After the Funding: Why Hospital Emergency

Preparedness Continues to Fall Short

Tracy Buchman, DHA Safety Director

University of Wisconsin Hospital & Clinics

Madison, WI

THIRD NATIONAL EMERGENCY MANAGEMENT SUMMIT

Renaissance Washington DC Hotel Washington, DC

March 5, 2009

National Preparedness Efforts♦

National Emergency Preparedness Community– 32 federal agencies & departments

• Department of Homeland Security (DHS)• Department of Health and Human Services (DHHS)

♦

DHS and DHHS agencies – FEMA– CDC– Health Resources and Services Administration (HRSA)

National Preparedness Efforts♦

2007 - The Office of Assistant Secretary for Preparedness and Response (ASPR) – Formerly the Office of Public Health Emergency

Preparedness– Serve as the Secretary’s advisory staff on bioterrorism &

public health emergencies – Coordinate interagency activities between DHHS and other

federal departments

Responsibility♦

All of these federal agencies have the primary responsibility– to support preparedness efforts throughout the nation, and – the state and local health departments are accountable to

identify and to prepare their communities to respond to an incident

♦

Leaders of both the CDC and the HRSA provide guidance containing benchmarks to facilitate cooperation and competencies to their grantees.

Federal Preparedness Funding♦

In 1995, Presidential Decision Directive 39 – prompted federal agencies to prepare for terrorist attacks

involving weapons of mass destruction ♦

Federal spending related to bioterrorism preparedness prior to 1996 was nonexistent

♦

Nunn-Lugar-Domenici Domestic Preparedness Program (DPP) of 1996

♦

Defense Against Weapons of Mass Destruction Act of 1996 – Required development of domestic preparedness programs

• The objective was to enhance the capabilities of emergency response agencies

Metropolitan Medical Response System♦

In 1996, Metropolitan Medical Response System (MMRS) shaped assistance for highly populated areas– developing plans, – conducting training and exercises, and – acquiring pharmaceuticals and personal protective

equipment

♦

Funding for first responders

Metropolitan Medical Response System♦

Funding was not directly inclusive of health-care organizations

♦

Because hospitals are not emergency response agencies – MMRS and DPP initiatives failed to integrate hospitals into

the plan– Funds went only to state and local responders– Not for public health

CDC Initiatives♦

Funded state bioterrorism preparedness efforts since 1999 ♦

Several CDC initiatives:– State and Local Bioterrorism Preparedness and Response

Cooperative Agreement Program – National Pharmaceutical Stockpile – Health Alert Network – Laboratory Response Network– Bioterrorism Core Capacity Project

♦

Cooperative Agreements – 50 states plus the District of Columbia, New York City, Los

Angeles, Chicago, and the territories.

Public Health Acts♦

Public Health Threats and Emergencies Act of 2000 – allocated nearly $300 million

♦

Public Health Security and Bioterrorism Preparedness and Response Act of 2002 – National Bioterrorism Hospital Preparedness Program

(NBHPP) – Priority areas:

• (a) administration, (b) surge capacity, (c) emergency medical services, (d) linkages to public health departments, (e) education and preparedness training, and (f) terrorism preparedness exercises

Pandemic & All-Hazards Preparedness Act♦

In December 2006, Pandemic & All-Hazards Preparedness Act – The Secretary of DHHS became the lead federal official

responsible for public health and medical response to emergencies

– Unifies DHHS preparedness & response programs – National Disaster Medical System moved from the DHS to

DHHS ♦

Goal: – To clarify responsibilities and lines of authority – Improve the public health and hospital preparedness

programs by amending the Public Health Security and Bioterrorism Preparedness and Response Act of 2002

Systems Theory♦

Emerged in the academic arena in the 1940s out of World War II operations research

♦

Emphasis on system dynamics and a feedback loop♦

Accounts for systems of influence– individual – social– environmental or societal contexts

♦

Health-care organizations are part of the environment of social systems and operate in a resource-dependent environment

Academic Medical Centers♦

Hospitals are subsystems within the larger social, political, economic, and technical system

