GOV. Emergencies happen all the time and even small ones can. The Role of the Board in Emergency Management. Information Bulletin #17 GOVERNANCE

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1 Information Bulletin #17 GOV GOVERNANCE Series The Role of the Board in Emergency Management Mollie Melbourne, M.P.H., M.E.P. National Association of Community Health Centers, Inc. Washington, DC For more information contact: Mollie Melbourne, M.P.H., M.E.P. National Association of Community Health Centers, Inc Wisconsin Avenue, Suite 210 Bethesda, MD Telephone (301) or (203) This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is published with the understanding that the publisher is not engaged in rendering legal, financial or other professional service. If legal advice or other expert assistance is required, the services of a competent professional should be sought. The Health Resources and Services Administration, Bureau of Primary Health Care (HRSA/BPHC) supported this publication under Cooperative Agreement Number U30CS Its contents are solely the responsibility of the authors and do not necessarily represent the official views of HRSA/ BPHC. Emergencies happen all the time and even small ones can have a big impact on a health center. Although the word emergency tends to conjure thoughts of September 11, Hurricane Katrina, and other catastrophic events, every day occurrences such as fires, floods, ice storms, and power outages can severely limit a health centers ability to provide health care to its patients. This Information Bulletin provides information for health center Boards of Directors about emergency management activities, including: Key legal requirements impacting a health center s emergency management efforts The importance of planning for emergencies Roles of health center staff and governing board 1 Emergency management resources. 1 Please note that this Information Bulletin is intended solely to provide general information. It does not, nor is it intended to, provide legal or other professional advice with respect to specific emergency management-related acts/omissions of health centers and their governing boards, in particular with respect to malpractice coverage for professional liabilities arising from such acts/omissions and the extent to which coverage under the Federal Tort Claims Act (FTCA) extends to emergency management activities. As such, NACHC recommends obtaining qualified legal (and, as necessary, other professional) advice prior to engaging in such activities. 1 September 2008 National Association of Community Health Centers, Inc.

2 To help lessen the impact of disasters or emergencies and to help health centers get back to the business of providing health care as quickly as possible following an event, it is important for health center boards to engage in the following emergency management activities: Set emergency management as an organizational priority and reflect this in the annual budget, Adopt policies to frame the emergency management plan, Provide oversight of response and recovery efforts, After appropriate training, participate in emergency management activities when the need arises WHAT CONSTITUTES AN EMERGENCY OR A DISASTER? There are a number of formal definitions of emergencies or disasters. Definition Robert T. Stafford Disaster Relief and Emergency Assistance Act The U.S. Congress enacted the Robert T. Stafford Disaster Relief and Emergency Assistance Act (P.L , as amended) (the Stafford Act) to support an organized response from the federal government to state and local governments to alleviate the suffering and damage which results from emergencies and disasters. The Stafford Act delineates the federal government disaster response in a federallydeclared emergency and defines emergency and major disaster as follows: Emergency is defined as any occasion or instance for which, in the determination of the President, federal assistance is needed to supplement state and local efforts and capabilities to save lives and to protect property and public health and safety, or to lessen or avert the threat of a catastrophe in any part of the United States. Major Disaster is defined as any natural catastrophe (including any hurricane, tornado, storm, high water, wind-driven water, tidal wave, tsunami, earthquake, volcanic eruption, landslide, mudslide, snowstorm or drought), or, regardless of cause, any fire, flood, or explosion, in any part of the United States, which in the determination of the President causes damage of sufficient severity and magnitude to warrant major disaster assistance under the Stafford Disaster Relief and Emergency Assistance Act to supplement the efforts and available resources of states, local governments, and disaster 2 relief organizations in alleviating the damage, loss, hardship, or suffering caused. Definition Federal Emergency Management Act The Federal Emergency Management Agency (FEMA) states: An emergency is any unplanned event that can cause death or significant injuries to employees, customers, or the public, or that can shut down a health center s business, disrupt its operations, cause physical or environmental damage, or threaten the facility s financial standing or public image. National Association of Community Health Centers, Inc. September 2008

