Integrated Emergency Operations Model for Public Health

State: OK Type: Promising Practice Year: 2014

Following the terrorist attacks of September 11, 2001, and more specifically the anthrax attacks in October of that same year, public health agencies were scrambling to determine their role in terrorism preparedness and response. Even as their role became better defined through the development of the cooperative agreements, presidential directives and guidance documents, it was still unclear what the specific nature of their role would be and how it would be implemented. Federal guidance clearly identified the states as the focal points for terrorism preparedness efforts. Unfortunately, most states, like most communities, had little or no experience with terrorism response and were still “finding their way” as the federal preparedness funds began to flow in the spring of 2002. Even now, twelve years later, while most state and local public health agencies are significantly more prepared for a terrorist attack, there is still little uniformity across the nation in terms of preparedness. Given the vast diversity of the states and the communities within the states, certainly some variation is appropriate, but, given the consistent nature of our roles, some similarities seem appropriate, as well. The subject of the practice discussed herein addresses just one component of preparedness in which the basic role of public health should be somewhat similar, and for which little or no guidance has ever been provided. That component is the model in which public health’s response emanates. While we in public health have come to embrace the National Incident Management System (NIMS) as the basic model for responding to incidents, a clear description of the model, as it relates to public health specifically, remains unaddressed in guidance documents. It is through twelve years of responding to multiple incidents and participating in dozens of exercises that a model for the organizational and physical infrastructures have evolved. That model, referred to herein as the “Integrated Emergency Operations Model for Public Health,” has only recently reached a level of maturity that can be considered for any public health agency, regardless of size or capability. Of course, as stated above, every state and community is different, and those differences should be considered as the implementing agency develops its own unique system. Jurisdiction size, population served and agency budgets will all play a role in how simple or how complex a system will be. The important thing to focus on when reviewing this practice is the "INTEGRATION" concept, not the physical plant (Emergency Operations Center) shared though out this document. As you will learn in this presentation, our initial EOC was intended to serve our entire jurisdiction, a population of approximately 700,000 people, but fell short of its goal. The second generation, likewise, was designed to serve a population of approximately 700,000 people. The third generation, developed for a different metropolitan area, is designed to support a population base of over one million people. The initial EOC design, installed in 2002, was based on the “traditional” EOC model still in use today in most jurisdictions – i.e. city, county, and state emergency management agencies. When the role of a jurisdiction’s EOC is reviewed, it is evident that the traditional model is still relevant. However, when that same model is implemented in a public health setting, inefficiencies, conflicts and limitations are evident. A model specifically for use by public health was needed. In the mid-2000s, a shift in the EOC evolution occurred. The strengths and weaknesses of the traditional model were analyzed and a new model emerged. As this agency prepared to construct a new health center, the EOC model continued to evolve based on lessons-learned during numerous responses. While physical enhancements based on lessons-learned through two previous incarnations are evident in the final design, the real key to the design of the integrated EOC is the “INTEGRATION” piece. Partnerships, collaborations and shared resources have long been a component of emergency operations. What makes this model unique is the integration of public safety and emergency management interests into the public health realm. As you will see in the subsequent sections, this model brings those components on board as permanent members of the public health model and gives them clear and direct access to the public health component before, during and after a response. While the initial implementation of this practice can be costly, the benefits far outweigh the financial challenges. For a detailed description of the Integrated EOC Model, including floor plans and photos; and details about the evolutionary process, lessons learned and public safety and emergency management integration, go to
