In terms of resilience planning, very few organizations need to be ‘told’ that they need to revisit and streamline their emergency management and business continuity plans any longer.
While healthcare leaders know that this sort of planning is essential to decreasing negative patient outcomes and avoiding unnecessary financial losses, accreditation guidelines and state law generally provide a concrete ‘requirement’ in this area. Texas State Bill 1614 aims to provide bona fide legislation to ensure that long term care facilities (LTCs) have adequate generators to provide for 72 hours’ worth of emergency power to provide residents with an air temperature between 68 and 81 degrees.
“This Isn’t the First Time…”
The introduction of Texas SB1614 comes on the heels of Winter Storm Uri which, in February of 2021, left nearly 69% of Texas’ 29 million residents with an average restoration time of 42 hours (1). While Winter Storm Uri caused emergency conditions at hundreds of LTCS and spurred the evacuation of 33 facilities in Texas alone (2), this event is, unfortunately, not the first to produce negative outcomes for residents of LTCs after anticipated power outages and failure (or lack of) backup sources.
In September of 2017, Hurricane Irma – a category 5 storm – directly impacted Florida. In addition to the $50-billion dollars’ worth of damage done by 37 hours’ worth of wind speeds at 185 mph (3), at least 12 nursing home residents’ deaths were directly caused by power failures related to the storm’s impact to a singular facility in Hollywood (4). Beyond the impact to this singular nursing home, Brown University found that an additional 433 nursing home residents’ deaths were linked to Irma’s impact (5).
In addition to the avoidable loss of life – which rippled through these patients’ families – LTC leaders should take note that the Administrator of Nursing, a Charge Nurse, and two other nurses were convicted of manslaughter (6). Additionally, Florida’s Agency for Health Care Administration fined the facility approximately $43,000 and pulled its license, shutting it down and forcing it to lay off its 254 employees (7).
“Planning for ALL hazards?”
While avoiding unnecessary loss of life, decreasing organizational liability, and reliably providing for our staff and community serve as more than adequate reasons to implement plans to deal with the unanticipated loss of power, healthcare leaders understand the power of regulatory requirements in moving these ‘good ideas’ along.
The loss of power represents only a fraction of the potential situations that should be included in LTCs Emergency Management (EM) plans. Considering other critical utilities required for the safe operation of LTCs, and the myriad of potential emergencies that can impact their operations, these facilities and systems would do well to ensure they are utilizing an all-hazards approach while planning their responses to other emergencies and disasters.
While the term may be interpreted as ambiguous, an all-hazards approach to planning does not particularly require that facilities plan for ‘all’ hazards; in fact, the term simply implies that ‘all hazards’ that are classified as probable (and those that could cause injury, property damage, business disruption, or environmental impacts) should be addressed in LTCs emergency procedures (8). Kaiser Permanente has created a handy toolkit that many hospitals and healthcare partners use as part of a Hazard Vulnerability Assessment (HVA).
In addition to helping LTCs consider ‘all hazards,’ using a systematic process for emergency planning helps those facilities prioritize planning and mitigation for emergency situations. While this sort of planning requirement already exists within the Center for Medicare and Medicaid Services’ (CMS) Conditions of Participation for LTCs, facility leadership should consider reviewing those requirements.
Business Continuity: Staying Steady
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–An organization’s ability to withstand changes in its environment and still function…” (McCarthy, Collard, Johnson, 2017)(9)
While sometimes included within emergency response procedures, Business Continuity Plans (BCPs) focus on continuity of critical operations despite impacts to the resources usually in place to complete them. In the hospital industry, for example, shutting down the hospital’s operations due to an incident that takes Pharmacy’s operations offline is simply not an option: plans must exist to ensure that patients receive critical medications and that effective safeguards to prevent patient harm remain completely functional.
A sound BCP should include contingency plans to ensure ‘continuity of business’ during the incident and steps that should be taken to quickly ensure resumption of normal (pre-incident) operations.
Generally, BCP’s are developed for each critical function of an organization and require leadership of those departments to determine their workaround procedures to the three S’s: Staff, Supplies, and Space. While each of these S’s may be considered self-explanatory, it may be helpful to briefly explore each.
Staff:
- In addition to cross-training and sharing of staff, to the extent possible, organizations should consider the input of departmental leadership to determine anticipated disaster maximum workloads and sources for specially-trained, certified, or licensed staff.
Supplies:
- Within the consideration of supply shortages, strategies to conserve inventory, determine safe and effective alternative supplies, and developing a list of approved alternate suppliers may be helpful. (Evaluating suppliers’ resilience during their selection may get more attention after the past 18 months.)
Space:
- Although complete loss of an operational space should be considered, contingency plans for the critical utilities required to make that space safe and operational should be considered. For example, most organizations’ operations rely on the availability of some combination of water, IT infrastructure, or electricity. (Note: the ‘generator’-related considerations of Texas SB1614 fall into this category.)
