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November 10, 2009
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VIEWS: RIC SKINNER
by Ric Skinner, GISP, Healthcare Preparedness Consultant, Sturbridge MA
[Jul 31 08]
Part I of this article will address the current process typically employed in Hospital Hazard Vulnerability Analysis. Part 2 will present a proposal for process improvements.
The Real Estate industry and the Disaster Preparedness & Response sector have three things in common:
When looking for my current house, I wanted one located in a woodsy setting with a brook or pond within view. When analyzing hazard events that a hospital might be exposed to, one should consider the hospital’s location with respect to weather patterns, hazardous storage facilities, transportation routes, population demographics, etc. For example, in a hazards analysis it should be obvious that a hospital located in a FEMA Q3 Flood Zone should consider and prepare for an external flooding event much differently than a nearby patient care facility on higher ground. Perhaps less obvious, a hospital located a half mile downwind from an industrial storage tank containing 10,000 gals. of anhydrous ammonia should give the hazard a higher priority in its disaster analysis than a patient care facility would located a half mile upwind from the same storage tank.
Identifying risks from hazards and assessing a hospital’s vulnerabilities to those risks is fundamentally about having the right information, and in many cases spatial information. The Joint Commission (JC) recognizes the importance of all-hazards vulnerabilities and requires that hospitals it accredits conduct an annual Hazard Vulnerability Analysis (HVA) in a formal, documented process.
An HVA is the process which identifies the internal and external risks of “all-hazards” disasters (natural, technological, human related and hazardous materials related) most likely to affect facilities and the probable severity of impacts if they were to occur. By understanding risk exposure the facility should be better able to develop adequate mitigation, preparedness, response, and recovery actions for those risks, thus reducing vulnerability and impact to the organization making it more resilient.
A hospital’s disaster preparedness and its ability to respond and recover from disasters depends on how well it has identified and prepared for the historically real and most likely hazards to which it could be exposed, and how well it has estimated the frequency and severity of impact of those hazards on people (i.e., patients, employees, visitors), facilities, and operations.
While no particular HVA method is prescribed by JC, it cites a manual scoring method originally developed by Kaiser-Permanente (KP HVA tool) and which is used by most hospitals in one variation or another. Using this tool a hospital can rank events based on their qualitative probabilities and determine where to focus preparedness and mitigation efforts. However, the KP HVA tool is essentially a blank form. No probabilities based on regional or local information are included. It is no easy task to research, identify, and quantify event probabilities and severities, therefore, making an assessment of the impacts of regional and local events upon facilities is left up to the evaluator’s – or often a group of evaluators’ – personal knowledge, recollections, and consensus regarding each event. This approach is consistent with results from a recent survey conducted by this author where half of healthcare facilities responding indicated their HVAs were completed by “group decision”, “mostly subjective” and may include “some factual or experienced-based information”. Consequently, the resulting assessment is essentially subjective since few fact-based probabilities and severities are researched and factored into the tool. From a hospital administrator’s perspective this has probably been justified as a reasonable use of limited staff time. This statement is supported by another recent survey conducted by this author and others which revealed that over half of 1500 responding facilities had 1 or less than 1 FTE assigned the responsibilities for emergency management/disaster preparedness.
A confounder in hospital HVAs is that many hospitals often have multiple buildings in various locations in a city or region that fall under their single JC accreditation. The majority of these hospitals manually complete a KP HVA tool type process in a time consuming consensus-driven manner to provide a composite assessment across all facilities covered by the single accreditation. However, JC is now emphasizing that location is a factor that should be considered in an HVA as remotely located facilities may warrant separate HVAs.In JC’s new Emergency Management chapter, which will become effective in January 2009, EM Standard 01.01.01 of the Hospital Accreditation Program requires that:
“The [organization] engages in planning activities prior to developing its written Emergency Operations Plan.”
These activities include identifying risks, prioritizing likely emergencies, attempting to mitigate them when possible, and considering potential emergencies in developing strategies for preparedness, response and recovery.
In the Elements of Performance for this requirement JC states:
“The hospital conducts a hazard vulnerability analysis (HVA) to identify potential emergencies that could affect demand for the hospital’s services or its ability to provide those services, the likelihood of those events occurring, and the consequences of those events.”
