Being prepared for a natural disaster, infectious disease outbreak or other emergency where many injured or ill people need medical care while maintaining ongoing operations is a significant challenge for local health systems.
Challenges to developing and sustaining community coalitions may reflect the structure of preparedness activities, which are typically administered by designated staff in hospitals or large medical practices. Health care providers’ focus on emergency-preparedness activities waxes and wanes, reflecting the many pressures and competing demands they face. Providers and policy makers alike increasingly have recognized the value of collaboration through community-based preparedness initiatives to minimize the amount of redundant capacity each provider must maintain.
Using the lens of the 2009 H1N1 influenza pandemic, this study examined the activities of emergency-preparedness coalitions in 10 U.S.
A number of different federal, state and local organizations work with health care providers individually and collectively to promote collaboration in preparedness activities. In contrast, much less attention and funding have focused on involving other health care providers, such as independent physician practices, ambulatory care centers, specialty care centers and long-term care facilities, in community-based preparedness activities. While hospitals and public health departments participated in all emergency-preparedness coalitions in the communities studied, involvement of nonhospital providers and other stakeholders varied significantly across the communities (see Table 1). When working with nontraditional partners, community coalitions reported difficulty in aligning goals and securing buy in from those who view emergency management as outside their scope of responsibility. Both hospital and community practice respondents acknowledged a sense of alienation from each other, noting that the smaller the practice, the more difficult it is to participate and have a voice in community collaborations.
Most primary care respondents agreed that physicians are focused mainly on their patients’ day-to-day needs and do not see preparedness as part of their mission.
A few respondents reported that competition did affect preparedness collaborations, particularly when hospital leaders are guarded about sharing capabilities and needs with peers at other institutions. During the H1N1 pandemic, for example, some coalitions developed plans to distribute supplies in advance.
Nearly all hospitals working with both hospital-employed physicians and independent community-based physicians reported that hospital-employed physicians are easier to engage, suggesting that markets with larger physician groups and more hospital employment of physicians would be better positioned to build integrated surge-capacity plans. Because of the generally collegial approach to preparedness activities, respondents reported that tighter hospital affiliations in consolidated markets had little impact. While all providers felt the strain of competing demands in allocating resources for emergency preparedness, rural providers were particularly strapped. Respondents did report that local partnerships and emergency response in small towns were more cohesive because of strong day-to-day relationships among health care providers, first-hand knowledge of the population they serve and a strong community feel. Across sites, respondents consistently reported that hospitals and hospital-owned physician practices typically are much more involved in emergency-preparedness coalitions than other stakeholders, reflecting both the federal financial support hospitals receive for preparedness activities and their size, structure and resources. There are two general approaches policy makers could consider to broaden participation in emergency-preparedness coalitions: providing incentives for more stakeholders to join existing preparedness coalitions or building preparedness into activities providers already are pursuing. Consider building preparedness into activities providers already are pursuing.An alternative approach to traditional preparedness coalitions would be to leverage activities providers already are pursuing unrelated to preparedness activities. One option would be to incorporate preparedness activities into existing incentive programs aimed at underrepresented stakeholders, including independent physicians and nursing homes. Other opportunities might include incorporating community-level preparedness activities into care-coordination activities that can count toward patient-centered medical home certification or encouraging electronic health record vendors to include features that facilitate electronic submission of important data to local, state and federal authorities during a disaster.
If collaborative preparedness activities leveraged existing affiliations and activities among stakeholders, the resulting coalitions might look very different from community to community. For example, nursing homes owned by or closely affiliated with hospitals may use the hospitals’ preparedness staff, making it easy to develop collaborative approaches to preparedness. This study examined the activities of community-based emergency-preparedness coalitions in 10 communities. The following pages examine key distinctions between emergency management and ICS and the roles that each is designed to fulfill during a major medical incident.
Emergency management describes the science of managing complex systems and multidisciplinary personnel to address extreme events, across all hazards, and through the phases of mitigation, preparedness, response, and recovery. The activities of the EMP address the phases of mitigation, preparedness, response, and recovery. It is important to note that the procedures and systems used to conduct preparedness activities (committee structure and meetings, memo writing, regular email notification of meetings, etc.) are typically not adequate for use during emergency response.
Consolidated action plans - a single, formal documentation of incident goals, objectives, and strategies defined by unified incident command.
Many of these procedures increase the efficiency of preparedness activities, while essentially training participants on the procedures to be used during response and recovery.
Main ContentIn the past, the HCO EOP was commonly (and inaccurately) referred to as the disaster plan. The management structure and methodology that will be used in an emergency, including the organization and operation of the internal HCO Incident Command Post (ICP).
