Target audience: Healthcare Delivery/Public Health/Emergency Management; 95% of the target population reached. Goal: Develop practical, evidence-based, local health response strategies that are accepted by the community and based on organizational learning principles, increasing the local healthcare system’s ability to respond to rapidly changing situations. Primary Objectives: Develop a Health/Medical Multi-Agency Coordination (MAC) Group comprised of hospitals and public health; develop an operational Health/Medical MAC Group Handbook to guide processes; develop an ethics framework based on community values to facilitate fair and transparent decision-making and reduce unintentional consequences; conduct an iterative exercise series (which became real-time due to H1N1) for the Health/Medical MAC Group to practice decision-making, collaboration, and organizational learning. The practice was implemented from October 2008 to February 2010, with evaluation continuing through May 2010.
Project activities were implemented in three phases:
Phase One: Developed information for functional exercises, including epidemiological projections for a 1918-like event; description of the current capacity of the healthcare system and strategies to increase capacity to handle the increased demand for care during a severe pandemic, while maintaining essential services not related to influenza; and an ethics framework based on community values on which to run decisions through in order to encourage community acceptance.
Phase Two: Identify and train members of the Health/Medical MAC Group, utilizing the Health/Medical MAC Group Handbook as a guide, and conduct an iterative functional exercise series (which became real-time meetings due to H1N1) for the Health/Medical MAC Group to practice decision-making (including the application of the developed ethics framework), collaboration, and organizational learning.
Phase Three: Conduct project evaluation activities to inform the refinement of the Health/Medical MAC Group, document what the group accomplished, and measure stakeholder acceptability of utilizing this public health practice for decision-making during a health/medical emergency.
A final evaluation report released in June 2010 was developed to be used by other communities wishing to replicate this public health practice. The final evaluation report includes: 1) analytic studies from phase one activities; 2) training materials, recruitment suggestions for effective group members, and an operational Health/Medical MAC Group Handbook with multiple process tools developed during phase two activities; and 3) qualitative data from community observers and Health/Medical MAC Group members on the effectiveness, acceptability, challenges, recommendations and identified next steps from phase three activities. Activities were designed to be easily modified and implemented by communities utilizing the “ordinary” capacities and resources likely to be locally available during a well-established pandemic. Activities started as part of a functional exercise series around a 1918-like pandemic event, but transitioned to a real-time, tested practice due to H1N1.
All practice objectives were met. The success of this practice is largely a result of the ongoing work of the HPO, the support of the Multnomah County Health Department, and the partnerships developed across institutions and jurisdictions over the past eight years. In the past five years, the Portland metropolitan region has undertaken significant planning on how best to coordinate the regional health/medical response with jurisdictional level emergency management agencies under the auspices of the HPO. This laid the groundwork for developing the Health/Medical MAC Group, the Health/Medical MAC Group Handbook, its associated ethics framework, and exercise series. The ability to effectively address real-time H1N1 issues was due to this groundwork having been laid, and the long-standing collaboration.
This practice addresses the public health need for coordinated healthcare and public health decision-making and response to health emergencies in a multi-county, multi-jurisdictional area.
The Health/Medical Multi-Agency Coordination (MAC) Group practice developed is a decision-making group comprised of hospitals, public health, and other healthcare entities with collective responsibility to: 1) prioritize which decisions must be made in order to support a strained healthcare delivery system; 2) develop ethically-based regional strategies to allocate critical resources; 3) propose altered standards of care and policy approaches; 4) propose community mitigation approaches to limit disease transmission; and 5) support accurate dissemination of information to the public.
The use of a MAC Group for public health is an innovative adaptation of a practice used by fire and police. Unique to the practice was the use of community observers' (individuals, non-governmental organizations, and businesses) feedback to refine the practice and measure the likelihood that the community would accept decisions made. Also important was the group’s ability to make decisions that resulted in reasonable operational and financial equity among hospitals/health systems, clinicians, and other providers to protect the health care system’s capacity to provide health care as usual to the community after the event.
Agency Community RolesSince August 2004, the Multnomah County Health Department has served as Regional Lead Agency for Healthcare Preparedness Region 1. This formalized the Health Department’s leadership and support for regional health preparedness that has been ongoing since the fall of 2001. In addition to providing long-term executive-level leadership, advocacy, and support for coordinated healthcare and public health decision-making and response to health emergencies, the Multnomah County Health Department actively participated in the practice development. The Director of the Multnomah County Health Department, and the Deputy to the Director both represented the Multnomah County Health Department on the Health/Medical MAC Group through participation in the Health/Medical MAC Group training, exercises, real-time meetings, and evaluation.
The Multnomah County Health Department Health Officer, who serves as a Tri-County Health Officer, served as the principle investigator for the practice as well as technical expert to the Health/Medical MAC Group, attending the training, exercises, and real-time meetings. Deputy Multnomah County Health Department Health Officers also served as technical experts to the Health/Medical MAC Group, attending the training, exercises, and real-time meetings. The Multnomah County Health Department’s Lead Epidemiologist and associated staff developed the epidemiological projections for a 1918-like event for use in the exercise series. Medical Interns to the Multnomah County Health Department’s Health Officer provided technical expertise in describing the current capacity of the healthcare system and strategies to increase capacity to handle the increased demand for care during a severe pandemic, and attended the Health/Medical MAC Group exercise and real-time meetings.