♦

Academic medical centers (AMC) consist of three related enterprises: – Medical school – Research activities – A system for delivering health-care services that might

include one or more hospitals, satellite clinics, and a physician office practice

♦

Consist of many interacting stakeholders who have intricate processes and multilevel collaboration at the federal, state, and local levels, often representing different and competing interests

Public Health Preparedness♦

Complex system requiring multilevel collaboration with federal, state, and local entities

♦

Entities consist of – First responders – Physicians and nurses, – Emergency management, – Hospital administrators, – Public health administrators, and – Federal agencies

♦

The federal government’s multifaceted approach to restructuring and continued financial support reflects efforts to manage the increasing level of public health EP in a systems-oriented way

Systems Approach♦

To maintain effectiveness, the systems approach requires agents, who often have diverse and dynamic networks of monetary flows to adapt to actions of others and to a changing environment

♦

Bureaucracy, jurisdictional conflicts among organizations, and factors in the academic environment might limit the adoption or use of the systems approach consequently producing a negative ripple effect throughout the system.

Systems Approach♦

The ongoing correlation involving elements or subsystems of the system and the modifications that transpire over time because of these ongoing relations may be useful in uncovering the influences internal and external systems have on the overall ability to implement EP system-level strategies and achieve system-level goals

♦

The systems approach facilitates the observation of health-care organizations in macro terms to detect problems and therefore offers a comprehensive organization approach to evaluating system-level EP

continued

Resource Dependence Theory♦

The resource dependence theory is one of several organizational theories used to describe organizational behavior

♦

The aptitude to acquire and sustain resources predicts organizational survival

♦

Organizations must acquire external resources as an essential tenet of their strategic and tactical management, and therefore organizations will respond to demands made by the external environment or they will try to minimize the dependence

Health-care Strategies♦

Limit resource dependence

♦

Incorporate creative strategies to manage the numerous competitive pressures that affect how hospitals allocate scarce resources

♦

Allocate resources to programs demanded by external customers and stakeholders providing the resources

♦

Many organizations trade their autonomy by collaborating to share critical resources

Test & Recognition♦

Investigate if the use of the theory can accurately predict the preparedness levels in health-care organizations

♦

Recognition of the environmental pressures for resources resulted in making federal preparedness funding sources available to health-care organizations after fulfilling particular deliverables.

Historical Healthcare Emergency Response Challenges♦

1984 deliberate contamination of restaurant salad bars with Salmonella typhimurium by the Rajneeshee religious cult in Oregon

♦

1993 bombing of the World Trade Center in New York ♦

1995 bombing of the Murrah Federal Building in Oklahoma City

♦

The response to the events displayed the health-care challenges and complications that arise during disasters.

♦

Members of the medical community recognize its disturbing lack of preparedness and experience in caring for victims of mass casualty incidents

Inadequate Level of Preparedness♦

Multiple streams of preparedness funds♦

Lack of strategic direction on how to manage funds judiciously foster duplication of efforts

♦

As preparedness progress begins, funding to states to maintain and improve preparedness is declining

♦

Hospital leaders continue to invest significant amounts of resources annually to develop and test disaster response plans, train staff, maintain and replace disaster response equipment and supplies, and enhance communication and surveillance capabilities

♦

Still an inadequate level of preparedness remains

Influence on Hospital Emergency Preparedness♦

Since 2003, members of the TFAH panel have issued annually the Ready or Not? report to examine progress to improving response to health threats and to identify vulnerabilities – In 2007, variations in preparedness levels among states

♦

Variations in preparedness levels among states signified that geographic location might still determine a person’s level of protection from vulnerabilities

Internal & External Factors♦

Significantly affect the ability to adequately prepare and sustain for intentional acts of terror and naturally occurring crises

♦

Funding, collaboration, communication, leadership, resources, and training and education – A mounting number of expensive, unfunded, or underfunded

regulatory mandates are counterincentives to hospital preparedness

– Existing disaster assistance systems severely limit reimbursement for hospital financial losses experienced in response to a disaster

– The ability to generate adequate funds to support the preparedness role is increasingly difficult to achieve

Internal & External Factors♦

Explicit funding is not available to support the hospital standby role.

