7
Feedback to Office of Emergency Preparedness on Program Management

Although the focus of the work of the Institute of Medicine’s (IOM’s) Committee on the Evaluation of the Metropolitan Medical Response System Program was the preparedness of the communities around the United States that have developed or that are developing a Metropolitan Medical Response System (MMRS), a second part of the charge to the committee (see Chapter 1) concerns the performance of the U.S. Department of Health and Human Services’ (DHHS’s) Office of Emergency Preparedness (OEP) staff themselves in their administration of the program. The committee was asked how OEP can determine, at the program level (i.e., at the national level), whether the strategies, resources, mechanisms, technical assistance, and monitoring processes provided to the MMRS development process are effective.

The question of effectiveness cannot be fully answered independently of some measure of the preparedness of the MMRS program communities, a task undertaken in subsequent chapters. It cannot be overemphasized, however, that whatever the state of local preparedness, many programs and initiatives—those of the federal, state, and local governments and of the private sector—as well as preexisting conditions in each jurisdiction contribute to preparedness. It is therefore impossible, even for the MMRS program communities themselves, to fully disentangle the causal effects of the MMRS program relative to the effects of these other influences. It is nevertheless possible to make some judgments about OEP’s administration of the program by asking its contractors, that is, the MMRS program communities, about the extent to which they used OEP technical assistance and resources in fulfilling the terms of their contracts, their per-



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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program 7 Feedback to Office of Emergency Preparedness on Program Management Although the focus of the work of the Institute of Medicine’s (IOM’s) Committee on the Evaluation of the Metropolitan Medical Response System Program was the preparedness of the communities around the United States that have developed or that are developing a Metropolitan Medical Response System (MMRS), a second part of the charge to the committee (see Chapter 1) concerns the performance of the U.S. Department of Health and Human Services’ (DHHS’s) Office of Emergency Preparedness (OEP) staff themselves in their administration of the program. The committee was asked how OEP can determine, at the program level (i.e., at the national level), whether the strategies, resources, mechanisms, technical assistance, and monitoring processes provided to the MMRS development process are effective. The question of effectiveness cannot be fully answered independently of some measure of the preparedness of the MMRS program communities, a task undertaken in subsequent chapters. It cannot be overemphasized, however, that whatever the state of local preparedness, many programs and initiatives—those of the federal, state, and local governments and of the private sector—as well as preexisting conditions in each jurisdiction contribute to preparedness. It is therefore impossible, even for the MMRS program communities themselves, to fully disentangle the causal effects of the MMRS program relative to the effects of these other influences. It is nevertheless possible to make some judgments about OEP’s administration of the program by asking its contractors, that is, the MMRS program communities, about the extent to which they used OEP technical assistance and resources in fulfilling the terms of their contracts, their per-

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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program ceptions of the value of that assistance and those resources, and how much fulfilling the terms of the contract improved community preparedness. A subsequent section of this chapter provides a suggested survey for administration to the OEP’s primary point of contact in each MMRS program community. That said, the committee believes that some independent analysis by the committee of the performance objectives identified in the MMRS program contract is both justified and desirable. Are they the right ones? Should there be more? That is, are the actions demanded of the MMRS program communities by their contracts with OEP necessary and sufficient for preparedness? Although these are questions for which input from the communities themselves would again be helpful and which cannot be fully answered before a full evaluation of local preparedness that presumably will follow publication of this committee’s report, the committee nevertheless believes that several modifications and additions to the contract objectives (“deliverables”) are very likely to enhance a community’s response to an event involving a chemical, biological, or radiological (CBR) weapon. OEP staff, the regional Public Health Service project officers, and the MMRS program contractors have identified two objectives as being especially important: Deliverable 2, the MMRS Development Plan, and Deliverable 8, Component Plan for Local Hospital and Healthcare System. The required elements of Deliverable 2, the MMRS Development Plan, include specifying the proposed leadership and membership of a development team and the roster of a steering committee that will assist in planning and developing the MMRS. The contract suggests a number of organizations and agencies that should be considered, but variations among communities probably ensure that no list of suggested members will be appropriate for all communities. More importantly, the IOM committee has repeatedly heard that the real value of assembling a steering committee lies in the personal relationships established in the course of preparing the plan. Yet, nowhere in the guidance to the contractor on this deliverable is that stated explicitly. Also missing from the required elements of this deliverable is a preliminary assessment of the planning environment, that is, the community’s strengths and weaknesses, opportunities and threats particular to that community, and any barriers and resources that might be unique to the community. A plan to enhance local capabilities should begin by identifying those capabilities in most need of enhancement. This should be a multidisciplinary effort offered by multiple voices in the community (e.g., police and fire departments, emergency medical services, public health agencies, and hospitals), with participation attested to by the signatures of all parties. The committee recognizes that this proposed addition to the list of deliverables comes

