1. Measuring and Enhancing Public Health Preparedness Nicole Lurie, M.D., M.S.P.H. August 15, 2006

2. Center for Domestic and International Health Security Todays Objectives Familiarize you with the public health infrastructure and the components that are most essential to public health preparedness Convince you of the importance and challenges of assessing public health system performance and of developing better tools to do so Share highlights of some of our work Discuss challenges in integrating public healths efforts with those of traditional first responders, and with the rest of public health Discuss the quality challenge

3. Center for Domestic and International Health Security Background (1) The public health system is in disarray – IOM, 1988 The public health system remains in disarray today – IOM, 2001 No reform of statutory framework Funding insufficient Limited support Gaps in workforce, laboratory capacity, IT, organizational capacity Mixed progress on environment, mental health, indigent care Rebuilding the public health system was on the back burner before 9/11 and the anthrax attacks Since then, Congress has allocated more than $5 billion to improve state and local public health –Vision of dual-use investment to both rebuild infrastructure and enhance preparedness –Evolving all-hazards emphasis

4. Center for Domestic and International Health Security A Big Investment, but No Guiding Principles Should we rebuild, or redesign? How much, and in what, should we invest? How can we be accountable for results? –How should the investment be structured and monitored? –How should preparedness be measured? How does preparedness relate to other public health functions? –Can investments really serve multiple purposes? How will we gauge success?

5. Center for Domestic and International Health Security What is the Basic Public Health Infrastructure? workforce capacity & competency information & data systems organizational & systems capacity surveillance laboratory practice epidemic investigation Public health response Essential Capacities Basic Infrastructure

6. Center for Domestic and International Health Security Ten Essential Services A Public Health Department Should... 1. Monitor community health status 2. Diagnose and investigate health problems and hazards 3. Inform, educate and empower people about health issues 4. Mobilize community partnerships to solve problems 5. Develop policies and plans to support health efforts 6. Enforce health and safety laws and regulations 7. Link people to needed health services 8. Assure a competent workforce 9.,10.Conduct evaluations and research

7. Center for Domestic and International Health Security Now, a Public Health Department Should Also… Be prepared for a bioterrorist attack or naturally occurring outbreak –Quickly recognize the disease (e.g. anthrax, pandemic flu) –Control spread (isolation, quarantine, vaccination) –Assure that people get needed care –Coordinate with national and international agencies –Prevent mass panic Be prepared for other public health emergencies, e.g. hurricanes, earthquakes, massive blackouts and heat emergencies

8. Center for Domestic and International Health Security Findings are based on multiple projects California Public Health Preparedness Project Assessing Georgias Public Health Preparedness Work with HHS –Case studies –Development and testing of exercises –Measurement strategies (SNS, lab, other) –Pandemic planning Work with VA Have visited close to 50 communities and conducted over 35 exercises since 2003

9. Center for Domestic and International Health Security Lack of Mission Clarity There is no public health system in California –No clear agreement on role of public health –Multiple uncoordinated agencies and efforts No coherent, forward-thinking vision for public health in general, or for preparedness –Skepticism about risk and need for investment in preparedness –Priorities often based on chasing money rather than population needs

10. Center for Domestic and International Health Security The State Lacks Central Leadership No clear state leadership Overlap between DHS, the Governors Office of Emergency Services, and the Emergency Medical Services Authority Health departments felt they could not rely on the DHS to address common needs or facilitate resource coordination Border and jurisdictional issues left to local agencies to resolve

11. Center for Domestic and International Health Security Local Officials Are on Their Own Widespread gaps in –Basic knowledge –Legal policies and procedures –Strategic planning –Community assessment and involvement –Workforce development –Lab capacity –Information systems Substantial redundancy, which results in unevenness and inefficiency Findings apply to both infectious and chronic diseases

12. Center for Domestic and International Health Security Bottom Line California was not unique Progress has been made, but there is a long way to go and still no good way to measure progress or quantify preparedness

13. Center for Domestic and International Health Security Some Assessment Approaches Case studies Check lists based on self report Exercises and drills Critical path analysis

14. Center for Domestic and International Health Security Envisioned as a way to objectively test attainment of a standard The CDC standard: –A LPHA should be able to receive and respond to emergency case reports 24/7/365 Have a single well-publicized telephone number Have a phone triage protocol to process urgent case reports. Be able to respond to urgent case reports with a trained public health professional within 30 minutes of receiving the report. Be able to handle calls with a warm transfer Developed and tested a measurement strategy Objective tests: 24/7 Receipt and Response

15. Center for Domestic and International Health Security Results 143 calls to 19 LPHAs over 10 months 3 of 19 (15%) tests terminated prematurely 9 of 19 (47%) responded to all calls 2 of 19 (9%) responded to all calls with warm transfers and within 30 minutes Vulnerable systems and periods Has led to work to identify ideal systems

16. Center for Domestic and International Health Security Table-top Exercises Provide opportunities for planning, training and assessment Require significant planning and testing Cannot test all aspects of a plan Continue to surface common issues: –Surveillance –Command and control –Communications –Surge capacity –Crisis response –Challenges in learning and change