Methods for adequately processing and disseminating information during an emergency, including names and contact information for external liaisons and contacts at other HCOs and the jurisdictional level (Tier 3). Guidance on how to develop and release public messages during emergencies, including coordination with the jurisdiction (Tier 3) public information function. The structure of the EOP in emergency management is becoming more standardized, and HCOs should consider conforming to this structured approach.


EOP Base Plan - Provides an understanding of how the organization responds and how it interfaces with the outside environment during response. The approach to emergency preparedness and response for these Tier 1 assets can be relatively simple. Where to obtain information on whether public health emergency powers have been invoked, allowing release of private patient information, and other deviations from standard medical practice.
Emergency preparedness requires coordination of diverse entities at the local, regional and national levels. There are two general approaches policy makers could consider to broaden participation in emergency-preparedness coalitions: providing incentives for more stakeholders to join existing coalitions or building preparedness into activities providers already are pursuing. 11, 2001, terrorist attacks, many health care providers have adopted emergency-preparedness plans, including participation in such activities as community-wide drills and tabletop exercises, to strengthen their ability to respond to a disaster. By April 26, the government determined that H1N1 represented a national public health emergency and began releasing stores of personal-protective equipment and antiviral medications to states from the strategic national stockpile. First, preparedness activities, such as planning, training and participating in drills, do not generate revenue for health care providers but have costs in staff time and materials. Nonmedical stakeholders, such as police, fire, coroners, school systems and employers, have varying degrees of involvement in medical emergency planning collaboration. Some offer on-site health care, which may serve as an alternate source of care that is not always coordinated with hospitals or independent practices, and others may require documentation from a clinician before potentially affected people can return to school or work.
In some hospital systems, the system’s preparedness plan directly encompassed physician practices owned by the hospital system. Rural respondents reported depending on buy in from a smaller pool of institutional leaders, and these leaders did not always perceive value in allocating limited funding and staff time for emergency management and participation in coalitions. For example, outside Seattle, three small rural hospitals pooled funds to hire a shared emergency manager across the facilities.
As one rural South Carolina respondent noted, a small town in which people know and look after their neighbors can help responders identify and protect more vulnerable community members in an emergency situation. However, most attention has focused on population-level management of obesity or chronic illness rather than disaster preparedness and response. Other stakeholders, particularly smaller and independent primary care practices, could potentially contribute to preparedness efforts, but there are significant barriers to involving them in traditional coalitions in a sustainable way. Policy makers could encourage groups whose participation is currently limited in most communities, such as independent physician practices, to join traditional preparedness coalitions that meet regularly to develop joint plans or coordinate responses. For example, programs that offer extra payment to primary care practices to coordinate care of patients with specific chronic conditions might also encourage and reward coordination related to emergency preparedness or the creation of business continuity plans. Employment of physicians is only one of the ways markets vary—hospitals may be independent or tightly affiliated with one another, nursing homes may be closely linked to local hospitals or to national chains, and health information may be shared widely or not at all.
Similarly, hospitals and physician practices using a common electronic health record platform may find it easier to share real-time information about utilization and to prepare jointly for surges. Hospital staff and other healthcare personnel might equate emergency management activities to a hospital's Disaster Committee (hence the recommended name change to Emergency Management Committee). In Comprehensive Emergency Management, mitigation activities are undertaken during the time period prior to an imminent or actual hazard impact.
It includes activities that establish, exercise, refine, and maintain systems used for emergency response and recovery. This point is often missed by organizations as they attempt to utilize emergency preparedness committees and their associated structures and processes to manage response to an event. It did not include objectives for managing the disruption of traffic or other countywide ramifications of the plane crash. Examples include the use of emergency notification procedures for disseminating preparedness information, the use of a management- by- objective approach when planning preparedness tasks, and using tightly managed meetings with detailed agendas. Fortunately, this has begun to change as the EOP evolves into a guide to address less overwhelming emergencies and hazard threats.
Figure 2-1 provides a synopsis of the EOP structure demonstrated in the National Response Plan (NRP)[8] and the example below provides an EOP structure and format specifically for HCOs. However, these entities may find themselves, during a major incident, compelled to participate in the community response beyond simply referring patients to a hospital or closing down their clinical operations. The organizing body must have the ability to manage ongoing EMP activities and, during response, to perform incident management processes, such as incident action planning and disseminating information to its participants.
Given the diversity of stakeholders, fragmentation of local health care systems and limited resources, developing and sustaining broad community coalitions focused on emergency preparedness is difficult.
Maintaining preparedness is a daunting task, given that emergencies can spring up at a national, regional or local level and take forms as varied as a global pandemic, a regional hurricane or a local outbreak of food-borne illness.
