Larger role in disaster planning seen for quality managers

Skills in planning, safety seen as assets for emergency management

When a disaster occurs, otherwise routine health care delivery can be complicated in a number of unexpected ways — and Hurricanes Katrina and Rita, it seems, were on a different level than disasters that had occurred in the past. As more than one emergency response expert told HBQI, no one will ever again look at disaster planning in quite the same way.

As part of this "new look" at disaster planning, observers say, quality managers should play a larger role in emergency planning and response than they have in the past.

For example, William Cassidy, MD, associate professor of medicine at LSU Health Science Center in Baton Rouge, LA, wishes he had had more quality professionals on his team at the field hospital he oversaw in a former Kmart facility.

A quality manager who knows hospital systems could be invaluable in such a situation, Cassidy observes. "Absolutely, a quality manager could have helped us," he says. "You need someone who is knowledgeable but who is also able to scale back to what is effectively a field hospital environment."

Quality managers also can play an important role in disaster response planning, adds Joe Cappiello, BSN, MA, vice president of accreditation field operations, for JCAHO.

"Quality managers have a key and important role in sitting at the table to develop response plans," he asserts. "When an organization does hazard vulnerability assessment, it looks at possible scenarios that may confront that facility — hurricanes if you are in Florida, tornadoes in Kansas, earthquakes in California — or perhaps your town is surrounded by petrochemical plants. We then ask them to sit down and say, is this a situation we might reasonably encounter? All of this should be thought of in the context of how we can give optimal, safe patient care based on the situation with which we are confronted."

If quality managers are to become part of the disaster planning and response team, it is important for them to also learn the lessons of Katrina and Rita and to understand just how different things can be in these situations.

"The first thing they can do is look at the preparation and response to Katrina versus Rita," says Coppell. "The lessons learned were immediately applied. On the hospital level, I think the lessons that will come out of New Orleans will be very key."

Lessons learned

And what were those lessons? "My own belief is that every one of those accredited hospitals [in New Orleans] had good emergency management plans, conducted drills, and were in compliance," says Cappiello. "With a storm of this size, you had not one but four situations: A hurricane, during which many stood tall and weathered the storm; then the flood; then essentially the loss of all internal support — power, water, sewage; then, a civil disturbance on top of that. A disaster plan must think not only outside of the box but outside of the carton."

Cassidy saw firsthand how difficult things could be. "On Wednesday after the storm, around 7 pm, they told us we might be putting [a field] hospital in place," he recalls. "Thursday at 4:00, it was confirmed. At 4:30 we did a walk-through of the facility — it lacked lighting, electricity, phone lines, and plumbing. The volunteers from various churches came and started unloading 18-wheelers with supplies, swept and mopped the facility, partitioned up the big box’ building with plastic Visqueen sheets that we draped on ropes between the pillars to create the wards.’ At 10:34 p.m. Friday, we were ready to accept patients."

How must a quality manager adapt to such a situation? "First, they cannot be bureaucratic if they are going to get something done that quickly," Cassidy advises. "Also, recognize that normal procedures, like HIPAA, are suspended; credentialing is suspended."

Efficiency is key during disaster response, Cassidy continues. "For example, the only copy of charts would be for people leaving our place to go to someone’s home," he explains. "If you go to another hospital or shelter, we would send the chart with you and save a face sheet and maybe a routing sheet. You don’t have a copy machine! Our goal is to take stable medical patients and continually flow them out into less acute settings. If you accept your goal as the need to complete medical management of certain patients and move them out, and you have to do it with a skeleton staff, then the redundancy you typically have in a normal hospital has to be suspended."

In addition, the facility did not have infection control at first, Cassidy says. "Volunteers came with food, but instead of putting rolls on single plates, people would just reach in and take the rolls," he notes. "There was no plumbing; we had to rely on people putting antibacterial gel on their hands. So, this was a quality manager’s issue: How do you guide people like church volunteers, who are meeting a need but do not have formal training in institutional food presentation?"

