VEMEC’s experience with VA and other health systems uniquely positions it to examine a wide range of healthcare system issues. For example, the US Department of Veterans Affairs (VA) consists of 152 acute care medical centers, 135 skilled nursing facilities, 48 residential domiciliaries, and over 800 community-based outpatient clinics across the country. As the nation’s largest integrated healthcare system, VA provides a laboratory for VEMEC’s efforts to build the evidence base that makes healthcare systems more resilient.
Quality Management System (QMS)
VEMEC is collaborating with the Veterans Health Administration Office of Emergency Management (VHA OEM) to design and implement a quality management system (QMS), a multi-year project based on ISO 9000 that monitors the performance of the VHA Comprehensive Emergency Management Program (CEMP). Performance will be evaluated across five domains: service continuity, readiness, competence, safety/security, and cost. Performance measures will provide a current picture of status, performance, customer satisfaction, and cost that can be used to improve OEM service delivery. The initial phase of this project (began in September 2014) examines what “ensuring the continuity of medical and hospital services” means in practical terms; identifying systems and functions that support these essential services; and establishing indicators of readiness/resilience related to these definitions. Subsequent efforts will examine other domain areas. The QMS project will allow VHA OEM to better design its strategic plans and operations, and align its project plans and funding with customer needs and outcome measures.
Impact of Disasters on Health Services Use, Costs, and Resource Allocation among Veterans
The VA’s large electronic medical records data systems provide a unique opportunity to study the impact of natural disasters on the health of VA’s Veteran patients and on the delivery of healthcare services, including disruptions to the service delivery chain. The CDW project includes a series of studies. One study examines the impact of Hurricane Ike on missed opportunities for outpatient clinic care. Scheduled encounters 60 days prior to and following Hurricane Ike were tracked for the service areas primarily impacted by the storm and compared to others in the same region. Completed and missed opportunities were identified and compared according to key clinical, patient, and timeframe characteristics. Three other studies focus on Superstorm Sandy: 1) Patient dispersion across neighboring VA medical facilities following the temporary closure of the Manhattan VA Medical Center (VAMC); 2) Re-admission rates of patients who were discharged prior to the evacuation of the Manhattan VAMC before Superstorm Sandy struck the facility; and 3) Types of health services used by veterans who were diagnosed with PTSD one year prior to Superstorm Sandy.
Evaluating the Readiness of VA Medical Centers through the Emergency Management Capabilities Assessment Program (EMCAP)
VEMEC is working with VA emergency managers on the development of the VA’s Emergency Management Capabilities Assessment Program (EMCAP), a tool to assess the preparedness of VA Medical Centers (VAMCs). The study identifies the most critical missions of an emergency management program, and the capabilities associated with those missions. From 2008-2010 (Phase I), 140 VAMCs were evaluated using an initial tool assessing 69 emergency preparedness capabilities organized in six domains. In 2011-2013 (Phase II), the measurement tool was modified and expanded to include 71 capabilities, which were then used to evaluate the preparedness of the same 140 VAMCs. Both phases of capability data have been analyzed using various analytical approaches. We compared EMCAP Phase I and Phase II capability-level descriptive data to identify trends in scores between the two phases.
Hospital Preparedness Planning for Evacuation: The VA NY Harbor Healthcare System Experience
The increasing frequency of weather disasters has been accompanied by an increase in the number of hospitals that are forced to evacuate in the midst of disaster. Yet there is little data on hospital evacuation. The Manhattan Evacuation project studies VA staff who have participated in New York Harbor Healthcare System’s (NYHHS) preemptive evacuations of the Manhattan Campus for Hurricane Irene and Superstorm Sandy. The study aims to expand our understanding of hospital evacuation, a critical disaster response capability for all hospitals. We conducted 31 key informant interviews as part of an in-depth case study. We found that the Irene evacuation experience was the most important factor in the successful evacuation for Sandy.
