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ASPR’s New Vision for a Regional Health Response System

The last activity of the workshop’s first day was a small-group discussion focusing on Assistant Secretary for Preparedness and Response Robert Kadlec’s blog post on a regional approach to disaster preparedness and response (Kadlec, 2018). The mixture of public- and private-sector workshop participants at each of eight tables discussed four topics:

• What is the common understanding of the problem?
• How do we coordinate joint strategic activities?
• What are the most pressing needs regarding communication and coordination?
• How do we measure shared performance for shared accountability?

After an hour of deliberation, a rapporteur from each group reported back to the assembled workshop participants on the small-table discussions. In the first report out, Freda Gail Lyon from WellStar Health System said her table discussed shared performance and developed a list of terms that individual participants suggested needed common definitions: urgency, emergency, disaster, catastrophic, loss of governance, loss of mutual aid, loss of infrastructure, and loss of community function. Lyon explained that definitions for these terms are needed to develop metrics for measuring good management and the efficiency of the emergency management structure. Many of these safety and quality metrics, she explained, are already in use in health care settings. Individual participants also discussed how technology could enable the sharing of data and metrics to assess relative performance and ultimately move the field toward shared accountability.

John Hick’s group divided the topic of shared performance into three categories: metrics, performance, and shared accountability. Hick explained that members of the group suggested that a preponderance of metrics are already available, such as regulatory metrics from the Joint Commission and CMS, and sets of metrics for engagement, process, exercises, and clinical care. Most of these metrics are useful before an emergency because measuring outcomes after an incident is more difficult.

From a performance standpoint, the group discussed completion of education and participation or engagement in coalition activities as potential metrics. Hick presented the idea that functional throughput and minimum supplies of certain pharmaceuticals could serve as useful metrics, too. The group explored the possibility of benchmarking against similar types of institutions, both regionally and nationally.

Regarding shared accountability, the group talked about the importance of regional councils and coalitions and the development of common policies and expectations formed through the development of relationships. Hick explained that shared accountability could be assessed based on after-action reports and the results of exercises, accounting for variations in size and capabilities among different institutions. The goal, said Hick, would be to create minimal expectations for facilities. Leadership accountability would also be important, the group noted. In the end, the group believed that success might involve tying preparedness activities to other time-sensitive emergencies, such as responding to stroke, trauma, or sepsis. In fact, this group suggested, there may be an opportunity to initiate pilot studies that would tie these existing time-sensitive emergency response systems into larger preparedness activities and serve as a means of driving investment in education systems for preparedness at multiple levels.

Laura Wooster from the American College of Emergency Physicians reported that her table discussed communication and coordination, particularly regarding whether health care coalitions have the resources, skills, and staff to engage in consistent and open communication across sectors for preparedness and response. Wooster noted the importance of looking for opportunities for daily use, such as communicating during the influenza season, using triage tags during smaller events, or using bed-tracking systems. One example discussed in the group was how the End Stage Renal Disease Network in Texas practices communication and coordination on a daily basis.

Wooster highlighted the group’s discussion of the importance of including both emergency management and public health in these day-to-day communication and coordination activities. Participants also discussed the value of having plans for measured responses to specific types of events and to include contingencies for different types of infrastructure and communication systems failures so that there are backup communication plans.

Wooster’s colleagues then explored how to build trust among organizations that typically compete with one another to ensure that everyone is working from the same guiding principles, shared vision, and common agenda. “Everyone needs to lay their cards on the table and take a leap of faith,” she said, adding that a public announcement about what the coalitions are doing might be able to bring everybody together. Also important, she added, is making sure the same people are at the table consistently and to make sure those people are empowered to speak for their organizations. Repeated contact with one another is one way to build trust, she said.

Craig Vanderwagen’s table also discussed the topic of communication and coordination and noted that everyone at the table immediately added the Wave 5.12 app to their smartphones,¹ giving them the capability to use a smartphone as a Motorola communication device among themselves. That action aside, the group spent much of its time discussing how to practice consistent and open communication for preparedness and response and how to build trust among organizations. Vanderwagen reported that whatever the solution, it has to be universal, bi- or multidirectional, transparent, and allow for dialogue between public and private entities.

Developing such a solution, he said, starts with understanding one’s own role in the agencies that make up the public sector, which the group took to mean federal, state, and county governments. He noted that he would talk on day two about the conflicts that developed among different agencies within HHS as an example why defining roles is important. “If we are not clear about our roles in the public sector and in the private sector, it is very difficult to engender a dialogue between the public sector and the private sector that will move forward,” said Vanderwagen.