3 Definition -- Health Resources and Services Administration In August, 2007, the Bureau of Primary Health Care (BPHC) within the Health Resources and Services Administration (HRSA) issued its own guidance on emergency management -- Policy Information Notice (PIN) Health Center Emergency Management Program Expectations (August 22, 2007). In that guidance, which applies to all federally-funded health centers as well as federally-supported entities certified as FQHC lookalikes, HRSA defines: An emergency or disaster as an event affecting the overall target population and/or the community at large, which precipitates the declaration of a state of emergency at a local, state, regional, or national level by an authorized public official such as a governor, the Secretary of the Department of Health and Human Services, or the President of the United States. See PIN at page two. PHASES OF EMERGENCY MANAGEMENT There are four phases of emergency management mitigation, preparedness, response and recovery. Each is described in more detail below: Mitigation Mitigation is the process of identifying threats specific to your location (such as an earthquake in California, a tornado in Nebraska, or a hurricane in Florida) and taking actions to reduce the impact of them. Each health center should: Conduct a Hazard Vulnerability Analysis (HVA) to identify conditions or hazards that may be a threat. Assess the severity of the direct and indirect impact if a hazard occurs. Minimize the impact of a hazard by: 1. Reinforcing, bracing, anchoring, bolting, strengthening, or replacing any part of a building that may be damaged and cause injury during a disaster. (Structural actions) 2. Reducing threats to safety caused by the effects of disasters on the contents within the building. (Nonstructural actions) Preparedness These are actions taken before an emergency to prepare a health center to respond to emergencies. This is the phase when health centers: Develop Emergency Management Plans (EMPs). Work with local partners to determine roles during an emergency. Coordinate training for staff. Conduct drills and exercises to test the EMP. Response Response is the action taken to address the immediate and shortterm impact of the emergency. The focus of EMP activities is to: Save lives of staff and patients. Protect property such as the health center facility, medical records, data, and other vital records that cannot easily be re-created. Resume services to patients. 3 September 2008 National Association of Community Health Centers, Inc.

4 Recovery This is the process by which the health center gets back to business as usual, or as close to it as possible and as quickly as possible. Recovery actions start at almost the same time as the response, but will likely take much longer. In this phase, it is important to: Document what happened and how it affected the health center in terms of damage to the building and equipment, time and supplies needed to respond to the emergency, and lost revenue due to disruption of services. Recognize that the disaster may have impacted staff and their families and provide mental health support. Recovery actions start at almost the same time as the response, but will likely take much longer. REQUIREMENTS RELATED TO EMERGENCY MANAGEMENT EFFORTS It is increasingly important for all health centers to engage in emergency management activities and efforts both as individual organizations and as leaders within the community. While there are several practical reasons for doing so, there also are certain legal requirements that impact the manner by which health centers establish and implement their EMPs and other emergency management-related activities. HRSA S Funding Applications In recent years, HRSA began requiring health centers to document their emergency preparedness and management efforts in the grant application process both for new funding as well as continuation of existing projects. Health centers must submit an Annual Emergency Preparedness Report as one of the required application forms. Additional legal requirements include: HRSA s Program Expectations Health centers are required to comply with HRSA s Health Center Emergency Management Program Expectations, as described in Policy Information Notice (PIN) While much of the guidance addresses guidelines or expectations to assist health centers in their emergency management efforts, HRSA makes it clear that all health centers must have plans and procedures for emergency management integrated into the center s overall risk management approach. In general, health centers are expected to safeguard human resources. i.e., protect their staff and patients, protect physical resources, and ensure business continuity. The PIN describes the following specific expectations for health centers: Emergency Management Planning Linkages and Collaborations Communications and Information Sharing Financial and Operational Stability 4 National Association of Community Health Centers, Inc. September 2008

