Public Health Incident Management Team

State: CO Type: Model Practice Year: 2014

In 2009 and into 2010, public health agencies all across the country responded to the largest public health threat in decades. The intense national response to the H1N1 pandemic required an incredible amount of resources at all levels of government and across many disciplines, making strong management of the response critical. Tri-County Health Department’s (TCHD) After Action Report for the incident recommended that additional training for health department staff on all-hazards incident management and the adaptation of incident management skills to public health response would enhance incident responses in the future. This was of particular concern for large-scale bioterrorism events, like an anthrax attack, where huge amounts of resources would need to be mobilized rapidly and for an extended period of time. To meet that need, TCHD created the Public Health Incident Management Team (PHIMT) in March 2011. The PHIMT is an incident management team, consisting of members from all divisions and offices at TCHD, trained to manage incidents using the Incident Command System (ICS) moderately adapted for use in a public health agency utilizing subject matter expertise from throughout the agency. It is a comprehensive program intended to provide TCHD with experts in all of Command and General staff positions to respond to any incident. TCHD is the largest local health department in Colorado. It provides public health services for Adams, Arapahoe, and Douglas counties, which consists of 1.3 million people surrounding the City and County of Denver to the north, east, and south. The purpose of the PHIMT is to promote response capacity, coordination, collaboration, and communication among all divisions in TCHD to ensure that TCHD can effectively respond to any public health event and remains an effective partner to all other disciplines in the TCHD jurisdiction, specifically in its role of Emergency Support Function (ESF) #8 Lead. The goals of the program are to: Create depth in the management of and response to complex and long-term emergencies and incidents Incorporate staff from each division/office within Tri-County Health Department to foster a culture of emergency preparedness throughout the organization. The PHIMT consists of approximately 38 individuals who are assigned to ICS functional areas (i.e., Command or General staff positions) and trained on the management of that function. Each Section and Command staff group is led by at least one individual who has received a training certificate from an approved outside all hazards incident management organization, primarily the Colorado Wildland Fire Incident Management Academy (CWFIMA). This leadership is responsible for the development of their command staff function or section and the training of the other staff in that group, making sure to adapt the all hazards approach to best meet the needs of a public health response while maintaining the position’s ability to integrate into a large response or command structure. The PHIMT meets monthly for two hours. The meetings consist of a training or exercise designed to improve the team’s knowledge and understanding of ICS and how to respond to an incident. The exercises ranged from table top exercises to functional and full scale exercises, including large scale multi-disciplinary/multi-jurisdictional exercises involving hundreds of responders and volunteers. The initial trainings were geared toward the roles and responsibilities of each position. As competency in this area increased, the trainings and exercises became more focused on how each position works together and interacts in order to make a cohesive team. This included a detailed investigation of the ICS planning process, or Planning ‘P’. The functional exercises have included support for health and medical response to a complex terrorism incident (Operation Mountain Guardian) and a mass prophylaxis response to an Anthrax incident (Operation Spore). These exercises saw the PHIMT work through the planning process and develop Incident Action Plans to manage an operational period in support of the overall incident objectives. After Action Reports were used to evaluate the exercise and identify corrective actions required to improve the response in the future. These functional exercises have shown that PHIMT members have developed a strong understanding of the principles of ICS and how they apply to public health. The foundation for implementation of our response plans has been laid. We believe this practice can effectively be applied to any local health jurisdiction with the resources required to fill the staffing positions. This would eliminate many of the smaller local health departments. However, this practice could be applied regionally in those areas where single health departments do not have the staffing resources to implement it on their own.