♦

Hospitals must incorporate preparedness into the overall cost structure of the hospital and support the preparedness with revenues received from patient care

♦

Hospital just-in-time method of procuring

Scientific Studies♦

Few scientific studies related to public health preparedness.

♦

Information obtained from first responders, after-action reports, lessons-learned commentaries, and comparative case analyses comprise the evidence base for improving preparedness.

♦

A lack of research exists to identify the hospital-level factors that influence the ability of hospitals to achieve system-level preparedness goals.

♦

The current study involved an attempt to uncover these factors through obtaining the opinions of hospital-level EP experts.

Problem Statement♦

With the current state of hospital underpreparedness and the predicted demand for medical care in future disaster situations, efficient and appropriate medical care will remain a challenge until the members of society develop solutions for increasing the level of hospital preparedness

Research Questions♦

1. What internal and external factors influence the ability of emergency preparedness experts in academic medical centers to implement system-level strategies and achieve system-level goals?

♦

2. What geographical factors influence the ability of emergency preparedness experts in academic medical centers to implement system-level strategies and achieve system-level goals?

Significance of Study♦

To gain insight into practical and effective approaches to advance the public health system’s preparedness for disasters.

♦

Provide needed quantitative guidance that will provide political leaders with an understanding of hospital-level EP perceptions

♦

Emergency Preparedness experts had an opportunity to express their own visions & perceptions regarding internal & external factors affecting why their hospital has been unable to meet the basic preparedness requirements after receiving preparedness funding

Q-methodology

♦

Combines the in-depth subjectivity of qualitative approaches with factor analysis to obtain a richer understanding of choice, motivations, values, and subjectivity combining both aspects in a true mixed- method format

♦

Strength in revealing the dominant patterns and clusters of opinions that surface within a group

Concourse Theoretical Design

Factors and levelsItems df

External

Communications 3 2

Funding

Sustainability

Internal

Leadership 3 2

Resources

Training & Education

Frequency Distribution for the Q-Sample

Statement number Interactions

1, 2, 3, 4 (4) ad = Communications x Leadership

5, 6, 7, 8 (4) ae = Communications x Resources

9, 10, 11, 12 (4) af = Communications x Training & Education

13, 14, 15, 16 (4) bd = Funding x Leadership

17, 18, 19, 20 (4) be = Funding x Resources

21, 22, 23, 24 (4) bf = Funding x Training & Education

25, 26, 27, 28 (4) cd = Sustainability x Leadership

29, 30, 31, 32 (4) ce = Sustainability x Resources

33, 34, 35, 36 (4) cf = Sustainability x Training & Education

Person SampleHospital Name City StateNorthwestern Memorial Hospital - Chicago Chicago ILRush University Medical Center - Chicago Chicago ILUniv of Chicago Medical Center Chicago ILUniv of IL Med Ctr at Chicago Chicago ILLoyola Univ Medical Center - Chicago Maywood IL

Clarian Health Partners - Indianapolis Indianapolis INWishard Health Services - Indianapolis Indianapolis IN

Univ of Michigan Hospitals Ann Arbor MISinai-Grace Hospital - Detroit Detroit MI

Univ of Minnesota Medical Ctr Minneapolis MNSaint Marys Hospital - Rochester Rochester MN

University Hospital - Cincinnati Cincinnati OHMetroHealth Medical Center - Cleveland Cleveland OHUniversity Hospitals Case Ctr - Cleveland Cleveland OHOhio State Univ Medical Center Columbus OHUniversity of Toledo Med Ctr Toledo OH

Univ of WI Hospital & Clinics Madison WIFroedtert Mem Lutheran Hosp - Milwaukee Milwaukee WI

Demographic Data

Participant state

Total

invites sent

Informed consents

returned

Q-sorts

returned

Return rate

(%)

