What You Need To Know: Developing A Regional Healthcare Situational Awareness Process

What You Need To Know: Developing A Regional Healthcare Situational Awareness Process Rebecca Lis, MPH Cory Fairbanks, MS December 13, 2016 National Healthcare Coalition Preparedness Conference

Today s Objectives Describe the coordination and partners included in the development of the healthcare situational awareness procedure Describe the multi-agency and multi-jurisdictional approach to the development of key questions for healthcare situational awareness decision making Outline a comprehensive approach that can be used by other jurisdictions to engage partners to develop a healthcare situational awareness process 2

What the Network Does We lead regional healthcare collaboration to effectively respond to and recover from emergencies and disasters. 3

Serving the State s Medical Epicenter public-private partnership 3 million residents almost 50% of the state s hospital beds > 2,000 healthcare organizations > 130,000 healthcare workers 4

Goals of the project Develop a standard procedure for healthcare situational awareness gathering, analysis and distribution Develop a standard set of healthcare situational awareness questions to ask regional partners in an emergency Coordinate with four counties in the Puget Sound Region to develop a standardized approach 5

Process Questions What decisions will we need to make during a disaster? How do we know when we need to make these decisions? How do we know when we have met decision-making triggers? What questions do we need to ask to gather the information? How do we gather the information? How do we analyze the information? How do we present the information? How do we share the information? 6

Intelligence Cycle 7

Planning Process Decisions, Indicators, & EEI o Identified using a Delphi process through a panel of experts Question Development o Based on information gathered during the Delphi process o Vetted with healthcare subject matter experts Procedure o Situational awareness gathering is informed by operational objectives o Follows a time-tiered approach Training o Performed both in-person and webinar based training Implementation o Established metric to track penetration of the procedure into facility processes Exercising o Aspects of situational awareness are built into every exercise 8

Data, Information and Intelligence 9

Procedure Overview 10

Healthcare Operational Objectives Healthcare Operational Objectives are vital to informing the situational awareness data and information needs of the moment; objectives are tied to groups of potential questions to inform regional healthcare decision making Healthcare operational objectives will be created from Consulting with healthcare organizations, Local Health Jurisdictions (LHJs), and other partners, as time permits Generic set of objectives that can be customized Impact based objectives to guide initial response that can be customized 11

Time-Tiered Approach Critical data gathering will be phased in over time following an incident to provide sufficient intelligence to support healthcare organizations but not cause undue burden Requested data and information may not be readily known As operational objectives change throughout an incident so might the data and information requested Phases of Data Gathering 0-4hrs. - data requested will be targeted and concise 4-8hrs. - data and information requested will be expanded to provide more detail and inform specific operational objectives >8hrs. - the amount and complexity of the data and information requested will be expanded to provide maximum detail to inform operational objectives 12

Expectations Healthcare Organizations o Share data honestly and transparently o Prepared to provide data o Communications will flow through their EOCs o Notify NWHRN during: EOC activation EOP activation Current or potential impact to essential patient care services 13

Expectations (Cont.) Healthcare Coalition o Share information and intelligence honestly and transparently o Make a good faith effort to ensure that all intelligence is accurate o Communications with NWHRN occur through the HECC Other Partners o Share information and intelligence honestly and transparently 14

Data and Information Gathering Sources of Information Healthcare organizations Local Health Jurisdictions Medical and non-medical vendors Disaster Clinical Advisory Committee Other Partners (WA State Fusion Center, EMS, state/federal/national organizations) Open Sources (Social media, news media) Active and Passive Gathering Active survey Passive situation reports, Incident Action Plans, news briefings, press releases, etc. 15

Example Timeline #1 Fast Moving Event: Example information gathering/dissemination schedule Flash Report Incident Notification Healthcare Data Collection Snapshot Report Healthcare Data Collection Snapshot Report Healthcare Data Collection Snapshot Report Healthcare Data Collection Snapshot Report Healthcare Data Collection Snapshot Report Healthcare Data Collection Situation Report Healthcare Data Collection Snapshot Report Healthcare Data Collection Snapshot Report Healthcare Data Collection Situation Report 0-4 Hours 4-12 Hours 12-24 Hours Key Flash Report = Immediately following notification of an incident Snapshot Report = Every 2 hrs. for first 12 hrs. every 4 hours after first 12hrs. Situation Report = At the end of each operational period (12 or 24hrs.) Healthcare Data Collection = Every 2 hrs. for first 12 hrs. every 4 hours after first 12hrs. 16

