By Jeffrey Tochkin, John Richmond, and Attila Hertelendy
Summary: The health care system in Canada has faced enormous pressures during the three consecutive waves of COVID-19 response. Without the efforts of emergency management practitioners, the health care system response would have been rendered less effective and less coordinated. This generational crisis not only challenged health systems, but had much broader societal impacts, which will be experienced for years to come. In this article we distill findings from a Pan-Canadian study which speaks to the COVID-19 experience of emergency management practitioners in health care organizations. Based on these experiences, we present the practical implications for emergency management practitioners working in health. From this analysis, it becomes clear that emergency management will have an integral role in strengthening systems following the pandemic.
Ramping up the response
From the time a mysterious novel coronavirus disease first appeared in Wuhan, China, the later named COVID-19 quickly spread globally. As Canadian cases first began to present in Toronto, provincial and territorial health care systems across Canada struggled to provide consistent guidance to health providers. As health care organizations scrambled to prepare for the impending presentations of COVID-19, services were constricted to focus efforts on building capacity for the anticipated volume of patients. Simultaneously, a variety of disaster preparedness activities were undertaken to ready these organizations for what was to come.
As discovered in our exploratory study (n=150) of emergency management practitioners (EMPs) – those with emergency management sole, primary, secondary or emergent responsibilities – on COVID-19 health care preparedness and response activities (Richmond, Tochkin, and Hertelendy, 2021, pp.1-12), a number of activities were enacted including pandemic plan reviews, personal protective equipment (PPE) training, activation of incident management (IM), clinical management strategies, setting up an emergency operations centre, multi-agency training, scenario planning and use of simulations. The prevalence (between 0-100%) and perceived effectiveness (between 1-5) of these activities are shown in Table 1.
On average, EMPs enacted 5 out of 9 preparedness activities. While pandemic planning was found to be the most prevalent activity (82%) it was also rated the least effective (4.07 of 5). This was likely due to the previous pandemic plans being more influenza-specific, outdated (52% of organizational plans were reviewed prior to 2018), and a lack of overall organizational knowledge of the plan. Effectiveness was rated on a Likert scale and based on the perception of the survey respondents. Meanwhile, simulation-based exercises were the least prevalent at 25%, but found to have a significant and strong positive correlation with the effectiveness of two other activities: training for multi-agency response and activating IM. Donning and doffing PPE ranked as most effective (4.6 of 5).
|Variable||N||% (n/150)||Mean||Standard Deviation||Min||Median||Max|
|Pandemic plan review||122||82||4.07||0.97||1||4||5|
|Donning and doffing PPE training||112||75||4.61||0.76||1||5||5|
|Activating Incident Management||108||73||4.39||0.85||1||5||5|
|Clinical management strategies||91||61||4.44||0.76||1||5||5|
|Setting up a physical EOC||79||53||4.20||0.91||1||4||5|
|Training for multi-agency response||73||49||4.32||0.78||1||4||5|
|Table-top only scenario planning||70||47||4.16||0.81||2||4||5|
|Setting up a virtual EOC||68||46||4.49||0.82||1||5||5|
|Simulation Based Exercises||38||26||4.32||0.77||3||4.5||5|
Table 1: Disaster preparedness activities in Canadian health care organizations (adapted from Richmond, Tochkin, and Hertelendy, 2021, pp 1-12)
Dedicated resources lead to effective response activities
These activities, which commenced prior to the onset of provincial declarations of emergencies, continued through the response. Interestingly, increasing activity prevalence in the organization had much to do with whether the EMP was dedicated as a sole function, as opposed to a secondary or emergent responsibility. In addition, prevalence increased when IM training was provided to incident leaders, often health executives, prior to COVID-19. The effectiveness of these activities was significantly associated with the prevalence of activities overall, and specifically if the incident response was managed by either a singular IM lead or multiple IM leads.