Following the terrorist attacks of September 2001, and the anthrax attacks of October of that same year, public health clearly became a first responder. Previously, public health had provided rapid response for such things as food borne illness outbreaks, disease investigations and disease surveillance. But, the events of 2001 clearly positioned public health as a first responder for events heretofore reserved for police, fire, emergency management and other public safety entities. As a new first responder, public health had the immediate challenge of figuring out what to do and how to do it if it was to become an effective partner of the public safety community. Early in the last decade, public health was tasked with learning and using the National Incident Management System. But, little guidance was forthcoming on the organizational or physical structure necessary to management an incident. Defining that structure was left up to public health’s own devices. Not surprisingly, the initial reaction of most public health agencies was to do nothing. Incidents, regardless of their extent, would be handled using “business as usual” tactics. Depending on the nature and scope of the event, employees would be rallied, space would be cleared and the response would be mounted. In the case of a food borne illness outbreak, shots would be administered wherever, whenever and to whomever it was identified as most appropriate. However, as public health’s role expanded to include Category A agents, including smallpox and anthrax, the “business as usual” approach was clearly inadequate. As public health became more involved with the traditional first responder community, it was evident that a place needed to be established from which to manage a response in an effective and efficient manner. The obvious answer at the time was to mimic the traditional EOC model in use in most communities across the country. That strategy seemed appropriate at first, but proved ineffective during the next year as we responded to several minor events and participated in a couple of major exercises. The traditional EOC model simply did not work for public health. Following several awkward responses in the early 2000s, it was necessary for us to take a hard look at what we were doing, analyze what wasn’t working, and determine what our specific needs were. We reviewed our interactions with other first response agencies, with the public, the media and others as we sought to identify a system that worked. The “business as usual” approach created more issues than it resolved. A commandeered conference room was too noisy and conditions were too disruptive from which to stage an organized response. Such an arrangement also disrupted the normal business activity of the agency. The traditional EOC model that had been employed in many agencies also proved inadequate with regard to addressing public health‘s needs. The keystone of the traditional model is a central meeting place for decision-makers to convene to review data, discuss options and make decisions regarding a response. The success of the traditional model is predicated on the fact that the decision-makers needed to mount an effective response would be active participants in the EOC. In our experience, unless a response was exclusively public health centric, no one came to the public health EOC.  They always convened at the community (city, county or state) EOC. Participation at the public health EOC, in most instances, was limited to public health responders. During a typical deployment, our policy staff (director and deputy director) was located at the community EOC. Our Incident Commander (IC), command staff and general staff were located at the public health EOC, and our technical staff (responders) were in the field; either conducting interviews at hospitals or at the homes of victims, establishing or operating mass immunization clinics, or conducting epidemiological investigations in the community. What public health needed was a command post from which to deploy, monitor and manage our staff, not a central meeting place for decision-makers. And, for public health to work efficiently, increasing our chances of saving lives and of decreasing illness, close integration of other first responders was needed. In the mid-2000s, following several events and dozens of exercises, we set out to design a model that better addressed public health’s needs. Clearly the traditional model, while still viable for community-wide responses, was inappropriate for public health. And, the “business as usual” approach proved inadequate for anything other than minor responses to localized events. What was needed was a model that would serve as a “nerve center” for public health, regardless of whether it was activated for a minor public health specific event or to coordinate the public health component of a major community-wide response. What was needed was one location for public health’s command staff to plan, organize, monitor and manage a response; a place from which to coordinate all communications of the public health workforce; and a place to integrate other first responder agencies into the response. Based on lessons-learned during event and exercise activations, and through the review and analysis of several designs, an optimal model was developed. The design addresses the specific needs of the public health responders. It provides a central command post where the public health command staff and partners could convene to review relevant data, plan a response and monitor the event. It provides a robust interoperable communications component that provides several levels of redundancy supporting reliable interactions between the command and general staff and staff in the field, at the community EOC, and in other locations. It provides a call center from which to field inquiries from the public. It provides dedicated space for several public safety entities including Medical Emergency Response Center (MERC), Medical Reserve Corps (MRC), 2-1-1 Call Center, Emergency Medical Services (EMS) and Emergency Management (EM). And, it offers support functions and assets designed to sustain a viable response posture throughout a response for all participants. The key to the integrated EOC