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MYTH: “A Dynamic Duo capable of responding adequately to All-hazards Events”

REALITY: Inside the All-Hazards Homeland Security Readiness Arena, the Public Health and Healthcare sector lags significantly behind most of its economic sector counterparts.

The coupling of public health and private public healthcare providers has had its legal, ethical, moral, communication, and philosophical problems. In many respects, they are the “odd couple”. The Public Health Service with its deep orientation to preventive medicine and bureaucratic stovepipe funding (underfunding) is an unlikely partner for the bottom-line oriented hospital, non-federal provider sector. The assumption is that the public health sector and the established, high profile, traditional first responder community would take the lead and coordinate committee planning with the non-federal healthcare provider groups.

The hospital-based healthcare provider responder groups were slow to be recognized as first responders and first receivers. As a consequence, the first responders funding was disproportionately distributed to public health and other seasoned first responder groups with traditional ties to existing federal and state ¡°stovepipe funding mechanism. The non-federal healthcare national and state level trade organizations were reluctant supporters of the nation’s strategy for homeland security, as were other segments of the industry. The initial frenzy to do their part in the larger effort slowly cooled, as it became obvious that federal funds were limited. The old mantra of “unfunded mandates” filled the halls of Congress. Some preparedness funds trickled down from states, and some states felt that they were in a better position to buy these things and distribute them to their hospitals.

The attempt to get hospitals NIMS compliant was a slow and painful process. Early practices of compliance “self-reporting” without follow-up verifications at state and federal levels have been troublesome. Some healthcare level trade organizations openly petitioned against acceptance of preparedness funds, which had state matching fund obligations.

The American College of Healthcare Executives (ACHE), the most powerful and influential healthcare executive educational organization in the nation, failed to advocate for all-hazards readiness and opted to let other trade organizations pick up the gauntlet. Failure in early attempts to attract its membership into all-hazards professional education programs discouraged any meaningful future offerings.

For the last four survey years, members (hospital CEO s) have shown little collective interest in all-hazards issues. Asked to identify their top financial and/or operational issues, disaster preparedness failed to make the top ten. Results in top CEO issues 2009 found their top three issues, in descending order: financial challenges 76%; healthcare reform implications 63%; patient safety and quality 32%. And at the bottom disaster was preparedness 1%. How would you design your educational program?

These are not your run-of-the-mill healthcare executives. They are today’s hospital leaders. Patients depend on them to provide for a safe healthcare environment. Employees depend on them to keep them safe from workplace hazards. Investors depend on them for fiscal stewardship. Board members depend on them to protect their reputation and keep them out of jail. Communities depend on them to make the difference between life and death in times of crisis. In many communities where hospitals are dominant employers, their future economic existence depends on informed decisions by hospital authorities.

The ultimate responsibility for safety and security for all hospital stakeholders is with the hospital board. The board delegates the day-to-day operations to the administrator. At the end of the day, the board retains the duty of care responsibility for quality care and safety for all.

A recent review of publications designed to alert hospital boards on serious healthcare quality and safety issues is a good example of denial and disinterest in all-hazards readiness. Getting the Board on Board . What Your Board Needs to Know about Quality and Safety devotes less than one page out of 104 pages on emergency management.

Dealing with issues of quality and safety during periods of routine care is important, but providing a measure of quality and safety during a crisis is the real test of stewardship. The book’s glossary and index are silent on the existence of a national strategy for homeland security healthcare readiness.

Recent publication in the industry’s Trustee magazine, which is targeted at hospital board members, has an 11-page article entitled, 2010 AHA (American Hospital Association) Environmental Scan (Hot Topics). Subject issues range across ten broad categories:

1. Information Technology and E-Health
2. Insurance Coverage
3. Political Issues
4. Provider Organizations and Physicians
5. Quality and Patient Safety
6. Science and Technology
7. Human Resources
8. Consumers and Demographics
9. Economy and Finance
10. Associations

It is difficult to believe that this article in a national hospital Trustee board publication did not consider all-hazards events as worthy of a discussion in an article purported to provide insight and information about market forces having a high probability of affecting the healthcare field. Additional expert commentary which followed seemed satisfied that the environment scan seemed comprehensive. Traveling the last mile to a viable national response of homeland security healthcare readiness requires harmonizing the efforts of organizations with disparate views of personal and professional success. Traditional first responders view risk as somewhat removed from that of a chief financial officer of a local hospital, much in the same way as the nation’s healthcare design and construction professionals and green groups view the all-hazards issue through a different prism. The professional healthcare media is not much help with changing the direction for a more robust workplace. The last three major articles on hospitals of the future were devoid of any concern for facility/physical protection.

