Centers for Public Health Preparedness Preparedness and Crisis Leadership Education

Centers for Public Health Preparedness Preparedness and Crisis Leadership Education A Compilation from the Centers for Public Health Preparedness REPORT September 2005 Acknowledgments The Preparedness and Crisis Leadership Education Exemplar Group would like to thank the following individuals for their valuable contributions as the group leadership and points of contact: Ann Anderson, Tulane University, Chris Atchison, University of Iowa, Donna Dinkin, University of North Carolina, Scott Lillibridge, University of Texas at Houston, Leonard Marcus, Harvard University, Leila Martini, University of South Florida, Michael Reid, University of South Florida, and Kate Wright, Saint Louis University. In addition, the contributions of the group members were critical to the completion of this document. In turn, the group would like to thank the CDC liaisons and the ASPH coordinators for their guidance and support Co-Chairs Ann Anderson, Tulane University Chris Atchinson, University of Iowa Donna Dinkin, University of North Carolina Scott Lillibridge, University of Texas at Houston Leonard Marcus, Harvard University Leila Martini, University of South Florida Michael Reid, University of South Florida Kate Wright, Saint Louis University CDC Expert Liaisons Dennis Jarvis, CDC Lynn Steele, CDC Group Members Gerald Barron, University of Pittsburgh Barry Dorn, Harvard University Robert Emery, University of Texas at Houston Steven Guillot, Vanderbilt University Becky Hall, Tulane University Mimi Joy, Emory University Howard Koh, Harvard University Danielle Landis, University of South Florida Laura Lloyd, Emory University David Piposzar, University of Pittsburgh Michael Proctor, University of Texas at Houston Melissa Sever, Ohio State University Michael Thomas, St. Louis University Mary desVignes-Kendrick, University of Texas at Houston Sondra Zabar, New York University ASPH Coordinators Beth Rada This project was supported under a cooperative agreement from the Centers for Disease Control and Prevention (CDC) through the Association of Schools of Public Health (ASPH) Grant Number U36/CCU300430-23. Background In 2000 the Centers for Disease Control and Prevention (CDC), with the Association of Schools of Public Health (ASPH), established the Center for Public Health Preparedness (CPHP) program to strengthen terrorism and emergency preparedness by linking academic expertise to state and local health agency needs. The program has grown to become an important national resource for the development, delivery, and evaluation of preparedness education. Over the past five years, the network of centers has assessed training needs, developed competency-based training products, and evaluated their effectiveness. The centers have also undertaken many collaborative projects with preparedness partner organizations to assist them in meeting the workforce and practice challenges posed by terrorism and other emergencies. Descriptions of the CPHP products, which include hundreds of training and educational resources, may be found in a Webbased Resource Center, which ASPH maintains at www.asph.org/acphp/phprc.cfm. To enhance the value of these products and to advance the centers’ emergency response preparatory mission, CDC and ASPH established a number of interdisciplinary, inter-CPHP committees, termed “exemplar groups,” to identify and examine CPHP resources in selected areas of preparedness -- both in core, thematic areas and in cross-cutting areas -- and to summarize the group’s experience, or lessons learned, in using the resources. The exemplar groups were composed primarily of academic CPHP representatives and included designees from the CDC and the practice community. ASPH staff coordinated the groups from start to finish. These exemplar groups’ products are compiled in a series of resource summaries and/or lessons learned, which may include listings of best practices, as appropriate. At the time of this series in 2005, a total of 40 Centers for Public Health Preparedness were in operation, many of them residing within academic institutions-primarily in accredited schools of public health, dentistry, medicine, and veterinary science-as well as in state and local health departments. Because of the evolving nature of resource materials and the ongoing growth in the number of centers, the exemplar group assessments cannot be considered exhaustive, although they do represent a thorough survey of the materials available at the time of the reviews. Introduction to Crisis Leadership The Preparedness and Crisis Leadership Education Exemplar Group was asked to focus on workforce preparedness in relation to the unique crisis leadership challenges facing public health and homeland security leadership in the aftermath of September 11, 2001. Purpose The purpose of the exemplar group was to produce a document that described existing CPHP network activities and resources related to crisis leadership workforce development programs and products. In addition, the document addresses crisis leadership competencies for emergency preparedness responders and receivers. The document is designed to assist national, state, and local partners