Example Timeline #2 Slow Moving Event: Example information gathering/dissemination schedule Flash Report Incident Notification Healthcare Data Collection Snapshot Report Healthcare Data Collection Situation Report Healthcare Data Collection Snapshot Report Healthcare Data Collection Situation Report Healthcare Data Collection Snapshot Report Healthcare Data Collection Situation Report 0-12 Hours 12-24 Hours 24-36 Hours 36-48 Hours 48-60 Hours 60-72 Hours Key Flash Report = Immediately following notification of an incident Snapshot Report = Mid-way through each operational period Situation Report = At the end of each operational period (24hrs.) Healthcare Data Collection = Every 12 hrs. 17

Types of Communications/Reports Informational Communications Preparedness Advisory Resource Advisory Response Communications Flash Report Snapshot Report Situation Report Healthcare Impact Report Twitter Resource Request 18

Distribution of Intelligence Example regular schedule for distribution Report Fast Moving Event Slow Moving Event Flash Report Immediately following an incident Snapshot Report Every two hours At the end of the operational Situation Report period (12 hrs.) Healthcare Impact Report Resource Request With a snapshot or situation report, when information is available As needed Immediately following notification of an incident, if applicable Every four hours At the end of the operational period (24 hrs.) With a snapshot or situation report, when information is available As needed 19

Distribution of Intelligence (Cont.) All relevant partners will receive communications (may include) Healthcare organizations EMS Local health jurisdictions Law enforcement State and Federal response partners Medical examiners WA State Department of Health (DOH) Emergency management Other government entities A more detailed overview of the healthcare impact report may be shared with LHJs for coordination of healthcare response and decision making 20

Overview of Process Pre-planning Regional decisions to support healthcare and Public Health in a response Consensus triggers and indicators created to inform regional healthcare decision making Intelligence informs Master list of survey questions created to inform specific triggers and indicators Creation of Healthcare Operational Objectives Informs Survey Questions Selected from prespecified topics based on the operational objectives Survey sent to partner agencies (may include): Healthcare orgs. Public Health DCAC Medical Vendors Others Surveys returned Surveys Analyzed Intelligence distributed to partners Situation Progression 21

Question Development 22

Essential Elements of Information Questions Targeted and strategic data and information gathering from: o Healthcare organizations, local health jurisdictions, vendors (situation dependent), and other partners Majority will come directly from responses to targeted questions concerning healthcare s capacity and capability during a response The questions are developed directly from the key decisions that public health and healthcare might face Each question is tied to one or more triggers or indicators to aid in decision making Questions will not be asked that are not clearly tied to healthcare operational objectives during a response Not all questions will be applicable for every situation 23

Key Decision Topics Resource Conservation Regional Medical Staff Changing the Standards of Care Provider Liability Protection Pharmaceutical Shortages Increased Surveillance from Healthcare Healthcare Capacity Issues Standardized Infection Control Standardized Regional Healthcare Practice Guidelines Healthcare Mutual Aid 24

Delphi Consensus building survey technique with clinical providers from across the state of Washington Process Outline: Pre-Rounds: Identification of key decisions for discussion via interviews and focus groups Round #1: Open ended questions to prompt individuals to identify possible triggers and data points for decisions. Round #2: Ranking of each possible trigger on a 5-point Likert scale (1: very unimportant, 2: unimportant, 3: neutral, 4: important, 5: very important). Round #3: Ranking each possible trigger a second time on a 5- point Likert scale. 25

Panelists Sampling: purposive and snowball sampling Met the defined criteria: 1. Works in a specialty or field that would be called upon to respond during healthcare emergencies 2. Has 8-10 years of work experience in their field 3. Holds sufficient experience within their specialty to be able to provide insight on departmental decision making 4. Has the capacity, willingness, and time to participate in all rounds of the process. Panelists: 21 recruited, 19 completed round 1 and 2, 17 complete round 3 26

