2023_06_02_Directive107-1_ContinuousImprovementProgram_v3_F.pdf

FEMA DIRECTIVE:

Continuous Improvement Program

FEMA Directive #107-1, Revision 2

BACKGROUND

Directive 107-1 applies to all Federal Emergency Management Agency (FEMA) employees at headquarters (HQ) components, in the regions, and at field establishments who are members of the Continuous Improvement Program (CIP) and/or involved in CIP operations or activities. This Directive supersedes FD-107-1:

Continuous Improvement Program, dated May 21, 2019, and other existing FEMA processes and standard operating procedures pertaining to CIP’s internal management of lessons learned and improvement actions. This Directive takes precedence if any part or section of it conflicts with other memorandums or guidance about CIP.

PURPOSE

FEMA Directive 107-1 establishes the primary responsibilities and functions of FEMA’s CIP, outlines requirements for CIP staff, and communicates leadership intent and direction for CIP building a culture of learning.

PRINCIPLES

CIP operates under the following guiding principles:

A. Continuously Improve FEMA Incident Management and Support Capabilities:

CIP collaborates with field, regional, and HQ subject matter experts (SME) to provide timely, actionable, and valid findings, observations, and recommended courses of action based on assessment of disaster operations to responsible program offices (RPO). This information is used to inform operations, improve future performance, and enhance service delivery to survivors and communities by helping RPOs identify, understand, and address their challenges or codify best practices.

B. Provide a Consistent Agency Approach: CIP applies a consistent, replicable, and methodologically appropriate process to conduct disaster assessments. This approach includes the use of standardized agency and program-driven operational priorities that drive CIP data collection across all Major Disaster Declarations (MDD) and enable trend analysis over time.

C. Make Information Available to Enable Learning and Support Decisions:

All FEMA employees are part of a culture of learning and improvement. CIP enables everyone in the agency to independently access after-action review results and improvement actions while maintaining the trust of those who contribute and programs seeking to improve.1 Through widespread availability of data, CIP enables

1 FEMA staff may access after-action review results here.

https://usfema.sharepoint.com/teams/RESNPD/NPAD/open/CIP/Pages/CII-Program-Resources.aspx agency staff to discover program insights and increases the likelihood of others taking action to effect change.

D. Empower FEMA Programs to Improve and Recognize Success: CIP coordinates with RPOs to support strategic decision making on improvement actions. CIP tracks program office accomplishments, provides analytical support and solution-oriented consulting to overcome barriers to action, and evaluates and recognizes the success of actions.

E. Support National Preparedness: Through training, tools, and guidance, CIP builds the capacity of emergency managers to conduct continuous improvement processes in dynamic and changing environments. This informs and advances FEMA and state, local, tribal, and territorial (SLTT) readiness and preparedness for disaster operations.

REQUIREMENTS

A. CIP STRUCTURE

Outcome: CIP staff are dedicated personnel, including permanent full-time employees and Cadre of On-Call Response/Recovery (CORE) employees, located at HQ, in each region, and in field establishments, such as Long-Term Recovery Offices (LTRO), to support CIP activities across operational locations.

1. CIP is managed by the Continuous Improvement Division (CID) within Resilience at FEMA HQ.

2. Each Regional National Preparedness Division manages and trains at least one full-time Regional Continuous Improvement Coordinator (RCIC) who is responsible for the management, coordination, and execution of all regional CIP activities and is essential for program delivery. Regions may also maintain CIP field staff located at select LTROs.

3. The CID Director leads CIP in coordination with regional leadership, primarily the Regional Integration Branch Chiefs (RIBC), or equivalent, and the Federal Preparedness Coordinators (FPC).

4. CID regularly communicates with RCICs for program development and delivery purposes.

5. CID is responsible for managing programmatic doctrine and training, overseeing cadre and deployment coordination, establishing national priorities, developing the program’s strategic vision, and facilitating action tracking at the HQ level, among other activities.

6. CID also leads the establishment and reporting of internal performance measures across CIP, which are used to promote an internal culture of learning, track accomplishments, and capture the effectiveness of CIP in achieving its vision. The performance measures also provide data-driven insights that can be used at all levels of CIP to inform decision making and strategy.

B. ASSESSMENTS

Outcome: CIP fulfills after-action review requirements and supports a culture of learning through the systematic collection and analysis of information about FEMA operations, referred to as assessments. The products developed from CIP assessments are used to improve FEMA’s future performance and help RPOs identify, understand, and address challenges.

