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Quality Improvement: Utilizing After-Action Reports and Improvement Plans to enhance Public Health Emergency Preparedness and Response

State: NY Type: Promising Practice Year: 2017

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Nassau County Department of Health
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Quality Improvement: Utilizing After-Action Reports and Improvement Plans to enhance Public Health Emergency Preparedness and Response
The Nassau County Department of Health (NCDOH), located in Mineola, Long Island, New York, was established in 1938. The primary responsibility is to enforce New York State Public Health Law as well as New York State and local sanitary codes. The mission of the Nassau County Department of Health is to promote and protect the health of all who live, work and play in Nassau County. Nassau County is a densely populated county within New York State with over 1.3 million people, making it the 27th largest county in the nation. The population density is over 4,700 people per square mile. Nassau County consists of 76.7% White, 12.4% black/African American, 15.7% Hispanic/Latino, 8.7% Asian, 0.5% American Indian, 0.1% Pacific Islander/Hawaiian, 1.6% two or more races (U.S. Census Bureau, 2013). The county has a total area of 453 square miles, of which 285 square miles is land and 169 square miles (37%) is water. It has two cities and three towns, containing 64 villages and numerous hamlets. Nassau County shares borders with New York City to the west and Suffolk County to the east. The county borders Connecticut across the Long Island Sound. The mission of Public Health Emergency Preparedness (PHEP) is to effectively plan for and respond to a range of public health threats—including infectious diseases; natural disasters; and biological, chemical, nuclear, and radiological events. The PHEP division manages the 934 volunteer members of the Nassau County Medical Reserve Corps (MRC) who are called upon to help strengthen public health, emergency response and community resiliency. In the summer of 1985, New York State became the first state in the country to offer a free adapted sports program for youngsters. The athlete's, ranging from 5-21 years of age, had physical challenges including, but not limited to, cerebral palsy, spinal cord injuries, muscular dystrophy, and dwarfism. They participated in competitive events such as track and field, slalom, swimming, wheelchair basketball, table tennis, and archery. Although the program was considered a success, funding was eliminated in 2010, due to financial difficulties within the state. As a result of state funding cuts, the Public Health Emergency Preparedness (PHEP) division was called upon to establish a pre-hospital triage and treatment system and provide targeted medical assistance to more than 1,000 physically challenged athletes and spectators during a three day Empire Games for the Physically Challenged” event during the years 2010 to 2016. Having never done this before, PHEP leveraged the talents of the Medical Reserve Corps volunteers and collaborated with Article 28 partners at NuHealth-Nassau University Medical Center. Drills and exercises are utilized by the PHEP division as opportunities to evaluate emergency preparedness and response capabilities. They are also essential in testing and validating plans. PHEP operates within the framework of the U.S Department of Homeland Security National Incident Management System's (NIMS) Incident Command System (ICS) and staff developed and implemented detailed Logistics and Operations plans. In order to continually improve planning and response, the Homeland Security Exercise and Evaluation Program (HSEEP) doctrine was utilized, focusing on After-Action Reports (AARs) and Improvement Plans (IPs). Opportunities for improvements are noted, corrective actions are identified and improvements are noted in each year's AAR. After-Action Reports are an important tool in the exercise process. The Improvement Plan section of the AAR provide details for corrective action measures. Implementing these corrective actions helped to achieve the goals of improving response and ensuring the safety of all athletes, spectators, staff and volunteers each consecutive year. The following objectives were met: 1. To write After Action Reports after each event 2. To review Improvement Plans and make improvements in planning 3. To deploy adequate staff/volunteers and medical supplies on hand for each day of event 4. To establish communication channels to effectively respond to the event This practice results, not only in annual improvements in planning and response for the Empire Games for the Physically Challenged, but enhances all-hazard public health emergency preparedness and response capabilities for the Nassau County Department of Health. http://www.nassaucountyny.gov/3925/Public-Health-Emergency-Preparedness-PHE
