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Program Details
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| Practice Type: |
Promising |
| Program Name: |
Health/Medical Multi-Agency Coordination Group |
| Organization: |
Multnomah County Health Department |
| Web site: |
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| Overview: |
This practice addresses the public health need for coordinated healthcare and public health decision-making and response to health emergencies in a multi-county, multi-jurisdictional area. The Health/Medical Multi-Agency Coordination (MAC) Group practice developed is a decision-making group comprised of hospitals, public health, and other healthcare entities with collective responsibility to: 1) prioritize which decisions must be made in order to support a strained healthcare delivery system; 2) develop ethically-based regional strategies to allocate critical resources; 3) propose altered standards of care and policy approaches; 4) propose community mitigation approaches to limit disease transmission; and 5) support accurate dissemination of information to the public. The use of a MAC Group for public health is an innovative adaptation of a practice used by fire and police. Unique to the practice is the use of community observers’ feedback to refine the practice and measure the likelihood that the community will accept decisions made. Practice Goal: Develop practical, evidence-based, local health response strategies that are accepted by the community and based on organizational learning principles, increasing the local healthcare system’s ability to respond to rapidly changing situations. Primary Objectives: Develop a Health/Medical Multi-Agency Coordination (MAC) Group comprised of hospitals and public health: Our community did not have a formal process to support decisions for regional, health/medical emergencies such as a pandemic. The MAC Group model is a decision-making, multi-agency coordination tool within the National Incident Management System. The use of a MAC Group as public health practice is an innovative adaptation of traditional MAC Groups used for fire/flood events. Additionally, unique to our practice is the inclusion of community observers’ feedback to refine and measure the acceptability of the practice. Develop an ethics framework based on community values to facilitate fair and transparent decision-making and reduce unintentional consequences: In the event of a severe pandemic, the demand for healthcare services will exceed the availability of resources. This will force policy makers to make difficult decisions possibly impacting the freedom, health, and prospects for survival of individuals. Public health and healthcare system officials believe that the community will be more likely to accept the decisions (and consequences) if they are made in a transparent and inclusive way. Conduct an iterative exercise series (which became real-time due to H1N1) for the group to practice decision-making, collaboration, and organizational learning: This type of learning creates an environment where groups expand their capacity to create desired results; where new and expansive patterns of thinking are encouraged; and where people continually learn to see the whole together. This learning is especially applicable for emergency preparedness because a learning team is adaptive and productive in rapidly changing situations. The group’s ability to function during the H1N1 pandemic demonstrated this assertion. Develop a Health/Medical Multi-Agency Coordination (MAC) Group: Organizational Quality Associates (OQA) guided us through this process. They have much experience serving on MAC Groups, and coaching on organizational development, emergency services, and the Incident Command System. A workgroup of HPO staff, hospitals, public health, emergency management and Consultants successfully developed the Health/Medical MAC Group concept and associated Handbook. Develop an ethics framework: The ethics framework was designed using community values on provision of medical services. An ethicist and the Manager of Assessment and Evaluation services gathered this information through five community discussions (in Oregon and Washington) exploring reactions to curtailing hospital services during a severe influenza pandemic. The information learned from these groups and ethics literature informed the framework development. The use of local community members’ values was seen by community observers as something that would make the larger community more likely accept its validity. Conduct an iterative exercise series: Between September and October 2009 the Health/Medical MAC Group was to participate in a scenario-based functional exercise series. The group participated in traditional MAC Group training conducted by the OQA Consultants, then met for their first exercise. Due to the H1N1 pandemic, they transitioned to real-time meetings. |
| Year Submitted: |
2010 |
| Responsiveness and Innovation: |
This practice addresses the public health need for coordinated healthcare and public health decision-making and response to health emergencies in a multi-county, multi-jurisdictional area. The Health/Medical Multi-Agency Coordination (MAC) Group practice developed is a decision-making group comprised of hospitals, public health, and other healthcare entities with collective responsibility to: 1) prioritize which decisions must be made in order to support a strained healthcare delivery system; 2) develop ethically-based regional strategies to allocate critical resources; 3) propose altered standards of care and policy approaches; 4) propose community mitigation approaches to limit disease transmission; and 5) support accurate dissemination of information to the public. The use of a MAC Group for public health is an innovative adaptation of a practice used by fire and police for emergency management. Also, the practice addresses the need to involve community (both individuals and businesses) in the identification and solutions to public health issues. Unique to the practice we developed was the use of community observers’ feedback to refine the practice as well as measure the likelihood that the community will accept decisions made as appropriate under the circumstances, respectful, compassionate, and ethical. Also important was the group’s ability to make decisions that resulted in reasonable operational and financial equity among hospitals/health systems, clinicians, and other providers to protect the health care system’s capacity to provide health care as usual to the community after the event. Between January and April 2005, HPO staff convened three workgroups to draft initial concepts of operations that represented consensus on the most practical and effective approach to meeting the demands of a novel strain influenza. In addition, the groups were to recommend what would be needed to develop and implement institutional-level plans (e.g., planning, training, equipment, staffing). The workgroups