Panelists (Cont.) Specialties Represented by Clinical Panelists Administration (8) Critical Care/ICU (3) Emergency Management (3) Emergency Medicine (9) EMS (4) Family Medicine Global Health Hospital Medicine Medical Informatics PACU Pediatrics Number of Panelists Radiology Surgery Transfusion medicine/blood center Trauma (3) 8 7 6 5 4 3 2 1 0 8-11 12-15 16-19 20+ Years of Experience 27

Consensus Reached Consensus? (70% of panelists) 70%: combined important and very important and unimportant and very unimportant Very Important Important Neutral Important Neutral Unimportant Very Unimportant Unimportant 28

Triggers and Indicators Decision Should we as a community implement standardized guidelines/orders associated with resource conservation? Triggers and Indicators (Select Examples) Monitor current and anticipated community supply. When we have ½ to 1 day inventory. When centralized distributors confirm that there is 3 days supply of perishable/disposable items. When 80% of a certain resource is consumed throughout the entire region, and it is known that it cannot be replenished via the conventional supply chain. Earthquake would mandate immediate consideration of conservation. When hospitals have to start going out of their standard supply chains to get materials. 29

Triggers and Indicators (Cont.) Decision Topic Number of Items in Group Agreement of number of items at end of round 3 (%) 80% 70% 69% Resource Conservation 28 9 12 7 Regional Medical Staff 27 6 9 12 Changing Standards of Care 25 3 7 15 Liability Protection of Providers 20 7 9 4 Pharmaceutrical Shortages 21 1 7 13 Increased Surveillance for Healthcare 18 2 7 9 Healthcare Capacity Issues 24 7 9 8 Standardized Infection Control 19 5 3 11 Standardized Regional Healthcare Practice Guidelines 16 0 5 11 Healthcare Mutual Aid 25 7 7 11 Total 223 47 75 101 30

Triggers and Indicators (Cont.) Decision Topic Number of Items in Group Agreement of number of items at end of round 3 (%) 80% 70% 69% Resource Conservation 28 9 12 7 Regional Medical Staff 27 6 9 12 Changing Standards of Care 25 3 7 15 Liability Protection of Providers 20 7 9 4 Pharmaceutrical Shortages 21 1 7 13 Increased Surveillance for Healthcare 18 2 7 9 Healthcare Capacity Issues 24 7 9 8 Standardized Infection Control 19 5 3 11 Standardized Regional Healthcare Practice Guidelines 16 0 5 11 Healthcare Mutual Aid 25 7 7 11 Total 223 47 75 101 31

Data Elements and Data Sources Decision - Should we as a community implement standardized guidelines/orders associated with resource conservation? Trigger or Indicator Data Element(s) Data Source(s) 1. Monitor current and anticipated community supply. When we have ½ to 1 day inventory. Current supply of scarce resource Healthcare facility/system inventory of scarce resource Usage rates and # of days/hours of remaining inventory 32

Questions Data elements and data sources were translated into draft question for evaluation by partners 1. What is your organization s current supply of insert scarce resource(s)/pharmaceutical? a. <24 hrs. b. 24-48 hrs. c. 48-72 hrs. d. >72 hrs. Question Feedback 1. Is this question answerable by your organization (yes/no)? 2. Is this the right question (yes/no)? 3. What is the timetable on which you could anticipate your organization being able to answer this question (0-4 hrs., 4-8 hrs., or >8 hrs.)? 4. Additional Comment 33

0-4 Hours Question Template A basic and limited number of questions that can be used in the first 0-4 hours of any no notice event Nine questions - address the following topics: Functionality of the facility Level of care provided (conventional, contingency, crisis) Infrastructure impacts and their limiting of essential services How long the facility can continue to function Do they need assistance (and when) Is facility evacuating Number of injured and deceased Current needs 34

Data Gathering/Analysis Tool The choice of tools will be determined by the process and questions created Collection Tool (partner data collection) o Survey Backend Analysis Tool (NWHRN analysis) o Sophisticated report building tool that seamlessly connects to survey tool 35

Tool Evaluation Key Goals User friendly Can store questions in the tool to create flexible surveys Quickly analyze data visually and flexibly Produce usable reports for partners Participants can save and return to surveys Participants can print their answers Key Components Store pre-created questions (library) Web-based Flexibly survey creation Dynamic data analysis Cost conscious 36

