The People, Process, & Progress Podcast - This is How the United States Can Re-Build Public Health Operational Competence | PPP #72

Episode Date: March 28, 2021

Sharing the "Foundational 5" for how Public Health and America as a whole can be more prepared for the next pandemic.

to say that there are many lessons learned from the past year's global pandemic response in America in particular is an understatement. To also think we should not have been prepared a little bit more and known this was going to happen, simply not true. I shared similar statements in People Process Progress 15, Pandemic Planning and Response is Not New, a review of the 15 Public Health Emergency Preparedness Capabilities, and then before that a little bit too when I touched on in episode 11, a brief history of public health emergency preparedness in America. Pandemic, influenza planning, and the notion that a major outbreak could be headed for

the world is well documented in the history of our species, let alone the United States. So how are we caught so off guard? My two cents is administrative overhead masquerading as preparedness, air quote, and air quote readiness. Preparedness deemed sufficient through the process of completing multi-page checklists that are reviewed by people who may or may not have ever participated in a real public health response at the local, regional, state, or national level. Readiness judged by a check of the box. have ever participated in a real public health response at the local, regional, state, or national level.

Readiness judged by a check of the box. If some practice giving a relatively small number of candy to people in a point of dispensing, that's those places that now we're calling vaccination centers, pod, point of dispensing, and documenting times and then sharing it in a really nice looking document. So what's my point and where's the gap? Administrative processes were deemed more important than developing individual, district, agency and national level competency and credentialing. This is not hyperbole. Instead of documents with links to lengthy, oftentimes unactionable plans, we should have

collectively been training our public health and healthcare staffs in core principles of all hazards incident management. These skills bring with them the ability to apply those foundational five key things I speak of here on the show, whether for a 10 person or 10,000 person outbreak. With these principles come credentialing. These credentials aren't given unless an individual can show another experienced and already credentialed person that they can perform the task. So how can we get better?

Well, in this episode, 72 Public Health Operational Competence, This is the Way, I'm going to share a foundational five things I know work for my five years as a local, regional, and state public health preparedness coordinator, and some of the rolling lessons learned that I've witnessed as the nation's responded and as I've been monitoring the ground truth from folks that are out there getting it done. So as we get started, please silence those cell phones, hold all sidebar conversations to a minimum, and we'll get into this episode of the People Process Progress Podcast in three, two, one. Hey everybody, thanks for sticking with the show. Let's get into this foundational five for public health operational competence. So as you may recall, those foundational five things that I've distilled down from project management, incident management, and various things that I've learned is that we need to have leaders intent. We need to establish smart objectives. We need to create some sort of functional or realistic workable organization chart or organizational structure. We need to

request and coordinate resources effectively, and we need to communicate. So separately, they're all good together. They really do encompass many of the practices and can get you through starting up a new project if you're new or a new incident response or something like that. So if you can roll through these. So in this episode, I'm going to focus on, as I mentioned, that public health operational competence, trying to address some of those gaps, some of the administrative overhead that should be focused on getting our people ready to do the deed like we are now. And that what I saw in my time in public health and public safety and a preparedness emergency management focus is it really varied by the individual, right? I got very much into

the incident management scene, became credentialed as a planning section chief and medical unit leader and trained in other areas. And it made me better at my public health job. It made me better as a project manager now. It is a really good process that teaches you how to think outside the box, not just within the confines of the checklist you have to turn in to get funding. That's the truth of it. So for me, if I could be in charge of helping us all get better from the unfortunate lessons learned over the past year, a little over a year,

my leader's intent would be to build and maintain a public health operational readiness model at the local, state, and national levels to be ready to address any disease of public health threat. Now, there's probably similar verbiage as that on documents all over the country. I would tie it to money. If we don't have real preparedness or our people can't really do things as opposed to some small tests or they're focused solely on the document, not the out there doing it stuff, you don't get funding. And that's a problem. There are awesome people and some of the best people I've ever worked with in my life in public health, but not all of them are ready to go from working in the clinic or investigating an outbreak in a nursing home to doing what we're doing now. That's why you

see a lot of crossover at the national level with FEMA taking the lead or at the local level with emergency management leading or coordinating and anything in between. So that's my leader's intent. We have to get every level ready for any disease of public health threat. And it's not impossible. And I'm going to give some tips on how to do that. So these SMART objectives, the first one I'm going to start with, and I didn't make this one up either, but not everybody does it or has done it. Establish an annual training exercise plan following the Homeland Security Exercise and Evaluation or HSEAP guidelines at the local, state, and federal levels. HSEAP is fantastic.