were: 1) hospital surge, 2) ambulatory surge, and 3) communications. In addition to the groups’ success in accomplishing these tasks, they provided invaluable information on what was needed to support the regional healthcare delivery system achieve an effective, efficient, community–accepted, appropriate, semi-autonomous response during a health emergency. As a result of this information Region 1 health responders identified five specific functions that were needed to support a regional response: 1) situation status regarding health care impacts; 2) optimal distribution of scarce health resources; 3) policy guidance; 4) provider information; and 5) situation status regarding non-healthcare impacts. Simply stated, the public health need for coordinated healthcare and public health decision-making and response to health emergencies in a multi-county, multi-jurisdictional area was clearly identified. In 2008, HPO staff convened a workgroup to examine a proposed framework to address the five functions above through establishment of a regional Health/Medical Coordination Center (HMCC). The HMCC was designed to serve as a centralized, regional, health and medical information coordination center with open lines of communications with involved hospitals, clinics, public heath, city/county emergency management, and state public health. The HMCC would collect information from health responders, synthesize the information into a regional health situation status report, and disseminate the report to key response partners. Based on information from healthcare delivery partners and projected needs, the HMCC would determine when/what health resources are scarce and direct healthcare delivery partners to send requests for identified scarce health resource to a designated County Emergency Coordination Center (ECC). The HMCC would also convene a MAC group to establish priorities for resource allocation. In November 2008, the HMCC was exercised in a small-scale MCHD functional exercise. While opportunities for improvement were identified, participants, evaluators and observers expressed support for continuing to develop and refine the HMCC. In addition, the observation was made that the HMCC might be a duplicative layer to the existing response structure. The suggestion was made to explore how to better integrate the HMCC with the supporting county ECC. That recommendation was moved forward, just in time for H1N1. We successfully integrated the HMCC functions into the Multnomah County ECC that: 1) created a regional situation status report; 2) supported the optimal distribution of scarce regional health resources; 3) conveyed regional policy guidance; and 4) conveyed provider information. These all supported the work of the Health/Medical MAC Group. As a result of this work, we, and our multiple community partners met the public health need for coordinated healthcare and public health decision-making and response to health emergencies in a multi-county, multi-jurisdictional area. This practice addresses the public health need for coordinated healthcare and public health decision-making and response to health emergencies in a multi-county, multi-jurisdictional area through the establishment of a Health/Medical MAC Group. When activated, this Group serves as a decision-making body comprised of representatives from hospitals, public health, and other healthcare settings who collectively have the responsibility and ability to: 1) Prioritize which decisions must be made in order to support a strained healthcare delivery system: All health emergencies present multiple decision-making opportunities and situations which necessitate prioritization. This practice utilizes MAC Group coordinators who prioritize issues for the Health/Medical MAC Group. It is crucial that this prioritization happens in order to conserve time and resources, yet support the most critical response needs. 2) Develop ethically-based regional strategies to allocate critical resources: Particularly in the interest of maintaining an intact community--one that is able to resume normal life physically, socially, economically, and spiritually following the event. This requires that the local healthcare delivery system utilize available healthcare resources effectively and efficiently, address health conditions in a balanced way, and act in a way that is perceived by community members as ethical and appropriate under the circumstances. Also important is that the response results in the equitable distribution of operational and financial burdens across individual hospitals, clinics, individual providers and larger health systems. 3) Propose altered standards of care and policy approaches: The interest is in minimizing death and disability as much as possible given available resources. An example of this was the real-time creation of a regional mask use policy recommendation that would optimize the safety of staff, patients and the community at large, while helping to conserve scarce resources in the community. 4) Propose community mitigation approaches to limit disease transmission: An example of this was the real-time development of a regional hospital visitation policy recommendation regarding who could visit patients in the hospital in light of the prevalence of H1N1 in the community. The policy was based on infection control practices and evidence-based medicine in the interest of protecting the public, hospital staff, and medically at-risk populations from becoming ill with H1N1 influenza virus. 5) Support accurate dissemination of information to the public: All regional policy recommendations stemmed from a desire to have uniform policies that were more easily communicated to the public in order to engender public trust and minimize public confusion, as well as protect the health of responders and the public. Because all decisions are grounded in the Ethical Framework, the community will be more likely to accept the need for and consequences of difficult decisions if they are made in an open, transparent, and inclusive way. In addition, policy makers want decisions that are made during a health emergency to be based on a consideration of community values as well as on science. The Ethical Framework provides that consideration. The Health/Medical MAC Group practice provides a framework for the development of similar practices in additional geographic areas, which could potentially bring in additional successful practice tools and outcomes. Development of the Health/Medical MAC Group began with a review of existing MAC Group models from various agencies and jurisdictions. We found a number of MAC Group models (particularly for fire agencies), but none for a health discipline. Because all of the models came from non-health disciplines, we had to identify one that was comprehensive and could be modified to meet the needs of a health/medical event. Through this initial review process, it was evident that we would benefit from consultation with technical experts who had been involved with MAC