An added time and resources consuming requirement is for the hospital to work with community partners to make sure its HVA meshes with similar efforts by the community.
Then, here is where JC recognizes “location” in a clarifying note:
“Hospitals have flexibility in creating either a single HVA that accurately reflects all sites of the hospital, or multiple HVAs. Some remote sites may be significantly different from the main site (for example, in terms of hazards, location, and population served); in such situations a separate HVA is appropriate.”
While the term ‘remote’ is not defined by JC, in my view this could mean patient care facilities under the same JC accreditation distantly located elsewhere in a county, or proximally located in different sections of the city. Separation of only a few blocks could result in significantly different risk exposure by certain hazards.
Worth interjecting here is that in a recent study the National Academy of Sciences concluded that location information, and tools for analyzing that information spatially, should be an essential part of all emergency management aspects -- from events planning, through response and recovery, to the mitigation of future events (“Successful Response Starts with a Map: Improving Geospatial Support for Disaster Management”). This would apply to an HVA conducted for any (not just healthcare) facility.
It has been the practice of many hospitals to carry out a single HVA regardless of the number and location of facilities covered by the JC Accreditation. The survey referenced aboverevealed that more than 46% of facilities do a composite HVA. However, from a preparedness and response standpoint, and the rationale that an HVA should lead to a relevant and appropriate disaster preparedness and response plan, the composite HVA can result in some very important facility-specific risks being averaged out to a lower priority.
The process and KP HVA tool approach in its current format would be very time consuming to apply to each building, especially where regional or local information should be included in the evaluation. The KP HVA tool does not support a composite score for multiple individually rated facilities because it does not recognize an individual facility’s location-based risk factors in the overall assessment.
The importance of the facility’s geographic location in estimating the probability of an event affecting a facility, along with the risk itself, historical data, proximity to local/regional high-risk locations (e.g., a chemical manufacturer, nuclear plant, “tornado alley”, coast line, etc.), and discussions with local emergency managers should all be factored into a facility’s HVA. Population (i.e., density and location) is another important risk factor applied in the context of the community population as well as a facility’s occupancy (e.g., employees, patients, visitors).
Therefore, the level of vulnerability to which hospital facilities and operations may be exposed due to impacts of a hazard event, or combination of events, can be summarized as a function of:
I believe there needs to be an objective (as opposed to subjective) standardized process, a format for capturing the inputs and relating them to location-based factors, and a scientifically based assessment methodology so that those hazards that can be quantified in terms of risk can be, and those that are more qualitative or lack historical or design attributes can be addressed to the extent feasible. And above all this must all be easy, relatively simple, time efficient and able to be archived from one year to the next so that only those aspects that have changed since the previous year need be revised. That will be the subject of Part 2 of this article.
Note: A draft of this article was reviewed by emergency management professionals at healthcare organizations in Florida and Oregon.Comments, corrections or suggestions are encouraged and should be sent directly to the author at email@example.com.
 While this article discusses HVA as required by JC for hospitals, it is also applicable to other JC accredited healthcare facilities.
[June 29 08]
My theory, not nearly as eloquently and insightfully stated as Jim Rush's commentary, is that too many hospital CEOs go to bed at night praying:
"Thank you for not putting my hospital in NYC or Arlington or in a field in western PA. And thank you for not putting it in NOLA. I only ask that you help me though my DISASTER and give me enough nurses to staff my beds tomorrow."
This thought is supported by the survey of healthcare preparedness at US hospitals & healthcare facilities that I and colleagues conducted last summer (download survey.ppt). A common theme (read "complaint") we heard from those assigned the responsibility for emergency management and disaster response was that there was little or no top-down support for their EM responsibility which had been added to the other 12-15 things already on their plate. More than half of the 1500 responding facilities said there was 1 FTE or less assigned to EM for their facility, regardless of size.
Frankly, in general I think too many hospital "C's" just don't get it. Someone please prove me wrong. I will add, however, we have seen some examples (e.g., Sanford Health) of those who really do get it, commit the staff resources and run a capable and ready EM program. These should serve as models for the rest.
