Oct 072016

It’s been awhile since we have had a hurricane season that actually produced hurricanes. I have pulled up a few posts from previous years that may have some value for my readers.matt

With Hurricane Matthew turning up the eastern seaboard the Governor of Georgia declined to order any mandatory evacuations. They instead deferred to local authorities to make the determinations. My post Leave or Stay: When Should We Really Evacuate and Why? might be a good read.

Thousands of people have moved out of the coastal areas and numerous shelters have been opened.  My post Could Current Shelter Requirements Keep People Out in the Cold is timely at this moment too.

My post Are Hericanes More Deadly Than Himicanes? It’s time to improve naming conventions looked at perceptions people might have based on the gender of the storm. I wonder if Matthew was chosen on purpose or just luck of the draw?

I took a good look at problems we’ve had with other high profile hurricanes in my post Do We Lack the Will to Prepare? I’m really hoping we don’t see repeat problems.

How quickly we bounce back will be interesting to watch. My post The Surrender of Self Reliance looked at some advantages developing nations had over the United States.

Enjoy the reads and I look forward to your comments.

Sep 122016

The Centers for Medicare & Medicaid Services (CMS) has published the Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers rule. Tipping the scales at 651 pages there is no doubt it is a federal document.  I was thinking what would have happened if my mom gave me a rule 651 pages long….I would still be grounded.

In reading through the estimated hours predicted for various facilities to develop the required documents it makes me question what the intent of the rule really is. I have no doubt organizations will come up with written documentation to meet the rule so they are in compliance. I also have little doubt that the documents produced in many cases will not actually enhance preparedness in the community.


This chart outlines the FEMA recommended process to follow in developing a plan (also listed in the rule as a helpful reference). If we compare the chart with the anticipated body of planning work to accomplish to meet the new rule it does not really match up well.

On the other hand I would look at this as an opportunity to boil the 651 pages down to what is necessary and more importantly what makes sense in enhancing preparedness of an organization among the whole community. In my experience there is an inverse relationship between the thickness of an organization’s (state and federal government included) plans, policies and procedures and their ability to actually implement them. It is possible to over plan and that should be avoided. In the CMS rule they point out four core elements to focus on. They are:Fire in Stairwell

  • Risk Assessment and Emergency Planning
  • Policies and Procedures
  • Communication Plan
  • Training and Testing

Over the years one of the most common reasons I heard why emergency preparedness programs were disliked in healthcare facilities is that the training and exercises were so disruptive of daily operations. No one objected to one poor soul writing a plan to make them “compliant”, but the issues started when the author actually tried to implement change and ensure competency. The reality is that a well designed preparedness program and sound understanding of the Hospital Incident Command System (HICS) can actually simplify life within your organization. Both on a day to day basis and when emergencies arise.  My suggested keys to building a successful program are:

  • Implementable Planning – Boiler-plate plans are going to be popping up and tempting many organizations to make them “CMS compliant” yet they are seldom a good fit for any facility. Many consulting firms love them because they are easy to develop and therefore profitable to sell. They may allow you to check the box necessary to meet a grant deliverable but they will most likely fail in a real event.  Developing plans that actually work may take more up front effort but make your life much easier in managing the event.  Keep in mind after an event you will be judged based on your plans, polices and procedures and training records.  If you can’t actually accomplish something you’ve documented in your plan you are setting yourself up for misery and liability.
  • Practical Training – I consider education to be a key factor in how people will perform under stress. Canned courses are like boiler-plate plans. Usually longer than they need to be and a good portion of the content is is irrelevant to your organization or performance expectations. I am often accused during my courses of making people think.  It’s not rocket science stuff. I simply give them material which is relevant to their current situation, aligns with organizational expectations and is focused on need to know material.
  • Realistic Exercising – Properly designed and facilitated, exercising is where we can evaluate the results of our planning and training components. Part of exercising is the evaluation component and developing a Plan of Improvement. These findings go into the next evolution of planning and training effort. Exercising without incorporating what we have learned is a waste of effort and resources. For additional information on ideas for a good exercise program click on the link.

While the intent of the ruling is to raise the bar of emergency preparedness in individual facilities, the final outcome should be a better prepared community.  You may be able to find assistance from other members of the healthcare or emergency management organizations in your area. Regardless of the route you take to meet the ruling, internal work effort, other community partner agencies or a consultant, make sure your preparedness program passes this common sense test.