1. After-Action Reviews: CIP will conduct after-action reviews and generate and disseminate, as appropriate, After-Action Reports or similar products as outlined in Instruction 107-1-1: After-Action Review Implementation for real-world events that receive MDDs, as required by the Post-Katrina Emergency Management Reform Act (PKEMRA).2

a. The scope of CIP after-action reviews focuses exclusively on improving the efficiency and effectiveness of FEMA’s activities and processes in disaster operations.

b. CIP categorizes after-action reviews into three tiers (Tier I, Tier II, and Tier III). The complexity and duration of the after-action review and the breadth and depth of the corresponding product increase with each tier. CIP has a standardized approach for determining the appropriate tier and corresponding product in consultation with regional and field leadership.

Instruction 107-1-1 describes this in detail.

c. CIP is responsible for conducting at least one after-action review per MDD.3

d. RCICs, in support of their regional and field leadership, ensure the completion of after-action reviews and associated products for MDDs within their regions. CID supports after-action reviews and the collection of data from MDDs in coordination with regional and field leadership.

i. For agency-wide products; multi-region or national incidents; or unique and unprecedented incidents or events, CID often plays a more significant role in after-action review development and approval.

Instruction 107-1-1 outlines additional details about CID’s involvement in the after-action review process.

ii. Regional National Preparedness Divisions make available RCICs, as possible, to support large-scale after-action reviews and collection efforts conducted in other regions. For multi-region incidents, CID will

2 The authority instructing FEMA to generate and disseminate After-Action Reports for real world events, as appropriate, is derived from 6 U.S.C. ⸹ 750. The Administrator delegated authority under section 750 to the Deputy Administrator, Resilience, “to exercise duties and powers for the resilience matters, including, among other, leading and managing national preparedness programs and activities required under 6 U.S.C. ⸹ 741 - 754, 761.”

3 When possible, CIP may conduct more than one after-action review across the disaster lifecycle to increase learning opportunities.

https://usfema.sharepoint.com/teams/OPPAPolicy/Lists/Policy%20Master%20List/Attachments/1059/Instruction-%20After-Action%20Review%20Implementation%201.6.2022.pdf https://usfema.sharepoint.com/teams/OPPAPolicy/Lists/Policy%20Master%20List/Attachments/1059/Instruction-%20After-Action%20Review%20Implementation%201.6.2022.pdf https://usfema.sharepoint.com/teams/OPPAPolicy/Lists/Policy%20Master%20List/Attachments/1059/Instruction-%20After-Action%20Review%20Implementation%201.6.2022.pdf https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title6-section750&num=0&edition=prelim coordinate with regional and field leadership to manage deployment of RCICs.

iii. CID completes a National Collection Analysis Priorities (NCAP) survey for every MDD (refer to Section C for additional details related to

NCAP).

e. CID is responsible for managing and updating policy, doctrine, guidance, and training related to after-action reviews and resulting products.

f. CIP staff deploy to disasters consistent with Field Operations Directorate policies and guides, and report to field leadership at the disaster, either the Federal Coordinating Officer (FCO) or Chief of Staff (COS). CIP deployments are primarily in-person to support collection activities outlined in the Discovery section and primarily virtual to complete the activities outlined in the Validation and Action sections below.

i. CID maintains and manages a roster of CIP staff consistent with FQS policies and doctrine to support incident management and incident support deployment requirements.

g. CIP may develop after-action review products for other real-world incidents if the Department of Homeland Security (DHS) Secretary or FEMA Administrator determines it is appropriate for FEMA to generate such reports.

Regional Administrators, Associate Administrators, and Assistant Administrators may also request after-action review products. The CID Director adjudicates requests from HQ offices and stakeholders. The FPCs adjudicate requests from regional offices and stakeholders.

h. CIP conducts assessments through a consistent, replicable, and methodologically appropriate approach by following a defined, four-phased process. The four phases are: Discovery, Validation, Action, and Evaluation.

The following sections explain each phase in further detail.

2. Discovery: CIP collects information about disaster operations and identifies strengths, potential best practices, and areas for improvement by conducting structured and repeatable assessments across the disaster lifecycle.

a. In the Discovery Phase, CIP staff collect and analyze operational and programmatic data to identify findings or observations, categorized as strengths, potential best practices, or areas for improvement.

b. CIP uses a variety of methods during the Discovery Phase, including but not limited to, surveys, interviews, hotwashes, feedback forms, document reviews, and direct observation to collect data about disaster operations.

c. CIP collects and uses data without attribution to individuals. If clarification or additional information is required, CIP conducts follow-up as appropriate.

d. CIP performs both qualitative and quantitative analysis on collected data.

