of resource management processes, including informal and formal agreements
  • Further development of processes to better meet regulations and recommendations
  • Changes in policy or procedure that hinders achievement of the best possible outcomes (see the Management of Informal and Formal Agreements below)

Utilizing Gap Analysis for Making Improvements to School Safety

Gap analysis compares performance with desired outcomes. It is sometimes referred to as need-gap analysis, need analysis or needs assessment. A strategic facet of planning, a gap analysis ensures the district has the human and material resources in place to implement the plan as written.

The gap analysis for planned courses of action must be done collaboratively, with input from multiple team members and stakeholders so that the process of resource allocation is transparent to everyone. Additional team members from departments, campuses and local first responders are very important to the successful outcome of a gap analysis.

Gap analysis typically involves comparing the district’s EOP to an evaluation of the district’s performance following a drill, exercise, or real-time event (such as a corrective action plan). The district may also compare its EOP to the Texas Unified School Safety and Security Standards, which contain benchmarks that all schools can meet.

Texas Unified School Safety and Security Standards Toolkit

From an emergency management perspective, gap analysis can be defined as the difference between the target capability and the current capability. Target capabilities are the goals or desired outcomes established by the district and its emergency planning team. Current capability is demonstrated in the district’s results when comparing their EOP (driven by their goals and objectives) to actual performance. The most common form of gap analysis in emergency management is found when the CAP is developed. However, to ensure improvement, a comprehensive gap analysis should also be conducted.

To comprehensively assess gaps, the planning team should consider the information and data provided from all available reports and assessments and categorize needs in a manner that encourages action. This categorization involves an evaluation of each goal from a multi-faceted functional perspective. The functions, commonly referred to as POETE categories, considered during a comprehensive gap analysis of a goal or objective include:

  • Planning
  • Organization
  • Equipment
  • Training
  • Exercise

The gap analysis is similar in content to the CAP. The primary difference is that the CAP addresses improvements in how we carry out a specific set of actions. The gap analysis addresses improvements in our policies, procedures, organizational design, staffing, training, and exercising of policies and procedures (and ultimately the EOP). Informational elements of a comprehensive gap analysis include:

  • Plan element – this field addresses a specific part or subpart of the EOP. The extent by which the plan is analyzed is the decision of the planning team, however care should be exercised to ensure that the analysis focuses on a specific subset of actions or capacities rather than the entire EOP or annex.
  • Assessment category – tasks to be completed are listed categorically (see the functional categories above) based on the nature of involvement. Some areas of the plan may have gaps in all functional categories while others may only have gaps in one or two functional categories.
  • Tasks to be completed – this field allows the planning team to evaluate sections of the plan and create specific tasks necessary to further accomplish the goals established by the district and its planning team.
  • Resources required – this field addresses the resources needed to carry out the listed tasks. Resources may include personnel (by position or role), equipment, or materials.
  • Estimated cost of completing the task – this references the fiscal costs of personnel, materials, contractual, and equipment costs necessary to accomplish the identified task.
  • Source or assignment of person(s) responsible for completing the task – this field identifies the company or individual responsible for completing the identified task.
  • Expected date of completion – this field references the deadline by which the identified task should be completed.

When determining what, if any, tasks should be included in the gap analysis, the planning team should consider the following questions:

Planning Category

  • Does the EOP adequately address the capability or function being analyzed?
  • Does the EOP integrate a NIMS-compliant incident command structure?
  • Does the EOP identify unique needs or situations?
  • Does the EOP integrate key stakeholders (both internal and external)?
  • Are lines of succession (individuals who will fulfill a role if the primary individual in not accessible) identified for key roles or positions?

Organization Category

  • What personnel are required to carry out the necessary courses of action in accordance with the EOP? Does the district/campus have these personnel at all times?
  • Are there Standard Operating Procedures for the function or capability in place?
  • Do existing policies allow for the anticipated course of action?
  • Are the required personnel able to and authorized to conduct the necessary activities as needed?
  • Are necessary contracts or agreements in place to carry out the course of action as prescribed in the EOP?

Equipment Category

  • What equipment is necessary to safely carry out the course of action?
  • Is the equipment in an accessible location?
  • Is the equipment in good repair and functioning properly?
  • Are qualified operators available for the equipment (i.e. persons trained on proper use of specialized equipment)?

Training Category

  • Are all appropriate personnel trained to manage incidents in accordance with the fundamentals of the National Incident Management System (NIMS)?
  • Are all appropriate personnel trained on proper response procedures as identified in the EOP and in accordance with commonly accepted best practices?
  • Are personnel trained on the safe and effective use of necessary equipment?
  • Are personnel trained on existing plans and policies?
  • Are training programs evaluated for adequacy (effective, efficient, and reoccurring)?
  • Is succession addressed in current training programs?

Exercise Category

  • Have all plans, protocols, policies, and standard operating procedures related to the section of the EOP being analyzed been validated by an exercise or actual incident within the past 2 years? If so, was an AAR conducted and a CAP developed? Were all corrective actions implemented successfully?
  • Are all necessary stakeholders involved in exercises that were conducted?
  • Are deficiencies and corrective actions identified and implemented appropriately and successfully?
  • Are exercises and drills conducted in different manners to ensure variations incident need are addressed (i.e. type of exercise, scenario, location)?
  • Are first responders involved with the planning, conduct, and evaluation of exercises?

Gap Analysis Worksheet

Upon completion of an effective gap analysis, the emergency management cycle and the planning process begin anew. This ensures that a high-quality EOP is continually updated to adequately reflect the needs and abilities of the district while encompassing the changes made throughout the district and incorporating the findings of exercise and incident evaluation.