Groups and processes during real-time responses to emergencies. We engaged contractors from Organizational Quality Associates (OQA). OQA is a firm with substantial national experience participating in management of complex emergencies, and with providing training and developing emergency response and coordination systems. Based on their national perspective, OQA agreed that the development of a Health/Medical MAC Group was truly an innovative use of the MAC Group model. As noted above, we were unable to find literature documenting use of MAC Groups by local public health or other health agencies. In Oregon, there is no well-established and consistent plan for multi-jurisdictional public and private coordination of healthcare delivery in an emergency. Various plans have been developed, and tested in response to exercises and real events. Despite this, the state lacks a fully developed and implemented healthcare response coordination plan. We believe that the Oregon experience with healthcare coordination during the autumn H1N1 wave was typical of that for many states. In Oregon, a variety of healthcare coordinating approaches have been adopted within formal regions or in ad-hoc community clusters. These approaches typically involved coordinating groups with membership that is similar to that of our Health and Medical MAC Group. However, these groups typically lacked a formal procedural and organizational framework, and were variably connected to the rest of the local emergency management system. In southwest Washington (which is part of the Portland metropolitan region), a coordinating approach based in a “Health Advisory Group” (HAG) has been developed and tested in a number of exercises. Similar to the Health and Medical MAC Group, the HAG membership includes local public health leadership, and representatives of health care delivery organizations. However, in past exercises, the HAG did not operate using specific procedural guidelines, nor was it fully integrated with a regional ECC. During the course of the autumn 2009 H1N1 pandemic response, we became aware that various communities attempted to coordinate health care delivery using entities that were called Multi-agency Coordinating Groups. However, from the minimal information available on the Internet, these groups appeared to be dominated by public health officials as decision-makers. There was also an absence of documentation that these groups operated according to NIMS-compliant Multi-agency Coordinating Group procedures and standards. Presumably, the various informal approaches described above were adequate to coordinate care in the face of the autumn 2009 mild H1N1 pandemic wave. However, it is important to note that this pandemic wave placed only a mild to moderate stress on health care delivery systems. As a result, there was not an overwhelming need for well-structured and well-supported coordinating approaches. Other more severe emergencies will likely require more rigorous approachesUtilization of MAC Groups is a well established strategy for management of wildfires and natural disasters; however the existence or use of a MAC Group for a health/medical emergency had not been formally tested in our region prior to this project. Historically MAC Groups have not been used for emergencies by any discipline or jurisdiction in the Portland metro area. In large part this has been due to an absence of large and complex events requiring community-level resource prioritization and response policy alignment. There has also been resistance by the local emergency management community to employ a variety of regionally-based response strategies, including MAC Groups. As a result, there is no established regional Emergency Coordination Center to support a MAC Group. Our local health/medical sector already had success coordinating exercise and real event responses regionally, and was eager to explore whether the MAC Group model could be effectively applied to help manage health/medical emergencies. With some initial hesitation, the local emergency management community supported the health/medical sector’s exploration of using a regional Health/Medical MAC Group.N/AWhat does the LHD do to foster collaboration with community stakeholders? Prior to 9/11, Portland Metropolitan area hospitals were engaged in Emergency Preparedness activities, but primarily only those required by JCAHO. Public Health was just getting involved in Emergency Preparedness through Metropolitan Medical Response System planning; this was an initiative that focused on response to a Weapons of Mass Destruction event. After 9/11 and the Anthrax Attacks, the Multnomah County Health Department Director charged the Multnomah County Health Department Health Officer with initiating the integration of and collaboration with public and private health sector planning activities. This effort started with creating plans to respond to a smallpox outbreak, and evolved into an established and effective planning approach; this public/private collaboration was formally named the NW Health Preparedness Organization (HPO). In the beginning, participants came from the major hospital/health systems and health departments in the Portland metro area. However, as the HPO, health department, and state preparedness approaches evolved, additional partners from the less populous adjacent rural and coastal communities were added. In addition, strong linkages were developed with governmental emergency management organizations in the region. Since 2001, coordination and leadership of regional healthcare delivery system preparedness activities for the now-seven counties participating in this project has been provided through the activities of the HPO, for which the Multnomah County Health Department serves as Regional Lead Agency. The HPO has a rich and successful history of multi-agency, multi-jurisdictional collaboration to support health emergency preparedness planning and exercising. This collaboration has overcome regional and organizational differences in the public and private health sectors that could be perceived as barriers to cooperation and success. HPO staff and stakeholders have developed a culture that is firmly rooted in making decisions by “working consensus,” conducting scenario-specific planning, and appropriately utilizing expertise and authority of participants through topic-specific work groups. The Multnomah County Health Department endorses, and the HPO utilizes, non-directive facilitative leadership and management techniques to engage stakeholders and manage preparedness planning processes. The HPO’s overall planning approach is to first develop consensus on which response results in the best and most effective community health impact; second to create implementation plans that are integrated with emergency management and public safety agencies; and lastly to exercise, refine, and integrate with related plans. The work of participants is differentiated based on differing organization positions and responsibilities. This approach includes a CEO-level Public/Private Executives Group, a managerial Steering Committee, and time-limited topic specific work groups typically made up of professional and technical staff and managers. This established community stakeholder collaboration, fostered by the Multnomah County Health Department, is at the heart of the work and success of this practice. In addition, the Multnomah County Health Department provides ongoing continuation and support of the practice through its continued commitment to act as Regional Lead Agency, which provides staffing and ongoing support to the HPO. In turn, the HPO identifies strategic work priorities; regional coordination has been established as the top planning priority for the past four years and is fully supported and further by the Multnomah County Health Department. |