e. Findings and observations are objective analytical conclusions derived from a CIP collection. Findings include in-depth analyses of quantitative and qualitative data that elicit higher confidence in the accuracy of the results and are the primary objective of CIP collections. Observations are generally of less detail than findings, and at minimum incorporate qualitative data from multiple objective sources. Refer to the Definitions section for further explanation of both. Hereafter, the term “finding” in this document refers to both findings and observations. Both terms follow the same process as described in the Assessments section.

f. CIP’s Discovery Phase activities may take place across operational locations, including but not limited to Joint Field Offices, Disaster Recovery Centers, Regional Response Coordination Centers (RRCC), or the National Response Coordination Center (NRCC). Additionally, these activities may take place in support of field activities, including before a disaster is declared, such as related to Preliminary Damage Assessments or Incident Management Assistance Team/Liaison Officer deployments.

g. CIP develops a Disaster Collection Analysis Plan (DCAP) to guide data collection efforts for Tier I and Tier II after-action reviews in accordance with Instruction 107-1-1. A DCAP should contain consistent measures and priority areas, including those identified in the NCAP, to enable cross-disaster analysis (Section C outlines additional details about NCAP) and should also include regional and field priorities. FCOs, or their designees, identify and approve field priorities.

h. Regions can identify regional priorities by creating Regional Collection Analysis Priorities (RCAP). RCICs are encouraged to engage with regional leadership, including the Regional Administrator and Division Directors, to establish a defined set of priority areas that are most important to regional leadership and can guide the collection, analysis, and evaluation of operational and programmatic data. Regions may request CID support with the development of RCAPs.

i. If CIP personnel discover a mission-critical matter that may result in mission failure, loss of life, bodily injury, and/or significant performance issues or safety concerns outside the scope of reporting during the collection period, they will immediately notify appropriate operational leadership.

j. At the end of the Discovery Phase, CIP staff provide FCOs, or their designees with an out brief of preliminary findings and significant trends that may inform immediate field leadership activities.

3. Validation: CIP ensures findings and recommended courses of action are accurate, actionable, and significant by engaging with applicable program offices and SMEs to provide review and feedback on the findings.

a. During the Validation Phase, CIP verifies the results of the analysis by soliciting feedback from relevant stakeholders through an objective and fact-https://usfema.sharepoint.com/teams/OPPAPolicy/Lists/Policy%20Master%20List/Attachments/1059/Instruction-%20After-Action%20Review%20Implementation%201.6.2022.pdf driven process. CIP staff work with pertinent FEMA field, regional, and HQ program offices, as well as SLTT stakeholders (as appropriate), to review all findings for accuracy, ensure that conclusions recognize comprehensive perspectives, and identify and corroborate recommended courses of action.

CIP staff review all feedback received and adjudicate it as appropriate.

i. FCOs will adjudicate disagreements or inability of a program to engage with findings if related to a field program. Regional leadership will adjudicate these issues when related to a regional program office. CID will adjudicate these issues when working with HQ program offices, coordinating with the applicable program offices and their component leadership.4

b. Each region will establish and maintain an after-action review product approval process, which includes a quality review for accuracy, actionability, and significance. The Regional Administrator or Continuous Improvement Working Group (CIWG) approves this process (refer to the Action section for additional information about CIWGs). The review and approval process for an after-action review product typically includes, at minimum, the Regional Administrator, or their designee, and the FPC. Additionally, FCOs, or their designees, will have an opportunity to review after-action review products developed for disasters for which they are responsible.

i. The Regional Administrator, or their designee, has final approval authority over the validation of findings and approval of after-action review products from operations in their region and can also request the revision, reopening, or closure of findings as needed.

c. CID will establish and maintain an after-action review product approval process, including a quality review. The Assistant Administrator of the Office of Resilience Strategy approves this process.

d. Applicable program office leadership responsible for reviewing a finding for validation purposes may determine that it is not valid and request the finding be closed. Whenever a finding is closed, CIP captures the rationale for that decision. The regional CIWG or applicable HQ component senior advisors have the discretion to review the rationale and request that CIP reopen the finding.

e. For each recommended course of action, CIP staff may suggest the level of responsibility (i.e., field, region, or HQ) to address it. For region-led after-action reviews, the CIWG or FPC confirms the level of responsibility prior to

4 FEMA Directive #259-3: FEMA Planning, Programming, Budgeting, and Execution defines “components” as:

FEMA Regions, programs, and offices; including, but not limited to, offices headed by a Deputy Administrator, Associate Administrator, Assistant Administrator or equivalent, Director, Chief Counsel, Chief Financial Officer, as well as other offices within the Office of the Administrator.

program referral. For HQ-led after-action reviews, CID works through component senior advisors and Action Offices to confirm the level of responsibility.

f. Once a finding is validated, recommended courses of action can move forward to the Action Phase and are not required to wait for after-action review product finalization.

g. For each finalized after-action review product, RCICs disseminate published information to their regional leadership, field leadership, and agency-wide through CIP tools, including the Comprehensive After-Action Report Analysis Tool (CAARAT).

h. RCICs regularly inform regional leadership and CID of the status of each after-action review. For each after-action review, CIP staff from the field, region, and HQ ensure that CID receives findings and finalized products. CID tracks the status of all after-action reviews and resulting assessment products for MDDs.

i. CID maintains information management systems to manage data collection;

develop, track, and analyze findings, recommendations, and program actions; and catalog resulting after-action review products. These systems include user-based access control and security.