We all know that "Response to disaster begins with local resources." This applies to municipalities, electric utilities, American Red Cross, etc.…….and hospitals. Hospitals need to "own" that understanding and make sufficient noise in Washington to effect proper programs with sufficient funding with limited strings attached for administration of those funds. What if we left states out of the equation?
The recent proposal to require Hospital Preparedness Program (HPP) cooperative agreement recipients to contribute 5-10% non-federal matching funds -- which I think we can all guess will be passed down to healthcare facilities without a similar match from the state -- is a big move in the opposite direction of assuring better readiness.
Don't cut the funding, but give the hospitals the opportunity and encouragement for more creativity and collaboration so they can stitch their little square in the "preparedness crazy quilt."
And you, healthcare facilities, get rid of the notion that "competition" and "market advantage" will mean anything when faced with the disaster and you're struggling just to survive and prevail. I'd like to hear from NOLA hospitals and midwestern weather-ravaged hospitals on that point.
As Jim illustrates, we don't need to reinvent the wheel.
Let's learn from past programs which had sound basis for design and utilization. Let's remove the politicians from the process of deciding what's best for hospitals and healthcare and seek input from "Healthcare Preparedness Subject Matter Experts (HP/SMEs). Let's reintroduce the notion of "science" (from Latin scientia, having knowledge) in finding the best set of solutions.
We have a start with HICS IV and NIMS but we need to go further. Let's draw from the military's "battlespace" model of a unified strategy to integrate and combine armed forces for the military theatre of operations and apply it a "healthcare preparedness battlespace."
I propose a National Academy of Healthcare Preparedness, along the lines of the National Academy of Science, to study the best of the best in hospital and healthcare facilities preparedness, health information technology, HICS IV implementations, patient tracking systems, disease surveillance systems, etc., and then make sound, science-based, relevant recommendations upon which adequate funding can be based.
We can do this, folks. As I used to tell my kids when faced with what seemed to them the impossible -- "yagottawannadoit!"
[with permission from Government Technology's Emergency Management / first published on May 16 08]
Though voice communications have been the focus of interoperability funding since 9/11, state homeland security programs are beginning to expand their focus to include data and information. The National Governors Association identified interoperable communications as the top priority for fiscal 2007.
Interoperability has typically been interpreted as -- and grant funding has typically been spent on -- voice communications, such as radios and related equipment. However, in fiscal 2007 the U.S. Department of Homeland Security (DHS) began placing greater emphasis on data, including geospatial data and information interoperability, as well as the tools to move data between municipal departments, communities and other agencies and entities, such as hospitals, blood banks, and human and animal shelters.
The doctrine of theNational Response Framework calls for common organizational structures and capabilities that are scalable, flexible and adaptable for diverse operations, and facilitate interoperability and improve operational coordination. As DHS funding resources decrease and the emphasis shifts from purchasing products to planning and preparedness, the value of information sharing becomes vital.
All disasters are local, and initial response requires local resources. Therefore, local information and locally managed interoperable information systems are critical assets for disaster planning, preparedness, response and recovery. Most data needed during a disaster or emergency is geospatial. In providing for homeland security, location is of paramount importance. The first questions typically asked are:
• Where is it?
The central conclusion of the 2007 National Academy of Sciences reportSuccessful Response Starts with a Map: Improving Geospatial Support for Disaster Management is that geospatial data and tools should be an essential part of all emergency management aspects -- from events planning, through response and recovery, to the mitigation of future events.
The DHS recognizes the important contribution that geospatial information and technology play in emergency management and disaster response. Federal, state and local organizations have increasingly incorporated geospatial data, information and technologies as emergency management tools and homeland security applications. Geospatial systems improve the overall capability of IT applications and systems to enhance public security and emergency preparedness and efficient response to all hazards, including natural and manmade disasters.
State homeland security strategy plans often include objectives that strive for enhancement of GIS capabilities in support of the all-hazards approach. As part of the incident management tool set, GIS allows emergency managers to quickly and accurately visualize patterns of activity, map locations, model potential hazards and put emergency situations into geospatial context. Communities across the United States have or are building GIS capability, resulting in essential geospatial data resources. This is a critical asset for preparedness, planning, response, situation awareness, resource asset status and tracking, decision support and disaster recovery.