in successfully navigating CPHP network products and courses to determine which options best meet their needs. It addresses the unique crisis leadership challenges facing public health and homeland security leadership in the aftermath of September 11, 2001. Centers for Public Health Preparedness | 1 The document is intended to: • Help national, state and local partners successfully navigate CPHP network crisis leadership programs and products; • Encourage work in this area through use and adaptation of existing resources to meet local needs; and • Expand competency-based crisis leadership curriculum, exercises, and product development. It is anticipated that this report will be useful to several partners and stakeholders, including academicians, state/national policymakers, training officers, community members and leaders, and multidisciplinary/cross-agency personnel interested in crisis leadership development. The materials collected and summarized to form this document were limited by time constraints on collection and analysis, and because the focal area is unique and newly developed. For a description of the methods and the process that the exemplar group used to develop the document, see Appendix A, “Exemplar Group Process and Methods.” For a description of the group’s charter, see Appendix B, “Crisis Leadership Exemplar Group Charter.” Definitions Managing and leading before, during, or after a crisis event or emergency are not synonymous tasks. It is necessary to discern the unique demands and challenges facing leaders and managers to develop competency frameworks that will form the foundation for all related curricula. The challenge is to ensure an integrated system of competency-based programs, exercises, and simulations to effectively prepare the public health workforce to perform as required to meet today’s challenges. Crisis Management. Crisis management is the practice of operating within existing policies, procedures, and structures to anticipate, mitigate, manage, and recover from crisis events. People in management positions are primarily influenced through direct-report structures by those in leadership positions. Crisis management functions are designated within command and control policies, plans, structures, and systems. These include defined roles, operations, and reporting positions with assignments related to proscribed tasks and actions (1,2). Competence in crisis management is critical for activation of existing preparedness plans and command structures to coordinate the best possible response. Individuals who work in organizations and agencies responsible for crisis and emergency response should be prepared in crisis management appropriate to their level of responsibility and expectations for performance. Managers should also be prepared and be competent to perform as leaders. Crisis Leadership.* Crisis leadership is the practice of creating integrated systems and capacity to anticipate, prevent, recognize, and respond effectively to the elements of crisis by influencing others through judicious use of moral, technical, positional, or assumed authority. Leaders must be prepared to confront unique challenges1 to address elements of crisis and emergency events on a daily basis, as well as during extreme and unexpected circumstances. These include extreme global threats—natural and human-made (accidental and deliberate)—such as existing and emerging infectious diseases, environmental conditions and events, and terrorism threats and events. Increasingly, leaders are confronted with related and unrelated multiple and escalating crises of varied duration, impact, and consequence, with limited time, information, and communications. 1 The definition of crisis leadership builds upon work of the National Public Health Leadership Development Network and its Crisis Leadership and Competency Development Work Groups, 2003-4. 2 | Preparedness and Crisis Leadership Education Scope and Assumptions The events of September 2001 including both the events of 9/11 and the subsequent anthrax attacks incited a dramatic and immediate response from various levels and types of public officials. The results and subsequent analyses of this response emphasized the need to define leadership, in comparison with management, and to delineate the separate competencies required for both crisis leadership and management in all phases of crises -- before, during, and in recovery. A primary objective of these efforts was to develop and improve access to competency-based education and training programs to prepare leaders to be more effective during times of crisis. The study and teaching of crisis leadership skills are specialties within the broader academic field of leadership development. Crisis leadership skills are unique in that they are nonlinear— simultaneously both constant and evolving—in the degree to which they are employed in critical situations. Therefore, unique expertise from a common scientific foundation is required in their instruction. Program directors and faculty that design and teach in crisis leadership programs must be well versed in the broad literature regarding leadership, as well as in the specific literature concerning crisis leadership. Fundamental to the