4. Action: CIP empowers FEMA programs to improve service delivery by referring actionable findings to RPOs, providing analysis that clarifies actions that are likely to have the greatest effect, and tracking program decisions and progress.

a. Each region will establish and maintain a CIWG, or related body, to support referral of findings and recommended courses of action to the appropriate program offices, assign and track actions, confirm completion of actions, and review the results of evaluations (refer to the Evaluation section for further details related to the Evaluation Phase).

i. The Regional Administrator or their designee chairs the CIWG.

ii. The CIWG meets regularly to fulfill its roles and responsibilities in a timely manner.

b. During the Action Phase, CIP manages referral of the validated finding and recommended course(s) of action to an RPO, requests action decisions, tracks action progress, and confirms action completion. The referral and action decision process differs according to the level of responsibility (i.e., field, region, HQ). The process for each level of responsibility is outlined below.

c. Field level of responsibility:

i. The FCO or CIWG reviews recommended courses of action categorized as having a field level of responsibility to confirm the https://analytics.fema.net/#/site/AnalyticsHub/views/CAARATDashboard_15762670116090/Welcome?:iid=1 https://analytics.fema.net/#/site/AnalyticsHub/views/CAARATDashboard_15762670116090/Welcome?:iid=1 appropriate field RPO and decide whether to approve for referral to an RPO for an action decision.

ii. The RPO can accept responsibility or indicate they are not the correct program office for this decision. If the RPO accepts responsibility, they can agree to develop an action, decline to develop an action, request an extension for the decision, or request a revision to the finding if they were not included in the validation process. CIP expects that some RPOs will decline actions given programmatic priorities and finite resources. When this occurs the RPO will provide a rationale for this decision.

iii. The RPO may also agree to take action but determine that the specific recommended course of action is not the best approach and develop an action they feel more appropriately addresses the root cause of the finding.

iv. The Regional Administrator, or FCO if designated by the Regional Administrator, has the authority to direct their RPOs to adjust any decision made on a recommended course of action.

v. If an RPO can no longer commit to working on an accepted action, the RPO may request it be withdrawn prior to the action’s completion. The RPO provides a rationale for this decision, and the CIWG, or FCO if delegated by the Regional Administrator, determines whether to approve this decision.

d. Regional level of responsibility:

i. The CIWG, or related body designated by the Regional Administrator, reviews recommended courses of action categorized as having a regional level of responsibility to confirm the appropriate regional RPO and decide whether to approve for referral to an RPO for action.

ii. For regional recommended courses of action, CIWG approval for referral indicates that the RPO has agreed to take action.

iii. Given programmatic priorities and finite resources, the CIWG may decline to refer for action; the CIWG provides a rationale for this decision.

iv. The RPO may agree to take action but determine that the specific recommended course of action is not the best approach and develop an action they feel more appropriately addresses the root cause of the finding.

v. The Division Director over the RPO assigns appropriate staff or resources to develop and implement an action.

vi. Each CIWG determines whether RCICs can route recommended courses of action to regional RPOs prior to CIWG approval to expedite action. In regions where this is approved, CIP requests an RPO decision about whether the program intends to act. For actions accepted, the CIWG will have awareness for tracking purposes. If the RPO declines action or indicates they are not the correct program office, the recommended action will route to the CIWG for decision.

vii. The Regional Administrator has the authority to direct their RPOs to adjust any decision made on a recommended course of action.

viii. If an RPO can no longer commit to working on an accepted action, the RPO may request it be withdrawn prior to the action’s completion. The RPO provides a rationale for this decision, and the CIWG, or related body, determines whether to approve this decision.

e. HQ level of responsibility:

i. Recommended courses of action that exceed the region’s scope and have operational consequences requiring agency action are categorized as having an HQ level of responsibility.

ii. For region-led after-action reviews, the CIWG, or related body designated by the Regional Administrator, will review each recommended course of action categorized with an HQ level of responsibility to determine approval for referral to CID.

iii. CID reviews all recommended courses of action with an HQ level of responsibility and their associated finding(s) for accuracy, actionability, and significance.