In summary, if the organization’s incident management team was trained prior, there was a singular leader, and the EMP was a dedicated position, disaster preparedness activities were found to be more prevalent and effective. It is also important to note that there may have been activities that occurred that EMPs may not have been aware of. In addition, it is important to recognize other factors may influence the effectiveness of an activity (i.e., PPE training is extremely effective; however, a lack of human resources can create PPE fatigue, leading to a seemingly lower effectiveness rate.)
|Emergency Management Responsibility|
Table 2: Emergency management responsibility in Canadian health care organizations (adapted from Richmond, Tochkin, and Hertelendy, 2021, pp 1-12)
The leadership challenge
Health care systems are complex and continuously evolving (Figueroa, et al., 2019, p.2). Leadership has to be adaptive to potential risks; however, there is an emergency management competency gap for leaders in health organizations (Hertelendy, et al., 2021, pp. 1-4). More specifically, leaders often do not understand incident management systems and planning cycles, as well as lack familiarity with intersecting municipal and provincial emergency management systems. This is compounded when the emergency is experienced beyond the health care organization and is more complex in nature. In this case, the EMP within the organization must gain trust within the core leadership group. Compounding this, the EMP commonly reports to middle level management and often has limited exposure and ability to convey messaging to senior management. As a result, the messaging can lose its original intent and effectiveness.
Highlighting the need to reduce this gap, Richmond, Tochkin, and Hertelendy (2021, pp. 1-12) found that only 68% of IM leads were trained in their roles and were familiar with lines of responsibility found in an IM system. Where leaders were trained, organizations took more action to prepare for COVID-19. In addition, as described above when the IM system was led by a single trained individual, as opposed to an untrained leader or multiple individuals cycling through the role, response activities were more effective. This decisiveness is helpful during times of uncertainty as experienced during the current pandemic (Schmidt, 2021, p. 1). Compounding this, terminology fatigue and unfamiliar language (ie. only used during emergencies) presents challenges to how the system is embraced. Therefore, more clarity and consistency is needed in how health care organizations adopt incident management systems.
|Incident Management Leadership|
|Sole Non-Medical Leader||56||38%|
|Sole Medical Leader||18||12%|
|Sole Emergency Manager||7||5%|
|Sole Subject Matter Expert||8||5%|
Table 3: Incident Management leadership in Canadian health care organizations (adapted from Richmond, et al., 2021)
Lesson Observed vs. Lesson Applied
How health care organizations apply lessons learned and transfer knowledge varies greatly. Francescutti, Sauve, and Prasad (2016, p. 54) suggest that health care organizations are underachievers in learning from past lessons due to a number of factors, including reputational management superseding honest public disclosures and lack of engagement and transparency with frontline staff. That being said, it is important to note that the ability for an organization to take action may be limited, in some cases, due to the complexity of the issue and cost. Underfunding in the healthcare system is a constant challenge for organizations to overcome. This can create a vicious cycle, where past mistakes are repeated and lessons not applied, leading to a less resilient health care system and one which is unable to adapt to ongoing events. Fortunately, many positive changes to the health care system followed SARS (Silverman, Clark, and Stranges, 2020, p. 1797; Webster, 2020, p. 936) at both the provincial, territorial, and federal level. The spirit of continuous improvement, including following a pandemic event, will undoubtedly need to follow a much more severe experience such as COVID-19 in order to apply lessons learned.
From this analysis, it becomes clear that effective emergency management is more likely when EMPs are a dedicated resource and have a place at the leadership table. In addition, leaders within organizations need to participate in IM training, understand their roles, and have a desire to increase their skill set in EM (Hertelendy, et al., 2021, pp. 1-4). All organizations need to consider potential risks, plan accordingly, respond in a measured fashion and evolve to the ever changing environment. Given the increasing frequency of disasters and multitude of complexities arising from this reality, leadership needs to be adaptive and open to change and health leadership – in particular, to solidify their commitment to emergency management.
While we have much to be proud of in this response, the next pandemic will take its own shape with specific challenges. Emergency management has its work cut out to impart lessons within the organization. These efforts are paramount in a more effective response to adverse events and building further community resiliency. We must learn from our experience and apply it in meaningful ways.
Dr. John Richmond
Dr. Attila Hertelendy
Jeffrey Tochkin is an Emergency Management Officer at Alberta Health Services. He currently holds the Certified Emergency Manager (CEM) designation and a Master of Arts degree in Disaster and Emergency Management. Dr. John Richmond is a Lecturer (Assistant Professor) in Healthcare Management and Leadership at The University of Sheffield. He has over 10 years of health management experience in public and private healthcare in Canada, USA, and UK. His current research has several interconnected streams including health emergency management. Dr. Attila Hertelendy is an Adjunct Professor at Georgetown University, and teaches in the International Executive Master’s in Emergency and Disaster Management Program. Dr. Hertelendy was a hospital executive in Canada, Saudi Arabia, and the United States. He is a certified chief fire officer and paramedic.
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