ARE YOU REALLY PREPARED Emergency Preparedness Competencies for Healthcare Executives

1. 1 ARE YOU REALLY PREPARED?Emergency Preparedness Competencies for Healthcare Executives

2. 2 It is 8 a.m. on Saturday, December 2, 2006 You just finished meeting with a Board member in your office and are catching up on some paperwork, when you receive a call from your hospital�s Emergency Department that, �A major accident� occurred on the overnight shift at a local, major, industrial plant. There are an estimated 150 patients with both burns and inhalation injuries. It is unclear whether there has been a toxic release

3. 3 The plant is the area�s largest employer, and you are informed that a many hospital staff have relatives working at the plant Your EP coordinator and ED Director are coming back from a few extra days in New Orleans after a VHA EP conference. Your COO is out on medical leave after a procedure There is no one to delegate to!!!

4. 4 As a Senior Healthcare Leader,Ask Yourself� Do I: Know what to do? Know who to contact? Be able to lead my organization through the disaster to �normalcy�? What competencies & skills do I possess to do so? What are my strengths & gaps? How can I confirm my assessment?

5. 5 There Are Distinctive Demands of Leading Healthcare Institutions During Disasters!! Unstable times Normal processes disrupted Outcomes unpredictable Always unique Occur infrequently May begin abruptly; Do not end abruptly Alter usual reporting structures Not simply an expansion of day-to-day operations Require someone to say, �I am in charge�

6. 6 �The events of September 11, 2001, served to crystallize a decade-long evolution of the role of hospitals in emergency preparedness and disaster management.� Berman, M.A. & Lazar, E.J, N Engl Med 348;14, April 3, 2003

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8. 8 NewYork-Presbyterian Healthcare System 9/11 Lessons Learned Patient flow can be unpredictable NJ, Brooklyn, Bronx Victims gravitate toward hospitals Excellent ability to mobilize staff Communications need strengthening Incident command structure not truly challenged Back-up systems not �bulletproof�

9. 9 Staff unable to come to work Bridge, tunnel and highway closures Staff already on duty asked to remain Housing Food Clothing Dependent Care Need for Employee Personal & Family Emergency Preparedness Plans

10. 10 Calls for Help From Scene Who Is Making the Request? Can We Spare Supplies? How Do We Handle Controlled Substances? HICS (IC) Must Activate Logistics Section

11. 11 Volunteers Can Donate Blood Provide Information Make Food Transport Patients OVERWHELM!! Physicians, Nurses Must Have A Plan Management of Community Resources

12. 12 In The Ensuing Days� Staff Affected Loss of loved ones Post Traumatic Stress Syndrome Transportation Patients Staff

13. 13 In The Ensuing Days� Family members coming in to find �missing� people Must Have Behavioral Services Inventory!!

14. 14 Billing Challenges Communications link to Medicaid hampered Large backlogs in Medicaid application process Fully operational by 10/15/01 NYS temporarily eased Medicaid eligibility requirements Offered 4 months of coverage based on attestations of income level & family size Received letters from HIP, Oxford, Aetna USHC, Empire and CIGNA They would pay health care claims related to WTC and reconcile with workers compensation carriers later

15. 15 Billing Challenges Some payors temporarily eased medical management procedures: No precertification required for two weeks Temporarily suspended administrative denials Utilization review curtailed for two weeks Limits of retrospective clinical reviews Elimination of referral requirements

16. 16 Billing Challenges Staff productivity disrupted causing cash decline in September, 2001 October, 2001 cash collections rebounded Lockboxes were delayed by 10 business days Empire�s claim processing was disrupted as they lost offices in the WTC Disruptions with some other smaller payors

17. 17 Estimate of Fiscal Impact of WTC attacks on New York Hospitals (Prepared by GNYHA) Incremental emergency expenses $48 millionUnreimbursed standby costs $92 millionContinuing fiscal impact $200 millionTotal estimated fiscal impact: $340 million

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19. 19 NYP/Weill CornellFiscal Impact - Loss of Revenue