iv. CID works with Action Offices to determine and assign the appropriate HQ RPO. This assignment does not imply that the RPO has agreed to act. Instead, it indicates that they are the appropriate program to make an action decision.

v. Once an HQ RPO is assigned, CIP requests an action decision. The appropriate HQ RPO Branch Chief (or above) reviews the recommended course(s) of action for an action decision and assignment of appropriate staff or resources.

vi. The RPO can accept responsibility or indicate they are not the correct program office for this decision. If the RPO accepts responsibility, they can agree to develop an action, decline to develop an action, request an extension for the decision, or request a revision to the finding if they were not included in the validation process. CIP expects that some RPOs will decline actions given programmatic priorities and finite resources. When this occurs the RPO will provide a rationale for this decision.

vii. The RPO may also agree to take action but determine that the specific recommended course of action is not the best approach and develop an action that more appropriately addresses the root cause of the finding.

viii. If the RPO can no longer commit to working on an accepted action, the RPO may request it be withdrawn prior to the action’s completion. The

RPO provides a rationale for this decision, and the HQ RPO Branch Chief (or above) determines whether to approve this decision.

f. For recommended courses of action accepted for action at all levels of FEMA, the RPO will outline the specific details of the activity the RPO intends to take to address the finding.

i. If requested by the RPO and pending CIP resource availability, CIP may provide planning and facilitation support to assist the RPO as they work to identify, develop, or plan implementation of actions.

ii. The RPO provides updates on the status of accepted actions at least every three months to CIP.

iii. To mark an accepted action as complete, the RPO provides written documentation to CIP showing that they have accomplished an action.

iv. The regional CIWG will adjudicate any nonconcurrence about completion at the regional or field level; component senior advisors for the related RPO will adjudicate nonconcurrence about completion at the HQ level.

g. While CIP supports and coordinates with program offices to address findings, program offices are responsible for developing and implementing actions.

h. CID manages the tracking of all decisions on findings, recommended courses of action, and actions. CID also tracks implementation of actions assigned to FEMA in federal interagency after-action reviews and reports.

i. CID conducts trend analysis on findings and actions to present to RPOs, Regional Administrators, and HQ leadership for consideration.

j. CID briefs HQ and regional leadership each quarter, to include at minimum the Associate Administrators of Resilience, of Response and Recovery, and of Mission Support, and the Regional Administrators, on the status of actions taken by RPOs and specific outcomes for high priority findings and actions.

These quarterly briefs also include information about other CIP initiatives and efforts.

5. Evaluation: CIP evaluates the completed action(s) taken to address a finding to determine if effects identified in the finding have recurred and determine if additional action is required.

a. For select findings with completed action(s), CIP performs an evaluation to assess recurrence of the finding. Recurrence of a completed finding may indicate that the completed action(s) did not address the root cause or that the finding was invalid.

i. CIP uses the following considerations when determining whether an evaluation should occur: 1) effect or significance of the finding, 2) agency leadership requests, 3) feasibility to evaluate the root cause, 4) availability of CIP resources for evaluation, and 5) the level of engagement from the RPO.

ii. For findings selected for an evaluation, CIP uses the finding and completed action(s) to develop a priority area which will be incorporated into relevant DCAPs.

iii. CIP may incorporate evaluation priorities into RCAP(s) or the NCAP, if appropriate, based on the considerations above.

b. CIP develops a new finding to document the results of an evaluation.

i. If effects did not recur, CIP documents the finding as a strength. If the originator of the finding (i.e., region or HQ) agrees with the results and determines that the completed action(s) fully addressed the root cause of the original finding, CIP will designate the evaluation as successful.

CIP notifies the related RPO(s) of the results. CIP works with the RPO(s) to determine opportunities to disseminate the results of the evaluation across the agency so others may consider similar actions.

ii. If effects recurred, CIP documents the finding as an area for improvement. If the originator of the finding agrees with the results and determines that the completed action(s) have not fully addressed the root cause of the original finding, CIP will designate the evaluation as unsuccessful. CIP notifies the related RPO(s) of the results. CIP works with RPOs to consider any additional action or analysis required to improve the outcome and routes the evaluation finding to the RPO for continued improvement and tracking.

iii. CIP may determine that multiple evaluations are required before designating an evaluation as successful or unsuccessful. Once CIP has a recommendation for successful or unsuccessful, they will present the results to the CIWG or Division for the relevant RPO.

iv. For region-led findings, the CIWG makes the evaluation determination;

the CIWG may only make the evaluation determination for findings that originated from their region.

v. For HQ-led findings, the Division for the relevant RPO makes the evaluation determination.

vi. CIP staff can support evaluation efforts across the program by incorporating evaluation priorities into DCAPs, regardless of a finding’s origin.

c. CID presents the results of evaluations to agency leadership, to include at minimum the Associate Administrators of Resilience, of Response and Recovery, and of Mission Support, and the Regional Administrators, during the CIP quarterly briefs.