Again, it's the Homeland Security Exercise and Evaluation Program. It's an outstanding program, training, templates, all that kind of stuff to plan out a training calendar, focus on what your people need in this case, right? If we're getting ready for whatever big thing happens, disease, how do we get a bunch of PPE masks and gloves? How do we coordinate that effectively? How do we get a bunch of vaccinations and give a whole bunch of those as fast as we can? Like I said, my mission statement the whole time I was at the local level was to give over 300,000 people, residents of a locality, a 10-day supply of antibiotics within 48 hours. So if you're always training to a super high standard,

you're going to try hard, right? Even if you go give 1,000 flu shots in your annual flu exercise, you've at least given 1,000 in a day in an exercise. So these guidelines should also include mandatory involvement with public health, public safety, health care, mortuary affairs, and long-term care communities. And I'll get into long-term care. That's its own kind of thing. And some places have those. And again, I'm from Virginia.

We have really good infrastructure in a lot of these areas. So don't take it that I'm saying we had none of this. But it varies, and I'll get into that in particular. So they have to be tangible guidelines, right? So again, it's not new what I mentioned as far as training and exercise, but if you don't have it, your state didn't get funded, your locality, et cetera, like that. And I have some thoughts on a reorg there. My second objective would be create a cadre of experience, public health evaluators to provide objective feedback to local, state, and federal public health personnel. In the opening, I mentioned experience, right? There's a lot you

can learn from books. There's a lot you can learn from simulations, but nothing replaces having done something for real. A lot of evaluations, a lot of preparedness, readiness, air quote both of those, was signed off on by people that were brand new because they just graduated from a public health program. That doesn't help. The cadre must be credentialed in an incident management position. Again, we're focused on operational competence. You have to be able to say, yep, I can go set up a vaccination clinic and give 2,000 shots today and 5,000 tomorrow or something like that. Public health at the national level, health and human services, HHS and CDC, partner with

NWCG, the National Wildfire Coordinating Group that spawned the incident management team, and then National Fire Academy and FEMA that helped convert that to all hazards. There's also some gems and some of the best incident management people on the planet at the local, regional, and state level of incident management teams. They are a ready cadre that have worked missing persons, disease outbreaks like I did with them, and many other things in between. So that's also who right now is doing a lot of this work. So why not get our public health folks ready?

Not every nurse needs to be a planning section chief. Not every refugee coordinator needs to be an operations section chief, but they have to have the basic skills to do that. Now, these evaluators also should come from somewhere else, because if you all have been involved in an evaluation, whether it's in the private sector or an exercise, you know that sometimes if you know the evaluator and you're friends with them, you don't quite get the objective, less filtered feedback that sometimes we need to keep us honest and keep us ready. That's what

this cadre would do. So that doesn't mean we're not friendly. And I've evaluated many exercises, you can be very helpful in the way that you give your feedback that you document your feedback, but you have to be honest with it. We all have to take ownership of what we are or aren't doing well, particularly when it comes to being ready in public health. The third objective I would propose is public health personnel across the United States that are charged with planning for and responding to diseases of public health threat must obtain an IMT, incident management team, credential within their first one or two years in their position.

That's what I did. So yes, I'm probably going to make that an objective. But why? Because I know I took the knowledge, I took the experience, I brought that back to my health department, then I shared it, then I got my folks ready, and every single time we had a small outbreak or a big one or, hmm, got ready for this, that knowledge was there. Like I mentioned, not every position needs to go through the full, you know, all the way up to section chief credentialing. But if they get credentialed as a check-in recorder,

that's someone that signs people in, or they are a group supervisor, that's a nurse in charge of other nurses, right? Giving shots. That teaches invaluable lessons that it doesn't matter what you throw at them, they will be ready. There's a time commitment, but it is worth every minute. The training and credentialing will provide the muscle memory that public health staff need to be ready to scale preparedness and response. And as we saw, it's also probably not the best position to place political appointees or family members in key positions. And I'm speaking of the strategic national stockpile. So if there is a position or one position, one of the many important ones at the national level that I would want someone

credentialed in logistics, it's as the strategic national stockpile coordinator. That is the giant warehouses scattered across the United States that are full of trauma stuff and masks and gloves and needles and all the stuff you need to do what's going on now, that then states say, hey, federal government, I need this. And they send some. And of course, you can't give it all to one state. You can't give it all to one city. So it's a hard thing.

