By James Ballard, MBA, CPHQ, CPPS, HACP and Christopher Pratt, MS, BSN, RN
A Futuristic Perspective for Incident Management
In Parts I and II of Emergency Preparedness, we provided an overview of what happens when disaster strikes and a process to trace your current procedure. In Part III, we offer a futuristic viewpoint on High Reliability Organizations (HRO), with a ‘collective mindfulness’ toward given goals in relation to Hospital Incident Command Systems (HICS) and National Incident Management Systems (NIMS). In healthcare, these goals include safe patient care that results in positive outcomes. HRO organizations also focus on learning from experiences, error events and best practices based in evidence. The question we propose is: How can Incident Command Center Operations be conducted utilizing the five (5) main HRO principles?
The Five HRO principles include:
1. A sensitivity to operations. Members of the organization, including both leaders and staff, are constantly aware of how processes and systems affect how the organization delivers healthcare services. Each employee pays close attention to what is or is not working.
2. A reluctance to accept “simple” explanations for problems. The most rational explanation as to why a problem occurs may be the easiest and fastest means to a solution. However, failure to dig deep enough to find the real source of a particular problem could have devastating consequences.
3. Preoccupation with failure. Members of the organization from the C-suite to the bedside are asked to constantly think of ways their work processes might break down. This includes minor inefficiencies and more complex failures including medical errors.
4. Deference to expertise. Process owners, regardless of seniority, are encouraged to voice their concerns, ideas, and input as they are most familiar with the details of organizational operations. Recognition that their input is essential will support robust growth of high reliability.
5. Resilience. Organizations when faced with unexpected failures, are steadfast in their response in seeking solutions. They are skilled in problem solving and seeking out solutions to avoid catastrophe.
Historical Context and Requirements
Hospital Incident Command began as part of the National Incident Management System (NIMS) back in 2005 and became a requirement under The Pandemic and All Hazards Preparedness Act of 2006. This Act stated:
“All hospitals and healthcare systems receiving Federal preparedness and response grants, contracts or cooperative agreements (e.g., Bioterrorism Hospital Preparedness Program, Department of Homeland Security grants) must work to implement the National Incident Management System (NIMS). Hospital and healthcare systems are defined as all facilities that receive medical and trauma emergency patients on a daily basis. These facilities do not include non-hospital receivers (i.e., nursing homes, assisted living communities, long-term care facilities and specialty hospitals (i.e. psychiatric, rehabilitation facilities)).
The Department of Health and Human Services (HHS) requires the following four (4) NIMS activities be adopted and/or implemented by hospitals receiving FY 2006 Federal preparedness and response grants, contracts, or cooperative agreements by September 30, 2007”.
The four NIMS activities that must have been adopted and implemented were:
• Revise and update plans [i.e. Emergency Operations Plan (EOPs)] and standard operating procedures (SOPs) to incorporate NIMS components, principles, and policies, to include planning, training, response, exercises, equipment, evaluation, and corrective actions.
• Complete IS-700: NIMS: An Introduction
• Complete IS-800.A: NRP: An Introduction
• Complete ICS 100 and ICS 200 Training or equivalent courses
There are 17 NIMS Implementation Activities for Hospital and Healthcare Systems. The second principle is the one we want to focus on in this newsletter: Command and Management. The command and management structure for healthcare began in the late 1980’s with the hospital emergency incident command system (HEICS) which later was reduced to just the hospital incident command system (HICS) as we know it today. This system was designed to:
• Be usable for managing all routine or planned events, of any size or type, by establishing a clear chain of command
• Allow personnel from different agencies or departments to be integrated into a common structure that can effectively address issues and delegate responsibilities
• Provide needed logistical and administrative support to operational personnel
• Ensure key functions are covered and eliminate duplication
The incident planning process takes place regardless of the incident size or complexity. This planning involves six essential steps:
• Understanding the hospital’s policy and direction
• Assessing the situation
• Establishing incident objectives
• Determining appropriate strategies to achieve the objectives
• Giving tactical direction and ensuring that it is followed (e.g., correct resources assigned to complete a task and their performance monitored)
• Providing necessary back-up (assigning more or fewer resources, changing tactics, et al.)
The Futuristic Perspective
There is no doubt that healthcare organizations benefit from incident planning and to predetermine emergency command center structure for most hazard events. However, the recommended HICS structure was based on the idea of hazard events that impacted a localized geographic area for a short period of time meaning that incident command operations would only be needed for a short duration; then recovery could start. The Covid-19 Pandemic has shown us that hazard events can be overwhelming, impact the entire world at the same time and have an unknown, and extended duration period.
Can healthcare organizations sustain incident command centers and operations indefinitely?
In listening to healthcare organizations talk about their response to Covid-19, most indicated that they did not follow the traditional HICS format, meaning they did not assign job action sheets to leaders, they did not fill out HICS forms and they did not keep manpower in one central ‘command’ center 24 hours a day for extended periods of time. This is perfectly understandable under the circumstances and this led us to believe that Incident Command could function differently utilizing both HICS and HRO principles. Healthcare is a learning industry and organizations should use Covid-19 as an opportunity to learn, plan and adapt to the unexpected.