C. NATIONAL COLLECTION ANALYSIS PRIORITIES AND SUMMARY OF

FINDINGS

Outcome: CIP gathers information about priority areas that are most important to agency leadership, collects standardized data across all MDDs related to those priorities, facilitates consistent analyses of that data, and performs long-term trend analysis based on available data.

1. CIP will develop the NCAP in coordination with agency leadership and program offices to guide disaster collection efforts across MDDs.

a. CIP regularly reviews the NCAP.

b. The Associate Administrators of Resilience, of Response and Recovery, and of Mission Support approve the NCAP priorities. CIP consults the Regional Administrators while developing the NCAP for their inputs to the priorities.

c. The FEMA Strategic Plan, the Administrator’s Annual Planning Guidance, and other relevant guidance documents inform development of the priorities, including applicable external documents and factors, such as DHS Office of the Inspector General (OIG) and Government Accountability Office (GAO) reports.

d. For each priority, the NCAP includes standard quantitative and qualitative metrics and research questions that CIP will use consistently for all disasters.

e. CID works with the Associate Administrators of Resilience, of Response and Recovery, and of Mission Support, or their designees, to identify program offices with vested interests related to the approved priority area(s). Program offices will provide SMEs with whom CIP can collaborate regarding NCAP and who can provide feedback and assistance related to the Discovery, Validation, and Action Phases of NCAP.

f. CID leads the development, analysis, and reporting of the NCAP.

g. CID performs an analysis of consolidated data to identify trends and findings on NCAP priority areas to inform agency disaster operations, policies, and programs. CID will develop a briefing that outlines NCAP findings. The briefing is published quarterly and can be accessed here.

h. CID briefs the status, major findings, and, where possible, any resulting actions discovered through NCAP or shared with CIP to agency leadership, to include at minimum the Associate Administrators of Resilience, of Response and Recovery, and of Mission Support, and the Regional Administrators, during the CIP quarterly briefs.

2. CID develops an annual Summary of Findings (SoF) on disaster trends outside the scope of NCAP.

a. CID analyzes field, regional, and HQ findings, along with other finalized CIP and agency documents provided to CIP, to inform this analysis.

b. CID performs an analysis of the consolidated data to identify cross-disaster, cross-regional, and cross-programmatic trends or findings that support or inform agency learning.

c. CID will complete the analysis and coordinate with RPOs who have equity in the emerging trends for their validation and action decision, when applicable.

CID will develop a briefing that outlines major trends identified from the SoF.

The briefing is published annually and can be accessed here.

d. CID presents the SoF to agency leadership, to include at minimum the Associate Administrators of Resilience, of Response and Recovery, and of Mission Support, the Regional Administrators, and field leadership, during one of the CIP quarterly briefs.

D. INCIDENT SUPPORT OPERATIONS

Outcome: CIP provides Assessment and/or Advisory and Decision Support services during incident support operations to inform ongoing operations, improve the efficiency and effectiveness of disaster operations, and aid leadership decision making through the incorporation of lessons learned from past disasters.

1. Senior leadership may request CIP to participate in early Discovery Phase activities before an MDD occurs, such as in support of NRCC and RRCC activations.

2. At the request of the Regional Coordinating Officer (RCO), or equivalent, as articulated in an Operations Order and in consultation with regional FPCs, RCICs deploy to RRCCs during activations as Continuous Improvement Program Advisors.5

3. At the request of the Chief of the National Response Coordination Staff (NRCS) as articulated in an Operations Order, CID staff deploy to the NRCC during activations as Continuous Improvement Program Advisors.

4. When FEMA activates the NRCC and RRCC(s) simultaneously, the Continuous Improvement Program Advisors at HQ and in the regions maintain regular lines of communication to coordinate CIP efforts. The Continuous Improvement Program Advisor(s) at the NRCC initiate this process.

5. CIP supports incident support operations through two primary but nonexclusive areas of focus:

a. Assessment: Assessment services follow the same methods and processes outlined within the Discovery, Validation, Action, and Evaluation sections of the document. Assessments in incident support may or may not result in an after-action review product, such as a Quick Look Report or After-Action

5 In incident support settings, CIP staff operate under incident support Position Task Books (PTB) as Continuous Improvement Program Advisors and report under the Chief and Advisory Section (CAS).

Report, depending on the scale, scope, and complexity of the activation.