The community of healthcare risk management is in locked step with the rest of the industry. The American Society for Healthcare Risk Management (ASHRM) Risk Management Handbook for Healthcare Organizations has few details on healthcare organizations expected role in homeland security. It gives short shrift to the national response framework and the importance of homeland security presidential directives.

The all-hazards threat issue rarely sees the light of day in their many educational programs and enjoys little attention in their major conference events. One would think that ASHRM would be the place to seek guidance on such issues. A very good place to start would be a conference to address,

What are the consequences of failure to prepare and respond to known threats to patient populations?

We authored an article in ASHRM Journal in 2005, Critical issues for homeland security in healthcare sector readiness, and at the same time we surfaced concern over the lack of coverage for the national strategy for homeland security in the existing Risk Management Handbook, Fourth Edition. The Fifth Edition published in 2007 shows little improvement in content associated with national response framework or national incident management systems, which is so critical to any future homeland security healthcare protection.

The Department of Homeland Security Risk Lexicon focuses on the management of meaning and concepts of risk and attempts to provide a single definition for each term. Some aspects of risk hold implicit meaning that one would knowingly, not unwittingly, risk a patient population to known death and injury. Is there a place in hospital stewardship to indulge in risk tolerance, or risk acceptance, when the acceptance of that risk is based on competing “return on investment”?

The last of the 2004, 9/11 Commission recommendations were implemented through Public Law 110-53, Recommendations of the 9/11 Commission Act of 2007. The original recommendations from #26 dealt with the adoption of Instant Command System (ICS) and #28, endorsing private sector adoption of the American National Standards Institute’s (ANSI) standards for private preparedness, including the statement:

“We also encourage the insurance and credit-rating industries to look closely at a company’s compliance with ANSI standard in assessing its insurability and creditworthiness. We believe that compliance with the standard should define the standard of care owed by a company to its employees and the public for legal purposes. Private-sector preparedness is not a luxury; it is the cost of doing business in a post 9/11 world. It is ignored at tremendous potential cost in lives, money, and national security.”

We find little to no evidence the nation’s healthcare insurance industry consistently factors this homeland security ideal into their hospital insurance coverage. The same may be said of the nation’s credit lending institutions, both federal and non-federal Healthcare accreditation organizations abound. Wikipedia provides a quick look at these organizations. We characterized them as “alphabet soup”: (HFAP, JC, NCQA, CHAP, ACHP, HQAA, AAAHC, DNV, etc.) of external evaluation mechanisms. None of the currently existing hospital external evaluation mechanisms for healthcare emergency management have yet developed assessment schemes which approximate an acceptable level of readiness envisioned by the National Response Framework. The author has been professionally engaged on one side or the other with healthcare external evaluations for more than 40 years. Established standards of care are designed to ensure a safe and secure patient environment, whether one is faced with earthquakes, floods, forest fires as was the case in Fairbanks, Alaska at -50 degrees, or dust storms, or terrorist attacks at +130 degrees in the desserts of Saudi Arabia. Most of us who are more than casual observers to evolving changes to standards over time understand that survey standards are subject to change as the treatment environment changes.

Many scholars have observed the harmful effects of the industry to government regulator swinging door. As we have seen, this leads to egregious conflicts of interest and other actions harmful to the trusting public. There are also concerns over the private sector bodies and the reality of their ability to balance the needs of the industry and the best interest of those receiving their services. These concerns were alive and well long before IOM’s landmark “To err is human,”probably best articulated by long-time critics and observers of the extant mechanisms for healthcare oversight. The following two quotes are taken from the Presidential Advisory Commission on Consumer Protection’s final meeting, March 1998.

“Conflicts of interest can arise from multiple sources. For example, private sector accrediting bodies have, as one of their customers, the entities that the organization accredits. The organizations to be accredited sometimes are the same organizations that created or fostered the creation of the accrediting entity, and often are necessarily involved in identifying the standards to which they will be held accountable.”

“Quality oversight organizations also have a second set of customers . healthcare consumers . who depend on the work of these organizations to make comparative judgments about the quality of certain types of healthcare organizations. This is particularly true when public regulators use accreditation as a means of meeting public standards (e.g., when JCAHO accredited hospitals are deemed to have met Medicare Conditions of Participation). Consumer advocacy organizations become concerned when the accrediting organization seems overly solicitous of the views of the industry, or when very few organizations have their accreditation denied.”

