Jim Rush, Salado, Texas, April 20th, 2011
In the GAO report GAO-11-260 (Measuring Disaster Preparedness, March 17, 2011) said….. “In summary. DHS and FEMA have implemented a number of efforts with the goal of measuring preparedness by assessing capabilities and addressing related challenges, but success has been limited.”
Perhaps the reason the Target Capabilities are not being measured is that many capabilities are written in aspirational rather than measurable, operational statements. In order to build resilient, “Disaster Ready” jurisdictions, a clearly defined process must be used to build and measure Readiness Capabilities and must consist of the following components:
1. Perform a Hazard Vulnerability Assessment (HVA)
2. Develop Planning Scenarios Based on the top several HVA vulnerabilities.
3. Estimate Casualties (injured and dead), using intelligence data or historical experience.
4. Develop Requirements based on planning scenarios and casualty mix
5. Develop Measurable Target Capabilities statements based on the event and the numbers of casualties.
6. Outline Response Tasks for Local, State and Federal response agencies-Based on NIMS and the National Response Framework.
We simply need to rewrite all Target Capabilities in quantifiable terms and with objective and precise measurement criteria. For a very long time, America has understood that some jurisdictions are more “Disaster Ready” than others. In Presidential Policy Directive (PPD)-8, we believe the President is interested in more precision in measuring current levels of Readiness. We also believe PPD-8 envisions a clear picture of what else remains to be done to achieve Full Readiness/Preparedness to manage all future disasters.
Purpose: The main purpose of this paper is to write just one measurable Target Capability and illustrate how we can move from aspirational to measurable operational language
The Mission: The President in PPD-8 has directed DHS to develop measurable standards by which America’s preparedness for future disasters can be assessed. The best way to depict our Disaster Readiness is in terms of Percentage of Readiness. If a disaster event calls for 3,000 burn beds and we have 1,500 we are at 50% Readiness. It really is easy; but in order for this formula to work, criteria must be quantifiable. I thought that we might set the stage by listing a few Principles of Disaster Readiness.
1. The Private Sector plans for normal operating conditions and Governments must plan for extraordinary events which threaten life, health or public safety. Whether it is medical materiel, bandwidth, security, staffing or any other area, the Private Sector must procure just enough of everything to do the job. Excess capacity in any commodity results in unacceptable financial carrying costs, and excess capacity is less tolerated today than ever before. We all understand that during a disaster, it is difficult to get a call out to relatives. We also understand that grocery store shelves are bare shortly after a major storm is forecast. Private entities answer to Boards of Directors and plan based on a “Just In Time” construct. Governments plan for “Just In Case” and answer to their citizenry. As long as planners remain in a mindset that maintains “The Private Sector should build excess capacity for use during disasters,” we are going to remain unprepared.
2. If “Everyone is Responsible” no one is accountable. There can be very well defined supporting roles, but the buck has to stop with one Agency responsible for specific missions at each level of Government.
3. If it is not being measured, it is not being done. Much like “good fences make good neighbors,” precise tasking and accurate measurements enhance accountability and may save lives and minimize suffering during future disasters. Those who do not want to have their performance measured will leave service and will make way for those who want to do a superb job and welcome fair and precise measurements.
The Readiness Process: Local Emergency Managers can use the following processes to develop highly effective and measurable Target Capability Statements
1. Hazard Vulnerability Assessment: Jurisdictions will conduct an annual Hazard Vulnerability Assessment (HVA) based on local, state and federal law enforcement intelligence information. Using the top three to five vulnerabilities, develop “Planning Scenarios” which reflect each identified vulnerability.
2. The Planning Scenario: For this paper, let’s assume that a very large metropolitan area has conducted its Hazard Vulnerability Assessment and has identified a vulnerability to a multiple IED attack on its mass transit system and established the following planning scenario: “Terrorists conduct five coordinated attacks on mass transit stations throughout the metropolitan area using Improvised Explosive Devices (IED).
3. Casualty Estimates: This estimate can be based on a historical event impacting a similar size jurisdiction. For this paper, we will use the casualty numbers and categories of injuries experienced in the 2004 Madrid Commuter Train bombings, rounded up to 2,000 total casualties.