Minnesota 2 1 1 50

Wisconsin 2 2 2 100

Michigan 2 1 1 50

Illinois 5 5 4 80

Indiana 2 2 2 100

Ohio 5 4 4 80

Overall return rate 78

Matrix of Q-Sorting Procedure-4 -3 -2 -1 0 +1 +2 +3 +4 Ranks

2 3 4 5 8 5 4 3 2 # Items

35 32 28 23 15 10 6 3 1

36 33 29 24 16 11 7 4 2

34 30 25 17 12 8 5

31 26 18 13 9

27 19 14

20

21

22

Least Challenging Neutral Most Challenging

Participants rank-order each statement of opinion on the range of most challenge factor (1) to least challenge factor (36) that influences the ability of the hospital to achieve system-level preparedness goals into a quasi-normal distribution.

Data Analysis♦

Use of the PQ Method 2.11® computer program

♦

Three types of statistical analysis were performed on the completed Q-sort: – correlation, – factor analysis, and – factor scores

Results♦

External sustainability, external funding, and internal resources were the most challenging factors for all geographical areas included in the study, with the exception of Illinois.

♦

The results affirmed that an adequate level of preparedness hinges on the ability to procure critical resources from the external environment consistent with the resource dependence and systems theories.

Results♦

Variations in preparedness levels among the states signify that geographic location still determines how well one is protected from vulnerabilities

♦

External funding may not be a significant challenge for EP experts who reside in Illinois because Chicago receives additional CDC and NBHPP funds in addition to funds allocated to the state of Illinois

continued

Results♦

Statistically distinguishing statements indicated – A growing number of costly, unfunded, or underfunded

regulatory mandates act as counterincentives to hospital preparedness

– Hospitals use a just-in-time method of procuring and adequate preparedness requires sustained, directed funding sources with controls that promote true hospital preparedness

continued

Results♦

Statistically distinguishing statements indicated – The fact that federal preparedness funds are allocated

annually and come from numerous sources and with various requirements also complicated sustainability and funding concerns, making it difficult for hospital EP experts to pursue a comprehensive strategy.

– The current level of financial commitment toward preparedness allocated by the Congress has only allowed the setup of infrastructure but is insufficient to support the successful development of comprehensive, sustainable preparedness programs.

continued

Recommendations♦

A quantitative understanding emerged in the current research in the form of distinguishing statements specific to each factor regarding the exact hospital-level preparedness challenges that require further evaluation and modification to advance the public health system’s preparedness for disasters.

Recommendations - Challenges♦

Hospital-level EP experts know and recognize their specific preparedness limitations and must be considered key stakeholders in future policy and funding initiatives.

♦

Understanding better the preparedness challenges by state allows the hospital EP community, hospital administrators, and government leaders the opportunity to evaluate challenging strategies and validate and reinforce success strategies found in other states to create a preparedness program that is more effective overall.

Recommendations - Systems

♦

Health-care organizations are part of the environment of social systems.

♦

The widespread concern about resource dependence, sustainability of preparedness investments, and the lack of overall EP is a problem that needs processing as a part of the overall national preparedness system

Recommendations - Funding♦

A multiyear funding process inclusive of health-care organizations as emergency responders needs evaluating to replace the annual allocation of preparedness funds to first responders and health-care organizations as separate components of the overall preparedness plan.

♦

Funding changes should reflect the individuality of each state or region and the particular challenges and risks associated with the geographic location and population of each state.

♦

Evaluating individual state challenges and risks

Recommendations- EP Experts & Health-care Leaders♦

Emergency preparedness experts and health-care leaders should take a proactive approach and champion significant reforms to existing preparedness funding processes before another crisis or event occurs.

♦

Health-care leaders should maintain a strategy to limit resource dependence by incorporating creative approaches to manage the numerous competitive pressures that affect how hospitals allocate scarce resources

Questions?