  • If a predictable event(contained in your Hazard Vulnerability Analysis) occurs, does your staff understand their role in ensuring the safety of all staff, clients and visitors?  This includes staff on campus as well as working at remote locations.
  • Does your organization utilize the HICS to manage events and trained staff have demonstrated competency in its use? If efficiency in operations and effectiveness in outcomes is desired, spend time learning how to use the HICS and not just spell it out.
  • Has your organization developed sufficient documentation (plans, polices, procedures, initial Incident Action Plans) for staff to understand how they will provide for the continuity of patient care in emergencies? This may require coordination with other community partners as necessary and appropriate.
  • Is organizational leadership 100% engaged in the preparedness process?

I would love to hear from organizations and how they are intending to proceed in order to meet the intent of the rule.

Aug 202016

I was rummaging through some old files the other day and I came across my copy of the After Action Report (AAR) for Quakex97.  0818161604This was a joint local, state and federal medical exercise based on a Cascadia earthquake event.  Having just finished up the medical exercise within Cascadia Rising 2016 I thought it would be interesting to see how far we’ve come in close to 20 years of exercising.  Bon Jovi’s song The More Things Change  came to mind as I read and determined we really have not made as much progress as 20 years of exercising would suggest.

I was trying to rationalize the apparently lack of progress after almost 20 years of exercise as I was working out at my gym the next day.  What I concluded is that we have been using wrong terminology when we refer to our process of training and testing of plans and procedures as “exercise”.  Exercise by definition it is an activity requiring physical effort, carried out especially to sustain or improve health and fitness. A good number of emergency preparedness exercises I have observed over the past 30 years don’t include the necessary components of resistance, weight and the exertion of energy. How much mental and physical muscle memory can we really be building?

twoTo support my hypothesis I tried a few reps on the rowing machine with no resistance and then back at my normal setting.  Definitely some noticeable difference.  Then I tried the Lat Pull Down machine just to make sure the rowing machine findings were not an anomaly….nope same results. My experiment showed me going to the gym to exercise without the use of appropriate weight and resistance is wasting your time.  I guess you can pretend to exercise and impress someone but when time comes to actually need to use those muscles you’ll be embarrassed. Same goes for our emergency preparedness “exercises”. If we pretend to actually work out we’ll be embarrassed by our lack of performance when the real thing happens. Exercise also needs to include reps to really work and build muscles. So how can one-off emergency preparedness “exercises” which includes pretending be accomplishing anything?  Certainly should not be called an “exercise” program.

Instead of the Homeland Security Exercise and Evaluation Program (HSEEP) maybe we should be calling it the Homeland Security Pretending and Sedentary Program  (HSPSP).  We “exercise” and evaluate our performance and then typically put away the AAR findings and rest until next year when we “exercise” again.  In some cases major  “exercises” are carried out every couple of years. We pretend we are prepared, but there is no way we build up muscle and mental memory with that kind of pattern.

Now as I age I have found that some sedentary activities such as reading, sitting, watching TV and pounding on the computer key board are enjoyable.  On the other hand carried to extreme a sedentary lifestyle can contribute to many preventable causes of death so I do try and exercise exercise, not pretend exercise.  Why don’t we do the same with our emergency preparedness efforts?  Following my gym workout analogy I have some steps listed below for us the really obtain the benefits of an exercise program.