Interoperability is the ability of two or more systems (and the people and functions they support) to share data and tools effectively and seamlessly, independent of location, data models, technology platform, terminologies, etc. Interoperable communications are essential elements of planning, preparedness, response and recovery, so those who need the information receive it, at the right time and in the correct format. For example, in establishing Massachusetts' State Interoperability Executive Committee via Executive Order 493, Gov. Deval Patrick recognized the need to "Enable emergency response agencies and other stakeholders to exchange critical communications and data with one another, permitting them to work together effectively and efficiently to prevent, respond to and recover from domestic incidents, regardless of cause, size or complexity."
The lack of consistent policy for collaboration, together with protocols and structures for coordination and communication, has long been a challenge to effective collaboration, sharing and reuse of geospatial data and tools among all government levels. A critical requirement for emergency preparedness, response and mitigation is to have rapid access to the most accurate, up-to-date geospatial content, whether it is current wind speed and direction, hospital locations, damage assessment data or predictive flood model results.
In addition to knowledge of the event's location, essential data would include other critical information about the impacted area, the nature of impact and locations of key assets, such as shelters, disaster equipment and potential responders. Without this information and the tools necessary to share and collaborate on what it means to effect appropriate decisions, the eventual detrimental impacts of the event will likely be greater than necessary, whether measured in loss of life, injury, damage to property or disruption of essential activities.
DHS funding to states and communities used for planning and preparedness for a terrorist attack or major disaster has remained steady or declined over the past four years, and it appears the trend will continue in fiscal 2008. Based on President George W. Bush's fiscal 2009 requests, overall funding for the State Homeland Security Grant Program could be 79 percent less for fiscal 2008.
Due to reductions in preparedness funding, the majority of local emergency management organizations will soon not be able to afford often pricey, commercial incident management products and solutions. Therefore, it behooves communities to use their limited funding resources to more creatively develop or enhance planning and preparedness capabilities, including becoming more interoperable with neighboring communities. Many communities still face obstacles in developing interoperable voice communications between police, fire, emergency medical services and public works departments. Even greater obstacles exist for data and information interoperability between community, regional and state agencies.
The diminishing of all-hazards preparedness funding is strapping local communities to the point where it creates a "necessity is the mother of invention" situation. It becomes necessary for communities to use their limited funding resources more imaginatively in developing or enhancing planning and preparedness capabilities, including becoming more interoperable with neighboring communities, other agencies and critical response organizations.
The DHS has invested extensively in good basic incident management software applications that are available at no cost. To qualify for DHS funding, a concept outlined in this article will need to be designed and developed in accordance with Federal Interoperable Communications Grant Guidance and the DHS Homeland Security Grant Program -- Supplemental Resource: Geospatial Guidance.
The Disaster Management Interoperable Information System (DMIIS) will provide participating towns, agencies and other resources with a cost-effective capability for enhanced situation awareness, disaster response, resource request and allocation, and a collaborative environment for training and exercises. In addition, the system will incorporate proven technology designed to use message content standards, a town and region may have interoperable capability with similar systems in other towns and regions.
The platform for communicating text and geospatial data uses the Common Alerting Protocol (CAP) message content standard. CAP standardizes the content of alerts and notifications across all hazards (i.e., natural, technological, human caused and hazardous materials).
CAP-compliant systems that have developed an interface to the DHS's freely provided Disaster Management Open Platform for Emergency Networks (DM-OPEN) allow CAP application programming interfaces to communicate with each other. DM-OPEN is a proven technology and provides an interoperability backbone that acts as a "level playing field" to allow disparate third-party applications, systems, networks and devices share information in a nonproprietary, open yet secure standards-based format. As federal infrastructure, DM-OPEN is designed to support the delivery of real-time data and situation awareness to public emergency responders in the field, at operations centers and across all levels of response management.
Where military installations are part of the regional picture, the same interoperable information systems have been successfully demonstrated for moving incident response information between civilian and military domains.
