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ARE YOU REALLY PREPARED?
Emergency Preparedness
Competencies for Healthcare
Executives
Eliot J. Lazar, MD, MBA
Vice President Medical Affairs
Chief Medical Officer
New York Presbyterian Healthcare System 1
It is 8 a.m. on Saturday, December 2, 2006
You just finished meeting with a Board member in
your office and are catching up on some
paperwork, when you receive a call from your
hospital’s Emergency Department that, “A major
accident” occurred on the overnight shift at a
local, major, industrial plant. There are an
estimated 150 patients with both burns and
inhalation injuries. It is unclear whether there has
been a toxic release
2
The plant is the area’s largest employer, and
you are informed that a many hospital staff
have relatives working at the plant
Your EP coordinator and ED Director are
coming back from a few extra days in New
Orleans after a VHA EP conference. Your
COO is out on medical leave after a
procedure
There is no one to delegate to!!!
3
As a Senior Healthcare Leader,
Ask Yourself…
Do I:
Know what to do?
Know who to contact?
Be able to lead my organization through the
disaster to “normalcy”?
What competencies & skills do I possess to do
so?
What are my strengths & gaps?
How can I confirm my assessment?
4
There Are Distinctive Demands of
Leading Healthcare Institutions During
Disasters!!
• Unstable times
• Normal processes disrupted
• Outcomes unpredictable
• Always unique
• Occur infrequently
• May begin abruptly; Do not end abruptly
• Alter usual reporting structures
• Not simply an expansion of day-to-day operations
• Require someone to say, “I am in charge”
5
“The events of September 11, 2001,
served to crystallize a decade-long
evolution of the role of hospitals in
emergency preparedness and disaster
management.”
Berman, M.A. & Lazar, E.J, N Engl Med
348;14, April 3, 2003
6
Hospitals’ Role During Disasters Has
Changed Significantly
The Six “C’s of Institutional Threat
• Catastrophic Events at Hospital
• Contamination of Facility
• Communications Disruption
• Capacity Issues
• Care-Appropriate Expertise
• Challenge to Continue Our Mission
7
NewYork-Presbyterian Healthcare System
9/11 Lessons Learned
• Patient flow can be unpredictable
NJ, Brooklyn, Bronx
• Victims gravitate toward hospitals
• Excellent ability to mobilize staff
• Communications need strengthening
• Incident command structure not truly challenged
• Back-up systems not “bulletproof”
8
Staffing Issues
Staff unable to come to work
Bridge, tunnel and highway
closures
Staff already on duty asked
to remain
Housing
Food
Clothing
Dependent Care
Need for Employee Personal
& Family Emergency
Preparedness Plans
9
Calls for Help From Scene
Who Is Making the Request?
Can We Spare Supplies?
How Do We Handle Controlled
Substances?
HICS (IC) Must Activate Logistics Section
10
Management of Community Resources
Volunteers Can
Donate Blood
Provide Information
Make Food
Transport Patients
OVERWHELM!!
Physicians, Nurses
Must Have A Plan
11
In The Ensuing Days…
Staff Affected
Loss of loved ones
Post Traumatic Stress Syndrome
Transportation
Patients
Staff
12
In The Ensuing Days…
Family members
coming in to find
“missing” people
Must Have
Behavioral Services
Inventory!!
