There is little existing in the literature that provides a definition of readiness for a whole health care system. Nelson et alReference Nelson 1 discusses conceptualizing public health emergency preparedness by defining a public health emergency, stating who is involved in such emergencies and the requirements for programs charged with addressing them. Although these components of a framework for planning for public health emergencies are useful and found to have validity in the project discussed here, the complexity of the health care system’s role is poorly addressed. Some authors focus on competencies for health care workers in emergenciesReference Gebbie and Qureshi 2 , Reference Slepski 3 . For example, DrenkardReference Drenkard 4 discusses nursing competencies as a framework for the preparedness of large health care systems. Yet, these approaches leave out the multi-agency, multi-role aspects inherent in large disasters.
As defining readiness at the system level for a jurisdiction’s whole health care system has proven to be challenging, an approach that provides a framework for planning and measuring health care readiness with broad utility is needed. Hick et alReference Hick, Barbera and Kelen 5 propose a taxonomy for understanding surge capacity. Surge capacity is at the heart of emergency response, but this focus does not encompass the multiple roles and functions that must be undertaken by hospitals, other health care organizations and the component entities making up the jurisdictional preparedness and response infrastructure for health care emergencies, such as fire, police, emergency management, and emergency medical services. The National Guidance for Health care System Preparedness 6 provides a focus on medical surge and defines several essential capabilities that support it. Although the document suggests a collaborative planning process that allows health care system planners to coordinate with a jurisdiction’s planning processes, the emphasis remains on development of capacity and capability within health care entities and resource coordination among jurisdictional partners to support health care entities. A methodology for describing and assessing interdependencies critical to the preparedness and response of the whole health care system is still poorly defined.
The health care system in New York City (NYC) is vast, including over 55 acute care and speciality hospitals, 7 health care networks (eg, New York Presbyterian Health System), over 400 ambulatory care centers, 170 plus nursing homes, and more than 75 adult care facilities. In addition, there are other outpatient service providers, such as dialysis centers, numbering in the hundreds. The NYC Department of Health and Mental Hygiene (DOHMH), 1 of the 4 directly funded cities of the Assistant Secretary for Preparedness and Response’s (ASPR) Hospital Preparedness Program (HPP) developed the Readiness Target Project in order to (1) ascertain the current state of readiness of NYC’s health care system by describing its multiple aspects and interdependencies; and (2) define and describe NYC’s readiness targets; that is, articulate components or interactions comprising readiness in its optimal state. In fulfilling this latter purpose, the project has provided a framework for describing what makes up health care system readiness for emergencies for NYC and a means for organizing planning efforts to make sure these components and interactions are working optimally.
To address these two areas of inquiry, DOHMH devised a project in two phases in 2012-2014. In the first, the agency convened NYC hospital and health care partner representatives and held a series of three structured focus groups. The information gathered during the focus groups was used to develop a Readiness Matrix (Matrix).
In the second phase, DOHMH presented the Readiness Matrix to 50 hospital stakeholders (emergency manager and emergency medicine physicians) and asked them to rank the readiness areas in terms of importance for planning.
Ascertaining the Current State of Readiness of NYC’s Health Care System
DOHMH met with a group of emergency management, emergency medicine, and nursing staff from 8 of NYC’s hospitals. Participants represented proportionally NYC’s trauma centers, academic medical centers, and independent and network-affiliated hospitals. Participants also represented all 5 NYC boroughs, public and private hospitals, and pediatric and other specialty hospitals. Respondents provided feedback on the following questions:
1. What is the current state of NYC health care system readiness?
2. How would you define the target state of NYC health care system readiness?
3. What are the gaps that need to be addressed to bring the health care system to the target state?
4. Which gaps hold the highest priority?
5. What are your recommended means to address the gaps?
6. Who should be responsible for addressing these gaps?
A facilitator led all discussions and a note-taker recorded data during each meeting. The facilitator led the group to categorize their answers and other input into groups of activities or themes that either fit together by virtue of their content (eg, communications and data needed during an emergency were grouped together) or by virtue of the logical “owner” of the interaction represented by the comments. For example, gaps related to actions under any health care facility’s control to alter were categorized as “facility issues.” Further, the facilitator asked participants to critique their groupings and confirm the “names” of each group of issues. DOHMH summarized the grouped activities or themes and prepared a preliminary Readiness Matrix, outlining current state, target state, gaps, and recommended means to achieve NYC health care system readiness.