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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program too late for the 122 cities already under contract, but it believes that it would be the most logical start to any OEP initiative to provide follow-on support to sustain their readiness. Deliverable 8, Component Plan for Local Hospital and Healthcare System, recognizes no distinction between public and private health care facilities, although it is clear from experience that some MMRS program contractors have had great difficulty involving private hospitals and clinics (see also U.S. General Accounting Office, 2001b). The contracts’ guidance on this deliverable should include or refer the contractor to some strategies, mechanisms, or incentives for ensuring the involvement of private hospitals and clinics that have proved successful in other cities. In addition, the committee has identified two important elements of coping with a mass-casualty event that are not addressed in the objective: staff callback procedures and replenishment of medical and ancillary (food, laundry, housekeeping, etc.) supplies and services. The committee also identified several other essential activities or MMRS functions that are not addressed at all in the current contracts: receipt and distribution of materials from the National Pharmaceutical Stockpile; evacuee care (shelter for healthy people fleeing an area of real or perceived contamination); volunteer utilization and management; traffic control at the scene of an event, at health care facilities, and in the community as a whole; evidence development, collection, and protection; decisions and procedures related to evacuation and disease containment; postevent follow-up of the health of responders and caregivers; and a plan for postevent amelioration of anxiety and feelings of vulnerability among the community at large. It might be argued that several of these functions are not medical in nature and therefore do not fall within the scope of DHHS’s MMRS program. However, all of these functions are essential to the ability of medical personnel to perform their jobs, even if, as seems likely, public safety personnel carry out the required actions. A realistic plan should therefore address these areas. OEP HELP TO MMRS PROGRAM CONTRACTORS OEP provides guidance and assistance to its contractor cities through

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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program a variety of mechanisms that extend well beyond simple specification of a series of performance objectives. These include the following: A detailed list of “planning considerations” for a bioterrorism plan. A collection of more than 130 issues in need of attention in any plan for coping with bioterrorism was appended to the 1999 modification to the fiscal year 1997 MMRS program contracts and all subsequent contracts. Regional project officer for consultation. Each of the 10 Public Health Service regions is assigned one to three regional emergency coordinators who also serve as the OEP project officers for the MMRS program cities within their regions. Many hold regular meetings with key personnel from their MMRS program cities, individually and as a group, for the exchange of information and advice. Yearly meeting of representatives from all MMRS program cities. In October 2000, OEP gathered representatives from all MMRS program cities for a development conference, intended to promote the exchange of ideas on how to address persistent problems in the planning process. This meeting will become an annual event, to be held 6 months after the annual meeting of the National Disaster Medical System, another OEP-sponsored event that includes a series of sessions devoted to MMRS program issues. List of contacts for all MMRS program cities. Distributed at the annual development conference, the list facilitates the sharing of information and solutions with other MMRS program cities. Public website with background materials, documents on terrorism, and links to other sources. The URL is http://www.mmrs.hhs.gov/Index.cfm. Secure website for key MMRS program personnel. A password is required for access to this site, which contains information of potential value to would-be terrorists. Access is restricted to a maximum of 15 designated individuals in each MMRS program city. Sample or model of a monthly report. Library of completed plans. OEP-funded research on common problem areas. Grants have been provided to a variety of institutions, including some cities that received MMRS program contracts in 1997, to devise and evaluate approaches to, for example, mass decontamination in cold weather, hospital decontamination systems, distribution of bulk drugs from the National Pharmaceutical Stockpile, electronic emergency department surveillance, and sustainment of preparedness after completion of the MMRS program contract. More recent contractors will presumably have access to the results of these studies. Checklist for self-evaluation of contract compliance. OEP staff use

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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program a checklist, the Contract Deliverable Evaluation Instrument, to determine whether the contractor has met the terms of the contract, that is, has provided all the required deliverables and addressed all the elements of those deliverables specified in the contract. The contractor is encouraged to use the same instrument as a guide to action throughout the contract. Appendix D is a copy of the checklist for the cities awarded contracts in fiscal year 2000. All of these efforts at helping MMRS program cities meet the terms of their contracts impress the committee as being potentially valuable, but the utility of this management assistance for both contract completion and effective preparation for CBR terrorism cannot be fully answered without input from the intended recipients, the MMRS program communities themselves. The initial section of the following proposed survey, which could be administered at any point in the course of the contract or after the completion of the contract, solicits that input directly. It then goes on to query the respondent, whom the committee envisions as OEP’s primary contact in the community, about the perceived abilities of the community in a number of functional areas that the committee believes are essential to preparedness. It concludes with several open-ended questions regarding the remaining barriers to preparedness for CBR terrorism and changes in the day-to-day and disaster-oriented operations of the public safety, public health, and health services agencies in the community.

