Triangulating a Three-legged stool Self- and Other-Assessments of

Triangulating a Three-legged stool: Self- and Other-Assessments of the Three Layers of North Carolina’s Public Health Preparedness System Doug Easterling Wake Forest School of Medicine dveaster@wakehealth. edu Lucinda Brogden Core Path Solutions, LLC lubrogden@earthlink. net Presentation at the 25 th. Annual Conference of the American Evaluation Association November 5, 2011

Complex Health Systems n Multiple actors (people, organizations, institutions) act in coordinated ways to produce “larger” benefits n n Each actor has its own mission and imperatives Actors regularly interact with each other (ideally in mutually reinforcing ways) Collectively the work of the actors achieves synergistic outcomes Examples n n n PCPs, hospitals, home health agencies, aging services, hospice, etc. work together to care for chronically ill patients (Chronic Care Model) Court counselors, judges, mental health providers, substance abuse programs, CBOs coordinate their approaches to working with courtinvolved youth with substance issues (Reclaiming Futures) Federal, state, and local agencies coordinate activities to help communities prepare for and respond to disasters

Public Health Preparedness n n n Assumption: Public health has a distinct and important role to play in ensuring that communities and regions are adequately prepared to deal with disasters Emergency Response has long been a priority for a variety of local, state and federal agencies (e. g. , police, fire, EMS, state departments of emergency response, transportation, FEMA) Events over the past decade have demonstrated that public health agencies (local, state, federal) also need to be directly involved n n n 9/11 attacks Anthrax-tainted letters Concern about bio-terrorism Hurricane Katrina Pandemic flu outbreaks The field of public health has changed in dramatic ways to accommodate this new function n n New requirements from CDC imposed on local and state health agencies Lots of new federal funding (at least initially) New lines of research New academic programs and text books

Public Health Preparedness in North Carolina n 3 Layers n NC Division of Public Health n n Local Health Departments (n=85) n n Office of Public Health Preparedness and Response (PHP&R) 79 individual-county health departments 6 multi-county health departments (between 2 -7 counties) LHDs are governed by local boards of health, not DPH Public Health Regional Surveillance Teams (n=7) n n Located with local health departments Charged with providing support services to LHDs throughout a region

Sample 27 Health Departments *15 Health Directors *12 PCs Distribution by Size of County Count Percentage Under 50, 000 9 33. 3% 50, 000 -100, 000 9 33. 3% 100, 000 -200, 000 5 18. 5% More than 200, 000 4 14. 8% Size of the County Distribution by PHRST Region Count Percentage Region 1 5 18. 5% Region 2 3 11. 1% Region 3 3 11. 1% Region 4 3 11. 1% Region 5 5 18. 5% Region 6 4 14. 8% Region 7 4 14. 8% TOTAL 27 Region

Assessment of Complex Health Systems n Mapping the system n n Assessing performance and effectiveness n n Who is in the system? What is each actor’s role and responsibilities? How do the actors connect and interact with one another? (SNA) Individual actors Overall Sectors of the system (regional or functional clusters) The special challenge in the case of public health preparedness n Small number of cases (threats or disasters) on which to assess performance n n Some geographic units may experience no threats over a long period of time Solution: Focus on capacity to anticipate, monitor and respond to threats

Current Study n Assessment of the capacity, strengths and weaknesses of the North Carolina Public Health Preparedness System n n Contracted by NC Division of Public Health, with strong support from NCALHD Assessment was envisioned as providing input for a strategic planning process and possible redesign of the NC system Carried out in February-March 2009 Context n System was moving from a phase of infrastructure building to one of system maintenance and improvement n Everyone acknowledged that the existing system had evolved in ways that were not always functional n Turnover of preparedness personnel at all levels over the past few years n Tension between the different layers of the system n Prior to the arrival of H 1 N 1 Influenza -Different perception of threats and vulnerabilities -No recent widespread or large incidents

Methods n Focus group with PHP&R staff n In-person Interviews with NC DPH leaders (n=5) n Telephone Interviews with representatives of local health departments n n n Health Directors (n=15) Preparedness Coordinators (n=12) Telephone Interviews with representatives of PHRST teams (n=8) n n 3 Physician/Epidemiologists, 2 Industrial Hygienists/Environmental Epidemiologists, and 2 Nurses/Nurse Epidemiologists. One Multi-region Pharmacist