| Agency and Community Roles: |
Since August 2004, the Multnomah County Board of Commissioners has annually approved an IGA designating the Multnomah County Health Department as Regional Lead Agency for Region 1. (Oregon is divided into seven regions for purposes of hospital/health system preparedness for emergencies; each Region is required to establish a Regional Lead Agency to coordinate and provide staff support for hospital/health system preparedness.) Accepting the IGA in 2004 formalized the Health Department’s leadership and support for regional health preparedness that has been ongoing since the fall of 2001. Preparedness efforts have involved all hospitals, medical providers, and other health system representatives; it has resulted in an effective voluntary public/private partnership – the NW Oregon Health Preparedness Organization (HPO). The HPO is comprised of representatives from all hospitals and public health departments in Region 1 (Clackamas, Clatsop, Columbia, Multnomah, Tillamook and Washington Counties in Oregon), and Clark County in Washington. Additional partners include representatives from Oregon Department of Human Services, medical and other health professional societies, the Coalition of Community Clinics, behavioral health providers, leaders of culturally-defined communities, non-governmental organizations, and fire/EMS agencies. Both public and private participants have expressed a high degree of satisfaction with this arrangement, facilitated by the Multnomah County Health Department individuals who staff the HPO. In the past few years, the Portland metropolitan region has undertaken significant planning on how best to coordinate the regional health/medical response with jurisdictional level emergency management agencies under the auspices of the HPO. This laid the groundwork for developing the Health/Medical MAC Group, its associated Ethics Framework, and exercise series. In addition to providing long-term executive-level leadership, advocacy, and support for coordinated healthcare and public health decision-making and response to health emergencies, the Multnomah County Health Department actively participated in the practice. The Director of the Multnomah County Health Department, and the Deputy to the Director, both represented the Multnomah County Health Department on the Health/Medical MAC Group through participation in the Health/Medical MAC Group training, exercises, real-time meetings, and evaluation. The Multnomah County Health Department Health Officer, who serves as a Tri-County Health Officer, served as the principle investigator for the practice as well as technical expert to the Health/Medical MAC Group, attending the training, exercises, and real-time meetings. Deputy Multnomah County Health Department Health Officers also served as technical experts to the Health/Medical MAC Group, attending the training, exercises, and real-time meetings. The Multnomah County Health Department’s Lead Epidemiologist and associated staff developed the epidemiological projections for a 1918-like event for use in the exercise series. Medical Interns to the Multnomah County Health Department’s Health Officer provided technical expertise in describing the current capacity of the healthcare system and strategies to increase capacity to handle the increased demand for care during a severe pandemic, and attended the Health/Medical MAC Group exercise and real-time meetings. The Multnomah County Health Department’s Health Assessment and Evaluation office served as the practice evaluators. The Manager or Health Assessment and Evaluation assisted in the ethics materials development and conducted community discussions to collect information on local values about health and healthcare, which contributed to the development of the Ethics Framework. Multnomah County Health Department’s HPO Program Managers had primary oversight of the development, implementation, and evaluation of the practice; additional Multnomah County Health Department HPO staff provided practice coordination, technical expertise, administrative assistance, contract tracking, and overall support. The ability to develop and sustain a Health/Medical MAC Group is a direct result of the HPO and the strong partnerships developed and cultivated across institutions and jurisdictions over the past eight years. Through the HPO’s leadership, health response partners in the region have jointly exercised institutional and community regional emergency response plans several times. This track record of highly successful public health and healthcare preparedness work is what brought stakeholders to the table to participate and contribute to this project. They saw this project as an opportunity to expand and complete critical ongoing preparedness work; the HPO Steering Committee strongly recommended applying for the CDC grant for this reason. Regional public health leadership, HPO Steering Committee members, and the Oregon Public Health Division provided ongoing strategic direction and practice support. Members of the HPO Steering Committee were actively involved in recommending individuals to participate as Health/Medical MAC group members from their respective system/organization. This authority of the Steering Committee to appoint members demonstrates the investment of private healthcare systems and public health into the HPO Steering Committee process and ultimately the Health/Medical MAC Group. This trust and value of system-wide collaboration was reinforced as the Health/Medical MAC Group shifted from grant-related exercises to real-time H1N1 issues. This shift provided an opportunity for broad regional coordination of health/medical efforts between public health officials, area hospitals, community health clinics, emergency management and state officials, in order to an ensure efficient and effective response to a pandemic event. This multi-agency coordination proved to be a key component in developing policy-level decisions and directives that were then disseminated to affected communities and target populations. Also important to the development, implementation, and evaluation of the practice were the following stakeholders: 1) Community