The Tri-County Health Department is the largest local health department in Colorado. It provides public health services for Adams, Arapahoe, and Douglas counties, which consists of 1.3 million people surrounding the City and County of Denver to the north, east, and south. The jurisdiction consists of a diverse mix of urban, suburban, and rural communities geographically situated in the plains and foothills to the east of the Rocky Mountains spanning more than 3,000 square miles and including three counties and 26 local cities and towns. The population served covers a broad socio-economic and political spectrum requiring a TCHD to provide a range of services to meet the diverse needs of the residents. In 2003, the President of the United States of America signed Homeland Security Presidential Directive 5 (HSPD-5) establishing the National Response Plan (to become in National Response Framework in 2008) and the National Incident Management System (NIMS). The Incident Command System was established as a core component of NIMS. Since that time, Public Health Preparedness has been recognized as a core public health competency and NIMS compliance is compulsory. H1N1 provided Tri-County Health Department with an opportunity to test our ability to respond effectively to a major public health incident. While the overall response was a success, there were some deficiencies identified in terms of general incident management, including a lack of depth of response staff, the need for better efficiency in resource tracking, and financial management. The PHIMT represents the successful strategy employed to fill that gap. The public health issues being addressed are all-hazards preparedness planning and public health workforce development for public health preparedness, #3 and #4 respectively in NACCHO’s Preparedness Priority Areas. #3) Promote All-Hazards Preparedness: ICS represents the foundation of all-hazards preparedness. By design, it can be utilized to manage the response to any kind and scope of incident. The PHIMT team members are trained not in a public health “adapted” version of ICS, but in ICS as it is taught to every other response discipline. They are prepared to meet the needs of any public health incident that TCHD may face, but would also have the knowledge to fill their position in a traditional all-hazards IMT and would be able to seamlessly integrate in that structure. The ability for TCHD to effectively implement its response plans depends on this knowledge and skill base. #4) Strengthen Public Health Preparedness Workforce Development: TCHD requires all employees to receive a basic level of ICS training, commensurate with NIMS requirements. The PHIMT requires that members from each office and division within TCHD are trained to have a far more in-depth operational understanding of ICS. It brings a culture of preparedness to the entire agency through increased knowledge and responsibility from all corners of the organization. The team is comprised of 39 individuals (approximately 11.5% of the TCHD workforce) who are ready to respond to incidents and who view this duty as an integral facet of their position and to the success of the agency as a whole. Prior to implementation of the PHIMT at TCHD, the agency had an Emergency Preparedness (EP) Team that focused on emergency preparedness and response policies and trainings. This group, though valuable, was not trained in incident management activities, leaving the Office of Emergency Preparedness and Response (EPR) solely responsible for these activities during an event or incident. EPR, the smallest of the offices at TCHD, when fully staffed employs only seven people. This limited number does not allow for depth in management for long term incidents or incidents requiring 24 hour operations. Additionally, EP Team members were untrained in existing agency response plans resulting in the need to train staff just-in-time on all response activities as well as working to ensure staff responded according to existing plans rather than creating a new plan in response to each incident. The current practice addresses these issues by providing the broad cross-section of trained public health staff necessary to meet the identified gaps. It promotes all-hazards preparedness by drastically expanding and enhancing Tri-County Health Department’s capacity to respond to incidents of any type. It strengthens the public health workforce by creating a cohesive, cross-divisional, multi-disciplinary team that brings together skilled and talented individuals from disparate programs in the agency to train and work together toward a common core goal. The PHIMT also strengthens knowledge of ICS within TCHD’s leadership. The innovation of this team is less about the differences between the PHIMT and a traditional IMT and more about the use of this organizational structure and incident management methodology as an agency wide tool for managing public health lead incidents. A thorough web search and a search for similar projects in the NACCHO Model Practice Database produced no results that matched the PHIMT. The Google search criteria included “Public Health Incident Management Team”, “Public Health ICS”, “Public Health Incident Command System”, “Public Health Incident Response Team”, and “Public Health Emergency Response Team”. The search turned up a myriad of different approaches of addressing the issue that did not reach the scope and potential of the PHIMT. There are many examples of public health “Emergency Response Teams” that generally focus on specific, operational components of a public health response like disease control, epidemiology, or Point of Dispensing Management. None of these dealt with the detail of the “overhead” positions required to support and manage those operational components. None of the identified approaches consisted of a team of individuals trained to the same level as general all-hazards IMTs to manage Planning, Logistics, Finance/Administration, Safety Officer, Public Information Officer, Liaison Officer, and Incident Commander duties as defined by NIMS or any other larger all-hazards approach. Because agency staff is trained in this manner, they are able to either manage an incident independently or seamlessly integrate with a traditional IMT for much larger scale incidents, allowing the agency to be able to independently manage more complex response operations while still maintaining continuity of critical services. This team is different from an all-hazards IMT because they are all public health subject matter experts capable of adapting the all-hazards approach and materials to meet the specific requirements of a public health incident. There is a large amount of literature regarding the adaptation of ICS to the public health context. These tend to go into structural differences, but not into the detail of how to manage an actual public health IMT. They tend to be general guidelines and collections of lessons learned without the operational component that the PHIMT represents. This practice is evidence based using standard materials from various sources, including: FEMA ICS Resource Center: The National Response Framework: Materials from position-specific trainings from the Colorado Wildland Fire Incident Management Academy (CWFIMA): This practice does not address one of the CDC’s Winnable Battles directly since they are deliberately focused on specific, existing high morbidity health conditions. However, it could be used in the management of any public health intervention and has been used, demonstrating its scalability, during non-routine outbreaks and incidents impacting TCHD throughout 2013. Emergency preparedness is considered a core public health service according to the CDC, our state health department, and Tri-County Health Department.