Participants at this table opined that it is easier to work at the community level than at the hospital level given that hospital administrators have to spend most of their time dealing with day-to-day concerns and have little bandwidth to address larger issues. While it is important to help hospitals reach the necessary state of preparedness, it would be more effective to do that through community leaders who can then work with their hospital-based colleagues, Vanderwagen reported. He also noted the importance of understanding that leadership does not have to rest with one individual and that it can move among many individuals or organizations depending on the contextual reality. At the same time, it is essential to have a third-party broker, such as the coalition, a professional organization, the trauma surgeons, or other trusted authority, that can mediate disputes, both in planning for and responding to a large-scale disaster, he said.

In its discussions, the group considered the question of whether health

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¹ See https://www.motorolasolutions.com/en_us/my-software/wave512.html#taboverview (accessed April 25, 2018).

care coalitions have the resources, skills, and staff to plan for and respond to a disaster, and participants suggested the answer was no overall. Yes, some organizations are well prepared, but others can barely function and those should be strengthened. One issue that came up during this group’s discussions was that at least some private-sector organizations have no idea what the federal government brings to the table during a disaster. Participants suggested that ASPR could create a menu of options that would allow all coalitions, both strong and weak, to begin to understand what they can expect from the federal government.

In the end, said Vanderwagen, communication and coordination are the hardest pieces of disaster preparedness and response. “We can talk about mission, but if we cannot communicate and coordinate around that mission, it does not matter,” he said. He noted that when he worked for the Indian Health Service, every staff member at every facility knew that their mission was to elevate the health status of American Indians and Alaskan Natives to the highest level possible. “We do not have that kind of clarity in this system because it isn’t a system yet,” said Vanderwagen, who added that building trust and communication channels will allow stakeholders to identify the common purpose of the coalitions. In his opinion, the ASPR blog post was a good attempt to get the coalitions headed in that direction.

Lewis Kaplan’s group discussed strategic action. He noted that the federal government has recognized there is a gap that needs to be filled to the benefit of the American public. To that end, it may make sense to leverage existing infrastructure, such as the coalitions and National Trauma Programs identified by the American College of Surgeons’ Committee on Trauma, he said. Marrying those requires a few important steps, including joining the trauma networks and public health regions so they are all working from the same plan, said Kaplan, who added that it was important to recognize that although trauma centers provide a model of bringing people together, not every patient should come to a trauma center. “The trauma centers can be leveraged to bring coalitions into more prominence so that patients are distributed and shared as appropriate during disaster responses,” explained Kaplan.

Kaplan explained that while being a Disaster Center of Excellence is likely to be a money-making proposition in the future, it is not today, and it may be necessary to create incentives, such as a tax offset for unreimbursed care, to get large health centers to embrace the idea of being a Center of Excellence. Kaplan said that because this system needs to work exceptionally well, funding through ASPR’s HPP that flows through public health departments may need to be changed because the current mechanism does not demand conformance to the HPP guidelines. The group discussed options to fund coalitions directly or have funds distributed in a competitive manner to those systems that do adhere to the HPP guidelines. Kaplan also

highlighted that because law enforcement serves as the major transportation resource during a disaster, line-duty police officers might benefit from enhanced training to serve as competent first responders during a disaster.

Tener Veenema from the Johns Hopkins Bloomberg School of Public Health and School of Nursing then reported on her table’s discussion about strategic initiatives. She said they suggested that there is a need for many distinct roles, strategies, skills, and expertise, depending on the event for which preparations are being made. However, she added, addressing workforce issues, such as education, training, composition, and sustainment, must be a major component of readiness in coalitions and a redesigned NDMS. So, too, is the development of leaders with crisis management skills, which she said the group members thought would be a key component of the strategic initiatives needed to build a bigger, better, smarter, and more coordinated disaster system.

Bruce Evans of the Upper Pine River Fire Protection District suggested that ASPR might follow the incident commander model developed by U.S. Forest Service and Urban Fire and Rescue. This model, he said, develops incident commanders through experiential learning that enables them to acquire the skills needed to serve as a member of an elite leadership team. He suggested these skills would give incident commanders the ability to go into any type of crisis situation, establish trust quickly, develop rapport, engender support, and execute decisions in times of increasing ambiguity.

Veenema’s group also discussed designing hospitals as medical cities with residential living that enable a certain sector of the health care workforce to live on campus and be present at all times. Such an arrangement would reduce the need to move people in and out of the hospital during disasters, she said. The group explored using bloodmobiles and the blood supply system as part of surge capacity. This led to a discussion about using other health care resources that are not normally considered in surge capacity planning, but that could make a substantial contribution and affect a major shift in the way the nation funds and sustains preparedness.

Participants at this table ended their discussion with the recognition that the current health care system is optimized to the point where there is little wiggle room with regard to capacity and that when aligning NDMS with existing regional health care coalitions, additional demands are made of people who are doing their jobs every day. As a result, Veenema noted, it will be beneficial to mobilize and deploy health care provider teams from other parts of the country in the event of a large-scale or catastrophic event. The World Health Organization’s emergency response team model might serve as an example for the United States as it develops regional, highly trained, event-specific strike teams that can be deployed rapidly at times of great disasters, she suggested.