model, and what makes the design unique to Public Health, is the direct integration of multiple public safety organizations into the physical design of the model. MERC, MRC, 2-1-1 Call Center, EMS and EM have dedicated space in the integrated EOC, center support services and resources, and 24/7 access. It’s their space to access whenever needed. While EOCs are relatively new to public health (post 9/11 for most), the concept is not new to the field of emergency management. The practice described herein is an adaptation of the traditional EOC, found in most communities, specifically for the purpose of supporting public health and its response partners. The model described accounts for public health’s needs and incorporates the needs of partner agencies that have a strong correlation with the public health mission. The goal of the “integrated” design described herein is the presentation of an efficient and effective model for coordinating a public health response. Considering that efficiency and effectiveness are the overbearing stalwarts of NIMS, it’s surprising that a model adaptation has yet to be prescribed for public health. Hence, the model described herein. As described previously, this practice includes: 1) the design and implementation of a public health-centric EOC model, and 2) the integration of several public safety organizations into the public health model. The design takes what works in the traditional (community-based) EOC model, drops the elements not needed for public health responses, adds the elements necessary for an efficient and effective public health response, and incorporates the public safety component unique to this model. And, finally, the design is optimized for it specific purpose – responding to a public health event. For a detailed description of the Integrated EOC Model, go to In an effort to design the most effective model for supporting public health, an exhaustive search of the Internet was conducted in 2004, supplemented by an online survey of dozens of public health agencies across the nation in 2005. While several examples of EOCs were found, none reflected a design as unique as the model described herein. In fact, with the exception of a few examples using a traditional EOC model, nearly all public health EOCs were using an adaptive “business as usual” model. By adaptive, I mean a model that utilizes a commandeered conference room, or similar open space, with telephones, computers, tables, chairs, white boards, etc. rapidly set up to support the response. Some had a quasi-permanent stature while most were event-activated. Ironically, most health departments across the nation still have no dedicated EOC. Considering the significant amount of federal funding available through the CDC Public Health Emergency Response (PHER) grants in the 2009-2010 time frame specifically targeted for EOC enhancement, it’s unfortunate that more public health agencies failed to capitalize on the opportunity. In a review of other public health agencies, it is apparent that the primary means of addressing the aforementioned issue is to adopt a “business as usual” approach or commandeer a conference room (or similar area) within an existing facility for their response. The model described herein encourages the allocation of resources specifically for the establishment of a permanent EOC. Additionally, the model is designed to meet public health‘s needs which are clearly unique and somewhat of a departure from the traditional EOC model in use in most communities. And, finally, the integrated component of this practice involves the establishment of strong partnerships with relevant public safety organizations and the incorporation of those organizations into the public health response component. It bears repeating that the primary focus of this model is the INTEGRATION of public safety and emergency management organizations into the public health response. The physical location from which the response is facilitated, i.e. Emergency Operations Center, is important to the implementation of the model, but the design can be flexible and consistent with an organization's available resources. The EOC described herein is just one agency's design and the evolution of the design associated with it. Saving lives and reducing illness is the foundation of public health's mission. Incorporating public health's unique elements into the traditional response model simply doesn't work. Asking public safety to redesign their system to meet public health's needs is ineffective, self-centered, and, quite honestly, unnecessary. Integrating public safety and emergency management organizations into public health, without compromising their participation in the primary emergency operation system bridges that gap. True integration requires a location, but the extent to which that location matches the EOC model described herein is not important. What's important is that public safety and emergency management personnel are infused into the actual operation facilitated from public health's perspective. Public health should still be incorporated into the primary EOC, but it is equally important that public safety and emergency management be infused into public health's response. The EOC model presented in this proposal is shared for the sole purpose of providing a proven model from which a response can be directed. We present the chronology of the evolution of the EOC simply to share our experiences, lessons-learned and issues encountered in hopes of saving other organizations valuable time and resources in achieving an integrated model.