members throughout the region participated in community discussions to identify widely held values about health. This information was used to develop the Ethics Framework used by the Health/Medical MAC Group; 2) Experts in decision science, health economics, epidemiology, preventive medicine, ethics, and public health who participated in the analytic processes used to support Health/Medical MAC Group development; and 3) Leaders from culturally-defined communities including people of color, aging, disabled, and homeless who participated in evaluation activities along with half of the Health/Medical MAC Group members and some of the technical experts. In all, nine Health/Medical MAC Group members and 74 observers (and technical consultants) participated in evaluation activities. The breakdown of who evaluated the Health/Medical MAC Group work is listed below: Group Represented Percent of Observers Community Leaders/Liaison 16% Local Public Health 15% Contractors 12% Hospitals 9% Behavioral Health 9% Emergency Management 8% Clinical Community 8% Skilled Nursing 7% Community Based Organizations 5% State Public Health 4% Ethics Field 4% Public Information 3% |
| Costs and Expenditures: |
No in-kind costs were required for the implementation or start-up of the project to develop the practice (Health/Medical MAC Group). All activities to develop the practice were paid for by the Centers for Disease Control and Prevention grant (described in the next question). Activities were designed to be easily modified and implemented by urban communities utilizing the “ordinary” capacities and resources likely to be locally available during a well-established pandemic. Activities started as parts of a functional exercise series around a 1918-like pandemic event, but transitioned to a real-time, tested practice due to H1N1. The activities were implemented in three phases: Phase One: Develop information for functional exercises, including epidemiological projections for a 1918-like event; description of the current capacity of the healthcare system and strategies to increase capacity to handle the increased demand for care during a severe pandemic, while maintaining essential services not related to influenza; and an ethics framework based on community values on which to run decisions through in order to encourage community acceptance. Phase Two: Identify and train members of the Health/Medical MAC Group and conduct an iterative functional exercise series (which became real-time meetings due to H1N1) for the Health/Medical MAC Group to practice decision-making (including the application of the developed ethics framework), collaboration, and organizational learning. Phase Three: Conduct project evaluation activities to inform the refinement of the Health/ Medical MAC Group, document what the group accomplished, and measure stakeholder acceptability of utilizing this public health practice for decision making during a health/medical emergency. Due to the complexity and evolving nature of this project, it proved crucial that local, consultative resources be retained to guide the Health/Medical MAC Group development, epidemiological modeling, ethics framework development, and the analyses of current hospital utilization and possible deferability of services. A final evaluation report scheduled to be released by May 2010 will be instrumental to other communities wishing to replicate this public health practice. This report will include: 1) analytic studies from phase one activities; 2) training materials, recruitment suggestions for effective group members, and an operational Health/Medical MAC Group handbook with multiple tools for participation developed during phase two activities; and 3) qualitative data from community observers and Health/Medical MAC Group members on the effectiveness, acceptability, challenges, recommendations and identified next steps from phase three activities. The project proposal was submitted by the Multnomah County Health Department (MCHD) on behalf of the NW Oregon Health Preparedness Organization (HPO) and the Oregon Public Health Division (OPHD). All costs required to develop the practice were paid by the Centers for Disease Control and Prevention’s Essential Healthcare Services Project: “CDC Pandemic Influenza Collaborative Planning and Delivery of Essential Health Services.” (Award: 1U90TP000129). The project team (approximately 6.0 FTE) employed a Principal Investigator, Program Managers, a Project Coordinator, Program Development Specialists, an Evaluation Analyst and Administrative Assistants. Contractors included PhD, MPH, and MD-level experts in decision science, health economics, epidemiology, preventive medicine, ethics, and MAC Groups; as well as leaders from culturally-defined communities including people of color, aging, disabled, and homeless. An inter-governmental agreement was established between the OPHD and the MCHD to outline grant award amounts, activities and reporting requirements, along with standard governmental requirements. |
| Implementation: |
This practice addresses the public health need for coordinated healthcare and public health decision-making and response to health emergencies in a multi-county, multi-jurisdictional area. The Health/Medical Multi-Agency Coordination (MAC) Group practice developed is a decision-making group comprised of hospitals, public health, and other healthcare entities with collective responsibility to: 1) prioritize which decisions must be made in order to support a strained healthcare delivery system; 2) develop ethically-based regional strategies to allocate critical resources; 3) propose altered standards of care and policy approaches; 4) propose community mitigation approaches to limit disease transmission; and 5) support accurate dissemination of information to the public. The use of a MAC Group for public health is an innovative adaptation of a practice used by fire and police for emergency management. Also, the practice addresses the need to involve community (both individuals and businesses) in the identification and solutions to public health issues. Unique to the practice we developed was the use of community observers’ feedback to refine the practice as well as measure the likelihood that the community will accept decisions made as appropriate under the circumstances, respectful, compassionate, and ethical. Also important was the group’s ability to make decisions that resulted in reasonable operational and financial equity among hospitals/health systems, clinicians, and other providers to protect the health care system’s capacity to provide health care as usual to the community after the event. Between January and April 2005, HPO staff convened three workgroups to draft initial concepts of operations that represented consensus on the most practical and effective approach to meeting the demands of a novel strain influenza. In addition, the groups were to recommend what would be needed to develop and implement institutional-level plans (e.g., planning, training, equipment, staffing). The workgroups were: 1) hospital surge, 2) ambulatory surge, and 3) communications. In addition to the groups’ success in accomplishing these tasks, they provided invaluable information on what was needed to support the regional healthcare delivery system achieve an effective, efficient, community–accepted, appropriate, semi-autonomous response during a health emergency. As a result of this information Region 1 health responders identified five specific functions that were needed to support a regional response: 1) situation status regarding health care impacts; 2) optimal distribution of scarce health resources; 3) policy guidance; 4) provider information; and 5) situation status regarding non-healthcare impacts. Simply stated, the public health need for coordinated healthcare and public health decision-making and response to health emergencies in a multi-county, multi-jurisdictional area was clearly identified. In 2008, HPO staff convened a workgroup to examine a proposed framework to address the five functions above through establishment of a regional Health/Medical Coordination Center (HMCC). The HMCC was designed to serve as a centralized, regional, health and medical information coordination center with open lines of communications with involved hospitals, clinics, public heath, city/county emergency management, and state public health. The HMCC would collect information from health responders, synthesize the information into a regional health situation status report, and disseminate the report to key response partners. Based on information from healthcare delivery partners and projected needs, the HMCC would determine when/what health resources are scarce and direct healthcare delivery partners to send requests for identified scarce health resource to a designated County Emergency Coordination Center (ECC). The HMCC would also convene a MAC group to establish priorities for resource allocation. In November 2008, the HMCC was exercised in a small-scale MCHD functional exercise. While opportunities for improvement were identified, participants, evaluators and observers expressed support for continuing to develop and refine the HMCC. In addition, the observation was made that the HMCC might be a duplicative layer to the existing response structure. The suggestion was made to explore how to better integrate the HMCC with the supporting county ECC. That recommendation was moved forward, just in time for H1N1. We successfully integrated the HMCC functions into the Multnomah County ECC that: 1) created a regional situation status report; 2) supported the optimal distribution of scarce regional health resources; 3) conveyed regional policy guidance; and 4) conveyed provider information. These all supported the work of the Health/Medical MAC Group. As a result of this work, we, and our multiple community partners met the public health need for coordinated healthcare and public health decision-making and response to health emergencies in a multi-county, multi-jurisdictional area. This practice addresses the public health need for coordinated healthcare and public health decision-making and response to health emergencies in a multi-county, multi-jurisdictional area through the establishment of a Health/Medical MAC Group. When activated, this Group serves as a decision-making body comprised of representatives from hospitals, public health, and other healthcare settings who collectively have the responsibility and ability to: 1) Prioritize which decisions must be made in order to support a strained healthcare delivery system: All health emergencies present multiple decision-making opportunities and situations which necessitate prioritization. This practice utilizes MAC Group coordinators who prioritize issues for the Health/Medical MAC Group. It is crucial that this prioritization happens in order to conserve time and resources, yet support the most critical response needs. 2) Develop ethically-based regional strategies to allocate critical resources: Particularly in the interest of maintaining an intact community--one that is able to resume normal life physically, socially, economically, and spiritually following the event. This requires that the local healthcare delivery system utilize available healthcare resources effectively and efficiently, address health conditions in a balanced way, and act in a way that is perceived by community members as ethical and appropriate under the circumstances. Also important is that the response results in the equitable distribution of operational and financial burdens across individual hospitals, clinics, individual providers and larger health systems. 3) Propose altered standards of care and policy approaches: The interest is in minimizing death and disability as much as possible given available resources. An example of this was the real-time creation of a regional mask use policy recommendation that would optimize the safety of staff, patients and the community at large, while helping to conserve scarce resources in the community. 4) Propose community mitigation approaches to limit disease transmission: An example of this was the real-time development of a regional hospital visitation policy recommendation regarding who could visit patients in the hospital in light of the prevalence of H1N1 in the community. The policy was based on infection control practices and evidence-based medicine in the interest of protecting the public, hospital staff, and medically at-risk populations from becoming ill with H1N1 influenza virus. 5) Support accurate dissemination of information to the public: All regional policy recommendations stemmed from a desire to have uniform policies that were more easily communicated to the public in order to engender public trust and minimize public confusion, as well as protect the health of responders and the public. Because all decisions are grounded in the Ethical Framework, the community will be more likely to accept the need for and consequences of difficult decisions if they are made in an open, transparent, and inclusive way. In addition, policy makers want decisions that are made during a health emergency to be based on a consideration of community values as well as on science. The Ethical Framework provides that consideration. The Health/Medical MAC Group practice provides a framework for the development of similar practices in additional geographic areas, which could potentially bring in additional successful practice tools and outcomes. Development of the Health/Medical MAC Group began with a review of existing MAC Group models from various agencies and jurisdictions. We found a number of MAC Group models (particularly for fire agencies), but none for a health discipline. Because all of the models came from non-health disciplines, we had to identify one that was comprehensive and could be modified to meet the needs of a health/medical event. Through this initial review process, it was evident that we would benefit from consultation with