role of crisis leadership is influence sufficient to reduce the probability of crises occurring or reoccurring, the duration of crises, the negative impact of crises, and the length of recovery from crises or chaotic events. Crisis leaders’ roles and functions are nonlinear, ongoing, and evolving. They cannot rely on static plans and structures or traditional relationships, but must continually refine, exercise, and adapt plans to ensure capacity to prevent, respond, mitigate, and recover from crisis events. Improving and integrating leadership performance and capacity are critical at all levels—local, state, federal, and international—in all disciplines and professions, and across all sectors, organizations, and agencies. Crisis leadership is integral to ensure the planning and response capabilities and improved preparedness envisioned by the National Response Plan (NRP) and National Incident Management System (NIMS). It is assumed by the broader public health community that crisis management education and training programs should be available to the public health workforce so these personnel can develop the required organizational and community capacity to operate and activate emergency operation centers and incident command structures. By comparison, there is a dearth of appropriate and accessible crisis leadership preparation for all leaders, across all sectors of government, including response (i.e., first responders) and receiver (i.e. hospital or clinics that receive patients) organizations. Leaders of these organizations must have access to a sustained integrated education and training system in crisis leadership. In summary, assumptions inherent in a systems approach to crisis leadership development include the following: • Crisis leadership is based on a scientific foundation of leadership development and systems thinking with a unique focus on the specialty. • It is based on definitions for and a distinction between crisis management and leadership competencies. • It is based on a role and functions that are nonlinear, constant, and evolving. • It is a separate and necessary component of public health workforce development to ensure integrated preparedness capacity. • It requires the integration of all sectors and levels of receiver and responder agencies. • It is integral to ensure planning, response capacities, and improved preparedness envisioned by the National Response Plan (NRP) and National Incident Management System (NIMS). Centers for Public Health Preparedness | 3 Competencies and Curriculum It is assumed that a leader has the necessary competence to perform technical, political, professional, disciplinary, and management responsibilities associated with the position held. Unique to leading during crisis and emergency conditions is the necessity to have profound competence, including- character, values, emotional strength, resilience, and endurance, as well as the ability to use critical and strategic thinking to anticipate probable and “unthinkable” events. Systems-thinking skills are fundamental to crisis leadership to create, improve, and sustain integrated response systems, including, policies, procedures, and structures—both vertically and horizontally—among responder and receiver agencies. A competent crisis leader has fundamental core knowledge, skills, and attributes associated with traditional personal transformational leadership competencies (3,4) See Appendix C, “The National Public Health Leadership Competency Framework” for a list of competencies as well as those competencies unique to capabilities required to lead before, during, and after crisis and emergency events. These leadership competency areas include the following: • Crisis Leadership Core Transformational Competence Areas. Utilizes critical thinking skills to unlock the situation and see new possibilities; develops and aligns capacity to follow new vision and create desired results; creates and reinvents new structures and systems with vision and mission. • Unique Crisis Leadership Performance Competence Areas. Anticipates, recognizes, responds, and recovers effectively to elements of crisis; makes unified/critical decisions and performs collective and decisive actions within the context of crises; addresses the human element before, during and after crises occur; influences others through judicious use of moral, technical, positional, attributed, or assumed authority. Competency frameworks and core attributes of leadership development should serve as a foundation for curriculum design, implementation, and evaluation. Crisis leaders influence others through: • Knowledge and skills (e.g., problem solving, decision making and anticipatory thinking, temporary systems development); • Individual traits and characteristics (e.g., integrity, courage, ethics, risk taking and role modeling); and • Beliefs and attitudes (e.g., reflection and self renewal, resilience and confidence). A conceptual model used in leadership development focuses on use of content, process, and methods designed to enhance a leader’s knowledge, skills, use of feedback for self-assessment and improvement, and personal growth for personal mastery and life-long learning. Following are examples of curriculum areas