The primary stakeholders of this practice include Public Health Department staff, Medical Emergency Response Center staff, Medical Reserve Corps staff, 2-1-1 Call Center staff, Emergency Medical Services staff and Emergency Management staff.The local health department’s role in the implementation of the practice described herein is the design, construction and implementation of the EOC, development of partnerships with public safety organizations relevant to the integration component, and oversight and management of the entire model. While the local public health agency has been the primary initiator for the model described herein, that should not preclude the collaboration of other first responder agencies, particularly those who are intended users of the integrated EOC. The EOC design is critical to the success of the model. EOC effectiveness is achieved through the efficiencies designed into the model. The “nerve center” is the central command post that includes workstations at which command and general staff and partners can review event status, hold ad-hoc meetings to discuss response strategies and monitor the response. Multiple team rooms are available for specific meetings held by Planning, Operations, or others. A large conference room is available for command staff meetings or teleconferencing. Communications, while in close proximity, is separated from the command post to eliminate congestion, conflicts and confusion. An incident-tracking station utilizing WebEOC is strategically located to have direct observable access to the command post and communications room to assure capturing of all relevant information. Dedicated space is available for MERC, 2-1-1 Call Center, MRC, EMS and EM, when activated. And, if properly implemented, it’s all secure, reliable and fully activated at a moment’s notice. The third generation EOC described above was constructed below grade-level, is secure from the rest of the health department facility, and is fully covered by an emergency backup generator. And, partner organizations will have unfettered 24/7 access to their dedicated areas. Now in its third incarnation, the integrated EOC was designed with the direct involvement of the intended partners. The design includes dedicate rooms/space for MERC use, MRC use, 2-1-1 Call Center use, EMS use and EM use. The rooms dedicated to the MERC and the 2-1-1 Call Center each have six workstations. The Call Center model is capable of handling up to 24 simultaneous calls from the public. The first six calls are routed to a prerecorded message that answers 80 percent of callers’ questions, the second six calls are routed to a live person, the next six calls are placed in queue for the recorded message and the last six calls are placed in queue for a live person. The six workstations in the MERC can be configured to supplement the 2-1-1 Call Center, increasing the capacity to 48 simultaneous calls, if the MERC is not activated. Depending on your relationship with your partners, the roles will be different. For example, in the Tulsa model, the MERC was supported by EMS who provided the computers, an applications server and interoperable communications equipment. The Call Center was equipped by the local 2-1-1 organization with computers, an applications server and remote connectivity to their IP phone network for seamless integration with their primary 2-1-1 Call Center. The Health Department provided all fixtures, phones, Internet access, etc. for both rooms. As mentioned previously, the partners have unfettered 24/7 access to the center. Public Health and public safety, including EM and EMS, in Tulsa and Oklahoma City have a long-standing tradition of working together for the greater good, but the relationships have flourished since September 2001. Both components have planned and prepared together for over ten years and continually look for ways to support each other for the enhancement of community preparedness. All agencies understand and respect the others capabilities and routinely exercise together to assure that those capabilities are maximized when needed.The most important lesson-learned through twelve years of working with public safety on preparedness and response is that, while mutual respect is critical, it is not enough. Effective working relationships require constant interactions between all parties, knowing each others' role, capabilities, strengths and weaknesses. The most significant technological barriers to successful collaboration between public health and public safety required for this practice have been in the area of communications. There were two incompatible systems in the region and interoperability was a challenge. Each sector had made significant investments in their respective communications infrastructures and was unwilling and unable (financially) to make the needed changes. Interoperability was difficult to achieve due to proprietary restrictions. The challenges associated with the communications have gradually been resolved over the years as the state Department of Homeland Security has heavily funded interoperable communications for many agencies, and as new interoperability technologies have been deployed. Most agencies are now on the same system. The processes described throughout this presentation emphasize the evolutionary aspects of the practice through three iterations of the design and implementation of an emergency operations center. The steps were many and were spread out over a twelve year period of time. Since the entire process involved a three phase evolution to get to the current model, the steps to implement this practice will be limited to the basic steps to implement only the current model. The lessons-learned from the first two incarnations are incorporated into the design of the current model. A general description of the physical design of the optimal public health EOC is described previously. For a floor plan of the current EOC design for Oklahoma City, go to The actual EOC design, while critical to an efficient