4. Requirements Development: The Agency for Health Research and Quality (AHRQ) has developed a Hospital Surge Tool which identifies various scenarios and enables planners to select a scenario and input the number of estimated casualties. With that information, the Hospital Surge Tool makes a number of calculations, including the daily casualty loading on hospitals, required medical staff specialties, numbers of medical staff required and the items and quantities of medical materiel required to manage each disaster scenario.
5. Example: Measurable Target Capability for a multiple IED attack on Large Urban Mass Transportation System:
“The Emergency Management Agency (EMA) will prepare plans, procedures and protocols and will build and lead community response coalitions robust enough to become self sufficient in managing 2,000 casualties for the first 24 hours following a multi-location IED attack.”
Tasking: In accordance with NIMS and NRF guidance, the planning jurisdiction will develop all requirements for treating 2,000 casualties for Day 1 and will pass on requirements for Day 2 through day 5 to the State (Territory/Tribe) Emergency Management Agency for planning and resourcing. The State (Territory/Tribe) then passes the requirements From Day 6 through the end day of the disaster to HHS.
HHS assumes the support and sustainment mission starting on day 6 for the remaining days of the disaster, as well as throughout the Recovery Phase, including staff and medical materiel listed in the AHRQ Hospital Surge Tool’s resource listing.
6. Overall Accountabilities: Per the NIMS structure and National Response Framework (NRF) guidance: As a disaster unfolds, local jurisdictions manage the initial phase of a disaster (Day 1). The State (Territory/.Tribe) assumes support functions from Day 2 through Day 5. Federal response agencies provide full support and sustainment services with the full complement of Federal resources from Day 6 through the end day and until the recovery stage of the disaster has occurred.
7. Jurisdiction Specific Accountabilities: Per the NRF and NIMS:
A. Local Jurisdiction Accountability: The local jurisdiction EMA will provide all resources (staff, materiel and services) sufficient to “stand alone” and to triage, stabilize treat and manage 2,000 casualties (injuries and fatalities) for one (1) day of disaster operations. Using the AHRQ Hospital Surge Model http://www.hospitalsurgemodel.org/, develop “Requirements Listings for staff, materiel and facilities ED/ICU/Floor (ward beds) and coordinate with the local EMA for services support, such as mortuary and grave registry, waste management and transportation services. The local Emergency Management Agency (EMA) will coordinate with the Public Health Department, local coalitions of healthcare organizations and local EMS entities to assess operational health and medical expansion capabilities and will provide ambulance busses and other transportation, security, environmental services and other jurisdictional services needed to support healthcare and public health organizations for day 1 of the event. The local jurisdiction is responsible for providing the financial, personnel and materiel resources to “Stand Alone” for 1 Day without state or federal support. The Local EMA will closely coordinate with State (Territory or Tribal) EMA officials to facilitate a smooth handoff of responsibilities beginning at Day 2 of the disaster.
B. State Accountability: Using the AHRQ hospital surge model tool generated resource requirements; the state will provide a full complement of materiel, staffing, facilities and logistical support services to the local jurisdiction (s) managing 2,000 casualties from Day 2 through Day 5 of the disaster. State Public Health Officers and their Bioterrorism (BT) Coordinators using HHS Hospital Preparedness Program grant guidance, will lead coalitions of healthcare organizations and emergency medical services (EMS) organizations in developing plans, building enhanced staffing through the Emergency Management Assistance Compact (EMAC), Medical Reserve Corps (MRC) and The Emergency System for Advance Registration of Volunteer Health Professionals (ESAR-VHP), procuring medical inventories sufficient to sustain healthcare operations for 96 hrs (4-days) and procure transportation assets such as ambulance busses. These will be used to transport stabilized patients from healthcare organizations in the affected area to outlying Sub-State and Statewide area healthcare organizations for additional definitive care and rehabilitation beginning at the latest on day 2 of the disaster.
Accountability Measurements: During pre-disaster Operational Readiness Evaluations and exercises (ORE), the State Emergency Management Agency will be responsible for measuring local Healthcare and EMA policies, procedures, protocols and available resources against the local jurisdiction’s accountabilities in order to accurately measure percentages of Readiness needed to complete their assigned support and sustainment missions to ensure 1 day of “stand-alone” capabilities to manage a multiple IED attack.