5 Emergency Management Planning Be engaged in an on-going continuous process to ensure that EMPs are appropriate. Develop and implement EMPs based on thorough risk assessments. Conduct a Hazard Vulnerability Analysis (HVA) specific to the health center and review and integrate with the community, if possible. Address the four phases of emergency management. Structure the plan in an all hazards in approach. To the extent possible, align and integrate EMPs with state and/or local EMPs. Clearly define the role of the health center in these plans. Linkages and Collaborations Maximize linkages and collaboration with state and local agencies and other health care and community organizations. Define their role in emergencies and integrate planning with key partners, such as local health departments and hospitals. Participate in community exercises and drills. Communications and Information Sharing Have policies and procedures for communicating and sharing information with internal and external stakeholders, including federal, state, and local agencies, staff, patients (including special populations), board members, and the public during an emergency. Identify a spokesperson during an emergency, implementing backup (redundant) systems and adopting the Incident Command System (ICS). Provide requested/required data to federal, state, and local agencies during emergencies to the extent possible. Solid data supports informed decision making. Have systems to collect and organize data to support reporting requirements/ requests. Financial and Operational Stability The health center s business plan should address maintaining financial viability in the event of an emergency. This section of the PIN is focused on maintaining or restoring operations through cash reserves, adequate insurance coverage, and back up systems that enable the health center to access billing, financial, and medical records during and after an emergency Accreditation Standards Health centers that are accredited by the Joint Commission or Accreditation Association of Ambulatory Health Care also face standards related to emergency management. It is important that health center governing boards understand where the HRSA program expectations overlap with accrediting standards and where they don t, ensuring compliance with both. Boards should understand how emergency management activities work into the daily business in the health center and be familiar with the basic concepts of emergency management. 5 September 2008 National Association of Community Health Centers, Inc.

6 PLANNING FOR EMERGENCIES OR DISASTERS Health centers have a lot to do to plan for events that they know are going to happen for many, it is hard to find the time, resources, and momentum to plan for future emergencies or disasters when there is no certainty that they will occur. But emergencies do happen, every day, and organizations that have planned for them are much more likely to respond appropriately and recover sufficiently. Approaching emergency planning as a long term project that is integrated into every day business practice can make it more manageable. In addition to the legal requirements discussed above, there are other reasons why it is important for health centers to get and stay involved in emergency management: The Link to Underserved Populations Health centers, by their very definition, serve medically underserved, vulnerable populations. These populations may be culturally, linguistically, or geographically isolated from the agencies that are traditionally involved in emergency response. Health centers that are able to maintain operation during a disaster can serve as a link to their patients and target populations, providing services, information, and access to resources. In addition, as organizations dedicated to serving vulnerable populations, health centers are well versed in the needs of their patients and can function as a voice for them in community wide planning efforts. It is crucial that the needs of vulnerable populations are brought into the planning process early to ensure integration and inclusion during and after disasters.... in previous disasters, patients and community members sought information, medical treatment, access to community resources, and mental health support from their local health center. Ready or Not, Patients Will Come As borne out in past events, patients will seek help from health centers in times of disasters. Patients seek more than just health care from their local community health center in previous disasters, patients and community members sought information, medical treatment, access to community resources, and mental health support from their local health center. In a disaster, people who need medical care will go to the nearest and most familiar health care facility. In many communities, that is the health center. Lack of Resources Events may cause temporary disruption to community infrastructure, delaying re-supply of basic needs and disaster aid; as a result, health centers may be on their own for 72 hours or more. Depending on the situation, communities may be effectively cut-off from the outside world and unable to restock grocery stores, pharmacies, gas stations, and experience delays in receiving aid from outside sources. Health centers should plan to operate without outside assistance for at least 72 hours. 6 National Association of Community Health Centers, Inc. September 2008