Reporting on her group’s discussions about a common agenda and a

shared vision for the future, Gina Piazza said the public does not necessarily understand the gaps that exist in the nation’s health care system and how they will affect the delivery of care during emergencies and disasters. The group also wrestled with whether medicine and professional societies are part of the public or private sector. She noted that participants believed that governments in general understand there is a problem with preparedness for large-scale disasters, but not necessarily at the appropriate level of detail. Piazza noted that some concerns were expressed that CMS might see the issues differently from ASPR, DHS, the Department of Transportation, or the National Highway Traffic Safety Administration, for example. Piazza went on to say that although hospitals may be aware there are challenges related to disaster preparedness, they tend to be focused on day-to-day operations and quarterly reports rather than large-scale and long-term planning.

With regard to a vision for future regional capabilities to respond more effectively and efficiently to the ever-expanding array of 21st-century health security threats, group participants expressed appreciation for ASPR’s vision for the future as described in the blog entry. The group’s discussion on regionalized health care pointed to the importance of defining regions for specific situations, Piazza reported. For example, she said, a region for burns might be different from regions for trauma depending on the specific capacities in those regions. Nonetheless, Piazza noted, a national emergency health and trauma system managed by regions that are networked to one another and connected to state governments would be the way to go. Then, in the event of a large-scale disaster that affected an entire region or two, they would be able to use the network to access additional resources. This pointed to the need for a resilient and adaptable regional system that can absorb a major hit and keep people alive, she said. As a final note, she said it might be important to develop standards of care for crisis situations that include provisions for relaxing some regulations so that providers are not so concerned about meeting HIPAA standards when trying to respond to a crisis situation during a large-scale disaster.

Ira Nemeth’s group also discussed the common agenda. He reported that the group participants expressed that the public sector, at least at the federal level, has a good understanding of the gaps in the current system. He said the group did debate whether the federal government was willing to commit the necessary resources to address these gaps given other current priorities such as tackling the opioid epidemic. Regarding the private sector, the group talked about the fact that some private institutions have put a fair amount of work into preparedness and developing resources, while others are focused more on running their day-to-day businesses. Nemeth reported a common thread that larger health systems are likely to have a better understanding of the importance of preparedness, but that there was

great variability across institutions depending on how many experiences they have had with large-scale disasters. Institutions along the Gulf Coast, for example, are likely to be more aware of the potential for large-scale disasters and therefore more likely to take preparedness seriously, he said.

When the group discussed a common vision for developing regional capacity to respond more effectively and efficiently, participants noted that the blog post referred to the trauma system frequently. Nemeth shared that the trauma system may be a good model in regions where it is already strong, but that preparedness is about more than trauma, and therefore, some individuals at his table were not very supportive of relying as heavily on the trauma system model. One alternative that might work in some regions would be to start by connecting community and smaller hospitals through the emergency medical system to larger tertiary facilities. Nemeth stressed that this would just be a start because it would also be important to include community partners such as home health care and dialysis centers in those coalitions.

One issue that was explored was that when talking about vision, there may be some misunderstanding that a specific institution would lead the coalition. That could lead to problems, said Hick, so it would be important to discuss what a coalition should look like and develop multiple examples of successful coalitions that different regions could draw from to meet the specific needs of their communities. Another challenge for establishing a coalition is getting buy-in from all of the necessary partners, and so it would be important to make the argument that joining a coalition can lead to cost sharing and reducing duplication of services, particularly for smaller institutions. Hick suggested that CMS regulations might also serve as incentives to join coalitions.

Nemeth reported that the group discussed how to include payers and insurance underwriters in developing a shared vision for preparedness. Underwriters, for example, might provide a break on insurance rates for facilities that belonged to regions that were more prepared to be resilient during a disaster, he said. Someone suggested that professional societies and local governments could be applying more pressure to hospitals and health care systems to join regional coalitions. The group even noted the possibility of conducting a public relations campaign that would help the public to understand how important preparedness is, which might convince consumers to apply pressure on their health care systems and local governments to take preparedness seriously and dedicate necessary resources.

Kellerman ended the session with a military phrase he learned when he became dean at USUHS: one team, one fight. “We may compete as hospital A, hospital B, and hospital C in a community for patients, and we may compete among the surgeons and emergency department doctors and the internists about who should get more reimbursement, but when a

hurricane, an earthquake, or a Las Vegas mass shooting happens, it is one team, one fight,” he said. “This discussion is all about how we assure that when the team comes together, it knows one another, trusts one another, and functions as a team and delivers as a team for the sake of our communities, our patients, and the national security of the country.”