13
Billing Challenges
• Communications link to Medicaid hampered
• Large backlogs in Medicaid application process
• Fully operational by 10/15/01
• NYS temporarily eased Medicaid eligibility requirements
– Offered 4 months of coverage based on attestations of income level
& family size
• Received letters from HIP, Oxford, Aetna USHC, Empire
and CIGNA
– They would pay health care claims related to WTC and reconcile
with workers compensation carriers later
14
Billing Challenges
• Some payors temporarily eased medical
management procedures:
– No precertification required for two weeks
– Temporarily suspended administrative denials
– Utilization review curtailed for two weeks
– Limits of retrospective clinical reviews
– Elimination of referral requirements
15
Billing Challenges
• Staff productivity disrupted causing cash
decline in September, 2001
• October, 2001 cash collections rebounded
• Lockboxes were delayed by 10 business days
• Empire’s claim processing was disrupted as
they lost offices in the WTC
• Disruptions with some other smaller payors
16
Estimate of Fiscal Impact of WTC attacks on
New York Hospitals (Prepared by GNYHA)
Incremental emergency expenses $48 million
Unreimbursed standby costs $92 million
Continuing fiscal impact $200 million
Total estimated fiscal impact: $340 million
17
NewYork-Presbyterian / Weill Cornell
9/11 Fiscal Impact
Emergency Staffing $482,000
Additional Security $50,430
Housing & Hotel $47,300
Food $16,600
Blood $85,000
Crisis Counselors $56,000
Supplies & Pharmaceuticals $92,200
Back-up Telecommunications $10,000
Other Emergency Equip. Rental $10,000
$849,530
9/11 Operating Loss $13,150,000
Property Loss (9 Vehicles) $800,000
TOTAL $14,799,530
18
NYP/Weill Cornell
Fiscal Impact - Loss of Revenue
• Average Patient Revenue Per Week: $54,193,000
• Actual Patient Revenue Week of 9/10: $44,216,000
• Patient Revenue Lost Week of 9/10: $9,977,000
19
NYP/Weill Cornell
Supply Chain Response
Opened lines of communication with Emergency Operations
Center & OR’s
Maintained added staff readiness to respond to anticipated
demands (e.g., burn unit requirements)
Assigned senior staff to cover purchasing & warehouses
Outside vendor cooperation
Vendors phoned in
Pharmaceutical companies air freighted drugs
Police escorts allowed specific product shipments
Helicopter delivery
Overstocked certain supplies
Liquid Oxygen tanks topped off
20
Do You Still Think You’re Ready?
Lack of Standardized Healthcare Emergency
Preparedness Performance Metrics
• Lack of universally accepted…
…Preparedness definitions
…Performance measures
• Difficult to measure capacity to manage
events that occur infrequently, if at all
• Relative newness of the field
Lack of evidence base / “references”
Lack of validity of existing metrics
21
“There are no standardized measures of hospital disaster
preparedness…”
Kaji & Lewis, “Hospital Disaster Preparedness in Los Angeles
County” Acad Emerg Med (8/2/06)
“While rigorous quality assessments of the myriad clinical and
administrative services healthcare institutions provide exist, few similar
means are available for healthcare institutions to evaluate the quality of
their emergency preparedness initiatives.”
“…this can be remedied through the application of traditional healthcare
quality paradigms…and when healthcare institutions, accrediting bodies,
regulators and industry groups, collaborate to develop a comprehensive
approach to performance measures in hospital emergency preparedness.”
Cagliuso, Sr., N.V. & Lazar, E.J., System Quality Review,
Special Issue, October 26, 2006
22
Traditional Categorization of
Healthcare Performance Metrics
“VSOP”
Volume: Frequency improves
quality
Structure: Binary metrics
Outcome: Morbidity /
Mortality
Process: Evidence shows that
doing these activities will
improve outcomes
23
Performance Metrics
Comparison