For the second focus group, DOHMH convened a group of health care emergency response partners representing NYC’s Emergency Support Function (ESF) 8 Health and Medical members (Greater New York Hospital Association, NYC Emergency Management, Primary Care Emergency Preparedness Network, Fire Department of New York Emergency Medical Services and the Regional Emergency Medical Services Council of New York City). DOHMH asked these participants the same questions used in the first focus group. The group also reviewed and provided feedback on the draft Readiness Matrix. All feedback from the second focus group was incorporated into a second, expanded version of the Matrix.
Participants of both focus groups were asked to meet jointly in a third and final focus group to reach consensus on the Matrix’s plan, which included a prioritized list of major health care system emergency preparedness and response gaps and recommendations to address them. Following that meeting, the Matrix was revised for presentation and feedback to a large group of hospital emergency managers.
Describing NYC’s Readiness Targets and Shaping a Framework
For the second phase of the project, DOHMH convened a group of 56 hospital emergency preparedness coordinators (EPCs) and emergency management leaders (attorneys, agency liaisons, deputy commissioners, and directors) representing several of the ESF 8 (Health and Medical) partners: Greater New York Hospital Association, The Community Health Care Association of New York State, New York City Office of Emergency Management, New York City Regional Emergency Services Council, and New York State Department of Health.
DOHMH facilitated 4 simultaneous groups of ~20 each of these participants. All four groups reviewed the resulting target findings found in phase 1 via a 45-minute facilitated discussion. Group facilitators collected additions and edits to these findings from the participants and then asked them to select the 3 highest targets to prioritize as focus areas for improving readiness of the NYC health care system for emergencies. Facilitators tallied the priorities selected and provided DOHMH a final list of 9 targets in rank order.
From the focus group discussions, 9 focus areas or targets emerged from consensus on both their content (gaps and target states) and names (broadly describing the content). Table 1 lists them in the order prioritized by the larger group described in phase 2.
Table 1 Readiness Focus Areas, Developed by Focus Groups Prioritized by a Broad Representation of Hospitals and Emergency Planning and Response Partners, 2013, New York City Department of Health and Mental Hygiene
In the process of developing this list of targets, several observations and recommendations emerged. It is useful to list these here in order to provide context for the Readiness Target Matrix and its use for closing gaps in the readiness of the NYC health care system.
1. Sharing information and situational awareness: hospitals described the need for real time data and information during emergencies in order to allocate assets, primarily staff assets. Without a reliable set of data or information, hospitals reported needing to rely on the media for news and weather information (during coastal storm responses). Data and information distributed must also be consistent and aggregated across response agencies who each have a lens on unfolding incidents but may report on similar data points. For example, NYC Emergency Management and the DOHMH may both report on availability of respirators (ie, N95 masks) during an influenza outbreak. Hospitals receiving the data should only get the aggregated number and not have to add the numbers coming from each of the agencies. Further, because information from city agencies tends to be unfiltered during disasters, hospitals are sent too much information and end up with “information overload.” If information comes from a new source, hospitals reported needing to verify the validity of the data before using it. Without certainty of the completeness and validity of the data received, hospitals spend a lot of time making what become redundant requests of multiple agencies.
2. Including health care sectors in multi-agency exercises: representatives in phase 1 focus groups noted the challenges of planning and conducting exercises that involved front line health care providers. They also noted that there is a missed opportunity to learn how operations for incident management would work in concert with city agencies when health care facilities or networks are left out. Stakeholders recommended an approach that integrates health care facilities in planning and participating in exercises on scenarios and hazards with broad impact.
3. Developing reliable communications systems and equipment for health care sectors: communications equipment failure was cited as a common problem for health care facilities. Some current systems had bugs, which increased the likelihood that they would fail during a disaster. One system, across which situational awareness of surge data (ie, bed availability) could be shared bi-directionally was most desired. This same system could also provide other kinds of incident-related data such as the status of resource requests.
4. Clarifying the resource request management process: hospitals reported needing quick answers to resource requests; and although EPCs generally follow the emergency resource request protocol (seeking resources first from within, then outwardly to networks, and then, ultimately to NYC Emergency Management), staff making the requests are often not those designated to do so.
5. Clarifying the role of health care coalitions in planning and response: hospital-anchored coalitions needed to broaden their scope by reaching out to other sectors (particularly, long-term care) while meeting the challenge of encouraging adult care facilities and nursing homes to participate in coalitions without financial incentives.