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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program SURVEY FOR MMRS PROGRAM CONTRACTORS Part I The Office of Emergency Preparedness provides guidance and assistance to its contractor cities through a variety of mechanisms. These are described on page 2 of this folder [page 2 is omitted from this IOM report, since the descriptions are included earlier in this chapter]. Please read the descriptions, and then, for each of the assistance mechanisms listed below, indicate by checking the appropriate boxes whet her you were previously aware of it and, if so, whether you found it helpful (a) in preparing the products (“deliverables”) demanded by your contract and (b) in preparing your community to cope with chemical, biological, or radiological (CBR) terrorism. ASSISTANCE I was NOT aware of this assistance until now I was previously aware of this source of assistance, and for meeting the terms of my contract, I found it: I was previously aware of this source of assistance, and for preparing my community to cope with CBR terrorism, I found it: Very useful Useful Not useful Made the job more difficult Very useful Useful Not useful Made the job more difficult “Planning considerations” for a bioterrorism plan [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] Consultation with a regional project officer [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] Consultation with OEP Headquarters [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] ASSISTANCE I was NOT aware of this assistance until now I was previously aware of this source of assistance, and for meeting the terms of my contract, I found it: I was previously aware of this source of assistance, and for preparing my community to cope with CBR terrorism, I found it: Very useful Useful Not useful Made the job more difficult Very useful Useful Not useful Made the job more difficult Yearly meeting of representatives from all MMRS program cities [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] MMRS “track” at annual National Disaster Medical System (NDMS) meeting [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] List of contacts for all MMRS program cities [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] Public website [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] Sample or model monthly report [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] Completed plans from other cities [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] OEP-funded research on common problem areas [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ]

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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program Checklist for self-evaluation of contract compliance [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] Other OEP assistance (please describe below) [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ]

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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program Part II Please help us assess the effectiveness of the MMRS program by rating your community’s current ability to cope with the consequences of a CBR terrorism event (alone or in concert with neighboring communities and state and federal agencies), using a five-point scale to estimate capabilities in each of the listed areas and a three-point scale to estimate the contribution of the MMRS program:   CAPABILITY MMRS PROGRAM CONTRIBUTION FUNCTIONAL AREA Very low Low Moderate High Very high None Small Large Command and control   Notification and alert procedures   Public affairs   Provision of accurate and timely information to responders and caregivers   Management and augmentation of transportation assets   Management and augmentation of medical personnel   Management and augmentation of medical supplies and equipment   Legal issues and credentialing, patient tracking and record keeping   Epidemiological services and support  

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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program Laboratory support   Protection of treatment facilities and personnel   Mental health services   Activation of mutual-aid support from federal, state, and local emergency response agencies   FOR CHEMICAL AND OVERT RADIOLOGICAL INCIDENTS:   Detection and identification of the weapon material or agent   Extraction of victims   Administration of the appropriate antidote   Decontamination of victims at the site   Emergency medical care for victims before their transportation to a definitive medical care facility   Emergency medical transportation of the patients to area hospitals   Management of patients arriving at hospitals without prior field treatment, screening, or decontamination     CAPABILITY MMRS PROGRAM CONTRIBUTION FUNCTIONAL AREA Very low Low Moderate High Very high None Small Large Definitive medical care at hospitals or designated off-site treatment facilities   Appropriate pharmaceuticals to care for up to 1,000 victims   Equipment and supplies required to care for up to 1,000 victims   Transportation of patients to distant treatment facilities via NDMS   Mass-fatality management   Environmental surety (decontamination of property and material for reentry or reuse)   FOR BIOLOGICAL INCIDENTS:   Early recognition of disease outbreaks  

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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program Timely diagnosis and identification of agents on the threat list   Mass immunization or prophylaxis   Definitive medical care at hospitals or designated off-site treatment facilities (up to 100 victims)   Definitive medical care at hospitals or designated off-site treatment facilities (100 to 10,000 victims)   Definitive medical care at hospitals or designated off-site treatment facilities (more than 10,000 victims)   Transportation of patients to distant treatment facilities via NDMS   Mass fatality management (up to 100 victims)   Mass fatality management (100 to 10,000 victims)   Mass fatality management (more than 10,000 victims)   Environmental surety (decontamination of property and material for reentry or reuse)   Part III Please describe any changes in day-to-day operations of the public safety, public health, or health services agencies in your c ommunity that are attributable, in whole or in part, to your participation in the MMRS program. Has your community suffered a disaster of any sort, natural or technological, since you began participating in the MMRS program? If so, please describe the disaster and the role, if any, that your MMRS or the planning and coordination required to develop an MMRS might have had on your community’s ability to cope with that disaster. Please list or describe any barriers, financial, political, cultural, or other, that hinder full preparedness in your community.

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