After the Funding: Why Hospital Emergency Preparedness Continues to Fall Short

1
After the Funding Why Hospital Emergency
Preparedness Continues to Fall Short

• Tracy Buchman, DHASafety Director
• University of Wisconsin Hospital Clinics
• Madison, WI

THIRD NATIONAL EMERGENCY MANAGEMENT SUMMIT
Renaissance Washington DC HotelWashington,
DCMarch 5, 2009
2
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)

3
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 Secretarys advisory staff on
  bioterrorism public health emergencies
• Coordinate interagency activities between DHHS
  and other federal departments

4
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.

5
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

6
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

7
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

8
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.

9
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

10
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

11
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

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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

13
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 governments multifaceted approach to
  restructuring and continued financial support
  reflects efforts to manage the increasing level
  of public health EP in a systems-oriented way

14
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.

15
Systems Approach
continued

• 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

16
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

17
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

18
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.

19
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

20
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

21
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 persons level of protection from
  vulnerabilities

22
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

23
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

24
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.

25
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

26
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?

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Significance of Study

• To gain insight into practical and effective
  approaches to advance the public health systems
  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

28
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

29
Concourse Theoretical Design
Frequency Distribution for the Q-Sample
Factors and levels Items df
External
Communications 3 2
Funding
Sustainability
Internal
Leadership 3 2
Resources
Training Education
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
30
Person Sample
31
Demographic Data
32
Matrix of Q-Sorting Procedure
Least Challenging Neutral Most Challenging
-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
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.
33
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

34
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.

35
Results
continued

• 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

36
Results
continued

• 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

37
Results
continued

• 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.

38
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 systems preparedness
  for disasters.

39
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.

40
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

41
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

42
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

43
Questions?
Tracy Buchman, DHASafety Director University of
Wisconsin Hospital Clinics Madison, WI
44
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