Understanding and Promoting Collaboration to Strengthen Hospital Resilience and Community Preparedness
Effective disaster preparedness and response needs to be a community effort. The Collaboration project works with VA Medical Centers (VAMCs) to: 1) describe VAMCs’ emergency management collaborations with non-VA partners; 2) describe the role VA facility and regional leadership, and VA headquarters' staff, have in these collaborations; and 3) identify facilitators and barriers to collaboration. We used purposive sampling to select 12 diverse VAMCs from across the nation, and conducted semi-structured telephone interviews with the facility’s emergency manager. Findings will guide the development of tools and processes to help strengthen VA emergency management collaborations, thereby contributing to a more resilient VA healthcare system.
VEMEC is partnering with Sandia National Laboratories to investigate the impact of different vaccine resource allocation and service partnership strategies on vaccination levels of Veterans. We use system dynamics modeling to explore hypotheses related to delivery of vaccine services through community partnerships and coordination. Preliminary analysis of data has identified that community partnership and coordination are strategic policy actions the VHA could take to improve vaccination uptake among Veterans. Ultimately, we hope to foster community partnerships in VHA disaster preparedness efforts and examine the effect of coordination on best practice adoption of vaccinations and other preventive efforts.
VA Healthcare Provider Assessments of the Preparedness of Homebound Veterans
The Home Based Primary Care (HBPC) project bolsters community preparedness by examining the barriers and facilitators of disaster readiness among Veterans Health Administration (VHA) HBPC programs. Home-bound Veterans are among the most vulnerable populations in a disaster because of their health conditions and functional limitations, which may prevent them from being adequately prepared. This project involved 30 semi-structured interviews with leaders and practitioners from 5 VHA HBPC programs, with 3 sites being in urban areas and 2 in rural ones. Results include: 1) individual HBPC programs are generally tasked with developing their own preparedness policies; 2) assessment tools are rudimentary; 3) comprehension of criteria for assigning risk categories varies among practitioners; 4) practitioners receive limited training on how to prepare their patients for a disaster; 5) practitioners recommend training focused on effective strategies to encourage patient engagement, formalization of the initial assessment, and having emergency preparedness be formally addressed on a more consistent basis; and 6) cognitive impairment and limited resources are the primary challenges to patient preparedness. Standardized strategies regarding disaster preparedness assessment for home-bound patients, which leave room for flexibility in consideration of local factors such as common hazards, could assist in creating more comprehensive planning agendas and ultimately improve the preparedness of this vulnerable population.
Call to Action: Nurses as Leaders in Disaster Preparedness & Response
On December 9, 2014, VEMEC led a workshop in conjunction with the 5th Annual Advancing & Redefining Communities (ARC) conference in Los Angeles, CA to discuss Nurses as Leaders in Disaster Preparedness & Response. The devastation caused by recent disasters has led to a heightened awareness of the importance of preparedness in healthcare. The 2011 IOM/RWJF report, The Future of Nursing, Leading Change, Advancing Health brought a greater understanding of the nursing profession’s breadth and untapped potential at a time when major disasters are occurring with increasing frequency. Nurses represent the largest segment of the US healthcare workforce, are employed in diverse settings, collaborate with a broad range of healthcare professionals, and are consistently ranked by the public as trusted sources of health information. Further, nurses are the healthcare professionals in highest demand following a disaster when care is needed. In addition to providing care on the frontlines to disaster victims, their families, and the community, nurses also assume significant leadership roles during disasters. Building on the 2011 IOM/RWJF report and the coalitions developed as part of the RWJ/AARP Future of Nursing: Campaign to Action, this event brought together nursing leaders and practitioners to develop an agenda to expand the role of nurses in emergency preparedness and response in the community and health system settings. Presentations and discussions explored:
- The pivotal role nurses can play as patient educators, responders, and decision-makers in disaster preparedness through improved efforts in education/training, practice, research and policy;
- Prior efforts to develop nursing education and competencies for emergency preparedness and response;
- Short- and long-term strategies to expand the role of nurses in emergency preparedness and response;
- Collaboration and partnerships necessary to achieve this goal.