for further crisis leadership development: • Self Awareness, Reflection, and Growth; • Clarity of Vision, Mission, and Values; • Risk and Crisis Communication; • Emotional Intelligence and Response; • Ethical Decision-Making and Crisis; • Public Health Law and Crisis; • Cultural Competence and Crisis; • Critical Thinking, Decision-Making and Decisive Action; • Anticipatory Thinking and the Unthinkable; 4 | Preparedness and Crisis Leadership Education • Integrated Systems Thinking, Design, and Response; and • Crisis Learning Development Systems, Teams and Stakeholders. CPHP Resource Findings Summary Data and information collected from the 11 CPHP that completed the exemplar group’s resource survey (Appendix D, “Crisis Leaders Curriculum and Resource Survey”) are summarized in Appendix E, “Crisis Leadership Comparative Program and Resource Matrix.” The matrix is organized to display primary characteristics of the crisis leadership programs and resources. For clarification, Appendix F, “Crisis Leadership Resource Matrix Definitions” provides a list of definitions for terms heading matrix rows and columns. The relative newness of this area of workforce development placed limitations on data collection and analysis. Nonetheless, the group’s comparative matrix should assist by: • Serving as a basis for further investigation of criteria, competency sets, curricula models, and evaluation methods to be used in crisis leadership development; • Serving as a baseline to track new curriculum and resource development; • Providing contact information for locating others involved crisis leadership development; • Identifying resources for those involved in developing curricula; • Identifying programs available for improving access to interested users; and • Identifying gaps in existing curricula for future development. Lessons Learned Individuals or teams working to create a development program for crisis leadership should build on the lessons learned from others that have developed and implemented public health leadership programs. At least 18 programs have been established for public health practitioners. Several other leadership courses or programs have been implemented through the work of the CPHP. Some of the lessons learned by the exemplar group are shared below and can be used as the basis for development and delivery of programs in crisis leadership. Related to the lessons learned, the incredible overlap from the Centers for Public Health Preparedness experiences made it virtually impossible to attribute any one lesson to a single center. Full contact information is provided for each in Appendix G, “Preparedness and Crisis Leadership Education Contacts.” Program Goals and Objectives. No single program can meet the needs of all individuals. Program goals in leadership development often focus on the enhancement of knowledge and skills. They should also promote the development of broader professional networks and teams that are based on supportive and trusting relationships. Program goals and objectives for crisis leadership programs should also be: • Related to an overarching set of community health goals; • Consistent with crisis leadership competencies; • Practiced-based; and • Measurable. Target Audience. Crisis leadership programs should include broad representation from all sectors of the response community. Other considerations include: • For most programs, an ideal class size is between 15 and 50 participants. • Recruitment of teams has advantages when the curriculum focuses on such areas as shared learning and trust-building. Centers for Public Health Preparedness | 5 • Participants should be trained with appropriate crisis management skills before entering a crisis leadership program. • Participants with strong technical or analytical backgrounds should recognize the importance of the behavioral sciences aspects of crisis leadership development. Course Length. Program length will contribute to the extent to which participants can build particular skills. Course length will be determined by: • Program objectives that designate levels of learning desired (e.g., awareness, knowledge, or skill level); • Available and sustained teaching resources; and • Participant time constraints. Certificate or Credentialing. Most public health leadership development programs offer certificates and/or continuing education credits. In some cases, academic credit has been made available. Leadership development has also become an important level of workforce development in consideration of preparedness and/or broad workforce credentialing. Consider offering a certificate program, courses for a certificate, or continuing education. Instructional Methodologies. Programs should be developed with adult-learning strategies in mind. Real-time, practice-based problem-solving offers the biggest opportunity for personal or team development. Consider the following when designing ongoing development programs and skill-building events: • Selection of a variety of methodologies helps address a variety of learning styles of participants (e.g., didactic sessions, telephone conference calls, online dialogues, Web/ satellite broadcasts, team projects, mentors and coaches, 360-degree self