and effective response, is just the location in which this practice is set. The design promoted herein is the optimal design for this community as determined through a collaborative effort of local public health and public safety partners. It is not the only design that works well for public health and is not required in its exact form to take advantage of the integrated aspects discussed herein. To fully appreciate the benefits of this practice, however, a dedicated permanent EOC is necessary. The components included in your EOC design should be what works best for your local community, your local partnerships, and your local response components. The design promoted herein is an excellent model from which to begin any EOC design project, but it’s only a template. The more challenging part of this practice to accomplish is the “INTEGRATION” component. This takes partnerships with local public safety organizations that can, and often, take years to nurture. If effective partnerships already exist in your community, the battle is nearly won. If effective partnerships do not exist, now is the best time to begin that process.The time frame to reach the level of success that this practice currently enjoys was approximately twelve years. However, as explained above, the process was evolutionary with three incarnations of the EOC model being implemented. Obviously, it is not necessary for subsequent organizations to go through the first two iterations of design and operation but can take advantage of the lessons learned and begin their process with the third generation model and design. Even as such, the time frame to replicate our success is totally dependent upon local conditions, including funding, partnerships, and resources. Given an environment conducive to accomplishing the goal of establishing an efficient and effective integrated EOC, it is not unreasonable to expect success within one to two years. The bricks and mortar piece is easy – the integration may take a bit longer. While integration of public safety and emergency management partners in this model is well documented throughout this presentation, it should also be noted that public safety and emergency management partners were also heavily involved in the design and implementation of the model, including the integration piece and the facility piece. Those organizations knew best what their needs were, how those needs could be met, what they had to offer and how they best could incorporate those elements into the public health response. Through multiple responses and exercises, public health, public safety and emergency management learned what worked well and what needed improvement. Lessons-learned in each event were reviewed and solutions were infused into subsequent events.
Objective One: Development of an efficient and effective EOC model for public health. Performance Measures: Establishment of a central command post specifically designed to address public health’s need for a physical location to review data, consider options, make decisions, and monitor response activities; Establishment of an interoperable communications system to facilitate the communications needs of public health; Establishment of a model consisting of adequate space and resources to support command and general staff’s needs; Establishment of a response model that supports public health’s specific needs in the field, at points of dispensing, at the community EOC and at other locations; and Establishment of a central incident tracking system for public health. Data: Since this practice is conducive to both process evaluation and outcome evaluation, the data to be evaluated are a combination of the extent to which the EOC model was completed, the extent to which it is efficient and effective, and the extent to which the practice improved collaboration among response partners leading to improvements in response capabilities and outcomes. Evaluation Results: All five objectives were met with the implementation of the second generation EOC model that was designed and implemented in 2004-2005. The central command post, while effective, proved to be somewhat limited in size in the second generation but was increased in size and capability in the third generation model. The second generation communications component was adequate but its location within the command post resulted in congestion, conflicts and confusion. The third generation model provides a separate room for communications and includes an incident-tracking workstation with direct observable access to the communications room and the command post. The second generation model included a separate conference room for meetings and a separate office space for the command staff, but lacked adequate meeting space for ad-hoc section meetings. Enhancements incorporated into the third generation model, based on lessons-learned through five years of operating under the second generation model, added needed meeting spaces and increased efficiency and effectiveness significantly. The integration of public safety into the public health model has been thoroughly tested in all three incarnations of the practice described herein; however, each subsequent generation has proven to be much more efficient and effective that the previous. Most public safety components (i.e. MRC, EM, EMS, MERC, 2-1-1, et al) have established a presence in the public health EOC during events ranging from ice storms to wild land fires. A long-term presence of several partners occurred during the H1N1 response of 2009-2010. While each subsequent model has demonstrated process improvement, the current model provides clear advantages over all previous models. Feedback: The feedback received from staff and partners through four years of operating under the first generation model and five years of operating under the second generation model provided EOC staff with many specific enhancements that are incorporated into the third generation model. While the third generation model is relative new, it too