Sample 27 Health Departments *15 Health Directors *12 PCs Distribution by Size of County Count Percentage Under 50, 000 9 33. 3% 50, 000 -100, 000 9 33. 3% 100, 000 -200, 000 5 18. 5% More than 200, 000 4 14. 8% Size of the County Distribution by PHRST Region Count Percentage Region 1 5 18. 5% Region 2 3 11. 1% Region 3 3 11. 1% Region 4 3 11. 1% Region 5 5 18. 5% Region 6 4 14. 8% Region 7 4 14. 8% TOTAL 27 Region

Content of Interviews n Collect complementary data from representatives of all levels of the system n n n Interviewees described their own agency’s approach to preparedness, capacity, accomplishments, and challenges. Also recounted their experience working with other layers of the system. DPH interviewees rated the capacity of LHDs and PHRSTs

Findings on Preparedness within Local Health Departments

Staffing of Local Health Department Preparedness Programs Structure of PC Position TOTAL Full Time Preparedness Coordinator (works on preparedness full time for one LHD) 9 Part-time Preparedness Coordinator, but the person is a full time health department employee 9 Shared Preparedness Coordinator, full time employee who works for multiple counties 4 Part-time Preparedness Coordinators where two or more people share preparedness duties 2 Part-time Preparedness Coordinator who is either a contract employee or independent contractor 2 Part-time Preparedness Coordinator (position is not shared or supported by another HD employee) 1 * 2 of the 4 LHDs in this cell are multi-county health districts.

Background of PCs n=12

Accomplishments Local Health Departments Reported as Valuable To Their Agency or Community LHD Accomplishments TOTAL Frequency (n=27) Development of new partnerships and/or improvements to existing relationships 20 Exercises 12 Changed awareness/ perceptions of PHP among partners and/or staff 9 Training and education of staff, partners, and public 9 Plans/Planning 7 Incident Response 5 Public Information and communications 5 New infrastructure and technology 3 Epi and surveillance 3 Meet contract addenda 2 Mass vaccination 2 Flu clinics 2 Geographic Information Systems (GIS) 1

16 Dimensions of Capacity for the NC Public Health Preparedness System (as identified by Assessment Steering Committee) 1. Epidemiology and surveillance 2. Regional laboratory testing (or access to testing) for bioterrorism and/or enhanced surveillance 3. Developing and updating plans 4. Developing and conducting exercises 5. Building local partnerships 6. Building other partnerships 7. Contacting and communicating with response partners. 8. Public information/risk communications 9. Receiving and distributing the Strategic National Stockpile 10. Mass prophylaxis/vaccination 11. Worker health and safety 12. Disease control: including the ability to manage isolation and quarantine 13. Recruiting and managing volunteers to support public health response (or access to a partner agency that does this) 14. Having personnel trained and knowledgeable in preparedness 15. Conducting preparedness training for your health department staff 16. Conducting preparedness training for your community partners

The four largest counties had much higher levels of capacity than the other counties on 6 of the 16 dimensions: • Epidemiology and surveillance • Lab testing (or access to) • Public information • Receiving and distributing the SNS • Mass prophylaxis and vaccination • Disease control

Bringing in the DPH perspective

DPH Views of Preparedness within LHDs n Areas of Strength: n n Areas where some LHDs are not so strong n n Building local partnerships Communication with response partners Mass prophylaxis / vaccination Recruiting and managing volunteers Epi and surveillance Training community partners Most prevalent “frustration” working with LHDs n Health Departments don’t regard preparedness as a “core function” of public health

So what do LHDs tell us about DPH?

Local Health Department Interactions with DPH Position # LHDs Reporting Frequent Interaction n=27 Most Valuable Services Provided By This Position Office Of Public Health Preparedness and Response (PHP&R) Planner/Evaluator (exercises) 13 Exercise consultation and questions: AARS, CAPS, HSEEP guidance Bioterrorism Coordinator 11 Information and guidance, expertise and dialogue from a leadership perspective, emails Sub-Recipient Monitor 9 Program monitoring, contract addenda questions, expenditure questions and reports SNS/Clinical Pharmacist 7 Technical assistance and planning guidance on SNS, confirmation plans have been received, TAR guidance, Pan flu questions Program Administrator 7 Purchasing and budget guidance, contract addenda clarifications Telecommunications Coordinator 4 Pack radio training, assistance, and problem solving, GETS cards reminders, Communications Coordinator 3 LHIT and PIO training and questions, planning assistance, templates for PIC materials for outbreaks Epidemiology Section Chief 5 Epi consultation outbreak, surveillance and planning information and guidance General Communicable Disease Control Branch (GCDC) 3 CD consultation, guidance on precautions for community, food borne Epi questions State Laboratory of Public Health 4 Sample testing and guidance on turnaround times Other positions within DPH