Question Development Lessons Learned Understand what you want to be able to say/do during a response before beginning this process Delphi is labor intensive but extremely informative for project manager and participants Would consider using a 3-point Likert scale in the Delphi to better evaluate consensus Questions must be validated with healthcare partners to ensure they are answerable and will provide information to inform decision making There is no perfect situational awareness process or tool Make sure the process dictates the tool, not the other way around 37

Implementation 38

Healthcare Executive Buy-in Purpose All policies and procedures require executive level support Situational awareness processes must be built into healthcare facility incident management procedures Sensitive information may be collected as part of this process Private healthcare organizations are independent and maintain control over what information they do and do not share Mutual expectation setting Healthcare Executive Response Committee Healthcare executives representing various healthcare sectors Provides guidance on emergency response-related healthcare policy issues during preparedness and response Provides healthcare executive buy-in of NWHRN response plans and strategies 39

Information Gathering Challenges Healthcare facilities are busy during disasters Competing requests and priorities for information (facility and regional) Healthcare system incident management structures (centralized vs. de-centralized) Solutions Communicate executive level support of regional situational awareness process Keep information requests concise, targeted, and actionable Leverage existing healthcare system reporting structures Maintain at least 2-3 deep emergency contacts for each facility Redundant communication methods Note: By acting as a clearing house for healthcare sector information coalitions can reduce information gathering workload for healthcare facilities and regional response partners 40

Analysis & Production Analysis transforms information into actionable intelligence: all data and information should be accompanied by some type of analysis Key to ensuring raw data is not misinterpreted and drives inappropriate response Labor intensive and time consuming, but can be reduced through the use of tools and procedures Requires a certain level of subject matter expertise Allowing facility subject mater experts to provide some interpretation during the information gathering process reduces workload and increases accuracy Important to keep the needs of the audience in mind throughout the process 41

Information Sharing Identified vs. De-identified Reports Identifying and sharing information on specific facilities that are experiencing problems during a disaster is essential for effective incident response Healthcare organizations are justifiably concerned about what information is shared about their facilities and who it is shared with Solutions Develop regional information sharing guidelines and expectations Involve healthcare leadership and emergency management in information sharing discussions Understand the information needs of healthcare, public health, emergency management, and other response partners Build trust Understand that mistakes will be made 42

Distribution Lists Challenges Keeping lists up-to-date Not knowing who is on the list Large lists can require multiple emails Increased production time Solutions Contact management system Build specific lists in advance At least 2-3 deep contacts Process for determining appropriate distribution lists Benefits The right people get the right information Significantly reduces production time Ability to justify who receive what and why 43

Implementation Tracking Establish metrics to track the penetration of regional planning into response processes Bi-annual facility self assessment survey Targeted towards healthcare emergency managers Milestones o Establish points of contact for gathering and completing situational awareness survey o Incorporate regional situational awareness into internal incident command processes o Ability to gather and provide situational awareness within established timeframes o Leadership has been incorporated into the process o Ensure interoperability and redundancy to communicate situational awareness Scoring system o Not started o In progress o Complete 44

Training and Exercise Situational awareness should be part of every drill and exercise Webinars Held multiple webinars on the regional situational awareness procedure Participation from multiple healthcare sectors and other response partners Recorded and shared webinars for those unable to attend Cascadia Exercise Provided a baseline for the current state of regional implementation of the process Information requests from other agencies may drive questions outside of your objectives Exercise artificialities can create challenges for testing situational awareness Mini-drills/further exercising Very short duration drills designed to test a specific task Maintain familiarity with low frequency tasks and processes 45

Next Steps 1. Continued Procedure/Question Training 2. Implement Survey/Analysis Tool 3. Finalize Questions 4. Track Implementation with Healthcare Partners 5. Mini Drills/Further Exercises 46

Questions? 47

CONTACT US: Rebecca Lis MPH Cory Fairbanks MS 425.988.2898 425.988.2898 rebecca.lis@nwhrn.org cory.fairbanks@nwhrn.org www.nwhrn.org www.facebook.com/nwhrn @TheNetworkNWHRN PREPARE. RESPOND. RECOVER. 48