6. Supporting facility-level preparedness needs: from the perspective of the hospitals, it was more important to align facility hazard vulnerability analyses at the regional or coalition level rather than the city level, because most vulnerabilities are localized to geographic areas smaller than NYC.
7. Representing all health care sectors in the health care system in planning: discussion in Phase 1 focus groups revealed a general consensus that emergency management efforts had focused almost exclusively on hospitals. The then recent occurrence of Super Storm Sandy had revealed to all participants the importance of broadening the scope of efforts to include community health/primary care, nursing homes, and adult care facilities. Although the group acknowledged that adult care facilities and nursing homes were less likely to have an available staff person to consistently serve on a health care facility representative group, it was important to begin capacity building with these sectors.
Further, due to recent health care reform, some health care tasks are being transferred from hospitals to community providers. Also due to health care reform, hospitals are coordinating primary care services.
8. Clarifying response roles: hospitals stated they have their own well-developed interagency relationships and would continue to use them. These pathways tended to be viewed as the most efficient during disasters by the hospitals themselves. However, using these relationships goes outside of the city’s incident management system and therefore does not support situational awareness and coordination for the larger operating picture needed to coordinate the whole response.
9. Developing strategies to address health care staffing issues: Multiple staffing issues were discovered: recognizable identification of, and an identification protocol for medical personnel was needed to permit them entry into incident perimeters by law enforcement and to access bridges and other checkpoints into NYC when safety and security are a concern. Prioritizing medical personnel for automobile fuel to permit them to drive to work was cited as vital. Staff transportation solutions were also needed for those dependent on public transportation when these services are discontinued for safety concerns during incidents like flooding from coastal storm surges. A hospital orientation program for Medical Reserve Corps and other registered volunteers was needed to encourage volunteers to become familiar with hospitals, hospitals to become familiar with volunteers, and to shorten the volunteer orientation time needed before an emergency event.
Given these results and recommendations, DOHMH developed the Readiness Target Matrix. This matrix lists the relevant details of the 9 readiness areas, current readiness state, desired target readiness state, gaps, recommended means to address the gaps, and responsible parties and timelines for closing the gaps.
Continued Development and Use of the Readiness Target Matrix
DOHMH used this matrix in the months immediately after its development to create and coordinate activities, such as work groups to detail problems and develop solutions. For example, for one of the targets, data and information sharing, DOHMH and its partners developed a list of data elements law enforcement officials would need from hospitals during a mass casualty event bringing a surge of patients to their emergency departments. This allows the hospital to plan in advance and appoint a staff person to collect the information and provide it to law enforcement while clinical staff can be left to care for patients.
After phase two of development, DOHMH began work to implement the recommendations from the Readiness Project. Setting the data and information sharing communications area as a priority helped DOHMH to develop communications tools such as a response agency fact sheet to provide information on roles and assets available for emergencies from each sector or body representing a sector (eg, adult care facility representative associations) and response partner (eg, Greater New York Hospital Association). DOHMH worked with ESF 8 partner agencies to develop a unified situation report template to provide guidance to NYC Emergency Management on what data are needed by each body receiving the report in order to make decisions and set further incident objectives. And a health care call protocol that sets similar, standard talking points for updates during incidents, provides a reliable way for affected agencies and health care facilities to obtain the information they need from city agencies.
DOHMH also dedicated a 3-hour symposium on planning and exercising in ways that were inclusive of all health care sectors. Attendees from New York City Emergency Management, New York Police Department, and Fire Department provided insight into their planning processes, particularly planning for upcoming exercises. DOHMH obtained and shared the planned exercise types, scheduled window of conduct and objectives of all NYC hospitals with these agencies and fellow hospitals after the symposium, permitting both these agencies and hospitals to plan or exercise together as they were able.
Beginning in December 2015, several NYC agencies came together in agreement to work closely to close persistent readiness gaps for NYC Health and Medical preparedness and response, using the readiness targets as a primary source document. The group, the Health and Medical Executive Advisory Group (HMExec), is an executive level planning and advisory team that establishes broad support for preparedness and response objectives for the health care system. It is made up of the same representative agencies that served in the second and third focus groups in the first phase of developing the target matrix. The emergence of this group in parallel with the maturation of mass casualty plans held at the city level (overseen by NYC Emergency Management) have brought on real progress in interagency exercising, the second of the prioritized areas in the readiness target matrix.
Most recently, DOHMH has undertaken the development and conduct of a workshop meant to bridge understanding of response operations between the city’s incident management system and that used by hospitals (hospital ıncident management system [HICS]). With the information gleaned in this workshop, NYC Emergency Management can build out the city’s incident management system and operationalize it further to complement HICS. This will go far in clarifying response roles for the health care system.