There were a number of lessons learned documented in the after action report pertaining to the TCHD response to H1N1. Primary amongst those findings were limitations in the existing agency emergency response procedures for the management of complex or long term incidents. Also, in a response to this type of incident it was identified as essential that the entire agency support day-to-day operations and the response activities. As a consequence of these lessons learned, the formation of the Public Health Incident Management Team (PHIMT) addressed two primary goals: To create depth in the management of and response to complex and long-term emergencies and incidents, and To incorporate staff from each division/office within Tri-County Health Department to foster a culture of emergency preparedness throughout the organization. The PHIMT was created from a pre-existing cross-divisional group, which met bi-monthly to discuss issues related to public health preparedness and response. The previous group, the Emergency Preparedness (EP) Team, had no operational role and was trained on incident management only to the level required by TCHD for general employees. The transition was conceived, planned, and managed by the Office of Emergency Preparedness and Response. The steps followed included: Identified individuals for leadership for each command and general staff position based on experience, leadership ability, and availability. Identified and provided position-specific training for each position through the Colorado Wildland Fire Incident Management Academy. Identified individuals for each team associated with the command staff positions and each section. Provided a kick-off meeting with the goal of explaining the operational role the group would play and provided an ICS refresher. Provided consecutive trainings and exercises designed to enhance the team’s understanding of ICS, including their roles and responsibilities. Tested staff understanding of their positions on the PHIMT and interactions with other command/general staff through a functional exercise. Provided additional training on interactions between the different positions and functions of the team. In order to effectively meet the identified goals, TCHD EPR staff established three objectives that can be used as building blocks to establish a functioning team, and guide ongoing sustainability, and as tools to measure the success of the program. These objectives, outlined below were initially established prior to the team being developed and have been reviewed and revised on at least an annual basis to ensure they are still applicable and appropriate. In the last year, a fourth objective was added to the list as an appropriate way to provide training and measure the success of individuals on the team as they respond to actual incidents. Objective 1: Maintain at a minimum one individual with a training certificate for each command and general staff position (Incident Commander, Safety Officer, Liaison Officer, Public Information Officer, Operations Section Chief, Planning Section Chief, Logistics Section Chief, and Finance/Administration Section Chief) A minimum of one TCHD staff member, including all EPR staff, were identified in command and general staff position to attend the Colorado Wildland Fire Academy or other similar offering of Incident Command Structure (ICS) position specific Training. These staff members have been required to complete the course work and work with EPR staff to adapt the position, if necessary, to meet the needs associated with a public health response effort. Objective 2: Maintain membership from each division/office within Tri-County Health Department. TCHD is made up of six Divisions/Offices. EPR staff, working with agency and division leadership identified staff from each of those divisions and offices to serve on the PHIMT. These staff were selected because of unique skills and abilities, a proven interest in incident response or management, and/or being identified as a good fit for this type of activity during response operations. Some, although not all, of the identified staff had been a member of the previous Emergency Preparedness Team. Additionally, not all members of the EP Team were included on the PHIMT as they would serve other roles during an incident necessitating that they not be located in incident command. oOnce identified, staff was trained on position specific roles, responsibilities, and products by the pre-identified and trained leader for their position. This leader also created a binder containing position checklists, important tools, and other guidance documentation to ease the transition between day-to-day duties to incident response roles. oAfter PHIMT members achieved a level of comfort in their specific positions, the team trained on interactions between positions and incident management as a system rather than on their specific roles. This assisted the PHIMT in growing into a cohesive unit during incident response rather than individuals working towards a goal. Objective 3: Provide at least six trainings per year with a minimum of 30 participants each, including a minimum of one functional exercise. oFor the