Assessment services, such as data collection and report development, may continue past the deactivation of the NRCC or RRCC, and relate directly to the specific incident operations.

b. Advisory and Decision Support: Based on analytical information available, CIP provides NRCC/RRCC leadership and decision makers with advice and/or knowledge products to help solve problems and inform decisions about current operations. NRCC and RRCC leadership may seek advisory support from CIP staff and help in identifying operational gaps or duplications of effort. When possible, CIP staff should address opportunities for improvement and refer identified issues to NRCC/RRCC leadership during disaster operations.

6. CIP primarily offers incident support Assessment or Advisory and Decision Support services to the NRCS Chief and RCO; however, other programs may submit requests for these services. Deployed CIP staff review incoming requests and provide services based on need, potential benefit to the requesting program, pending CIP resource availability, and level of expertise required to conduct the requested service. If requested services require CIP assistance beyond activation of the NRCC/RRCC, or do not relate to a specific incident support operation, CIP personnel should follow the procedures outlined in the Program Consulting and Support section.

E. PROGRAM CONSULTING AND SUPPORT SERVICES

Outcome: CIP champions improvement and effects change with other FEMA program offices by delivering solution-oriented assistance through its Program Consulting and Support services.

1. CIP collaborates with FEMA program offices at the field, regional, and HQ levels to help them think through and solve their challenges. Services CIP provides may include support with process improvement, change management, project management, and program management. Program Consulting and Support services are customizable, scalable, and flexible, and CIP conducts these services in a collaborative manner with the requesting office.

2. FEMA program and field offices submit requests for Program Consulting and Support services. CIP further scopes out each request in coordination with the requesting office to develop a clear understanding of the need, issue, or problem.

CIP provides these services based on need and likely benefit to the requesting FEMA program office, pending CIP resource availability.

a. RCICs manage requests from regional and field offices.6 The RCIC, in consultation with the RIBC, or equivalent, and the FPC review and assess these requests. The RCIC accepts the request pending resource availability, fulfillment of after-action review legal requirements, and level of expertise required to conduct the requested service.

b. CID manages requests from HQ program offices. The CID Director reviews and assesses requests and then accepts them pending resource availability and level of expertise required to conduct the requested service.

c. If CID or the region are unable to meet the requests outlined above (a. and b.) with current available resources, CIP will evaluate other program resources available to fulfill requests.

F. CONTINUOUS IMPROVEMENT TECHNICAL ASSISTANCE PROGRAM

Outcome: CIP supports SLTT partners, non-governmental organizations (NGO), the private sector, and other organizations with emergency management functions in building and/or enhancing their continuous improvement capabilities through CIP’s Continuous Improvement Technical Assistance Program (CITAP).

1. CITAP supports partners from the whole community through three primary areas of focus:

a. Interactive Community of Practice: CITAP provides partners with opportunities to share continuous improvement best practices, questions, and lessons learned. Partners can also access tools, templates, emergency management case studies, and other collaborative engagements for sharing information across jurisdictions and organizations.

b. Training Suite: CITAP offers partners trainings that can increase knowledge and skills for conducting continuous improvement activities in emergency management. As part of the training suite, partners can access the National Continuous Improvement Guidance (NCIG), which provides an approach to conduct consistent and rigorous continuous improvement activities before, during, and after real-world incidents. The NCIG can be accessed here.

c. Advisory Services: CITAP offers partners scalable, customized consulting support to provide guidance on specific continuous improvement activities and initiatives. This helps to increase capability-building and program development by focusing on maturing continuous improvement efforts within an organization.

i. CID provides Advisory Services support based on the assessed need and likely benefit to the requesting partner, contingent on resource availability.

6 RCICs manage requests from field offices in coordination with the deployed Continuous Improvement Advisor Lead(s), as appropriate.

https://preptoolkit.fema.gov/web/cip-citap/ncig

2. CID manages CITAP. CID coordinates with the regions as appropriate based on identified partner needs and requests. The regions participate in CITAP activities based on resource availability and areas of expertise.

Deanne Criswell Administrator

_______June 2, 2023___________________

Date

ADDITIONAL INFORMATION

REVIEW CYCLE

FEMA Directive 107-1 will be reviewed, reissued, revised, or rescinded within four years of the issue date.

AUTHORITIES

A. Post-Katrina Emergency Management Reform Act (Pub. L. 109-295, § 650 (6 U.S.C.

§ 750)

REFERENCES

A. FEMA Strategic Plan (FY 2022-2026), Goal 3 – Promote and Sustain a Ready

FEMA and Prepared Nation B. FEMA Instruction 107-1-1: After-Action Review Implementation

DEFINITIONS

A. Action: A measure taken by an RPO to address the root cause of a finding and remedy deficiencies or standardize strengths.