7 THE ROLE OF THE BOARD IN EMERGENCY MANAGEMENT Effective emergency management programs in health centers include the involvement of multiple disciplines on the planning and response team, of many departments to ensure a comprehensive approach, and of the governing board to ensure that the health center s emergency management efforts and activities are aligned with and further the overall mission and vision of the health center. Approve the Role of the Health Center Health centers may play various roles during an emergency occurring within their communities. The health center board should review and approve these various roles (actual and potential) to ensure that they do not (and will not) impede the ability of the health center to fulfill its primary mission of providing access to health care for their current patients and target population. Establish Agreements with Outside Agencies Further, the board should ensure that formalized agreements with outside agencies are in place as needed to support the health center. For example, if a health center is planning on taking minimally injured or ill patients following a large event, there should be formal agreements in place that will provide medical supplies, patient transportation to and from the health center, and access to a generator or alternate site, as needed. Assure Emergency Management is an Organizational Priority One of the first and most important steps that a governing board can take to ensure that its health center is prepared for disaster is to establish emergency management as an organizational priority. The importance of emergency management should also be reflected in the annual budget with an allocation to cover all of the emergency management-related activities planned for that year and a solid commitment to not re-allocate or tie-up emergency management funds and resources when other projects arise. Ensure the Emergency Management Plan is in Place Governing boards should ensure that their respective health centers have an EMP in place, or are working on one with a reasonable deadline for completion, by (1) formally resolving to establish the EMP; and (2) adopting the policies necessary to provide its framework. The plan should be all-hazards, meaning that it covers disasters of all types, with specific sections on the risks that were identified through the HVA process described earlier. Test Emergency Management Plans Plans should be tested through exercises or drills at least annually and revised as needed based on the outcome of the test. At the very least, to ensure that the board is able to exercise its oversight responsibilities, the outcome of drills and exercises should be reported to it along with any changes made to the EMP as a result of the test. Ideally, the board should be included in the exercise or invited to participate as an observer, player, or evaluator. 7 September 2008 National Association of Community Health Centers, Inc.

8 Develop a Business Continuity Plan In addition to the EMP, health centers need to develop a business continuity plan, which is sometimes called a continuity of operations plan. This plan is designed to protect essential functions of the health center, such as providing health care, maintaining mental health services, paying staff, and tracking charges and reimbursements. The business continuity plan also guides the ways that vital documents and information are kept safe so that back-ups are available if needed. As the stewards of the health center s federal funds (which support these essential functions), and with ultimate responsibility for the expenditure of funds, the board should be apprised of the business continuity plan and its key elements. Governing boards need to understand their role during an actual emergency. The health center s EMP should include a provision for notifying board members in the event of a disaster and keeping them updated throughout the event. Board members may have specific roles to play based on their experiences and linkages within the community. For instance, a board member with significant media experience may be a great candidate to serve as a Public Information Officer and provide information to health center patients, stakeholders, and the public at large. Members with many community connections may be tapped to serve as Liaison Officers and to interface with other local agencies and organizations in a local emergency operations center to maximize resources during a response. Just as the health center s staff members need emergency management training to support the implementation of the EMP, so do board members. It is important that all board members have an understanding of the principles of emergency management and how the health center fits into the response system in their community. If board members are assigned specific duties, they should have additional training to support successful performance of those roles as well. The Department of Homeland Security developed a standardized framework, called the National Incident Management System (NIMS) that helps government, private-sector and nongovernmental organizations integrate their efforts in response to a disaster. As health centers work with their local partners, it is important that both staff and board members understand NIMS and how health centers fit into it. Governing board members should incorporate preparedness into their own lives. Having a solid personal or family plan in place will greatly increase the chance that board members will be able to fully participate as needed in the health center response. In addition, board members can spread preparedness efforts to their workplace, helping to ensure that more community members and organizations are better informed, resilient, and self-sufficient before, during, and after disaster. 8 National Association of Community Health Centers, Inc. September 2008