first three years, the PHIMT was scheduled to meet monthly for a minimum of two hours for training or an exercise. As with any standing appointment involving this number of professionals, it was expected and did occur that one or more of those monthly meetings would be cancelled. However, the PHIMT more than meetings the objective of six meetings per year. After three years, the meeting schedule was reevaluated and adjusted to meet the needs of the participating staff and to avoid training fatigue. As the staff has stayed remarkably consistent with only a few changes over three years, the decision was made to create a three month training cycle with a built in month off between each cycle. Each training cycle would involve a key theme or topic (hazard specific or intervention specific training). The first month involves a PHIMT wide training, the second month is comprised of position specific training for that theme, and the third month entails a PHIMT wide table top or functional exercise. This schedule ensures six trainings and three exercises per calendar year as well as any additional training received during incident response at TCHD or through mutual aid. oThe impact on PHIMT members’ day-to-day duties is minimal. Though some staff has attended the more time intensive trainings at the Wildland Fire Academy, once that training is complete their time commitment is scaled back to the previously discussed monthly schedule. However, the impact on the state of readiness and the ability of each division in the agency to respond to any non-routine incident efficiently, effectively, and in a timely manner has been recognized in response to a number of outbreaks, incidents and a boil water advisory impacting our jurisdiction. Objective 4: Encourage PHIMT staff to support surrounding jurisdictions in disaster response and recovery efforts through the use of MOUs to allow members to gain real world experience, practice ICS skills, and stress the importance of working in a state of readiness. TCHD PHIMT members have been part of incidents affecting our own jurisdiction in support of outbreak investigation, wildland fire response, and flooding response and recovery. For example, Logistics Section staff were requested and assigned to serve in support of the Adams County Disaster Assistance Center following the September 2013 floods impacting 17 Counties in Colorado to ensure that this complex operation had the facilities, supplies, and equipment necessary to operate smoothly for the impacted public. PHIMT members reported back that because of their ongoing training and experience through exercises, they were able to comfortably and confidently fill these positions during recovery operations normally outside of their scope of work. TCHD PHIMT members have played an active role in supporting partner jurisdictions in response and recovery efforts for wildland fires and flooding. PHIMT members, specifically a Safety Officer and members of the Planning and Logistics Sections, were deployed in response to the 2013 Black Forest Fire during re-entry operations. During after action conversations, they reported that PHIMT trainings and exercises gave them the ability and confidences to not only serve in their assigned roles, but to take leadership positions during operations and to provide feedback and make improvements in the ongoing response efforts. The PHIMT kicked off on March 17, 2011 and implementation is ongoing. The team has been incorporated into standard response operations for TCHD at all levels and was tested at full strength during the 2013 Operation Spore full scale mass prophylaxis exercise. This exercise served to validate the existing goals and objectives and allowed EPR to evaluate the processes and tools utilized to ensure that incident management activities were conducted and that TCHD response was capable of being fully integrated into a region wide incident. The primary internal stakeholders for the PHIMT are the executive management team for TCHD, consisting of the division/office directors as well as the executive director for the agency. The TCHD leadership has the responsibility to ensure that the agency is prepared to meet its obligations to protect the public health during a disaster response and recovery. This project could not have been accomplished without this recognition from the TCHD executive management team and their willingness to provide the personnel resources required to support this effort. These stakeholders provided the necessary staffing resources for this project. This includes at least a two hour meeting for 38 public health staff every month, which was extended to a half day exercise and a full day exercise over the course of the first year of implementation. In addition, 11 individuals attended three to five days of intensive position-specific training at the Colorado Wildland Fire Incident Management Academy (CWFIMA). Having conceived, planned, and implemented the PHIMT, TCHD is currently the only participating agency. However, emergency preparedness requires coordination across a broad spectrum of agencies and disciplines, and Tri-County Health Department’s enhanced ability to manage incidents