C. Federal Accountability: ESF-8 Public Health and Medical Services (HHS). Through an enhanced and expanded National Disaster Medical System (NDMS) HHS will build and maintain Federal Reserve Inventories (FRI) of medical materiel (supplies, equipment medicinal gases, antidotes) in sufficient categories, line items and quantities to sustain all Private Sector healthcare and Public Health disaster operations from Day 6 throughout the remaining days of the disaster and until jurisdictional, Private Sector healthcare organizations, public health departments and their associated supply chain systems have recovered. Augmented staffing will be provided by HHS through the MRC/ESAR/VHP and with US Public Health Service (USPS) Commission Corps personnel to support the affected jurisdictions per the ESF-8 Mission. HHS will coordinate closely with the Drug Enforcement Administration (DEA) to ensure the exceptionally large quantities of Controlled Medical Items (Including Morphine and other analgesics) are safeguarded and prepositioned in or near high risk jurisdictions in sufficient quantities for immediate issue to Healthcare Providers (Hospitals, Trauma Centers, Medical Centers and Mass Care Shelters) in the affected jurisdiction (s).
Catastrophic Disasters. While not applicable to this planning scenario, if HHS had procured and managed a Mobile Hospital Program prior to 2005, these mobile healthcare assets could have been deployed to New Orleans in 2005 and to Galveston in 2008. Deployable medical facilities such as mobile hospitals, public health departments, burn units, trauma units, radiological sickness care units etc, can not only bolster healthcare and public health operations, they can also preserve the affected jurisdiction’s Health and Medical Infrastructure. Healthcare services would have been available immediately after the hurricanes and thus would have obviated the astronomical costs of Air Evacuating every patient requiring hospitalization in both disasters.. An additional benefit of using mobile hospitals and other specialty care units is healthcare staff preservation. Most of the medical professional staff in both events were forced to look for work outside the affected jurisdictions. Had the mobile healthcare facilities been available, the professional staff would have continued to serve the community and been moved back into the repaired or replaced hospitals during the Recovery stage of each disaster.
ESF-6 Mass Care (DHS/FEMA): In this example and for the purpose of this paper, healthcare coalitions at local, sub-state and state levels were thought to be sufficient to manage all 2,000 casualties in healthcare organizations using Medical Surge (Hospital Expansion) capabilities acquired as a part of past Hospital Preparedness Program (HPP) funding. Still, FEMA should reexamine its ESF-6, (Mass Care) mission:
Mass Care: “Includes sheltering, feeding operations, emergency first aid, bulk distribution of emergency items, and collecting and providing information on victims to family members.”
Past disaster experience points to the fact that many evacuees with chronic illnesses presented to Mass Care shelters without required pharmaceuticals, medical supplies and medical life support equipment. The Mass Care mission needs to be expanded to include Primary Healthcare when the Private Healthcare System is overwhelmed, especially in catastrophic disasters. As an interim measure, FEMA should consider developing a medical materiel system capable of receiving orders, rapidly processing orders and efficiently delivering supplies and life support equipment to requesting Mass Care shelters for a wide variety of Chronic Illnesses.
Accountability Measurements. During pre-disaster operational readiness evaluations and exercises, DHS will be responsible for measuring state and federal policies, procedures, protocols and available resources against the Accountabilities listed above, in order to accurately measure Percentages of Readiness needed to complete their assigned support and sustainment missions.
8. Summary: PPD-8 is the first Presidential directive requiring measurements in lieu of qualified representations regarding America’s state of Readiness for All Hazards disasters. For the first time, jurisdictions and agencies at all levels of government will be in a far better position to list all unmet requirements and their associated dollar costs needed to achieve full Readiness in their respective mission areas. All requirement shortfalls can then be reflected in jurisdictional and agency budget requests for prioritization and funding by the elected officials
If PPD-8 is fully implemented and standardized Operational Readiness Evaluation systems are adopted, statements such as “we are better prepared than we were five years ago”, will be replaced by “America has achieved 85%.Readiness across all Emergency Support Functional (ESF) mission areas. Our current budget requests for National Disaster Readiness reflect the line items and associated costs required to bring America to 100% Readiness.”
With measurable Target Capabilities expressed in percentages of Readiness, America can move forward toward total Readiness. With precise measurements, we will likely experience a quantum leap in American jurisdictions’ capabilities to effectively manage future disasters. Enhanced Disaster Readiness will save lives, protect the most vulnerable among us and lessen the suffering in future disasters.