9 THE ROLE OF THE HEALTH CENTER ORGANIZATION DURING DISASTERS The role that a health center organization plays during an emergency may vary based on the type of event that happened, the needs of its community, and the resources that are available to help. What must remain constant is that the health center is the entity to define its role in an emergency based on the capacity, capabilities, and resources available to it. As discussed, there are many different roles that a health center may elect to play in response to a disaster. The following list is certainly not exhaustive, nor is it a list of recommended roles each health center must examine its unique environment and determine which roles work best for it. Remain Open The role that health centers play in their communities every day is vital to maintaining the health and well being of their patients. Chronic diseases and acute illnesses do not stop during a disaster and combined with the stress of the event, symptoms and the need for care may actually increase. Health centers that have planned for emergencies and are able to stay open to provide primary health care to their patients and community play a critical role in overall emergency response. If health centers are unable to stay open, patients who need treatment will be forced either to seek services from hospitals reeling from increased patient surge following the event or, at worst, to delay treatment, potentially resulting in a more dire health situation than prior to the emergency. Increase Surge Capacity Some communities are working with health care facilities, including health centers, to provide care to minimally injured or ill patients to prevent overloading local hospitals. This assistance can be provided at the health center site or by placing providers at the hospital, if malpractice coverage allows. Communicate with Their Patient Base Dissemination of information during a disaster is vital, yet often very challenging. People need to know what is happening, how they can stay safe, and where they can access shelter, food, water, and other types of aid needed. Health centers can provide a much needed link for getting information to underserved and vulnerable populations through existing relationships. Information can be relayed to patients calling or visiting the health center as well as outreach workers going into the community to provide information to migrant farm workers, homeless, limited English proficient persons, and other hard-to-reach populations. Observe and Report Infectious Disease Trends Health centers will likely see cases of an infectious disease outbreak early on in the event as patients seek treatment from their primary care providers. Health centers can play a valuable role for public health by being able to identify trends in certain infectious diseases, such as pandemic influenza, and having a mechanism to get this information to public health authorities. Early information can provide valuable time to help stem a major disease outbreak. Serve as a Distribution Point In the event of a large disease outbreak, public health officials may determine that there is a need to distribute antibiotics, anti-virals, vaccine, or other medications to the public. To do this, many communities have been planning for Points of Distribution (POD). This is a system in which public health officials will establish a central 9 September 2008 National Association of Community Health Centers, Inc.

10 location, such as a high school or community center, where people will go to get their medication or vaccination. In some communities, health centers may be perfect facilities to serve as the POD. In others, health center staff may be well suited to help fill registration, triage, treatment, translation, and mental health support positions within the POD. Use Your Mobile Vans Health centers with mobile vans can offer a critical asset to emergency response in their community by bringing the care to where it is needed. Health centers without vans may be able to help staff a mobile clinic or serve as a referral point for follow up care. FUNDING FOR EMERGENCY MANAGEMENT For fiscal year 2008, there are two main federal programs that fund emergency management efforts for public health and medical facilities. The Hospital Preparedness Program (HPP) and the CDC s Public Health Emergency Preparedness Program (PHEPP) both go to the state health department, which then usually sub-contracts out with hospitals, health care facilities, and local health departments. A thorough assessment of funding was conducted in May of 2007 to determine which states included Primary Care Associations (PCAs) and/or health centers in emergency management funding that originates from either the HPP or the CDC s PHEPP. The assessment included all 50 states, Washington DC and Puerto Rico, and had a 100% response rate. The assessment revealed that: Thirty of the 52 states/ territories fund PCAs and/or health centers for emergency management activities, or only 58% of states. Twenty-five PCAs receive HPP funds only, 4 receive HPP and CDC funds, and 1 receives CDC only. In total, only 0.7% of healthcare and public health emergency management funding was awarded to PCAs and/or health centers during FY 2006, or $11.1 million of the $1.54 billion awarded nationwide through HPP and CDC funding (including Pandemic Influenza funding Phase I and II) for that year. The average funding level per state for PCAs and/or health centers was $353,408; however, nearly 1/3 of all funding ($3.5 million) was provided by one state (CA), leaving the average funding level for the other 29 states which were included at about $260,000 per state, not organization. NACHC recommends that health centers contact their respective PCA to find out how these funds are distributed in their states and if there are any funds available to support emergency management activities at the health center level. If not, there may be access to these resources through the local health department. 10 National Association of Community Health Centers, Inc. September 2008

11 RESOURCES There are many resources available to help health centers begin and maintain emergency management programs. Here are a few. Tools, Templates, and Other Resources The National Association of Community Health Centers This site will provide access to emergency management plan templates, health center assessment tools, HRSA/BPHC Policy Information Notices, and much more. Training Principles of Emergency Management FEMA Independent Study Program IS National Incident Management System FEMA Independent Study Program Yale New Haven Center for Emergency Preparedness and Disaster Response EM 103 or Risk Communication CDC Emergency and Risk Communication Personal and Family Preparedness Be Red Cross Ready ( FEMA Are You Ready? For questions or additional information, please contact Mollie Melbourne at mmelbourne@nachc.com or (203) September 2008 National Association of Community Health Centers, Inc.

12 7200 Wisconsin Avenue, Suite 210 Bethesda, MD Telephone: Fax: 301/ Website: 12 National Association of Community Health Centers, Inc. September 2008