in which they are involved therefore impacts every agency with which we interact during an emergency. Our stakeholders for this project therefore include our Offices of Emergency Management (OEMs) as well as our Emergency Support Function #8 (ESF#8) partners, which include hospitals, coroners, behavioral health agencies, Emergency Medical Services, the state health department, federal health partners and other community based members of the healthcare system serving Adams, Arapahoe, and Douglas Counties and the Greater Denver Metro Area. The all-hazards nature of the program also allows for improved integration with traditional first responder agencies such as fire and law enforcement. TCHD continually shares the resources, tools, and practices that have been developed through this process with other jurisdictions and agencies in Colorado that are planning to start all-hazards IMTs. Costs associated with the PHIMT are primarily staff time for planning, developing meetings, trainings, and exercises, and for participation in those said events. The planning costs were absorbed primarily by the Office of Emergency Preparedness and Response, which is specifically funded for this type of effort. The staff time required for the planning was approximately 12 person-hours per month. Annual agency staff participation time includes 7 two-hour meetings and one four-hour functional exercise, with participation from approximately 40 (the number may fluctuate depending on staffing) individuals. Average hourly costs for a member of PHIMT is $30.21, with a full PHIMT meeting costing approximately $2,416.80 in staff time. The Average registration for the Colorado Wildland Fire Academy is $300. Eleven individuals have attended the Academy making the approximate registration cost $3,300. These costs were spread throughout the agency.  
TCHD EPR has conducted an evaluation survey of all PHIMT members. The purpose of the survey was to evaluate members’ knowledge and increased capability to carry out their assigned incident management roles by requiring them to self-asses their level of operational readiness prior to and after participation on the PHIMT. This was a nine question survey with yes/no questions sent via email through SurveyMonkey. The survey was open one week and 34 of the 38 PHIMT members completed the survey by the deadline. Analysis through descriptive statistics was completed. Of those 34 respondents to the survey, 58.8% (20/34) have been on the PHIMT for more than two years, and 32.4% (11/34) have been on the team from one to two years. The remaining members have been on the team for less than one year and have not yet received in depth training. The results of the survey show that 91.2% (31/34) know what job or role they will be expected to fill during PHIMT activation. The same percentage of team members, 91.2%, responded that based on the trainings and exercises in which they have participated, they understand how their position/job interacts with other positions on the PHIMT during activation. 88.2% (30/34) indicated they understand what tasks their assigned position/job is responsible for during activation. It may be inferred that the three PHIMT members that responded as not knowing what their job is during activation or how their position interacts with other positions are the three members newest to the team and have not yet received all necessary training. The results of this survey show that TCHD staff serving as members of the PHIMT self assess as having the knowledge and ability to fulfill their responsibilities during incident management operations. The number of persons capable of completing these tasks reflects an increased depth in management staff as well as a culture of preparedness within the agency. These were the primary goals in the formation of the PHIMT. The PHIMT has also been evaluated through use of the pre-identified objectives: Objective 1: Maintain at a minimum one individual with a training certificate for each command and general staff position (Incident Commander, Safety Officer, Liaison Officer, Public Information Officer, Operations Section Chief, Planning Section Chief, Logistics Section Chief, and Finance/Administration Section Chief) Performance measure: Training certificates obtained by PHIMT members from the Colorado Wildland Fire Incident Management Academy (CWFIMA) or other approved organization. Data: Training is tracked in a TCHD responder database and the EPR Training and Exercise Database (TIE) Evaluation results: 11 total certificates have been obtained, including Incident Commander (1), Safety Officer (1), Liaison Officer (2), Public Information Officer (1), Operations Section Chief (1), Planning Section Chief (2), Logistics Section Chief (2), and Finance/Administration Section Chief (1). Feedback: CWFIMA ICS trainings have provided an excellent foundation for the PHIMT leaders to train the other individuals in their areas. Maintaining a minimum of one certified person in each position will remain a priority. Objective 2: Maintain membership from each division/office within Tri-County Health Department. Performance measure: Roster review to ensure all divisions/offices are