Public Health Emergency - Leading a Nation Prepared
The concepts described in the MSCC Management System present an overall strategy for defining cohesive management and operational relationships for the diverse and often disparate entities that collaborate to provide MSCC. The MSCC Management System does not require an all-or-nothing approach; it may be partially implemented or fully implemented, but in a stepwise fashion over time. It is meant to complement ongoing initiatives that establish individual components of MSCC, such as identifying pools of qualified personnel, pharmaceutical and equipment caches, plans for medication-dispensing stations, plans for alternative care sites, and enhancements to laboratory capabilities. In addition, the MSCC Management System can serve as a comparison tool when assessing and revising current programs and plans, as a tool for planning and evaluating exercises, or even as a metric for conducting incident after-action review and analysis.
The concepts described in this handbook should be incorporated with existing assets and processes to limit the amount of new infrastructure that must be developed. Therefore, implementation efforts should focus first on evaluating established Emergency Management Programs (EMPs) and Emergency Operations Plans (EOPs) within individual tiers. If systems already in place meet the objectives of the MSCC Management System but operate differently than presented here, they most likely do not require change. If deficits are detected, this document could suggest where revisions to the system (rather than replacement) might enable the system to integrate more effectively into the overall response.
The Centers for Medicare and Medicaid Services (CMS), State survey agencies, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and other accrediting agencies require all HCOs (hospitals, integrated healthcare systems, nursing homes or other skilled nursing facilities, hospices, etc.) to have individual EOPs. As stated in Chapter 2, excellent models already exist that describe how HCOs can organize internally to respond to extreme events. Tier 1 focuses on the internal HCO processes that enhance external integration with other HCOs (Tier 2) and with jurisdictional assets (Tier 3). Persons reviewing existing HCO EOPs or developing new ones should consider the following major issues in applying MSCC concepts to their facility:
To the maximum extent possible, these efforts should be standardized across jurisdictional HCOs through Tier 2 mechanisms. Smaller entities that provide hands-on care in the community (community health centers, neighborhood outpatient clinics, nursing homes or other skilled nursing facilities, private physician offices, etc.) should not be neglected in preparedness efforts. Presenting methods for participation (as described in Chapter 2) to individual practitioners and smaller HCOs may greatly enhance their participation in major response efforts.
HCOs are increasingly engaged in joint-planning efforts, particularly as they participate in Federally-funded bioterrorism preparedness initiatives. Moreover, many localities already have established operational interaction between HCOs to monitor emergency department and critical care capacity, ambulance diversion, and other everyday situations. These activities provide an ideal opportunity for HCOs to come together to discuss and plan for coordinating major medical response.
Key issues to consider when implementing Tier 2 concepts include:
Implementation of MSCC concepts at the jurisdictional level should follow a process in which representatives of various response disciplines (including public health and acute-care medicine) assemble to examine how to improve the delivery of public health and medical care during extreme events. The process should examine specific questions, such as:
Initiatives undertaken to address these questions should use currently available assets and processes to enhance operational relationships. For example, most jurisdictions have 911 emergency communication centers (ECCs) for everyday emergency services. The ECC may be adapted to perform the notification and early planning function for the jurisdiction's (Tier 3) EOP until this can be established at the Incident Command Post (ICP). In addition, the ECC and its paging/messaging services can provide initial notification to on-call representatives of the UC and be used for the early teleconference that initiates unified incident planning.
Examinations of the jurisdictional (Tier 3) response system should focus on identifying processes that promote unified incident command. Below is a series of basic steps that can be followed to incorporate UC processes into the jurisdictional EOP. In addition, each response entity should be assessed for its ability to integrate into the system. Assets that do not reach a threshold of desired management capability (e.g., effective incident information processing, incident planning, and informed decision-making) should be prioritized for improvement through jurisdiction EMP actions.
The following is a general guide for establishing unified incident command techniques in the jurisdiction's EOP.
A starting point for implementing State level MSCC is to establish the management processes that would occur if the State were to assume primary incident command responsibility. Preparedness activities should examine how State public health and medical assets would be incorporated into UC, and how State managers would interact with jurisdictional (Tier 3) response entities.
The State must examine critical information requirements to coordinate intrastate jurisdictions:
Other important implementation tasks include conducting an inventory and assessment of existing tactical mutual aid arrangements. These plans should be reviewed to determine possible ways to address the medical (e.g., licensure, liability) and financial (e.g., lack of guaranteed reimbursement) barriers for private HCOs that provide mutual aid services. State level incident management systems that do not incorporate the private medical sector should consider adopting a healthcare coalition (Tier 2) function to address the concerns of HCOs. Recognizing medical and health assets (Tier 1) as crucial players in public safety emergency response may promote their participation in an incident command system. It may also promote an understanding by State officials of the specific requirements of medical and health assets.
Activities to improve interstate regional management coordination should focus on expanding current initiatives to better address MSCC in the private health and medical sector. Processes should specify key information requirements, explain how data will be shared between States, and identify key points of contact at the State level and their counterparts in neighboring States. The organization of State incident command (Tier 4) should be shared between partner States to enhance coordination of management activities, such as the exchange of incident action plans and support plans.
Examinations of strategic, or "master," mutual aid guidelines should ensure that key "top-line" issues for medical and public health entities have been addressed. Important issues include licensing, liability coverage, and worker's compensation for out-of-State healthcare personnel, as well as reimbursement mechanisms for medical and public health assets. Tactical mutual aid agreements may provide the specific methods for requesting, receiving, and managing interstate mutual aid, transporting and distributing assets, and demobilizing public health and medical resources. Preparedness activities should examine Emergency Management Assistance Compact (EMAC) legislation and regulations to ensure that public health and medical requirements for MSCC are adequately addressed.
Because of significant changes in the Federal response system following 9/11 and, more recently, Hurricane Katrina, State emergency planners should review and understand the Federal response capability, how Federal public health and medical assistance may be obtained, and under what authority it may be activated. The State and jurisdictional EMP should determine what their own response capabilities are (i.e., what can the system handle, and what can it definitely not handle), and identify what types of information will be critical in demonstrating the need for Federal assistance. Before an emergency or disaster occurs, State and local response systems must identify the criteria they will use to determine that their system has reached capacity and that additional support, through mutual aid or Federal assistance, is necessary.
States and local jurisdictions should also have operational plans (within their EOP) describing how Federal resources (personnel, supplies, equipment, or facilities) will be integrated into the State and local response effort. Among other issues, it is important to consider:
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