Tracy Buchman, DHA Safety Director

University of Wisconsin Hospital & Clinics

Madison, WI

References♦

American Hospital Association. (2006, August). Prepared to care: The 24/7 role of America’s full service hospitals. Retrieved December 16, 2007, from http://www.aha.org/aha/content/2006/pdf/PreparedToCareFinal.pdf

♦

American Medical Association/American Public Health Association. (2007, July). Improving health system preparedness for terrorism and mass casualty events. Retrieved October 1, 2007, from http://www.ama- assn.org/ama1/pub/upload/mm/415/final_summit_report.pdf

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Arthur, N., & McMahon, M. (2005). Multicultural career counseling: Theoretical applications of the systems theory framework. The Career Development Quarterly, 53, 208-222.

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Assistant Secretary for Preparedness and Response. (2007b, November). Pandemic and All-Hazards Preparedness Act: Progress report. Retrieved November 6, 2007, from http://www.hhs.gov/aspr/conference/pahpa/2007/pahpa- progress-report-102907.pdf

♦

Baker, R., Thompson, C., & Mannion, R. (2006, January). Q methodology in health economics. Journal of Health Services Research & Policy, 11, 38-45.

♦

Barbera, J. A., Macintyre, A. G., & DeAtley, C. A. (2002, March). Ambulances to nowhere: America's critical shortfall in medical preparedness for catastrophic terrorism. Journal of Homeland Security. Retrieved September 15, 2007, from http://www.homelandsecurity.org/newjournal/articles/ambulancesbarbera.htm

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Bell, M. M. (2005). The vitality of difference: Systems theory, the environment, and the ghost of parsons. Society and Natural Resources, 18, 471-478.

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Bernard, T. J., Paoline, E. A., & Pare, P. P. (2005). General systems theory and criminal justice. Journal of Criminal Justice, 33, 203-211.

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Brown, M. (2004, October). Illuminating patterns of perception: An overview of Q methodology. Retrieved August 2, 2006, from http://www.sei.cmu.edu/pub/ documents/04.reports/ pdf/04tn026.pdf

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Brown, S. R. (1996). Q methodology and qualitative research. Qualitative Health Research, 6, 561-567.

References♦

Ciraulo, D. L., Fryberg, E. R., Feliciano, D. V., Knuth, T. E., Richart, C. M., & Westmoreland, C. D., et al. (2004). A survey assessment of the level of preparedness for domestic terrorism and mass casualty incidents among eastern association for the surgery of trauma members. Journal of Trauma Injury, Infection, and Critical Care, 56, 1033- 1041.

♦

Clinton, W. J. (1995, June 21). Presidential Decision Directive 39. Retrieved December 10, 2007, from http://www.fas.org/irp/offdocs/pdd39.htm

♦

Federal Emergency Management Agency. (2007a). Metropolitan Medical Response System. Retrieved September 16, 2007, from http://www.fema.gov/mmrs/

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Federal Emergency Management Agency. (2007b, September 11). Region V. Retrieved September 15, 2007, from http://www.fema.gov/about/regions/regionv/

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Hick, J. L., Einweck, R., & Tommet, P. (2005, June). Preparedness progress: Update on Minnesota hospitals. Retrieved August 2, 2006, from www.mmaonline.net/ publications/MNMed2005/June/Clinical-Hick.html

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Institute of Medicine. (2006). Hospital-based emergency care: At the breaking point. Washington, DC: National Academies Press.

♦

King, I. M. (2006). A systems approach in nursing administration. Nursing Administration Quarterly, 30(2), 100-104.♦

Maldin, B., Lam, C., Franco, C., Press, D., Waldhorn, R., & Toner, E., et al. (2007). Regional approaches to hospital preparedness. Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science, 5, 43-53.

♦

Mallon, W. T. (2004). The handbook of academic medicine. Washington, DC: Association of American Medical Colleges.

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Mann, N. C., MacKenzie, E., & Anderson, C. (2004). Public health preparedness for mass-casualty events: A 2002 state-by-state assessment. Prehospital Disaster Medicine, 19, 245-255.

continued

References♦

Matheny, J., Toner, E., & Waldhorn, R. (2007). Financial effects of an influenza pandemic on US hospitals. Journal of Healthcare Finance, 34, 58-63.