20. 20 NYP/Weill Cornell Supply Chain Response Opened lines of communication with Emergency Operations Center & OR�s Maintained added staff readiness to respond to anticipated demands (e.g., burn unit requirements) Assigned senior staff to cover purchasing & warehouses Outside vendor cooperation Vendors phoned in Pharmaceutical companies air freighted drugs Police escorts allowed specific product shipments Helicopter delivery Overstocked certain supplies Liquid Oxygen tanks topped off

21. 21 Do You Still Think You�re Ready? Lack of Standardized Healthcare Emergency Preparedness Performance Metrics Lack of universally accepted� �Preparedness definitions �Performance measures Difficult to measure capacity to manage events that occur infrequently, if at all Relative newness of the field Lack of evidence base / �references� Lack of validity of existing metrics

22. 22 �There are no standardized measures of hospital disaster preparedness�� Kaji & Lewis, �Hospital Disaster Preparedness in Los Angeles County� Acad Emerg Med (8/2/06) �While rigorous quality assessments of the myriad clinical and administrative services healthcare institutions provide exist, few similar means are available for healthcare institutions to evaluate the quality of their emergency preparedness initiatives.� ��this can be remedied through the application of traditional healthcare quality paradigms�and when healthcare institutions, accrediting bodies, regulators and industry groups, collaborate to develop a comprehensive approach to performance measures in hospital emergency preparedness.� Cagliuso, Sr., N.V. & Lazar, E.J., System Quality Review, Special Issue, October 26, 2006

23. 23 Traditional Categorization of Healthcare Performance Metrics �VSOP�

24. 24 Performance Metrics Comparison Traditional Healthcare Evidence-based Defined metrics Large case #s Replicability of cases Focus on high volume / high risk Established clinical principles Established benchmark mechanisms Emergency Preparedness Little evidence Undefined metrics Infrequent events Unique situations Rapid evolution of the discipline Few agreed upon best practices No benchmarking

25. 25 Hospital EP Measures�Volume� Metrics Volume may or may not be applicable ICU Patients ED Visits for major trauma Ambulance Lack of �volume� may not be correctable May need to compensate elsewhere Rotate personnel Increase drill frequency Identify institutional choke points

26. 26 Hospital EP MetricsIdentify Institutional Choke Points

27. 27 Hospital EP Measures�Structure� Metrics Binary (Yes/No) Designated EP Coordinator Digital Camera Equipment & Supply Cache NIMS Certifications BDLS & ADLS Easiest aspect to correct in hospital EP quality efforts May be most difficult aspect to correct in general healthcare quality efforts

28. 28 Hospital EP Measures �Outcomes� & �Processes� Paradigm I Examine normal occurrences that most closely replicate disasters Cumulative statistics (mean, median, mode) don�t show distribution To compensate, focus on outliers as they most closely replicate disaster situations Separate cohort during �outlier� periods rather than aggregating with general performance or simply discarding

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31. 31 Hospital EP Measures �Outcomes� & �Processes� Paradigm IExample ED LOS

32. 32 Hospital EP Measures �Outcomes� & �Processes� Paradigm IExample ED LOS

33. 33 Hospital EP Measures �Outcomes� & �Processes� Paradigm IExample ED LOS

34. 34 Hospital EP Measures �Outcomes� & �Processes�Paradigm II Analyze data during disaster situations applying traditional quality metrics For example ED LOS during blackout Performance targets may be different during disasters (e.g., outliers) Establish targets for both normal & disaster Definitions of metrics may be different during disasters Establish disaster scenario definitions

35. 35 Hospital Emergency Preparedness Performance Metrics Current practice of increasing hospital Emergency Preparedness �structure� metrics alone will not yield improvements Apply traditional healthcare quality paradigms where possible (VSOP) Identify proxies such as outlier periods Establish and define emergency preparedness definitions and metrics Institutions must come together to share best practices and benchmarks

36. 36 The Senior Healthcare Leader Emergency Preparedness Competency Self Assessment Tool