LHD Frustrations with NC DPH n Conflicts between LHDs and PHP&R personnel over plan requirements and the process for reviewing plans (especially SNS plans). n Unclear or changing guidance on contract addenda. n n n Perceive that state PH personnel are out of touch with the concerns and day -to-day reality of local health departments (e. g. , excessive demands given the available resources and the competing responsibilities). Health Directors and PCs want clearer guidance and more timely feedback on plans, more clarification on what PCs should be doing, and more substantive information on how to better prepare their communities. Felt PHP&R focused on meeting their own reporting needs rather than listening and responding to the concerns of local health departments There was a sense that PHP&R focuses on “crossing T’s and dotting I’s. ”

Findings regarding PHRSTs

How Much Local Health Departments Report That They Interact with PHRSTs (Local Health Directors and PCs) Health Directors Response Category Preparedness Coordinators COMBINED Number Percent A great deal 9 60% 8 67% 17 63% Somewhat 4 27% 3 25% 7 26% Only a little 2 13% 1 8% 3 11% Not at all 0 0% TOTAL 15 100% 12 100% 27 100%

Local health departments’ reports of how PHRSTs have been valuable Ways in which the PHRST helped # of LHDs reporting that PHRSTs helped in this way Provided training to LHD staff and community partners 16 Assisted LHD in responding to disease outbreaks and other incidents affecting public health 14 Available to PC and/or Health Director for ongoing advice, expertise, coaching, orientation, etc. 12 Conducted or participated in exercises 11 Provided specific Industrial Hygiene services (e. g. , design or improve the negative pressure room, perform fit testing for masks) 11 Assisted LHD in developing plans 8 Convened or participated in local or regional meetings in ways that promoted partnership-building 5

LHD Frustrations with PHRSTs n n n n n The PHRST is non-responsive to Local Health Department requests and/or unavailable Ineffective communication Lack of clarity in the role the PHRST plays and/or the services they provide Services are of poor quality or lack the needed skills PHRST does not provide services that would be most useful PHRST gives preference in time and service to the host health department PHRSTs put state interests over local needs Problems with PHRSTs acting as liaisons between DPH and Local Health Department Problems associated with staff turnover among team members

Recommendations: For Self and Others

Health Directors’ and PCs’ Recommendations for Local Health Departments • Strong interest in Regionalization, to take some of the burden off local health departments and reduce the costs associated with preparedness. -Create shared PC positions -Develop plans that are regional rather than local in scope (increased consistency) • Want plan templates. (optional use) • Preparedness capacity could be increased through more sharing of best practices, -Planning and exercises -Models for the PC position • Health Directors in particular expressed a desire for guidance on filling the PC position. -Standard job description -What type of background and skills are needed to carry out the duties of a PC • Want additional training, especially for new PCs. (In addition to on-line training) • PCs requested that PHP&R provide an in-person orientation for new PCs. -Establish relationships with state personnel

PHRST recommendations for LHDs : n n n Preparedness should be more of a priority for Local health Departments. Local Health Departments should have a full-time PC or shared PC dedicated to preparedness. In counties where funding is insufficient to hire a full-time PC, the LHD should consider sharing the PC position across multiple counties.

Health Directors’ and PCs’ Recommendations for PHRSTs n n Spend more time interacting with all the health departments in their region -Take the initiative in reaching out to offer relevant services (e. g. , exercises, training) Play a larger role in the coordination and promotion of regional planning -Providing templates for plans Create a formal mechanism so Health Directors from throughout a PHRST region (not just the host health department) can provide input and oversight for the PHRST. -Who is hired to staff the team in their region, -Manage issues around quality assurance - Resolve grievances related to the services provided by the PHRSTs. Consider alternative structures for the PHRSTs. -Become state employees. -Number of PHRSTs reduced to three (east, central and western regions). -Fewer counties in each region that is true under the current model.