has proven its value with the most recent event being a coordinated response to two separate EF5 tornadoes in central Oklahoma. Partnerships with several public safety organizations were critical to the efficient responses needed to protect human lives. Dozens of changes were made in the design significantly increasing efficiency and effectiveness of the center, providing a well-tested model for public health. The current model is sufficiently proven in capability and functionality and should work well for any public health agency. Some modifications may be needed to meet the unique challenges of other agencies, but the template is well vetted and it works. Objective Two: Integration of public safety partners into the public health EOC model. Performance Measures: Incorporation of MERC, MRC, Call Center, EM and EMS into the public health model. This was important to the success of the current model because of the strong collaboration required between public health and public safety for the management of events. Data: Since this practice is conducive to both process evaluation and outcome evaluation, the data to be evaluated are the extent to which public safety partners were integrated into the public health model. Evaluation Results: As described in previous sections, all five of the aforementioned public safety components have been successfully incorporated into the current model. MERC and Call Center each have dedicated rooms for their respective operations and have activated those rooms on numerous occasions. The two rooms are adjacent in the current model allowing for expansion of either component if the other is not activated. MRC, EM and EMS each have workstations, meeting rooms, and communications support in the current model should they be activated for a response; and each have utilized those resources during recent responses. And, all of the public safety partners have unfettered 24/7 access to the center. Feedback: The response of the public safety community in regards to providing them with workspace and response support in the public health EOC has been very positive. Not only does the close proximity significantly increase efficiency and effectiveness of all parties, it also enhances the interactions of the responders. Most have also established the public health EOC as their respective alternate response center. Objective Three: Establishment of a system for sustaining the integrated public health EOC model. Performance Measures: Continued budgetary support for sustaining all EOC functions. Data: Since this practice is conducive to both process evaluation and outcome evaluation, the data to be evaluated are the extent to which a model to sustain the EOC could be established and the extent to which sustainability is actually working. Evaluation Results: The initial cost of designing and constructing the second generation model was an integral part of H5N1 (pan flu) preparedness activities during the 2004-2005 time frame, and involved remodeling a basement storage area at a cost of approximately $45,000. Sustaining that model became a standing budget item for the agency. Periodic repair or replacement of infrastructure was absorbed in the IT or Facilities budget. Design and construction of the current EOC model was an integral part of the construction of a new health and wellness center. The portion of the new construction attributable to the EOC component was approximately $500,000. The new health and wellness center, along with clinical and administrative components, house the agency’s emergency preparedness and response program, including the EOC. The EOC was constructed below grade-level, is secure and has full emergency backup generator coverage for operational assurance. It also provides shelter capabilities for the entire facility in the event of severe weather. As a primary component of the new health and wellness center, sustainability of the EOC is incorporated into the agency’s budget. Ongoing infrastructure needs are supported with the IT and Facilities budgets. Sustainability of the infrastructure requirements in the MERC and Call Center are the responsibility of the respective partners and is a standing budget item for those agencies. Feedback: Each of the partners that have been integrated into the current model considers the public health EOC a remote component of their respective operations. They are fully vested in the success of the center and strongly support the model. Sustainability is a standing part of their budgets. It should be reiterated that the collaboration of the partners began during the design of each of the models described herein and has continued throughout the various iterations as the model has evolved. Their participation has included "means and methods" of improving the integration component of the model as well as the facility portion of the model. One of the less obvious challenges has been making the environment "comfortable" for the respective partners. Their involvement in that regard is strongly reflected in the design of the model whose evolution has incorporated many of their traditional components.
There is sufficient stakeholder commitment to sustain this practice indefinitely. The primary financial investment was in the design and construction of the physical facility that houses the EOC, and the necessary technology to implement an effective operation, including communications equipment, audio-video equipment, computers, monitors, phones, etc. Maintaining the center and the equipment has been absorbed into the standing operating budget of the agency. As stated above, the technology infrastructure in the MERC and Call Center was provided by the respective partners and will be maintained by those partners.For the majority of the technology installed in the EOC and for the physical facility, sustaining the practice over time will be a standing component of the agency budget. Maintenance of the components supported by the partners will be the responsibility of the respective partners.