While there is limited funding for preparedness activities, hospitals are not subsidized to keep beds empty and supplies stockpiled for a disaster, and it is impractical for trained staff to sit idle until a disaster strikes. The H1N1 influenza pandemic was the most recent national event that required large-scale preparedness and response. Given the low probability of certain events, stockpiling supplies and committing staff to emergency preparedness often are not high institutional priorities.4 In addition, community coalitions require competitors to work collaboratively.
Regional or specialty-based medical societies may maintain similar lists and can provide basic training in disaster planning through continuing medical education.


A hospital respondent in another community coalition cited reluctance to work with nursing homes because of the perception that they are primarily looking for a place to offload patients in an emergency. However, respondents across all sites generally agreed that providers put normal competitive dynamics aside for preparedness efforts and meet and share information on capacity and supply chains when needed.
As one respondent said, “Rural hospitals are facing huge budgetary issues right now. At the same time, public health preparedness experts have sought to develop methods to evaluate community coalitions. Changes in local market structures, such as increased hospital employment of physicians, also may diminish barriers in some communities. Likewise, hospital efforts to work with physician practices and long-term care facilities to prevent avoidable readmissions might incorporate preparedness activities. Each of these factors may affect how planning responsibilities, staff and information are most efficiently shared in preparation for and during a disaster.
The sum of all emergency management activities conducted by a response organization may be collectively referred to as an Emergency Management Program (EMP) for that entity. The critical task in preparedness planning is to define the system (how assets are organized) and processes (actions and interactions that must occur) that will guide emergency response and recovery. The EOP defines effective process and procedures for the context of emergency response (emergency notification procedures, establishing an incident management team, processing of incident information, etc.).
The management transition from response to recovery (both timing and methods) must be carefully planned and implemented to avoid problems.
Arlington County emergency management officials, therefore, quickly knew they had to manage these other problems through their Emergency Operations Center (EOC), which was geographically separate from, but closely coordinated with, incident command at the Pentagon.
As a prolonged, low-mortality event, H1N1 tested community preparedness, clarified the challenges different stakeholders face, and pointed to ways to broaden and strengthen local collaboration. And, unlike other events that health care organizations must prepare for, such as Joint Commission inspections, there are no predictable, short-term consequences for failing to engage in collaborative, community-level disaster planning.
The focus on hospitals reflects their historic importance in providing staff, space for planning and response, and treatment of emergency victims, including such specialized services as decontamination or burn care. Hospital staff in nearly all sites reported challenges with fit-testing disposable protective face masks because of the staff time required and because fit-testing alone consumed a substantial proportion of their inventory. Some health systems did expect employed physicians in community practices to work collaboratively in disaster planning. This study’s findings suggest that preparedness work could be integrated with broader care delivery, with possible implications for how to evaluate coalitions. The term program is used because it denotes activity that is continuously ongoing, whereas a plan is often considered a series of actions that occur only in response to defined circumstances.
Physicians and other clinicians employed by hospitals or working in community-based practices owned by hospitals usually fall under the umbrella of hospital preparedness activities. Even in a disaster where victims seek care at hospitals, community-based clinicians can play a role. In some cases, this reflected a commitment at the highest levels of organizations, but, in other cases, it reflected rapport among preparedness staff.
Maintaining adequate supplies, particularly of masks, was a challenge when hospitals in a community, as well as public agencies, were competing for the same products. High levels of physician participation in those markets were attributed to hospital systems setting the expectation that physicians would participate and paying them for their efforts, and, in some cases, even allotting them administrative time to participate in preparedness or other system-level work.
That’s the mentality at small as well as big hospitals, [but] you can multiply that by 100 for small [rural] hospitals. No rural respondents described working with their state office of rural health on emergency preparedness. Two additional sites were added: New York City because of significant investment in preparedness and Chicago to increase Midwestern representation. An effective mitigation effort should begin with, and be based on, a valid HVA as this will help an organization prioritize issues during follow-on mitigation and preparedness planning.
For example, in a disaster, hospitals generally try to discharge as many inpatients as possible, and community-based providers could help by seeing or contacting discharged patients to ensure they are receiving needed follow-up care.
Sixty-seven telephone interviews were conducted between June 2011 and May 2012 with representatives of state and local emergency management agencies and health departments, emergency-preparedness coalitions, hospital emergency preparedness coordinators, primary care practices and other organizations working on emergency preparedness and response. With well-developed ICS and emergency management support, the incident response proactively addresses both types of demands and, in fact, reduces many response-generated demands to routine status. Other respondents reported frequent communication among competing hospitals on shared pandemic plans and hospital policies for emergencies.



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