Traditional Healthcare Emergency Preparedness
Evidence-based Little evidence
Defined metrics Undefined metrics
Large case #s Infrequent events
Replicability of cases Unique situations
Focus on high volume / Rapid evolution of the
high risk discipline
Established clinical Few agreed upon best
principles practices
Established benchmark No benchmarking
mechanisms
24
Hospital EP Measures
“Volume” Metrics
• Volume may or may not be applicable
ICU Patients
ED Visits for major trauma
Ambulance
• Lack of “volume” may not be correctable
• May need to compensate elsewhere
Rotate personnel
Increase drill frequency
Identify institutional choke points
25
Hospital EP Metrics
Identify Institutional Choke Points
100
50
0
-50
-100
-150
-200
Nursing Physicians
Availability Needs Surplus/Deficit
26
Hospital EP Measures
“Structure” Metrics
• Binary (Yes/No)
Designated EP Coordinator
Digital Camera
Equipment & Supply Cache
NIMS Certifications
BDLS & ADLS
• Easiest aspect to correct in hospital EP quality
efforts
• May be most difficult aspect to correct in general
healthcare quality efforts
27
Hospital EP Measures
“Outcomes” & “Processes”
Paradigm I
Examine normal occurrences that most
closely replicate disasters
Cumulative statistics (mean, median, mode) don’t
show distribution
To compensate, focus on outliers as they most closely
replicate disaster situations
Separate cohort during “outlier” periods rather
than aggregating with general performance or
simply discarding
28
LOS (hrs) Visits
50
100
150
200
250
300
350
400
450
0
10
12
0
2
4
6
8
9/ 9/
1/ 1/
20 20
06 06
9/ 9/
2/ 2/
20 20
06 06
9/ 9/
3/ 3/
20 20
06 06
9/ 9/
4/ 4/
20 20
06 06
9/ 9/
5/ 5/
20 20
06 06
9/ 9/
6/ 6/
20 20
Date
Date
06 06
9/ 9/
7/ 7/
20 20
Hospital X Avg ED LOS by Date
06 06
Hospital X ED Visits by Date (80k/yr)
9/ 9/
8/ 8/
20 20
06 06
9/ 9/
9/ 9/
20 20
06 06
9/ 9/
10 10
/2 /2
00 00
6 6
29
LOS (hrs) 100 Visits
150
200
250
300
350
400
450
0
2
4
6
8
10
12
0
50
9/ 9/
1/ 1/
20 20
06 06
9/ 9/
2/ 2/
20 20
06 06
9/ 9/
3/ 3/
20 20
06 06
9/ 9/
4/ 4/
20 20
06 06
9/ 9/
5/ 5/
20 20
06 06
9/ 9/
6/ 6/
20 20
Date
Date
06 06
9/ 9/
7/ 7/
20 20
Hospital X Avg ED LOS by Date
06 06
Hospital X ED Visits by Date (80k/yr)
9/ 9/
8/ 8/
20 20
06 06
9/ 9/
9/ 9/
20 20
06 06
9/ 9/
10 10
/2 /2
00 00
6 6
30
Hospital EP Measures
“Outcomes” & “Processes” Paradigm I
Example ED LOS
18
16
14
12
10
Total
8
6
4
2
0
Month 1 Month 2 Month 3 Month 4 Month 5 Month 6
31
Hospital EP Measures
“Outcomes” & “Processes” Paradigm I
Example ED LOS
18
16
14
12
10 Total
8 Normal
6
4
2
0
Month 1 Month 2 Month 3 Month 4 Month 5 Month 6
32
Hospital EP Measures
“Outcomes” & “Processes” Paradigm I
Example ED LOS
18
16
14
12
Total
10
Inlier
8
Outlier
6
4
2
0
Month 1 Month 2 Month 3 Month 4 Month 5 Month 6
33
Hospital EP Measures
“Outcomes” & “Processes”
Paradigm II
Analyze data during disaster situations
applying traditional quality metrics
For example
ED LOS during blackout
Performance targets may be different during disasters
(e.g., outliers)
Establish targets for both normal & disaster
Definitions of metrics may be different during disasters
Establish disaster scenario definitions
34
Hospital Emergency Preparedness
Performance Metrics
• Current practice of increasing hospital Emergency
Preparedness “structure” metrics alone will not
yield improvements
• Apply traditional healthcare quality paradigms
where possible (VSOP)
• Identify proxies such as outlier periods
• Establish and define emergency preparedness
definitions and metrics
• Institutions must come together to share best
practices and benchmarks
35
The Senior Healthcare Leader
Emergency Preparedness Competency
Self Assessment Tool
Developed by VHA Health Foundation &
NewYork-Presbyterian Healthcare System
Assesses 30 “Elements” Across Six “Dimensions”:
Leadership
Communication
Partnership
Logistics & Facilities
Workforce
Evaluation & Follow Up
36