♦

McKeown, B., & Thomas, D. (1988). Q methodology: Quantitative applications in the social sciences (Series 66). Newbury Park, CA: Sage.

♦

National Foundation for Trauma Care. (2004, May). U.S. trauma center crisis: Lost in the scramble for terror resources. Retrieved December 10, 2006, from http://www.traumafoundation.org

♦

National Foundation for Trauma Care. (2006, September). U.S. trauma center preparedness for a terrorist attack in the community. Retrieved December 10, 2006, from http://www.traumafoundation.org

♦

109th Congress. (2006, December 19). Pandemic and All-Hazards Preparedness Act. Retrieved January 3, 2007, from http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=109_cong_public_laws&docid=f:publ417.109.pdf

♦

PricewaterhouseCoopers' Health Research Institute. (2007). Closing the seams: Developing an integrated approach to health system disaster preparedness. Retrieved November 2, 2007, from http://www.pwc.com/extweb/ pwcpublications.nsf/docid/9CEC1E9BDCAC478525737F005C80A9

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Rubin, J. N. (2004, January). Recurring pitfalls in hospital preparedness and response. Journal of Homeland Security. Retrieved August 2, 2006, from http://www.homelandsecurity.org/newjournal/articles/rubin.html

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Schmolck, P. (2002). PQ-method, version 2.11 manual. Retrieved January 3, 2008, from http://www.lrz- muenchen.de/~schmolck/qmethod/

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Sklar, D. P., Richards, M., Shah, M., & Roth, P. (2007). Responding to disasters: Academic medical centers' responsibilities and opportunities. Academic Medicine, 82, 797-800.

♦

Stephenson, W. (1953). The study of behavior: Q-technique and its methodology. Chicago: University of Chicago Press.

♦

The Joint Commission. (2003). Health care at the crossroads: Strategies for creating and sustaining community-wide emergency preparedness strategies. Retrieved December 12, 2007, from http://www.usaprepare.com/ep3-12-03.pdf

continued

References♦

Trochim, W. M., Cabrera, D. A., Milstein, B., Gallagher, R. S., & Leischow, S. J. (2006). Practical challenges of systems thinking and modeling in public health. American Journal of Public Health, 96, 538- 546.

♦

Trust for America's Health. (2005, December). Ready or not? Protecting the public's health from diseases, disasters, and bioterrorism, 2005. Retrieved August 1, 2006, from http://healthyamericans.org/reports/bioterror05/bioterror05Report.pdf

♦

U.S. Department of Health and Human Services, Office of the Inspector General. (2002). State and local bioterrorism preparedness. Retrieved August 1, 2006, from http://oig.hhs.gov/oei/reports/oei-02-01- 00550.pdf

♦

U.S. Department of Health and Human Services. (2004, April 28). HHS fact sheet: Biodefense preparedness: Record of accomplishment. Retrieved August 2, 2006, from http://www.hhs.gov/news/press/2004pres/20040428.html

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U.S. Department of Health and Human Services. (2007a). Announcement of availability of funds for the hospital preparedness program. Retrieved September 14, 2007, from http://www.hhs.gov/aspr/opeo/hpp/2007_hpp_guidance.pdf

♦

U.S. General Accountability Office. (2003a, April). Bioterrorism: Preparedness varied across state and local jurisdictions. Retrieved August 2, 2006, from http://www.gao.gov/cgi-bin/getrpt?GAO-03-373

♦

U.S. General Accountability Office. (2004, February). HHS bioterrorism preparedness programs: States reported progress but fell short of program goals 2002. Retrieved August 2, 2006, from www.gao.gov/cgi- bin/getrpt?GAO-04-360

♦

Von Bertalanffy, L. (1968). General system theory; foundations, development, applications. New York: G. Braziller.

♦

Williams, W., Lyalin, D., & Wingo, P. A. (2005). Systems thinking: What business modeling can do for public health. Journal of Public Health Management and Practice, 11, 550-553.

continued