In the summer of 1985, New York State became the first state in the country to offer a free adapted sports program for youngsters. The athlete's, ranging from 5-21 years of age, had physical challenges including, but not limited to, cerebral palsy, spinal cord injuries, muscular dystrophy, and dwarfism. They participated in competitive events such as track and field, slalom, swimming, wheelchair basketball, table tennis, and archery. Although the program was considered a success, funding was eliminated in 2010, due to financial difficulties within the state. Identifying the importance of this program, Nassau County stepped up to the plate and with the support of officials, private donations and community outreach, the Nassau County Empire Games for the Physically Challenged” was born 2010. The Public Health Emergency Preparedness (PHEP) division of the Nassau County Department of Health (NCDOH) was called upon to establish a pre-hospital triage and treatment system to provide targeted medical assistance to more than 1,000 physically challenged athletes and spectators during a three-day event. Beginning in 2010, the Public Health Emergency Preparedness (PHEP) division began coordinating the medical response to the Empire Games for the Physically Challenged. PHEP successfully coordinated the medical support for the event during the years 2010 through 2016. One hundred percent of these athletes were reached and targeted through available medical services on-site at the games. In order to continually improve planning and response, the Homeland Security Exercise and Evaluation Program (HSEEP) doctrine was utilized, focusing on After-Action Reports (AARs) and Improvement Plans (IPs). Opportunities for improvements are noted, corrective actions are identified and improvements are noted in each year's AAR. This practice results, not only in annual improvements in planning and response for the Empire Games for the Physically Challenged, but enhances all-hazard public health emergency preparedness and response capabilities for the Nassau County Department of Health. On average, medical response was needed for 10-12 persons each year during the time frame 2010 to 2016. If a person needed to be transported to a hospital, an on-site ambulance was activated. This occurred three times within the six- year period that the PHEP division managed the medical support of the Empire Games. This can also be attributed to the invaluable participation and input from NCDOH's Medical Reserve Corps. After Action Reports and Improvement plans (AARs/IPs) were drafted after the event each year to ensure that the outcomes improved on a continual basis. For example, the After Action Report from the 2010 Games noted that the Incident Command System and chain-of-command were not followed in both planning and operations. In response to this, NCDOH PHEP began to plan for and implement changes that would improve medical response outcomes at the games for the following year. Five years later, at the 2015 Games, it was apparent that the NCDOH PHEP response had implemented the suggestions made in the 2010 After-Action Report. The provision of sufficient medical and support staff was originally listed as an area needing improvement in the 2010 Empire Games AAR, and in 2015, that same area was highlighted as a strength. Appropriate documentation was distributed to Medical Reserve Corps volunteers to keep the event running smoothly. Examples include staffing schedules, job, action sheets, maps, event schedules, and contact lists. Lack of coordination in communication was noted in the 2010 AAR, but in the 2015 AAR, the highlighted strength included successful radio and cell phone communications established upon arrival at the event site. All 800 MHz radios were tested for efficiency prior to the event and extras were made available in the event of any malfunctions. Cell phone numbers were documented and distributed amongst response staff as a means for back-up communications. Just-in-time” training was conducted with staff on the use of the radios before the event began. Utilization of After Action Reports and Improvement plans enabled NCDOH PHEP to successfully plan for and respond to the Nassau County Empire Games for the Physically Challenged and enhances the ability of the county to respond to all-hazard public health emergencies. This practice is a creative use of the Homeland Security Exercise and Evaluation(HSEEP) program toolkit. HSEEP is a national best practice for exercise planning and implementation.
