Christopher Nelson

Conceptualizing and defining public health emergency preparedness

Since September 11, 2001, and the anthrax attacks that followed, a substantial federal investment—totaling well in excess of

Small Businesses and Workplace Fatality Risk: An Exploratory Analysis

5 billion—has been made to increase our nation’s ability to prepare for, and respond to, public health emergencies. Yet despite anecdotal reports suggesting that progress has been made, it is unclear whether these investments have left the nation better prepared to respond to a bioterrorist attack, pandemic influenza, or any other large-scale public health emergency. This situation is not because of a shortage of measures of preparedness. Over the past 5 years, federal agencies, state health departments, and various nongovernmental organizations have proposed and implemented myriad measures of public health emergency preparedness. But these efforts have not resulted in a clear picture of the nation’s preparedness owing to ambiguous and uncertain preparedness goals, a lack of agreement about what the measures should aim at and how they should be interpreted, and a weak system of accountability for producing results.1 Measures often vary considerably across agencies and shift dramatically from year to year, leaving state and local health officials, businesses, nonprofits, and citizens confused and perplexed by a maze of overlapping and sometimes contradictory requirements, checklists, and ideas about what constitutes preparedness.2–4 What our nation needs in order to bring coherence to the debate is a clear definition of public health emergency preparedness and an articulation of the key elements that characterize a well-prepared community. In this editorial, we propose a candidate definition of public health emergency preparedness and describe its key elements. Both the definition and the elements were developed by a diverse panel of experts convened by RAND in February 2007. We propose the following definition: public health emergency preparedness (PHEP) is the capability of the public health and health care systems, communities, and individuals, to prevent, protect against, quickly respond to, and recover from health emergencies, particularly those whose scale, timing, or unpredictability threatens to overwhelm routine capabilities. Preparedness involves a coordinated and continuous process of planning and implementation that relies on measuring performance and taking corrective action. In developing the definition, we considered what constitutes a public health emergency, what public health emergency preparedness requires, and who is involved in it.

How can we strengthen the evidence base in public health preparedness

6 Jump down to document THE ARTS CHILD POLICY CIVIL JUSTICE EDUCATION ENERGY AND ENVIRONMENT HEALTH AND HEALTH CARE INTERNATIONAL AFFAIRS NATIONAL SECURITY POPULATION AND AGING PUBLIC SAFETY SCIENCE AND TECHNOLOGY SUBSTANCE ABUSE TERRORISM AND HOMELAND SECURITY TRANSPORTATION AND INFRASTRUCTURE WORKFORCE AND WORKPLACE The RAND Corporation is a nonprofit research organization providing objective analysis and effective solutions that address the challenges facing the public and private sectors around the world.

Developing national standards for public health emergency preparedness with a limited evidence base.

The lack of frequent real-world opportunities to study preparedness for large-scale public health emergencies has hindered the development of an evidence base to support best practices, performance measures, standards, and other tools needed to assess and improve the nations multibillion dollar investment in public health preparedness. In this article, we argue that initial funding priorities for public health systems research on preparedness should focus on using engineering-style methods to identify core preparedness processes, developing novel data sources and measures based on smaller-scale proxy events, and developing performance improvement approaches to support the translation of research into practice within the wide variety of public health systems found in the nation.

IMPACTS OF PARTICIPATORY SAFETY RULES REVISION IN U.S. RAILROAD INDUSTRY: AN EXPLORATORY ASSESSMENT

OBJECTIVE The paucity of evidence and wide variation among communities creates challenges for developing congressionally mandated national performance standards for public health preparedness. Using countermeasure dispensing as an example, we present an approach for developing standards that balances national uniformity and local flexibility, consistent with the quality of evidence available. METHODS We used multiple methods, including a survey of community practices, mathematical modeling, and expert panel discussion. RESULTS The article presents recommended dispensing standards, along with a general framework that can be used to analyze tradeoffs involved in developing other preparedness standards. CONCLUSIONS Standards can be developed using existing evidence, but would be helped immensely by a stronger evidence base.

A peer assessment approach for learning from public health emergencies.

Increasingly, the proliferation of safety rules is viewed not just as a nuisance but also as a threat to safety itself. Indeed, voluminous and overlapping rules might contribute to poor compliance because of confusion and disagreement about which rules are to be followed. When combined with the existing regime of fault-based injury liability laws governing the industry, rules often become the focus of worker–management conflict rather than tools for communication about safety hazards and solutions. An exploratory assessment of participatory rules revision as an instrument of safety improvement in the U.S. railroad industry is presented. A key premise of the intervention is that rules proliferation is symptomatic of deeper problems with the organizational safety culture that can be addressed through extensive stakeholder participation in the revision process. Data for the study came from three railroads and one in-land barge line. While interview data provided evidence for an impact on the safety culture, initial statistical analysis of the incident data failed to find decreases in incident rates associated with the advent of the formal rules revision process. Further exploration, however, suggested that the intervention actually began earlier with various preparatory activities. Statistical analysis of this revised hypothesis found a significant impact of the intervention on incident rates at one rail carrier, while incident rate declines at two other carriers could not be attributed to the intervention with confidence.

Building Performance-Based Accountability With Limited Empirical Evidence: Performance Measurement for Public Health Preparedness

As an alternative to standard quality improvement approaches and to commonly used after action report/improvement plans, we developed and tested a peer assessment approach for learning from singular public health emergencies. In this approach, health departments engage peers to analyze critical incidents, with the goal of aiding organizational learning within and across public health emergency preparedness systems. We systematically reviewed the literature in this area, formed a practitioner advisory panel to help translate these methods into a protocol, applied it retrospectively to case studies, and later field-tested the protocol in two locations. These field tests and the views of the health professionals who participated in them suggest that this peer-assessment approach is feasible and leads to a more in-depth analysis than standard methods. Engaging people involved in operating emergency health systems capitalizes on their professional expertise and provides an opportunity to identify transferable best practices.

Assessing Public Health Emergency Preparedness: Concepts, Tools, and Challenges

Efforts to respond to performance-based accountability mandates for public health emergency preparedness have been hindered by a weak evidence base linking preparedness activities with response outcomes. We describe an approach to measure development that was successfully implemented in the Centers for Disease Control and Prevention Public Health Emergency Preparedness Cooperative Agreement. The approach leverages insights from process mapping and experts to guide measure selection, and provides mechanisms for reducing performance-irrelevant variation in measurement data. Also, issues are identified that need to be addressed to advance the science of measurement in public health emergency preparedness.