When considering writing contingency plans for the items above, it’s imperative that the context of each plan relates to the most probable hazards identified in the HVA mentioned above.
“Plans are worthless, but planning is everything.” – Dwight Eisenhower
In the mid-90’s, Mike Tyson seemed to prophetically remind us that “Everyone’s got a plan until they get punched in the mouth,” while preparing for a bout with Evander Holyfield. (Do you think Mike entered the ring planning on biting Holyfield’s ear off?) While Tyson’s interpretation of this notion is among the most popular, healthcare leaders can not agree that “plans are worthless” without, in the same breath, acknowledging Dwight Eisenhower’s addition that ‘planning’ is the practice that produces all of the benefits of coordination.
That statement is not to negate the necessity of plans; comprehensive and robust ‘all-hazard’ plans provide a critical framework for how we ‘anticipate’ our fight – operational interruptions – will go, but many healthcare leaders may agree that they do little more than collect dust without regular review from appropriate stakeholders, a comprehensive exercise plan, and regular review of incidents to determine wins, opportunities for improvement, and preparation gaps.
There is no singular, specific ‘call to action’ for this post. Regarding the conversations and actions required to ensure plan alignment, a holistic common operating picture, and management of realistic operational expectations & limitations during crises, there is no silver bullet that stands in for sound pre-planning, thoughtful consideration, and prioritized effort.
It’s time to phone a friend. If they have not already, LTC leaders in Texas and beyond should consider tapping into their local resources to bolster their organizations’ preparedness and to learn more about their local resources. If an LTC is tied to a hospital system, that hospital’s Emergency Management team might be a great place to start. If unaffiliated with a healthcare system, the local Healthcare Coalition would be a fantastic call to get more information on how to partner for preparedness.
In addition to being ‘a good idea,’ this legislation in Texas seems to be a move pushing LTCs toward operational resilience. When adding this sort of legislation to all of the circumstances and challenges we faced during 2020 and 2021, it appears that we are running out of excuses to be caught off-guard.
Bringing it all together: “When you know better, do better” – Maya Angelou
While we desperately hope to discover opportunities for improvement before any sort of a disaster or emergency, the past several years’ worth of disasters have taught us that this rarely occurs. In the context of emergency management, we tend to discover the root causes of systematic shortcomings through what we refer to as after action reviews (AARs). In short, AAR processes are designed to determine how to replicate strengths displayed during a response and how to address opportunities for improvement in a sustainable manner.
Traversing the AAR process can be complicated. It can be difficult to establish an environment that encourages the vulnerability required to objectively evaluate our responses to incidents. The consciousness competence learning model (CCLM) indicates that there are four primary stages of competency through which we traverse as we learn or develop new skills:
- Unconscious competence: The things that we know and can do without much thought.
- Conscious competence: The things we know, but have to focus on to skillfully execute.
- Conscious incompetence: The things that we know we don’t know or understand.
- Unconscious incompetence: The things that we don’t know we don’t know.
As long as we are exposing areas of unconscious incompetence and moving toward competence, we are ultimately moving toward a more favorable state of readiness. Prior to 2020, our knowledge of how far-reaching the impacts of a global pandemic would be on modern society were theoretical; we simply didn’t know what we didn’t know.
While SB1614 focuses specifically on Texas, the implications may reach beyond its borders. Whether we focus on the impacts of COVID-19, the devastation of recent years’ major hurricanes, or the repercussions of power grid failures, we are now charged with doing better based on the knowledge we’ve acquired.
*Note to the reader: In May 2021, Texas SB1614 was noted to be ‘dead in committee‘. It does appear to have given way to Texas HB2325, which gained bipartisan support… shortly before it was marked ‘dead in committee‘. Although it doesn’t appear that any immediate legislation is coming down the pipe for Texas, awareness of the need to bolster LTC resilience is imperative to ‘doing better.’
References:
1. https://uh.edu/news-events/stories/2021/march-2021/03292021-hobby-winter-storm.php
2. https://www.mcknightsseniorliving.com/home/news/winter-storm-brings-question-of-mandatory-generators-back-into-focus/
3. https://www.esrl.noaa.gov/gsd/learn/stories/hurricane-irma.html
4. https://www.cnn.com/2017/09/14/health/florida-nursing-home-irma/index.html
5. https://www.brown.edu/news/2020-10-06/disasters
6. https://www.sun-sentinel.com/local/broward/hollywood/fl-ne-nursing-home-employees-surrender-20190826-5zwicz2hazhtpngxd6feru7afq-story.html
7. https://www.sun-sentinel.com/local/broward/fl-reg-nursing-home-fined-ahca-20171018-story.html
8. https://www.ready.gov/planning
9. https://www.sciencedirect.com/science/article/abs/pii/S1877343517300283?via%3Dihub