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In order to establish a pre-hospital triage and treatment system to provide targeted medical assistance to more than 1,000 physically challenged athletes and 250 spectators during the three-day event Empire Games for the Physically Challenged, the Nassau County Department of Health Public Health Emergency Preparedness (NCDOH PHEP) Division collaborated with Article 28 partners at NuHealth-Nassau University Medical Center. NuHealth provided medications, hydration drinks and staff for the event. The Office of Emergency Management provided logistical support and pallets of water. A local vendor donated ice. NCDOH staff maintains and utilizes a logistics team; this team was utilized for the event. NCDOH PHEP leveraged the talents of the Nassau County Department of Health's Medical Reserve Corps volunteers. It is estimated that the in-kind value of the Medical Reserve Corps volunteer hours totaled over $10,000 dollars. Goals: 1. To improve response each year for the Empire Games for the Physically Challenged, ensuring the safety of all athletes, spectators, staff and volunteers Objectives were: 1. To write After Action Reports after each event 2. To review Improvement Plans and make improvements in planning 3. To deploy adequate staff/volunteers and medical supplies on hand for each day of event 4. To establish communication channels to effectively respond to the event PHEP operated within the framework of the U.S Department of Homeland Security National Incident Management System's (NIMS) Incident Command System (ICS) and staff developed and implemented detailed Logistics and Operations plans. Homeland Security Exercise and Evaluation Program (HSEEP) compliant After-Action Reports (AARs) and improvement plans were also utilized to achieve our objectives. Opportunities for improvements are noted, corrective actions are identified and improvements are all noted in each year's AAR. This ongoing practice results in annual improvements in planning and response for the Empire Games for the Physically Challenged. It also enhances all-hazard public health emergency preparedness and response capabilities for the Nassau County Department of Health. The following timeline and steps were taken to achieve goals and objectives: March: Review prior year Improvement Plan and make recommended changes Inventory medical and non-medical supplies Order necessary supplies April: Obtain annual event information from organizers Contact Article 28 partner for collaboration Conduct Initial Planning Conference with partners (Article 28, ambulances) May: Develop Project Plan Create event maps identifying locations of stationary and roving medical teams and ambulance Develop organization chart Send activation email to Medical Reserve Corps Assign roles and identify staffing gaps Participate in Event Planning Meetings Conduct event site location Walk Through Complete On-Site Medical Briefing Create Sign-in Sheets Develop Radio Communications Plan Develop Pick and Pack List for Logistics Team Two days prior to event in June: Pick and Pack mobile trauma bags Pick and Pack stationary medical and non-medical supplies One day prior to event Pre-deploy medical tent, generator and A/C unit to site Morning of event: Pack 800 MHz radios Just-in-time training medical protocol for volunteers Just-in-time radio communications training Tracking staff and volunteers Tracking equipment Set up feeding/resting schedule for event Conduct after action survey to obtain feedback Attend hot wash meeting with event organizers and partners After event: Write After Action Report and Improvement Plan
The utilization of After Action Reports and Improvement plans enabled NCDOH PHEP to successfully plan for and respond to the Nassau County Empire Games for the Physically Challenged. After Action Reports and Improvement plans (AARs/IPs) were drafted after the event each year to ensure that the outcomes improved and objectives were met on a continual basis. For example, the After Action Report from the 2010 Games noted that the Incident Command System and chain-of-command were not followed in both planning and operations. In response to this, NCDOH PHEP began to plan for and implement changes that would improve medical response outcomes at the games for the following year. Five years later, at the 2015 Games, it was apparent that the NCDOH PHEP response had implemented the suggestions made in the 2010 After-Action Report. The provision of sufficient medical and support staff was originally listed as an area needing improvement in the 2010 Empire Games AAR, and in 2015, that same area was highlighted as a strength. Lack of coordination in communication was noted in the 2010 AAR, but in the 2015 AAR, the highlighted strength included successful radio and cell phone communications established upon arrival at the event site. NCDOH PHEP staff also made improvements to enhance volunteer readiness by providing Medical Reserve Corps volunteers with their scheduled activities in advance: detailed briefings were also provided for each shift. Sufficient staffing coverage involving roaming teams and two ambulances on the scene were deployed. Ordering signs for medical and first aid stations, testing the efficiency of blue medical tents (Zumros) prior to the event, and updating/keeping inventory of medical equipment used all contributed to the success of the practice. It was also noted in the AAR, that efficient use of radio communication enabled the multiple agencies involved in the event to work together easily and that sufficient supplies such as trauma bags and medical tents were available. Each of these factors were significant in achieving the goals and objectives.
Recognizing the importance of the Nassau County Empire Games for the Physically Challenged for physically challenged athletes, the practice utilizing After-Action Reports and Improvement Plans effectively caring for the medical needs of this population is sustainable as long as Nassau County remains committed to this event and improving response each year. In addition, the availability of a robust and trained Medical Reserve Corps allows for sufficient staffing for the event. One of the most important lessons learned, is that partner collaboration needs to take place on a regular basis, and not just when an emergency occurs. As a result of this lesson learned, the Public Health Emergency Preparedness (PHEP) division continues to collaborate with stakeholders on an ongoing basis. Lessons learned over the past 6 years and the continued improvements noted in the After-Action reports and Improvement Plans leads the Nassau County Department of Health's Public Health Emergency preparedness division to believe that this practice is sustainable for many years to come.
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