The Multnomah County Health Department’s Health Assessment and Evaluation office served as the practice evaluators. The Manager of Health Assessment and Evaluation assisted in the ethics materials development and conducted community discussions to collect information on local values about health and healthcare, which contributed to the development of the ethics framework. Multnomah County Health Department’s HPO Program Managers had primary oversight of the development, implementation, and evaluation of the practice; additional Multnomah County Health Department HPO staff provided practice coordination, technical expertise, administrative assistance, contract tracking, and overall support.
ImplementationThe overall practice goal was to develop practical, evidence-based, local health response strategies that are accepted by the community and based on organizational learning principles that increase the healthcare system’s ability to respond to rapidly changing situations.
Objective 1: Developed a Health/Medical Multi-Agency Coordination Group (H/M MAC Group) comprised of hospitals and public health; developed a H/M MAC Group Handbook. Tasks: Reviewed existing MAC Group models from various agencies and jurisdictions (because all of the models came from non-health disciplines, we needed to identify one that was comprehensive and could be modified to a health/medical event): January 2009-June 2009 Engaged a consultant for technical assistance to help adapt traditional MAC Group model to Health/Medical MAC Group, assist in developing the H/M MAC Group Handbook, and assist in training/exercise design: January 2009-December 2009 Convened a workgroup to develop H/M MAC Handbook: January 2009-August 2009 Included all hospitals, health systems, and public health in the membership of the H/M MAC Group: January 2009-August 2009
Objective 2: Developed an ethics framework based on community values to facilitate fair and transparent decision-making and reduce unintentional consequences. Tasks: Conducted community discussions designed to explore reactions to curtailing hospital services during a severe influenza pandemic: May 2009-June 2009 Enlisted the Multnomah County Health Department’s Diversity and Quality Team to help identify groups for inclusion in the discussions to ensure that the voice of vulnerable populations was heard: June 2009-July 2009 Develop the ethics framework informed by the findings from the community discussions, ethics literature and expertise of project’s ethicist: June 2009-August 2009 Applied the ethics framework during decision making by incorporating it into the H/M MAC Group Handbook, and reviewing it at each H/M MAC Group meeting: September 2009-February 2010 Evaluated the application/acceptability of the framework: September 2009-November 2009
Objective 3: Conducted an iterative exercise series (which became real-time due to H1N1) for the group to practice decision-making, collaboration, and organizational learning. Tasks: convened analytic teams comprised of experts in decision science, health economics, epidemiology, preventive medicine, public health, ethics, and MAC Groups to conduct the following studies, which were used in the scenario-based functional exercises: • Assess current area hospital utilization patterns; • Explore ambulatory and home-health capacity; • Estimate morbidity and mortality outcomes for both influenza and non influenza conditions based on available resources; • Identify strategies to increase capacity to meet the demands of the surge created by pandemic influenza; • Develop a framework to maintain essential healthcare services; • Explore types of alternative care delivery sites/methods utilized; • Estimate the supplies and resources needed in the face of a Severity Index Category 5 Influenza pandemic: January 2009 to August 2009 Convened a workgroup to prepare exercise materials with results of the above studies: January 2009 to August 2009 Conducted one H/M MAC Group training session: Sept 2, 2009 Conducted on H/M MAC Group functional exercise: Sept 16, 2009 Conducted eight meetings with H/M MAC Group to deal with real-time H1N1 issues: Oct 7, 2009: Developed hospital visitation policy Oct 22 and 29, 2009: Developed policies for distribution of government-controlled Tamiflu and mask use Nov 18, 2009: Developed antiviral distribution policy Dec 16, 2009: Continued hospital visitation policy Jan 6, 2010: Relaxed hospital visitation policy Feb 3, 2010: Planned future operations Evaluated the H/M MAC Group: September 2009-November 2009
Develop a Health/Medical MAC Group comprised of hospitals and public health, and a Health/Medical MAC Group Handbook.
Performance Measures: Include all hospital systems and public health in order for all interests to be represented. Develop and test Health/Medical MAC Group Handbook to guide Group processes.
The following activities were implemented on schedule: Review existing MAC Group models: January 2009-June 2009; Engage OQA Consultant for technical assistance: January 2009-December 2009; Convene a workgroup to develop MAC Group: January 2009-August 2009; Conduct training, functional exercise and real-time meetings: September 2009-February 2010; Evaluate the Health/Medical MAC Group: September 2009-November 2009.
Data Collection: Evaluation data were collected from the Health/Medical MAC Group members and observers representing emergency management, public health, hospital systems, community-based organizations, culturally-defined communities, and project consultants (ethics, decision-making science, health economics, clinical, etc). Data were collected from observers via surveys during the Health/Medical MAC Group exercise, and the second and fourth meetings, as well as through focused group discussions and interviews once the original meeting series was completed. Health/Medical MAC Group members “debriefed” their experience after each exercise and meeting to identify areas for improvement. Observers and Health/Medical MAC Group members also participated in focus groups after the meeting series.