The Readiness Target Matrix is a dynamic tool. It expands to include the breadth and depth of the health care system and its complex needs. For example, further workshops of the readiness targets with nursing home and adult care facilities groups have expanded the matrix to include a 10th focus area of emergency response training for facility staff. This has helped launch significant emergency preparedness development programs for these sectors that now includes basic emergency management principles and practice, exercise design and conduct and continuity of operations during emergencies.
And just as a hazard vulnerability analysis should be carried out at regular intervals, the Readiness Target Matrix likewise has evolved. DOHMH is now in the midst of developing a Health care System Playbook that, like the Readiness Target Matrix, will be based on partner agency buy in and input (voiced by the HMExec) and provide concrete foci for preparedness and response activities for the whole of the NYC health care system.
The Benefits of the Readiness Target Matrix and the Challenge of System-Level Readiness for Health Care Emergencies
NYC’s Healthcare Preparedness Program is housed in the city’s DOHMH. As the recipient of preparedness funding from the ASPR for the HPP, DOHMH uses the matrix developed and provided herein as a systematic approach to discovering and closing gaps in health care preparedness and response. It has chosen to do so as a complement to the ASPR capabilities. These capabilities, while providing a set of functions whose competency is essential to preparing health care systems of the nation’s jurisdictions broadly, do not provide a view to how the system subject to them makes them operational. However, the system-level targets identified through this process cannot be achieved without continued involvement and contributions from all parts of the system. Federal funding is vital to build and maintain capabilities at the system level, as individual facilities and health care delivery organizations are often in competition with one another and may not be otherwise incentivized to contribute to efforts toward strengthening the whole system. The NYC jurisdiction’s methods described here have examined the interdependencies of the system using the ASPR capabilities and functions and revealed ways in which the system can and must leverage federal funding as well as private and local resources to improve, closing gaps in its readiness.
From a practice point of view, the development of the Readiness Target Matrix, especially through a process that was inclusive of all preparedness and response stakeholders from the beginning, has benefitted the DOHMH and the readiness of the NYC health care system in several ways. It has established both a closer dialog with sister response agencies on sharing plans and planning with the health care system as well as clear, agreed upon goals for including the health care system in exercise planning with city agencies. It has also provided a practicable way of understanding the challenges facing NYC health care preparedness and response from a system’s point of view. Moreover, it provides a repeatable methodology for updating the list of gaps and prioritizing them.
When looking to the problem of defining readiness, the approach DOHMH has taken helps to elucidate the large and complex set of considerations and functions that make up readiness for a jurisdiction’s health care system. One conclusion for health care response scholars and practitioners is that readiness is best defined as a set of functions shared by the preparedness and response system of which hospitals, nursing homes, adult care facilities, primary care and others are a part. Once this definition is accepted, in order to address the readiness of the whole system, representatives of these constituent sectors and health care leaders must come to consensus on the gaps present in each function. The methods the NYC jurisdiction used to come to its definition of readiness in health care and this model for developing readiness can be repeated in other localities for their particular needs. Readiness frameworks that come out of such a process would then be locally valid and establish a local set of targets to address the optimal interactions of the various parts of that system.
Conclusion
Federal funding for health care preparedness is vital for local jurisdictions to build and maintain the readiness of their own complex health care systems. This funding makes it possible for each recipient of the ASPR HPP award to also develop an approach to readying its health care system that has local relevance and aligns with the uniqueness of the system in each jurisdiction.
The framework proposed above, DOHMH, the NYC HPP awardee, and its emergency preparedness and response practitioners, planners, and policy developers can see that any one constituent sector or response partner of the larger health care system, such as emergency management or public health, cannot be responsible for the readiness of the whole. Readiness arises out of an interdependency of functions and roles played by each partner or sector and a dialog to recognize what impedes or enables each to play those roles.
Even as funding and mandates change for health care system readiness, several of the focus areas found by the readiness target project will remain perennial; these include communications, situational awareness, and keeping response roles clear. The NYC Healthcare System Readiness Matrix development process, designed to encourage early and robust engagement of all stakeholders, successfully provided a locally valid document to drive continuous improvement and set strategy for the Healthcare Preparedness Program.
Acknowledgments
This publication was supported by the Cooperative Agreement Number 1U90TP000546-01 from the Centers for Disease Control and Prevention and/or ASPR. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention and/or ASPR.