The above referenced JCAHO is the re-branded TJC, or The Joint Commission. This organization has enjoyed a near monopoly in the hospital external evaluation arena and is used extensively as the mechanism of choice to assess healthcare quality, safety and security in the nation’s worldwide military, veterans, Native American, and public/private facilities.

The effectiveness of the accreditation and deeming mechanisms on the quality of care measured by hospital acquired infections, treatment errors, and violence in the workplace speak for themselves.

Our attention is focused on the other side of safety and security, all-hazards readiness. It should be obvious to all that the process did little to protect patients from the ravages of Katrina. The response to 9/11 exposed the gaps in the industry’s ability to protect the integrity of the hospital internal space. A quick look back at recent history of what appears to be a movement toward a “culture of preparedness” is in question.

A year before the 9/11 attacks, key elements of the private/public and governmental healthcare sectors met to consider how best to prepare for and respond to looming threats which would call for a mass casualty response from the industry. The broad consensus was to follow the JCAHO 1998 Environment of Care Standards and expand involvement with the greater community. This was followed by a number of public policy initiatives promoting community-wide emergency management.

Fast-forward to June 2007. The Joint Commission alerted the industry that effective January 2008, hospitals were to meet six critical areas of emergency management. These new Elements of Performance (EP) were fundamental to any meaningful decision-making on “to protect in place or evacuate.” – THE question related to all-hazards response. The push back from client hospitals and trade organizations intensified, and by the end of the first quarter of the calendar year 2008, these EPs were no longer scored. We see evidence that critical all-hazards evaluation tools have been formally DE-emphasized in 2010 Emergency Management and Environment of Care guidelines. One such process tool useful in reviewing emergency preparedness is the formal emergency management tracer. This procedure follows the clinical care tracer model, which is highly regarded in evaluating quality of care given at various levels and locations of care provided throughout the patient’s stay in the hospital. Loss of the formal tracer tool is unfortunate, because the removal of documented measures of success requirement further erodes meaningful oversight.

Then there are the alerts to the industry which have us scratching our heads. One such “heads-up” alert is the article, Annual security assessments become California law, which in part states: California, often the forerunner in compliance standards, may be leading the pack when it comes to security assessments. The law may be unique, but the requirement has been on the books for decades.

The growth of external threats and poor preparedness and response performances in recent all-hazards events on the Gulf Coast and the lack of preparedness for H1N1 pandemic are, at least in part, reflective of a systemic failure of extant external evaluation mechanisms. The vulnerability of hospitals to both inside and outside attacks has increased over the last decade. We see a workplace struggling to deal with hospital acquired infections and seemingly unprepared to protect its own workforce from its own workforce, and one that has dismissed the need to defend their organizations from known man-made threats.

We congratulate the Tuscon AZ response team from first responders to the AZ Medical Center ER to all levels of clinical treatment. The limited scope of the tragic shooting incident allowed for the treatment of all victims in a timely manner. Unlike larger mass casualty events, all victims were properly treated and evacuated to the area Medical Center. Resources were available to care for all, the near-dead, seriously wounded, lightly wounded and walking wounded. without having to resort to a “ mass casualties triage” where painful decisions about who could be saved and who would be left behind. Even so, the Medical facility was stressed but did not have to reduce their traditional standard of care.

 We have had a week of expert? testimony about: How could this tragic event have been prevented; What if someone had detected and reported the bizarre behavior to proper mental health authorities in a timely manner?; Were those resources available? ; What were the barriers to law enforcement community to identify shooter as a community risk?

It appears that a vigilant Wall-Mart clerk refused to sell the shooter ammunition and another sales clerk in the area had little concern about such a sale. Why did a gun store salesperson feel that he could not legally refuse to sell the gun and super magazine? If extant laws posed these barriers to timely identification and weapons purchases then what does that mean for the trusting public?

If authorities are not willing to change the laws then the only alternative is to be prepared to respond to these random events. The Mental Health community tells us that there are upward to 4 million seriously ill individuals in the population who could act out in very dangerous ways. There are very few communities with the same level of response capabilities as were available in Tuscon.

Contrast that to a Mumbai-style attack with hundreds of casualties with a range of wounds, some fatal, some near-fatal, walking wounded and worried well. In Mumbai the receiving hospitals were under direct attack with running gun and grenade battles adding to the casualties and denying timely organized care for all casualties.