One of the principal design criteria of the DMIIS is cost effectiveness. The interoperable platform for data and information communications will use the DHS's Disaster Management Interoperability Services (DMIS) tools to extend incident management and information exchange capabilities to jurisdictions that lack another feasible solution. The free software provides a good basic capability that enables the emergency management community to securely share text and geospatial digital information. By providing information sharing capabilities, tools and supporting infrastructures, DMIS installations help local/regional practitioners better prepare for, respond to and recover from emergencies and day-to-day operations.
DMIS supports one of the president's 24 e-government interagency initiatives established by the Office of Management and Budget. DMIS and DM-OPEN are proven technologies that provide a cost-effective solution enabling communications between municipal departments, municipalities and other organizations, municipalities and regions, state emergency management agencies, public health departments, etc. DMIS plans for and manages incidents and focuses on local needs and control.
DMIS will soon have the capability to interface with the National Oceanic and Atmospheric Administration's HazCollect, which provides an automated capability to streamline the creation, authentication, collection and dissemination of non-weather emergency messages quickly and securely. DMIS is also expected to incorporate resource messaging and Hospital AVailability Exchange (HAVE) standards. These new standards, which are near completion, will provide DM-OPEN with more information exchange capabilities relevant to emergency management.
DMIIS is based on essentially the same DMIS/DM-OPEN model that was identified as one of the most promising new technologies successfully demonstrated in Trial 3.27 of the Joint Chiefs of Staff Coalition Warrior Interoperability Demonstration 2007. Trial 3.27 won the top award in its category from the International Association of Emergency Managers for Technology and Innovation.
At the time this article was written, DMIS was under review by the DHS and FEMA to determine the technical, economic and operational feasibility for recommended enhancements and improvements.
Another no-cost solution that has emerged is Sahana, an open source disaster management system. Unlike DMIS, Sahana is a Web-based collaboration tool that addresses common coordination problems during a disaster, such as finding missing people, managing aid, organizing volunteers, and tracking refuge camps effectively between government groups, nongovernmental organizations and victims. Sahana is an integrated set of pluggable, Web-based disaster management applications that provide solutions to large-scale humanitarian problems during the disaster aftermath. The application's scale may be a major distinction from DMIS, which is perhaps better suited for managing incidents at the local and regional levels.
Part One - The Environment
© 2008 Directions Media. All Rights Reserved
[with permission from Directions Magazine / first published on April 17 08]
Ed. Note: This is a
two-part article. In this first part, the author describes the environment
that is putting pressure on disaster response resources, requiring them to
"do more with less." The second part of the article, which will appear next
week, offers a solution to the challenge.
Department of Homeland Security
(DHS) funding to states and communities, which is used to prepare for a
terrorist attack or major disaster, has remained steady or declined over the
past four years, and it appears the trend will continue in FY 2008. Based on
the president's FY 2009 requests, overall funding for the State Homeland
Security Grant Program could be 79% less than for FY 2008 (Sen.
For an effective response, expertise and experience must be leveraged to support decision making and to summarize and prioritize information rapidly. Information must be gathered accurately at the scene and effectively communicated to those who need it. To be successful, clear lines of information flow and a common operating picture are essential (emphasis added; NRF 2008).The National Governors Association identified interoperable communications as the top priority (pdf) for FY 2007. Interoperability typically is interpreted as - and grant funding is typically spent on - voice communications such as radios and related equipment. However, in fiscal year (FY) 2007, the Department of Homeland Security placed greater emphasis on data, including geospatial data, and information interoperability, including the tools to move data between municipal departments, communities, other agencies and other entities such as hospitals, blood banks, and human and animal shelters.
Due to the reductions in preparedness funding, the vast majority of local emergency management organizations will soon be unable to afford the often pricey commercial incident management products and solutions. Therefore, it behooves communities to use their limited funding resources to be more creative in developing or enhancing planning and preparedness capabilities, including becoming more interoperable with neighboring communities. Many communities still face obstacles in developing interoperable voice communications (i.e. radio) between their own police, fire, EMS and public works departments. Even greater obstacles exist for data and information interoperability between communities, regions and state agencies.