represented. Data: A tally of number of individuals from each division/office using the PHIMT roster. Evaluation results: Emergency Preparedness and Response: 7 Environmental Health: 18 Epidemiology, Planning and Communication: 3 Administration: 2 Nutrition: 5 Nursing: 3 Feedback: Membership spans all TCHD divisions/offices. Membership is appropriate for the skills and abilities of each member. Objective 3: Provide at least 6 trainings per year with a minimum of 30 participants each, including a minimum of one functional exercise. Performance measure: Number of trainings provided, After Action Reports (AARs) from functional exercises Data: Count of sign-in sheets from provided trainings, Count of AARs Evaluation results: In the first year, between March 2011 and February 2012 there were seven trainings and one functional exercise held for the PHIMT. Between March 2012 and March 2011, eight trainings were provided during PHIMT meetings and one full scale exercise was held. Feedback: The number of trainings provided exceeded the expected number. Membership spans all TCHD divisions/offices. Membership is appropriate for the skills and abilities of each member. The first exercise was a functional exercise that was part of a larger, regional, full-scale exercise called “Operation Mountain Guardian”. This was a terrorist attack scenario involving multiple coordinated attack strategies at multiple locations throughout the Denver Metro Area. The PHIMT was activated to help manage health and medical aspects of the response. The team worked through the Planning ‘P’, producing products for an Incident Action Plan for the following operational period. Lessons learned included: Recognition of the successful interface between the PHIMT, the Environmental Health Division, the TCHD Policy Group, and other participating organizations; PHIMT staff had a strong understanding of their roles and responsibilities on the team, but needed further clarification on the roles of other positions and how they interact; A more in-depth protocol was needed for activation of the TCHD Department Operations Center; Additional mechanisms for maintaining situational awareness were necessary, as well as a procedure for monitoring the various available situational awareness tools; and Additional staffing was required to assist the PIO. All of these recommendations led to corrective actions that have been addressed. The full scale exercise conducted in March 2013 was a multi-jurisdictional, multi-disciplinary mass prophylaxis exercise meeting all of the requirements for a Cities Readiness Initiative grant recipient. The PHIMT was fully activated in response to a widespread mock anthrax exposure spanning the entire Denver Metro area. TCHD opened one walk-up and one drive-through point of dispensing (POD). Lessons learned from this exercise included: The ability of PHIMT members to receive and respond to notification and activation procedures; PHIMT staff has an increased understanding of the complexity of their individual roles during incident management operations; Procedures were needed for the efficient and timely approval of messaging and tactics; Additional space is needed to break out command and general staff during operations to minimize noise and distractions; ICS forms need to be adapted to better reflect the needs of public health incidents. All of these findings led to corrective actions that have been addressed are or currently in the process of being addressed.
TCHD EPR has continually monitored the success of the PHIMT through exercise after action evaluations and dialogue around successes and challenges. There have been a number of lessons learned identified through these means during the implementation of the PHIMT. The implementation process for the team development and activation is neither expensive nor extensively time consuming. Resources for all-hazards incident management are readily available and, though requiring some alternations, do not need drastic modifications for use in a PHIMT. Finding staff interested and eager to learn incident management is a key to successful implementation. Support from agency administration is requisite for success of the project. The ability to disburse staffing time and costs throughout the agency allows for shared commitment and added sustainability. Following H1N1, the TCHD administration elevated the priority level for emergency preparedness and response in recognition of the intensive resource demands a public health incident entails. The new expectation continues to be that all divisions/offices within TCHD will be requested to provide staffing resources for preparedness and response efforts. The PHIMT represents the agency resource commitment. Each division has committed their assigned individuals for one two hour meeting per month, plus any additional training or exercise time that might be necessary. The Office of Emergency Preparedness and Response provides funding for outside trainings only. This disburses the resource commitment throughout Tri-County Health Department as a whole, making the program far more sustainable than it would be otherwise.
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