B. Action Decision: A determination made by a program decision maker indicating the program’s choice on whether to act on the finding and recommended course(s) of action provided. The choice set includes accept, previously completed, decline, request extension, request revision, and incorrect program office.

C. After-Action Review: A targeted collection with a defined time period that identifies strengths, potential best practices, and areas for improvement across the disaster lifecycle. After-action review products may vary in format and length but contain validated findings and recommended courses of action which are approved by field and regional leadership for dissemination within the agency.

D. Area for Improvement: A type of finding that explains how outcomes did not meet expectations set out in plans, policies, processes, or procedures, or where gaps exist.

E. Collection: The process of gathering and analyzing operational and programmatic data in a systematic fashion to develop findings or observations in the form of strengths, potential best practices, and areas for improvement. This typically occurs during the Discovery Phase at the onset of after-action reviews or program assessments.

F. Continuous Improvement Working Group: The regional decision-making body which supports the referral of findings and recommended courses of action to appropriate program offices, assignment and tracking of actions, confirmation of completion of actions, and review of evaluation results. Each region establishes and maintains a regular CIWG comprised of regional leadership, such as the Regional Administrator, Deputy Regional Administrator, Division Directors, and other relevant RPOs.

https://usfema.sharepoint.com/teams/OPPAPolicy/Lists/Policy%20Master%20List/Attachments/1059/Instruction-%20After-Action%20Review%20Implementation%201.6.2022.pdf

G. Disaster Collection Analysis Plan: The DCAP defines the scope, tasks, tentative timeline, objectives, and personnel requirements for a given collection. CIP staff work with relevant field and regional leadership to develop disaster specific DCAPs prior to Discovery Phase activities at each incident.

H. Finding: An objective analytical conclusion derived from a CIP collection categorized as a strength, potential best practice, or area for improvement. Findings include in-depth analysis of quantitative and qualitative data, should consider root cause(s), and include evidence that elicits higher confidence in the accuracy of the results. Generating findings is the primary objective of CIP collections. A finding should include, at minimum, a topic sentence, analysis, and recommended course(s) of action. Findings are generally used in Tier I after-action reviews, After-Action Reports, and all public-facing documents.

I. Level of Responsibility: A determination of the appropriate level of FEMA’s organization to address a recommended course of action. The choice set is field, regional, or headquarters.

J. Observation: An objective analytical conclusion derived from a CIP collection categorized as a strength, potential best practice, or area for improvement.

Observations at a minimum include qualitative data from multiple objective sources;

however, the evidence may be less detailed or comprehensive on a topic and therefore may warrant additional analysis by the RPO to determine an appropriate action. It should include, at minimum, a topic sentence, analysis, and recommended course(s) of action and/or next steps for further assessment. Observations are generally used in Tier II after-action reviews, Quick-Look Reports, and for time-sensitive products.

K. Potential Best Practice: A type of finding that captures a change to how something is done that results in improved performance but is not yet fully implemented across the unit, organization, and/or workforce; is not codified within policies, plans, guidance, or procedures; and could potentially be applied to other incidents.

L. Preparedness: The actions taken to plan, organize, equip, train, and exercise to build and sustain the capabilities necessary to prevent, protect against, mitigate the effects of, respond to, and recover from those threats that pose the greatest risk to the security of the nation.

M. Recommended Course of Action: A suggestion or set of suggestions to a program office of action(s) that may address the root cause of a finding.

N. Readiness: The condition of being prepared and capable to act or respond to an event as required.

O. Responsible Program Office: The office with the primary responsibility to develop and implement an action to address an identified finding and recommended course of action. Each action should be assigned to only one RPO.

P. Strength: A type of finding that explains how actions, activities, processes, or systems stated within policy, plans, or guidance yielded better results than usual in a particular incident.

Q. Summary of Findings: The review and analysis of CIP findings, along with other CIP and agency data if deemed relevant, to identify cross-disaster, cross-regional, and cross-programmatic trends or findings that support or inform agency learning objectives.

R. Validate: A formal request from CIP to applicable program offices and relevant SMEs to review a finding for quality and accuracy.

S. Validation Adjudication: The process by which the CIP collection team documents feedback on findings from SMEs and the response or action taken.

MONITORING AND EVALUATION

CID will employ a range of evaluation methods to assess and improve CIP, including soliciting feedback from field and regional leadership, HQ program offices and governance bodies, and RCICs regarding opportunities to enhance the efficiency of CIP activities and the utility of support and analysis to improve survivor service delivery.

QUESTIONS

Please direct any questions to fema-cipsupport@fema.dhs.gov.

mailto:fema-cipsupport@fema.dhs.gov