assessments, simulations, exercises, participant reports, and presentations). • One-time didactic sessions are helpful for building awareness, but are limited in building competence. Lectures should be tied to pre-session assignments and post-session applications (e.g., projects or coaching). • Online discussion forums often have limited participation and, therefore, should be carefully designed and facilitated. • Self-assessment instruments are commonly used and highly rated for satisfaction among participants. Feedback from self-assessments should be provided by a highly skilled and competent professional. Personal coaching/mentoring typically increases the usefulness and value of this methodology. • Technology mediated sessions can be used to support learning between on-site meetings. • Tabletop exercises, drills, and simulations help to demonstrate performance and competence improvement. All interactive activities require highly-skilled facilitators and observers to ensure an effective learning experience, and to extract lessons learned and plans for correction. • Practice-based projects and assignments are important development methods. They provide opportunities to apply new knowledge to real-world problems. Program Content. Program content for crisis leadership should include content focused on behavioral science (e.g., relationship building, self-awareness, and critical thinking). Other considerations include the following: • Participants should have an opportunity to reflect on a broad range of leadership styles including reflections of their own beliefs about effective leadership and the views of others. 6 | Preparedness and Crisis Leadership Education • Self-assessment instruments provide an opportunity for participants to increase their understanding of how others view their behaviors, abilities, and skills. Evaluation. Evaluation of leadership development presents unique challenges. Evaluation considerations should be competency-based and include baseline, as well as intermittent, assessment of improvement. Evaluation of actual performance is difficult, but can be achieved through: • Assessment of practiced based projects; or • Observation of performance in exercises and simulations. Suggestions The exemplar group recognized that the requirements and characteristics of crisis leadership depend upon the needs of the state and local health departments and other organizations with whom CPHP collaborate. These requirements and needs may not correspond fully to the following suggestions. Additional criteria may need to be developed depending upon target audience and may include consideration of alternative formats and curriculum design; objectives and competencies; practice partnerships and collaborations; and program prerequisites and evaluation methods. The exemplar group’s suggestions to the CPHP network include the following: • Crisis leadership and crisis management are not synonymous. Differences and requirements for each area of curriculum design need to be articulated, and the competencies required for each area clarified. • Certification or credentialing of crisis leadership and crisis management competence should be considered. • All public health crisis leadership programs at CPHP should be developed using competencies as a foundation for design and evaluation. The National Public Health Leadership Development Framework and the newly created subset of crisis leadership competencies are suggested for use for curriculum design. • Basic and advanced levels of curriculum should be defined as standards for certifying competence. New competency frameworks should be continually integrated with other national certification criteria for bioterrorism and emergency preparedness and response. • Existing curricula in crisis leadership serve as resources and best practice examples for CPHP to adapt for local needs. Conclusion Crisis leadership is an essential component of emergency preparedness. It encourages integration and expansion of existing preparedness plans and structures into more unified systems that promote connectivity and facilitate collective action. Programs in Crisis Leadership Education should be expanded nationwide in the sphere of public health workforce development and beyond. This document may help expand such programs by offering working definitions for the field, basic assumptions for curricula, descriptions of existing programs and resources, and lessons learned and suggestions for the future. Centers for Public Health Preparedness | 7 References 1. Klann G. Crisis Leadership. Center for Creative Leadership. Greensboro, North Carolina. 2003 2. Mitroff I. Crisis Leadership, Planning for the Unthinkable. Wiley Inc. 2004. 3. Wright K, Rowitz L, Merkle A, Reid W. Robinson B. Herzog D. Weber D. Carmichael D. Balderson T. and Baker E. Competency Development in Public Health Leadership. Am J Public Health. 90,8, 2000:1202-1207. 4. Wright K, Rowitz L, and Merkle A. A Conceptual Model for Leadership Development. J Pub Health Man Prac. 2001;3(5);72-79. Marcus, Leonard J. Connectivity and Public Health Preparedness: Resolving Conflicts and Building Collaboration to Enhance System Readiness. Harvard School of Public Health. 2003. 8 | Preparedness and Crisis Leadership Education