  • Exercise controls weight – When you engage in physical activity, you burn calories. The more intense the activity, the more calories you burn. This doesn’t need to be designed to always lose weight as much as maintain a healthy weight for you. No need to set aside large chunks of time for exercise to reap weight-loss benefits.  For example by taking the stairs instead of the elevator or walking to lunch instead of driving. Exercises for emergency preparedness don’t all have to be elaborate and take months of planning. The only ones burning calories for months is the planning team.  If you’ve ever been on a planning team you know exactly what should happen when things kick-off and yet you’re constantly amazed at what people have forgotten or fail to implement. Your mental fitness is great but the people who have not been exercising their brains are too over-weight mentally for a healthy response. One way to get more people to burn some calories regularly is do have mini no-notice “what-if” exercises around the lunch table, coffee machine or even while driving.  The more you exercise the more you can cut through the excess mental fat surrounding what actions you expect people to take.
  • Exercise combats health conditions and diseases – Worried about heart disease? Hoping to prevent high blood pressure? No matter what your current weight being active keeps your blood flowing smoothly which decreases your risk of cardiovascular diseases. In fact, regular physical activity can help you prevent or manage a wide range of health problems. Look back over the last 10 AARs from your organization’s exercises and I’m sure you will see signs and symptoms of diseases consistent with the organizational couch potato syndrome. Focus on these areas over this next year with a frequent exercise workout schedule. Reassess if some of the problems are mitigated or prevented all together by the end of the year.  As you get better increase the weight and resistance during your exercises. This is one of the things I take issue with when changing federal grant guidance says we expect you to focus on exercising X,Y,Z this year when A,B,C continues to be a problem.  It’s difficult to build muscle and mental memory when constantly changing our workout pattern.
  • Exercise improves mood – Need an emotional lift or just need to blow off some steam after a stressful day? A workout at the gym or a brisk 30-minute walk can help. Physical activity stimulates various brain chemicals that may leave you feeling happier and more relaxed, boost your confidence and improve your self-esteem. I think the worst thing organizations can do is not adequately prepare their staff for likely events and actions you want them to take.  Regardless if your organizational exercise program improves self-esteem it certainly should help eliminate the crushing sense of doubt and second guessing their actions after an event because they didn’t know what to do. Exercise until they regularly demonstrate competency in the skill set you’re looking for. They will feel better about themselves and so will you.
  • Exercise boosts energy – Winded by grocery shopping, household chores or surfing the web? Regular physical activity can improve your muscle strength and boost your endurance. Exercise and physical activity deliver oxygen and nutrients to your tissues. Getting more oxygen to our brain is going to help it work more efficiently as well.  I see too many organizations exercising when they have adequate staff, daylight, equipment and ideal conditions. Sometimes to make themselves feel better they will pretend they have adverse conditions but it is just not the same as trying to work when cold, wet and tired. The world changes as night falls and organizations that focus on daytime exercising will find themselves out of breath and struggling in no time at all in a real major event. Adding the unpleasantness of darkness, wind and rain and staff shortages during exercises helps build their energy reserves for that one day when someones life will be dependent upon their actions.  Exercises don’t have to be elaborate to build endurance. Often just focusing on the simple things under adverse conditions is enough.
  • Exercise promotes better sleep – Struggling to fall asleep or to stay asleep? Regular physical activity can help you fall asleep faster and deepen your sleep. Proper preparedness exercising in my mind means you are prepared to do your job, so sleep can come easily. Having said that there are major events that can keep me awake at night. Not because of my own lack of preparedness, but my assessment that others are not prepared for the extensive need of collaboration, cooperation and coordination necessary to maximize outcomes. Most people rest easily playing the odds the big one won’t happen tonight. I guess that works for some and maybe I should envy them. I’d rather give some folks nightmares during exercises so they stop pretending and do the job right or they’ll experience negative consequences.
  • Exercise can be fun – Exercise and physical activity can be a fun way to spend some time. It gives you a chance to unwind, enjoy the outdoors or simply engage in activities that make you happy. Physical activity can also help you connect with family or friends in a fun social setting. Nothing builds team camaraderie like over coming an obstacle collectively.  Anyone who has partaken in one of my training evolutions or exercises understands that I am their common enemy they must band together to defeat. I fondly recall the night exercise where my physician advisor was crawling around at 11 PM in the rain, covered in sand, trying not to get compromised by a hostile element while looking for the team dinner boxes.  It may not sound like fun but he told me later it was the best meal he had eaten in some time.  I had another student going through the same course who thanked me years later for all the night work under adverse conditions. They felt it probably contributed to them surviving their tours overseas as a medic.  Exercise like you mean it, sweat and curse and you can talk about it was later how fun and rewarding it was.

I believe it was Richard Marcinko who wrote a couple of quotes regarding the necessity for our training and exercises to reflect real-life and prepare us properly. “The more you sweat in training, the less you bleed in combat”,  and “Pain was their body’s way of telling them that they’d pushed themselves to their limits — which was exactly where they were supposed to be.”  Picture1

Is it possible to make our organizational exercise program really reflective of what exercising should achieve or will we continue to go through the motions?  We can pretend we’re prepared but pretending everything will be fine doesn’t work for the victims and survivors.  I’m curious your take on the topic and look forward to your comments.