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Emergency Preparedness Initiatives

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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/
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                06                                                                                     06

        9/                                                                                     9/
           3/                                                                                     3/
              20                                                                                     20
                06                                                                                     06

        9/                                                                                     9/
           4/                                                                                     4/
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                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/
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                06                                                                                     06

        9/                                                                                     9/
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                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