technical experts who had been involved with MAC Groups and processes during real-time responses to emergencies. We engaged contractors from Organizational Quality Associates (OQA). OQA is a firm with substantial national experience participating in management of complex emergencies, and with providing training and developing emergency response and coordination systems. Based on their national perspective, OQA agreed that the development of a Health/Medical MAC Group was truly an innovative use of the MAC Group model. As noted above, we were unable to find literature documenting use of MAC Groups by local public health or other health agencies. In Oregon, there is no well-established and consistent plan for multi-jurisdictional public and private coordination of healthcare delivery in an emergency. Various plans have been developed, and tested in response to exercises and real events. Despite this, the state lacks a fully developed and implemented healthcare response coordination plan. We believe that the Oregon experience with healthcare coordination during the autumn H1N1 wave was typical of that for many states. In Oregon, a variety of healthcare coordinating approaches have been adopted within formal regions or in ad-hoc community clusters. These approaches typically involved coordinating groups with membership that is similar to that of our Health and Medical MAC Group. However, these groups typically lacked a formal procedural and organizational framework, and were variably connected to the rest of the local emergency management system. In southwest Washington (which is part of the Portland metropolitan region), a coordinating approach based in a “Health Advisory Group” (HAG) has been developed and tested in a number of exercises. Similar to the Health and Medical MAC Group, the HAG membership includes local public health leadership, and representatives of health care delivery organizations. However, in past exercises, the HAG did not operate using specific procedural guidelines, nor was it fully integrated with a regional ECC. During the course of the autumn 2009 H1N1 pandemic response, we became aware that various communities attempted to coordinate health care delivery using entities that were called Multi-agency Coordinating Groups. However, from the minimal information available on the Internet, these groups appeared to be dominated by public health officials as decision-makers. There was also an absence of documentation that these groups operated according to NIMS-compliant Multi-agency Coordinating Group procedures and standards. Presumably, the various informal approaches described above were adequate to coordinate care in the face of the autumn 2009 mild H1N1 pandemic wave. However, it is important to note that this pandemic wave placed only a mild to moderate stress on health care delivery systems. As a result, there was not an overwhelming need for well-structured and well-supported coordinating approaches. Other more severe emergencies will likely require more rigorous approachesUtilization of MAC Groups is a well established strategy for management of wildfires and natural disasters; however the existence or use of a MAC Group for a health/medical emergency had not been formally tested in our region prior to this project. Historically MAC Groups have not been used for emergencies by any discipline or jurisdiction in the Portland metro area. In large part this has been due to an absence of large and complex events requiring community-level resource prioritization and response policy alignment. There has also been resistance by the local emergency management community to employ a variety of regionally-based response strategies, including MAC Groups. As a result, there is no established regional Emergency Coordination Center to support a MAC Group. Our local health/medical sector already had success coordinating exercise and real event responses regionally, and was eager to explore whether the MAC Group model could be effectively applied to help manage health/medical emergencies. With some initial hesitation, the local emergency management community supported the health/medical sector’s exploration of using a regional Health/Medical MAC Group.N/AWhat does the LHD do to foster collaboration with community stakeholders? Prior to 9/11, Portland Metropolitan area hospitals were engaged in Emergency Preparedness activities, but primarily only those required by JCAHO. Public Health was just getting involved in Emergency Preparedness through Metropolitan Medical Response System planning; this was an initiative that focused on response to a Weapons of Mass Destruction event. After 9/11 and the Anthrax Attacks, the Multnomah County Health Department Director charged the Multnomah County Health Department Health Officer with initiating the integration of and collaboration with public and private health sector planning activities. This effort started with creating plans to respond to a smallpox outbreak, and evolved into an established and effective planning approach; this public/private collaboration was formally named the NW Health Preparedness Organization (HPO). In the beginning, participants came from the major hospital/health systems and health departments in the Portland metro area. However, as the HPO, health department, and state preparedness approaches evolved, additional partners from the less populous adjacent rural and coastal communities were added. In addition, strong linkages were developed with governmental emergency management organizations in the region. Since 2001, coordination and leadership of regional healthcare delivery system preparedness activities for the now-seven counties participating in this project has been provided through the activities of the HPO, for which the Multnomah County Health Department serves as Regional Lead Agency. The HPO has a rich and successful history of multi-agency, multi-jurisdictional collaboration to support health emergency preparedness planning and exercising. This collaboration has overcome regional and organizational differences in the public and private health sectors that could be perceived as barriers to cooperation and success. HPO staff and stakeholders have developed a culture that is firmly rooted in making decisions by “working consensus,” conducting scenario-specific planning, and appropriately utilizing expertise and authority of participants through topic-specific work groups. The Multnomah County Health Department endorses, and the HPO utilizes, non-directive facilitative leadership and management techniques to engage stakeholders and manage preparedness planning processes. The HPO’s overall planning approach is to first develop consensus on which response results in the best and most effective community health impact; second to create implementation plans that are integrated with emergency management and public safety agencies; and lastly to exercise, refine, and integrate with related plans. The work of participants is differentiated based on differing organization positions and responsibilities. This approach includes a CEO-level Public/Private Executives Group, a managerial Steering Committee, and time-limited topic specific work groups typically made up of professional and technical staff and managers. This established community stakeholder collaboration, fostered by the Multnomah County Health Department, is at the heart of the work and success of this practice. In addition, the Multnomah County Health Department provides ongoing continuation and support of the practice through its continued commitment to act as Regional Lead Agency, which provides staffing and ongoing support to the HPO. In turn, the HPO identifies strategic work priorities; regional coordination has been established as the top planning priority for the past four years and is fully supported and further by the Multnomah County Health Department. |