Back to External Evaluation Mechanism for Emergency Management after the 2008 nine month hiatus of not scoring for essential elements to determine all-hazards response for hospitals (TJC). (see previous article on “To the Rear March”)

The Center for Medicare and Medicaid Services (CMS) assesses the effectiveness of their contracted hospital external evaluators through periodic “Validation Surveys” performed by State Survey Agencies. CMS has limited oversight authority over JCAHO’s hospital accreditation program because of the program’s unique legal status effectively prevents CMS from taking actions that it has authority to take with other accrediting bodies.

These “Validation Surveys” (VD) have been significantly curtailed this last decade, however, a two year sample of 500 JCAHO accredited hospitals identified alarming deficiencies missed by the JCAHO surveys (GAO-04-850). Eighty-seven (87) of the One hundred sixty seven (167) serious deficiencies were related to hospital’s physical environment. Weakness in assessments of these standard elements were evident in the Katrina and Ike responses and continue to surface in the failure to enforcement of the E.C. standards in 2008.

Emergency Management (EM) enjoyed a higher profile in the The 2009 TJC standards. A stand alone Chapter with its own set of of Elements of Performance EPs). TJC periodic reports which surface challenging areas of standards compliance did not identify all-hazards preparedness (Emergency Management) as troublesome areas. They did surface concern for the safety and security of healthcare caregivers. Personal assaults on women caregivers have more than tripled in recent years. Hospital shootings have been on the rise. Physical violence in the workplace has pushed the sector into one of the nation’s most dangerous work sites.

The threats come from many quarters, lack of access control, weak employment screening, increased outsourcing, downsizing of security force etc.

We have been spending a lot of time on quality and reliability of TJC safety and security external evaluation of hospitals There are others and we would hasten to add that none of the extant external evaluation mechanisms for healthcare emergency management have yet to develop assessment schemes which come close to approximating an acceptable level of readiness envisioned by the National Response Framework (NRF).

Personal observations and scattered reports from trade organizations question the selective reporting which leads one to believe that the all-hazards emergency management gap has been addressed. We see evidence of a wholesale trend to de-emphasize the efforts to hold hospitals accountable for E.M. compliance. The May 19, 2010 Joint Commission Online announces the deletion of the requirement to document “Measures of Success” associated with Elements of Performance, among them over 20 Environment of Care Standards.

The formal removal of the “Emergency Management Tracer” which followed the very successful model “Clinical Care Tracer” to evaluated quality of care, is indeed unfortunate and does not bode well for an in-depth evaluation of all-hazards readiness.

The January, 2010 report funded by the DHHS provides us with a current overview of the Nation’s Hospital and Healthcare readiness to deal with known hazardous threats.

The Next Challenge in Healthcare Preparedness: Catastrophic Health Events, Changing the name “ Weapons of Mass Destruction (WMD) or All-hazards Readiness ” to “Catastrophic Health Events” does not erase twenty years of Healthcare Industry Apathy, Denial and Cognitive Dissonance.(old wine in new bottles).

The Administration’s characterization of the “National Health Security Strategy of the United States of America” as the first call to the healthcare industry to prepare for all-hazards readiness is inexplicable.

Along the continuum of human errors are legitimate mistakes and a range of “sins of Commission and sins of Omission” From where I sit, “sins of Ommission “ are much more harmful to the public good, and take less personal courage. JB

 This article was adapted from excerpts from Blair’s book, Unready: To Err is Human: The Other Neglected Side of Hospital Safety and Security, which was published in June. He is also a career-retired army colonel with 28 years of active service. Among his private sector experiences, he served as VP of Hospital Corporation of America, Middle East Limited and as an independent consultant to Joint Commission International.

It underscores the existing threats posed by the shift to softer targets using multiple teams of terrorists, of which hospitals are a favorite international target, contributing to the current characterization of the Public Heath and Healthcare Sector as the “weakest link in the Homeland Security Chain”. Click to View Article:

This is the third in a series of articles published in Family Security Matters, a blog dedicated to engaging families in our Nation’s Security. The article includes information based on the author’s recent book: “Unready: TO ERR IS HUMAN, The Other Neglected side of Hospital Safety and Security”, a critical overview of the current state of readiness to support healthcare provision in the face of natural and man made disasters. This and subsequent articles will include pending material for the upcoming book titled “Deadly Neglect: Act of God vs. Apathy and Denial”.

It underscores the existing threats posed by recent proliferation of bio-labs and internal and external threats posed by to increasing access to to deadly biological agents. This contributes to the current characterization of the Public Heath and Healthcare Sector as the “weakest link in the Homeland Security Chain”.