Most data needed in a disaster or other emergency are geospatial. In providing for homeland security, location is of paramount importance. The first questions typically asked are: "Where is it? What's in the area I need to know about? How do I get there?" The central conclusion of the National Academy of Sciences report, "Successful Response Starts with a Map -- Improving Geospatial Support for Disaster Management," is that geospatial data and tools should be an essential part of all aspects of emergency management - from planning for future events, through response and recovery, to the mitigation of future events (NAS 2007).
DHS recognizes the important contribution that geospatial information and geospatial technology play in emergency management and disaster response. Federal, state and local organizations have increasingly incorporated geospatial information and technologies as tools for use in emergency management and homeland security applications. Geospatial systems improve the overall capability of information technology applications and systems to enhance public security and emergency preparedness and efficient response to all-hazards, including both natural and man-made disasters.
State Homeland Security strategies often include objectives that recommend enhancement of GIS capabilities in support of the all-hazards approach to homeland security. GIS, as part of the incident management tool set, allows emergency managers to quickly and accurately visualize patterns of activity, map locations, model potential hazards, and put emergency situations into a geospatial context. Communities across the U.S. have or are building GIS capability resulting in essential geospatial data resources.
The concept that will be further discussed in Part Two of this article is interoperability. Interoperability is about the ability of two or more systems (and the people and functions they support) to share data and tools effectively and seamlessly, independent of location, data models, technology platform, terminologies, etc. Interoperable communications (voice, data) are essential elements of planning, preparedness, response and recovery so that all those who need the information receive it, at the right time and in the right format. For example, here in Massachusetts, in establishing the Massachusetts State Interoperability Executive Committee, Governor Deval Patrick recognized the need to:
"... enable emergency response agencies and other stakeholders to exchange critical communications and data with one another, permitting them to work together effectively and efficiently to prevent, respond to, and recover from domestic incidents, regardless of cause, size or complexity." (Executive Order 493)The lack of consistent policy for collaboration, together with protocols and structures for coordination and communication, has long been a challenge to effective collaboration, sharing and reuse of geospatial data and tools among all levels of government. A critical requirement for emergency preparedness, response and mitigation is to have rapid access to the most accurate, up-to-date geospatial content, whether it is current wind speed and direction, the location of hospitals, damage assessment data, or the results of predictive flood models.
In addition to knowledge of where the event has occurred, essential data would include other critical information about the area it has impacted, the nature of impact, and the locations of key assets such as shelters, disaster equipment and potential responders. Without this information, and the tools necessary to share and collaborate on what it means in order to effect appropriate decisions, the eventual detrimental impacts of the event will likely be greater than necessary, whether measured in loss of life, injury, damage to property or disruption of essential activities.
Part Two of this article in a subsequent issue of Directions Magazine will discuss a proposed cost-effective information interoperability solution.
Author's note: A previous draft of this article was reviewed by Sarah Hyder, Avagene Moore and Rick Hauschildt who provided helpful comments.
Part Two - The Solution
© 2008 Directions Media. All Rights Reserved
[with permission from Directions Magazine / first published on April 20 08]
Ed. Note: This is a
two-part article. In the first part, which appeared last week, the author
described the environment that is putting pressure on disaster response
resources, requiring them to "do more with less." This second part of the
article offers a solution to the challenge.
Your comments: Send your comments, complete with your name, company/ organization with the subject: Comments on Ric Skinner's article to firstname.lastname@example.org
Please note: The views expressed here reflect the views of the authors alone, and do not necessarily reflect the views of any of their organizations. In particular, the views expressed here do not necessarily reflect those of Big Medicine, nor any member of Team EMS Inc. Team EMS Inc. retains the right to edit or delete any comments posted herein.
Ric Skinner is a Geographic
Information Systems Professional (GISP) with 35+ years experience gained in
hospital/ healthcare, healthcare preparedness, emergency management/
disaster preparedness, state cancer registry, automated vehicle location
systems, strategic planning, environmental assessment, fisheries biology,
wetlands delineation & mitigation, facility siting, biomonitoring of
wastewater effluents, electric utility industry, environmental permitting,
and probably a few others he has neglected to mention.
He also enjoys outdoor
photography, wooden ship modelling, small stream restoration, and has just
begun a project to research and map the old stone walls of his town,
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