| Sustainability: |
Absolutely. At its two-year strategic planning meeting in January 2010, the HPO steering committee assigned the refinement and solidification of regional coordination as its number one priority for 2010-2011. The HPO steering committee further identified specific activities to ensure the refinement and solidification of regional coordination. They are: 1) continuation of Health/Medical MAC Group development in the areas of relationships and processes; 2) continuation of the Health/Medical MAC Group development in the area of Incident Support Organization and Expanded Resource Ordering Group; 3) affirmation of single-point resource ordering, documentation and distribution of the process; and 4) coordination of HPO and Portland Urban Area Regional Disaster Preparedness Organization processes. This priority and associated activities are ensured in the following ways: • The Office of Multnomah County Emergency Management is committed to continuing serving in a regional capacity to provide regional situation status and regional resource ordering, which are crucial to the support and functioning of the Health/Medical MAC Group • Regional Emergency Managers are supportive of the Health/Medical MAC Group and its role in health emergencies. • During the last formal Health/Medical MAC Group meeting, members requested meeting quarterly for the purpose of continuing the development of relationships and processes. HPO staff, assisted by Mike Edrington of Organizational Quality Associates (OQA), convened and facilitated the first quarterly Health/Medical MAC Group meeting on February 3, 2010. Meeting topics and activities were as follows: 1) shared understanding of NW Health Preparedness Organization (HPO) Steering Committee; knowledge of HPO 2010-11 priorities; 2) understand proposal for how to move Health/Medical MAC Group forward; identify missing components; consensus and prioritization of areas to pursue; assign timeframe; and 3) set meeting dates for the year (May 5, August 4, November 3). Health/Medical MAC Group members have also committed to obtaining and retaining alternate members in the event primary members are not available. • Nearly one-half of Health/Medical MAC Group members participated in either a focus group or key stakeholder interview as part of the project’s evaluation, even in the light of competing priorities. Of these evaluation participants, there was representation from small hospitals, large heath systems, emergency management, and public health. Their willingness to participate in evaluation activities and their feedback demonstrated strong support that they valued their involvement in and the use of the Health/Medical MAC Group. As previously described, at its two-year strategic planning meeting in January 2010, the HPO steering committee assigned the refinement and solidification of regional coordination as its number one priority. The HPO steering committee further identified specific activities to ensure the refinement and solidification of regional coordination. Activities and plans are as follows: 1) Continuation of Health/Medical MAC Group development in the areas of relationships and processes: The services of Organizational Quality Associates (OQA) will be retained to assist HPO staff in this plan. The FY10 Hospital Preparedness Program grant will provide funding for the ongoing participation of Health/Medical MAC Group members, and for OQA to continue in their role. Following is a list for future Health/Medical MAC Group work in 2010 and 2011 as determined by members at the February 3, 2010 meeting: 1. Review and revise Health/Medical Multi-Agency Coordination (MAC) Group Handbook. Develop Working Guidelines. 2. Conduct team building activities on the topics of decision-making, communication skills, and learning members’ personal and organizational values perspectives. 3. Discuss and select processes to bring in new Health/Medical MAC Group members. 4. Develop procedures to respond when there is less than 100% consensus during initial decision-making, when the overall situation changes, and when one or more organizations dissent after decision has been made. 5. Determine how issues go to the Health/Medical MAC Group and how issues are prioritized. 6. Develop the ways technical specialists will be utilized by the Health/Medical MAC Group. 7. Determine how member alternates are utilized and trained. 8. Determine relationship between and perspectives of the Public Health MAC Group and the Health/Medical MAC Group. 9. Determine level of public transparency, how and when to inform the public of decisions, and obtain public feedback. In the event additional funding is obtained, the Health/Medical MAC Group’s work plan will be expanded to include: 1) Further develop an ethics tool for use during Health/Medical MAC Group meetings to ensure and demonstrate consideration of the four dimensions of the current Ethics Framework in decisions; and 2) Provide additional Health/Medical MAC Group trainings for new members and those identified as alternates in order to ensure a sustainable community methodology. 2) Continuation of the Health/Medical MAC Group development in the area of Incident Support Organization: In order to provide real-time support to the Health/Medical MAC Group during a health emergency, development in this area will be completed through formal agreement amongst regional emergency managers (and supporting Memorandums of Understanding) for one county ECC to serve a regional Incident Support Organization role, and increase ISO support capacity and capability through Incident Command System training. 3) Affirmation of single-point resource ordering, documentation and distribution of the process: This will be completed through formal agreement amongst regional emergency managers (and supporting Memorandums of Understanding) for one county ECC to serve a regional Incident Support Organization role, and increase ISO support capacity and capability through Incident Command System training, particularly for an Expanded Resource Ordering Group. |
| Lessons Learned: |
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