HICS is a system with a typical structure including incident command staff identification, building incident command staff depth, job action sheets, and incident response guides. HICS is about planning how the organization will manage the life cycle of an incident, which includes:
• Alert and notification
• Situation assessment and monitoring
• Emergency Operation Plan(s) implementation
• Establishing the Hospital Command Center
• Building the Incident Command System structure
• Incident action planning
• Communications and coordination
• Staff health and safety
• Operational considerations
• Legal and ethical considerations
• System recovery (Continuity of Operations)
• Response evaluation and organizational learning
HRO is a set of principles that guide organizations into this ‘collective mindset’ seeking to avoid complacency while recognizing that ‘one-size’ does not fit all, especially in emergency response efforts. There is no one single way that meets all needs of all healthcare organizations. What healthcare organizations should focus on are:
1. Sensitivity to operations.
To hard-wire this principle, organizational leadership must first become more transparent through improved communication and data sharing. Employees who are well informed will pay close attention to events as they unfold to ensure they stay abreast of organizational plans and changes to those plans. One major complaint heard during Covid-19 by staff was that leadership did not keep information flowing to them fast enough and they felt that they were being kept in the dark. We understand this was an extremely challenging situation as fast as Covid-19 spread and recommendations changed. However, communication is the binder for all activities and is the process that often gets interrupted during busy times.
Second, leaders should use rounding to drive outcomes. “Management by walking around”, also known in Lean practice as the Gemba Walk, can help leaders develop a more detailed understanding of their Emergency Management practices by observing the process and talking with staff and their supervisors. This also promotes greater communication and help identify those processes that are working and those that are not. Rounding should be done with purpose to identify issues that may hinder effective operations.
By hard-wiring rounding and other means of communication to enhance not only emergency operations, but daily operations as well, improved communication results. Organizations will not only be able to improve communications, they will also develop a better understanding of critical operations. Communications cannot be improved by simply talking about it or having education sessions about it. Organizations must instill this practice. Communication practices must be included in EM drills and offer multiple methods of sharing information like newsletters, daily email blast, text messages and computer screen crawlers. The practice sessions must include a repeat-back cycle or allow for questions to show the receiver heard and understood the messages.
2. Reluctance to Simplify.
The organization can hard-wire this principle by ensuring that it avoids making assumptions about the cause of operational issues. Data, benchmarks, and performance measures should be used in seeking solutions, but highly reliable organizations will dig further into their metrics than may seem plausible to ensure that they have a true picture of what is happening. Leaders should be bold in looking for measures that may challenge their assumptions. In Emergency Management response situations like Covid-19, data may not be available, and information must come from multiple sources. Organizations must be willing to try various activities to address the situation. HRO principles direct leaders to seek facts and evidence-based practices before jumping the gun and following one or two simple recommendations.
3. Preoccupation with failure.
When leaders are confronted with areas where processes are not working correctly, they should look to those work centers where these same processes are working to determine what is leading to success and why there is failure. Additionally, looking at near misses, where errors do not affect the patient or cause catastrophic results, as examples of safeguards to learn from, enables the organization to identify vulnerabilities that can be addressed across the organization.
During the Covid-19 response, it appeared that information was coming from two sources, the Centers for Disease Prevention and Control (CDC) and the World Health Organization (WHO) where information did not always match. When confronted with challenges, HRO leaders should seek other like entities facing similar challenges and share information learned from these challenges. When organizations have an understanding that improvements come from working through failures, they truly become a learning organization. The response to Covid-19 may have been less challenging if healthcare organizations were up front and ‘on-stage’ leading the conversation as to what was working and what did not work.
4. Deference to expertise.
Leaders can hard-wire this principle through discussion and role modeling, by conducting discussions regarding organizational processes where they occur as much as possible. This supports greater opportunity for deference to expertise by the employees present in addition to a level of detail in conversation that may not be possible in a meeting room. This could also occur during simulations or drills where system processes are stressed. Additionally, many people in healthcare have experiences from other organizations which can be used to support a look with fresh eyes on organizational processes.
What we heard from colleagues through calls and discussions was that the medical team was involved in daily huddles providing needed input from all disciplines. Incident command does not always have the answers. The HRO principle of deferring to the experts provides a way for those with expertise to collectively seek solutions to the emergency event at hand. Healthcare is always better when multidisciplinary teams practice together – learning and sharing from each other for consensus building on what may work best for all involved.
In hard-wiring this principle, leaders must ensure that their actions and performance are effectively evaluated in terms of their response to Emergency Management events including drills. Performance should be evaluated against specific and measurable goals to ensure that leaders are challenged and improving their skills in terms of their disaster response. Healthcare will be best served after Covid-19 if organizations recognize the efforts of all staff members. Their collective efforts show how teams grow together and how the ‘culture’ of an organization develops. A culture of safety can be the result of an Emergency Management response when HRO principles are applied.
Additionally, it is imperative that the organization emphasizes skill development based on performance critiques and lessons learned from other organizations. Identifying problems that have occurred at other facilities can provide the organization with ideas on how to address potential shortfalls in their processes.
We agree that the requirements for NIMS and HICS provide structure by outlining actions necessary for organizations to be prepared and to document evidence during the disaster response situations. We also agree that organizations need to pursue HRO in all aspects of their operations – including Emergency Management. Organizations that are sensitive to operations, defer to the expertise of their staff, both within and outside of the organization, can develop resiliency in their organizations that allow them to adapt and overcome, emerging from hazard events in a better position than they were when then event began.
Covid-19 showed us that we should always expect the unexpected and that we cannot plan for everything because we do not have the capacity to know everything. What healthcare can do as an industry is: 1) Prepare for the worse-case scenario as we know it from historical events, 2) Learn as we go through hazard event situations, 3) Cross train staff to ensure we have the labor pool available for whatever is next, and 4) Develop leaders who are well rounded in business, ancillary services and clinical services. We do not need leaders who can perform clinical functions every day, but we do need leaders who fully understand clinical processes as well as support ancillary processes. Healthcare is a complex system and the more that leaders understand about the interconnectedness of processes and operations, the better prepared the organization will be to face the next unexpected event.