Cassidy also cites a specific instance where a quality manager could have offered skills not available from a volunteer. "A quality manager looks into all facets of hospital operations," he notes. "What our volunteer coordinator did was tag along. She told me she saw her role as following along with nurses, doctors, the facility manager, the food person, and hearing that they needed x’ done and telling the volunteers to get it done. You could see a quality manager tagging along with the other members of the team, and saying, Okay, you need to have an intake and registration system, a system to move patients between wards, and a way to track their departure. Here’s how it’s normally done, and here’s how the process can be adapted.’"

A unique model?

Having a quality professional intimately involved with disaster planning may not be the norm, but at William Beaumont Hospital in Royal Oak, MI, the chairperson of the emergency management committee is a quality professional — Kay Beauregard, RN, MSA, the facility’s Director of Hospital Accreditation and Nursing Quality, as well as its safety officer.

Beauregard was given this responsibility shortly after 9/11, and to her it makes perfect sense. "It is an interesting overlap," she says, "But there is a relationship. Many quality people oversee patient safety, and this position oversees employee safety. I think more organizations are starting to see this overlap."

"It’s a wise place for quality managers to be — on the disaster planning committee," says Cappiello. "While we don’t by standards mandate who should sit on that, or publish the roster, one would think a common sense approach is you would gather an array of experts who can advise the hospital on the development of plans, assist in the development of drills, and be called upon should disaster strike to provide guidance for the office of emergency management and the administration as they conduct their response."

In her role, Beauregard has overall responsibility for the group that assesses the hospital’s risks, what could happen to its infrastructure, events that might possibly occur in the area around them, and what patients they might receive. "Then, based on that information, we put plans in place to try to decrease the likelihood of the events occurring and have a plan in place to respond if they do," she says.

There are other reasons quality managers are well qualified for such responsibility, she continues. "They bring performance improvement expertise, and that’s what this is — to take a chaotic situation and organize it into an action plan is similar to taking a quality issue and organizing it into an action plan," she observes.

Many organizations have their emergency departments (EDs) in charge of this committee, "but we’ve learned that disasters impact the entire organization, and the rest of the hospital is needed to help the ED to provide resources," Beauregard says. "It involves coordinating bigger issues — like supply chain, electrical outage problems, and so forth — that do not just hinge around the ED."

Quality managers, she continues, also are often involved in regulatory compliance. "Regulators have standards regarding disaster management — they are used to reviewing those standards and making sure the hospital is in compliance."

Beauregard also is among those who believe the recent disasters will cause everyone involved to take a second look at their own plans. "We are definitely going to review our disaster plan," she says. "This hurricane has taught us that we need to look at issues like sending our hospital staff to respond to disasters outside of ours, whether down the street or in a different state. We need to look at a lot of issues — licensure in other states; liability; workman’s comp.

"Internally, we learned we need to revisit our evacuation plan — particularly, how would we evacuate the entire hospital? That’s a biggy,’ because we have over 1,000 beds."

If you do not have an official role such as Beauregard’s, you could nevertheless play an important role if a disaster strikes your area. "One volunteer coordinator just showed up and started hanging around the field hospital, where patients were being dispositioned out of the original triage hospital," recalls Cassidy. "I ran into him and said, We may be creating this hospital — would you want to help and be our volunteer coordinator?’ If someone presented themselves to me and said, I know hospital systems — can I help?’ my answer would have been Yes!’"

Need More Information?

For more information, contact:

  • Kay Beauregard, RN, MSA, Director of Hospital Accreditation and Nursing Quality, William Beaumont Hospital, 3601 W 13 Mile Rd., Royal Oak, MI 48073. Phone: (248) 898-0941. E-mail: kbeauregard@beaumont.edu.
  • William Cassidy, MD, Associate Professor of Medicine, LSU Health Science Center, Baton Rouge, LA. E-mail: wcassi@lsuhsc.edu.
  • Joe Cappiello, BSN, MA, Vice President, Accreditation Field Operations, Joint Commission on Accreditation of Healthcare Organizations, One Renaissance Blvd., Oakbrook Terrace, IL 60181. Phone: (630) 792-5000.