Health Directors’ and PCs’ Recommendations for DPH n n PHP&R should be more visible throughout the state. n Make rounds once or twice a year to PHRST and Health Director meetings to listen and to give feedback. Better communications and improved relationships n Each side needs to better understand the other’s perspective. n Develop a more balanced relationship/partnership between NC DPH and local health departments. Be more sensitive to the realities that Health Directors and PCs face at the local level. n Recognize that preparedness is only one of many important functions that LHDs are responsible for. Be more realistic about contract requirements. n Sensitivity to limitations of small counties. n Focus on a limited number of critical issues that LHDs are capable of addressing. n Limit the number of new plans required.

Recommendations for the Overall System n Improve communication and coordination between PHP&R, local health departments, and PHRSTs. n n n Increase dialogue between levels n n PHP&R personnel should spend more time outside of Raleigh and have conversations about what works and what does not in different communities. Possible shift towards a more grassroots approach n n n The Health Directors and PCs saw the need for more face-to-face dialogue with their PHRST and with DPH personnel. Several, mentioned that DPH and LHDs need to work together more closely, so they can better understand the issues faced by one another. Inclusive process where everyone is recognized as a partner All partners would have more of a say about the design and operation of the statewide system. Less attention on low-probability high-impact events such as an outbreak of smallpox or bioterrorist event involving anthrax. n n Preparedness is viewed by some Health Directors, as out of touch with local needs and the daily reality of LHDs. Accordingly, the preparedness system should focus more of its attention and resources on threats that are more likely to occur.

Additional Recommendations n DPH personnel want to see the system become more flexible with regard to the use of funds (within the limits of federal guidelines). n n n For this to occur, the system needs to become more “nimble. ” Viewed not so much as a collection of individual parts, (85 LHDs, 7 PHRSTs, and 1 state), but rather a “cohesive overarching system” that has to change and adapt for what in a way that makes sense for where we are now. Toward this end, DPH leaders stressed that a strategic plan was needed for the entire PH preparedness system. n n Such a plan would determine the right size, scope, and focus of the system Ensure that appropriate resources are located at the state, local, and regional levels.

Strategic Issues for Local Health Departments n n The PC position is critical in having a strong preparedness program. n Many health Directors report difficulty recruiting and retaining qualified PCs. n The PC position requires skills and training (especially planning) that are outside the usual skill set of the staff members that Health Directors typically turn to. Building a strong preparedness program requires commitment and leadership on the part of the Health Director. n Many Health Directors assign only average importance to preparedness. Local health department have found it difficult to integrate preparedness into their core operations, n Even though in theory this would expand the number of staff members who share responsibility for preparedness tasks, n Could increase buy-in, build capacity, and promote sustainability. Federal and state funding allow for only minimal staffing even though Public health preparedness is a complex function defined by many demanding tasks. n Local policy makers are reluctant to provide supplemental funding. n As a result, preparedness capacity is only partially built.

Strategic Issues for PHRSTs n n The original PHRST staffing model is more relevant for responding to shortduration incidents than it is to regular service delivery to local health departments. n Building/enhancing the capacity n Training, planning, exercises, and regional coordination n Supervision of shared PCs There are significant variations between the seven PHRSTs in the scope and quality of their services, the areas of specialty they have developed, and the level of the “customer service” they provide to LHDs in their region. n No shared understanding of the role of PHRSTs. The role of PHRSTs is anticipated to increase with regard to support for local health departments and regional coordination of planning, exercises, and response. Unless the lack of consistency among teams is addressed, the problems that LHDs now have with PHRSTs will likely be magnified. There are no clear guidelines about how PHRSTs and their host health departments should be accountable to the other local health departments in their region. n Hired by their host LHD, n Accountable to supervisors and the personnel policies of the county in which they are employed n Potential conflicts with other local health departments over regional service and response expectations.

Additional Strategic Issues for PHRSTs n n n There is no shared understanding of the role of PHRSTs. There are no clear protocols outlining priorities in how PHRSTs should allocate their time between local health departments and the state. n PHRSTs provide support and back-up to the state during incidents, exercises, and disaster response. n Local Health Departments and DPH each expect that PHRSTs should be available when they need them. There appear to be barriers to the use of PHRST services, especially for rural LHDs (e. g. , distance, travel restrictions, large number of counties in some regions). n LHDs serving the smallest counties (less than 50, 000 residents) generally had lower levels of preparedness capacity but were not the heaviest users of PHRST services. n In at least some regions, it is difficult for the PHRST to spend sufficient time in each county or meet the requests for hands-on attention requested.