17. Center for Domestic and International Health Security Drills Allow discrete aspects of system to be assessed Process mapping/critical path analysis helpful Can measure actual performance Efficient, bite-sized chunks Combined with table-top exercises, could be useful predecessors to full scale functional tests

18. Center for Domestic and International Health Security Use naturally occurring events as proxy events –West Nile Virus, SARS, Monkeypox … and Katrina Examine state-local organizational structure Examine public health – health care system interface Case Studies

19. Center for Domestic and International Health Security Summary of Case Study Findings Funds have helped close significant gaps in PH capabilities –Significant progress in communications, surveillance, disease investigation, and relationship building Infrastructure in place pre-9/11 was also instrumental Skepticism about emphasis on preparedness has been moderated by outbreaks and Katrina

20. Center for Domestic and International Health Security Findings (2) Leadership is critical Limited surge capacity for virtually all PH functions and services –Relatively small outbreaks studies stressed disease investigation capacity; larger outbreaks likely to be problematic –Needs of vulnerable and minority populations not adequately considered Jurisdictional arrangements are complex and may thwart standardized efforts at testing and emergency response –Responsibility for key functions are inconsistent and unclear

21. Center for Domestic and International Health Security Findings (3) Accountability lacking at all levels of government Resources need to be devoted to measuring and demonstrating value and accomplishments of PH Unrealistic expectations regarding CDC delayed and/or reduced the effectiveness of the response to MP, WNV No formal processes for incorporating lessons learned from outbreaks or exercises –Continued cycles of missed opportunities –Much learning resides with individuals rather than systems

22. Center for Domestic and International Health Security Findings (4) No magic bullet with respect to organizational structure –Need for explicit discussion among fed., state, and local health officials on responsibility for various PH functions and accountability Financing drives the way preparedness is organized Workforce challenges inhibit preparedness Cultural transitions are occurring, but are challenging for all

23. Center for Domestic and International Health Security What have we learned about measuring preparedness Measurement is essential Having a plan does not predict exercise performance Self-reported measures are of questionable value Unit of observation is critical but often overlooked Site visits, 24/7 tests, and exercises all provided similar information but have differing roles in: –Objective assessment –Assessing progress –Training –Improvement –Accountability

24. Center for Domestic and International Health Security What have we learned about preparedness (2) Significant improvement in some key areas Has highlighted the need for performance measurement and quality improvement in public health Many remaining gaps –Early internal processes –Local-state handoffs –Health department/health care system interactions –Community involvement and trust –Early media/public communication –Ambivalence and lack of clarity about state and federal role Need for sustained efforts

25. Center for Domestic and International Health Security What have we learned about preparedness (5) The system is perfectly designed to get the results that it does Many state and local agencies are still desperate for help Important lessons learned and applied to newer outbreaks, but learning rests with individuals Department of Homeland Security has largely ignored public health issues

26. Center for Domestic and International Health Security Does preparedness help? Georgia study and its aftermath illustrate the value of exercises –Assisted in Katrina response that involved absorbing 70,000 evacuees Demonstrated need to coordinate messages across levels of government Illustrated importance of interoperability (e.g., GIS systems made it easier to communicate data across agencies) Provided examples of benefits associated with defining priority groups for public health services Alerted health department to surge capacity issues that needed to be addressed, ranging from the need for sufficient staffing for incident management to ways in which response partners can reinforce one another Aided in the development of ways to maximize use of volunteers

27. Center for Domestic and International Health Security But, Preparedness Has a Hidden Cost PreparednessHidden cost Federal money for bioterrorism Local cuts in funding for other public health activities Increased emphasis on preparedness Decreased attention to other public health functions Staff reassignmentsShortages in other critical areas Modest improvementElimination or reductions in key programs: TB control, STD contact tracing, teen pregnancy prevention, direct care

28. Is There a Quality Chasm in Public Health?

29. Center for Domestic and International Health Security What makes a Quality Chasm ? Widespread variation –Inefficiency –Equity System failures –?Unsafe Thin evidence base Lack of patient/population centeredness Lack of performance measurement and accountability Lack of ability to fix itself

30. Center for Domestic and International Health Security If the system is perfectly designed to get the results that it does, what should we do… Learn lessons from other transformations Understand preparedness problems in system terms –Preparedness may not be fundamentally different than other public health components Focus on regularly occurring, high impact processes Develop and use firm, plausible and meaningful metrics Develop models for accountability Develop models for QI in public health Develop leadership in public health

31. Center for Domestic and International Health Security

32. Many thanks to the health departments and their staff who participated in these activities, and to William Raub and Lara Lamprecht RAND Collaborators: Jeffrey Wasserman, Karen Ricci, David Dausey, Jeanne Ringel, Debra Lotstein, Lisa Shugarman, Ed Chan, Sam Bozzette, Julia Aledort, Terri Tanielian, Chris Nelson and others…