Evaluation Results: Participants believed that the group would be accepted if the public knew that decisions were made by public health and healthcare systems, not just healthcare systems “[This combination] forces the decisions to be reasonable and as fair as possible.” “Having a regional response made sense. I think decisions made by all of us would be accepted by the community rather than have the separate systems or hospitals making them.” “There has never been a MAC Group before, so having one is a significant success.” “The fact that proactive discussions and decision making are being undertaken to optimize the use of healthcare resources would, I think be accepted by the public.”
Feedback: The Health/Medical MAC Group and guiding Health/Medical MAC Group Handbook developed will be a long-term strategy used for health/medical emergencies. Group members want to continue to meet quarterly; future work is planned that includes evaluation findings activities. Additionally, there is continued interest in expanding the Health/Medical MAC Group to include alternatives and content experts (e.g. infectious control, finance, hospital operations, etc.). The willingness to continue is in response to the series of planned scenario functional exercises and, more importantly, the real-time meetings in response to H1N1. The group’s ability to change gears and address real-time issues as a unified group of healthcare systems and public health demonstrated to Agency Administrators and group members the utility and effectiveness of making regional decisions using this practice. As part of this practice, the Handbook as well as a detailed narrative describing how this practice was developed, supported and evaluated is available.
Findings from the evaluation activities—both from the Health/Medical MAC Group and community observers strongly support the use of this practice. Additionally, Also, other Regions throughout Oregon as well as emergency managers have expressed interest in learning from this project so that they may utilize adaptations of this practice. Findings have been presented at national/regional conferences. Develop an ethics framework based on community values to facilitate fair and transparent decision-making and reduce unintentional consequences. Performance Measure: Framework is developed. Data Collection: The ethics framework was designed based on widely held community values
There is sufficient stakeholder commitment to perpetuate the practice at three levels:
1) the NW Oregon Healthcare Preparedness Organization (HPO) Steering Committee; 2) the H/M MAC Group; 3) HPO partners and stakeholders.
1) The HPO is a regional health emergency planning collaboration of regional hospitals and health systems, local and state public health, county emergency management, emergency medical services, medical societies, safety net clinics, and behavioral health. A steering committee guides the HPO’s health preparedness activities. In January 2010, the HPO steering committee assigned the refinement and solidification of regional coordination as its number one priority for 2010-2011. The committee further identified specific activities to ensure this: 1) continuation of H/M MAC Group development in the areas of relationships and processes; 2) continuation of H/M MAC Group development in the area of Incident Support Organizations and expanded resource ordering.Their identification of these priorities ensures the HPO’s commitment to the H/M MAC Group.
2) During the H/M MAC Group’s last formal meeting during the H1N1 influenza pandemic, members requested meeting quarterly to continue the development of relationships and processes. Nearly one-half of H/M MAC Group members participated in either a focus group or key stakeholder interview as part of the project’s evaluation, even in the light of competing priorities. Their willingness to participate in evaluation activities and their request to continue meeting demonstrates strong support for their continuing involvement in the H/M MAC Group.
3) HPO partners and stakeholders now rely on the activation of the H/M MAC Group in a real-time regional health emergency that warrants policy recommendations and scarce resource allocations. This includes hospitals/health systems, public health, private and safety net clinics, and emergency management.
The Office of Multnomah County Emergency Management is committed to continuing serving in a regional capacity to provide regional situation status and regional resource ordering, which are crucial to the support and functioning of the H/M MAC Group. Regional Emergency Managers are supportive of the H/M MAC Group and its role in health emergencies. They are working towards developing Intergovernmental Agreements to support a County ECC serving this role. We held quarterly H/M MAC Group meetings, beginning on February 3, 2010. We are finalizing additional process components to the H/M MAC Group Handbook that were developed since then including: working guidelines; processes for bringing in new H/M MAC Group members; procedures to respond when there is less than 100% consensus during initial decision-making, when the overall situation changes, and when one or more organizations dissent after decision has been made; process for how issues go to the H/M MAC Group and how issues are prioritized; how technical specialists will be utilized by the H/M MAC Group; how member alternates are utilized and trained; the relationship between and perspectives of the Public Health MAC Group and the H/M MAC Group; and level of public transparency, how and when to inform the public of decisions, and obtain public feedback.
These additional processes will aid in sustaining the practice over time. The H/M MAC Group has requested to meet tri-quarterly during FY11. They have identified alternates. FY11 meetings will focus primarily on H/M MAC Group trainings, exercises, and bringing in new and alternate H/M MAC Group members. HPO activities are funded by the federal Hospital Preparedness Program (HPP) via the State of Oregon Public Health Emergency Preparedness Program. The HPO steering committee allocates the annual federal HPP grant to hospitals, health systems and other related entities in Oregon Healthcare Preparedness Region 1 (Clatsop, Clackamas, Columbia, Multnomah, Washington, and Tillamook counties). Public and private partners from Clark County.