But it's basic logistics to get it there and process and prioritize requests. Right? prioritize requests, right? It's a critical path area that should never have been given to a family member of a politician or an appointee that has no experience doing it. I know logistics section chiefs that, gosh, they could have coordinated the strategic national stockpile like champions because they had the experience in getting requests, moving them around on who goes where, getting equipment together, packaged equipment that someone requested in their good resource requests, and then sending it to where it needs to go and then tracking it. That's what the SNS is for. So that's a little addition to the credentialing thing,

just because that's a pretty big call out for me on that one looking back at the past year. The next objective that I believe will help us establish or build on, because there is some public health operational competency out there, is that we're going to together conduct an annual national level full scale exercise that incorporates local, state, and federal public health and healthcare personnel. There are some national level exercises. A lot of them, they change each year. They have big whiz bag names, but they should be expanded on. I mean a national level exercise where every single state at the same time for two to three days, not a few hours, is doing what they're doing right now for pretend, right? But everyone, go stand up your, you know, in one big city or your major cities, your

vaccination center or your screening center or your distribution center or something like that. And there are, again, are variations on this theme that happen at different levels depending on the commitment and the dedication and the competency of the people that are there to do it. So let's fix the competency. The commitment is a tough one, right? But imagine if we're coordinating every year, we're going through this when it happens again, which now we do have the experience. Unfortunately, there was a price to pay, a pretty heavy one. The next objective is we need to create task forces to address the key underlying conditions that made the impact of COVID-19, this is a specific one, worse. And I'll touch on what some of these are here in a little bit with the messaging to ourselves.

But obesity, smoking, diabetes, et cetera, and there's more, I'll touch on it a little bit. Why don't we have a national campaign for healthiness? Remember, and you know, I'm 47, but I remember the eighties and nineties when Arnold Schwarzenegger was like the national fitness ambassador or something like that. That's a great thing, right? And I get it. I have kids, they're on electronics all the time. I'm on electronics all the time, but you have to stay active, right? We have to be honest with ourselves too. We're not a very healthy country, right? And we have to have that honest conversation, even though some might feel bad. But, you know, won't some folks feel worse if they do get sick because their immune system is lowered because they're not

putting out the effort to exercise. And again, I'm going to touch on some examples of how we can look at that. The last objective, and there could be many more, right? I'm sure you all have some great ones. You know, send them to me, peopleprocessprogress at gmail.com. Share them if you're in the public health, public safety space. What do you think? What are you learning out there? But my last one is to improve the public health technology infrastructure and create interconnectivity between the local, state, and federal levels.

Why don't we have a national level health information exchange for disease outbreaks? There are some semblances of that, but the technology has existed and certainly today exists to connect every system right everyone's concerned about privacy but are we more concerned about stopping an invisible threat like a like a disease outbreak right it's not a fire that you can see it's not gunshots you can hear it's not blood you can put pressure on so we got to balance that privacy thing and and you know no network is purely secure we've seen hacks of just about everything you could you could think of. Technology exists. We should share the expense. We should create the interfaces and we should optimize those communications. And again, I'll loop back into communications as our last of the foundational five here in a little bit. Again, if you want to communicate with me,

peopleprocessprogress at gmail.com, peopleprocessprogress.com. And there you can hit on the subscribe link and it's got all my social media connections and ways to subscribe to the show. So the third of those foundational five things is organization, right? How do we organize? Well, it's kind of hard to do an org chart or is it, I guess, right? I'm really going to speak on this one too, for exercise and then day-to-day organization. So for exercises, when we're practicing, because we have that annual plan, right? And we're going to do both local, state, and federal level stuff more regularly

and kind of upscale it. There's got to be coordination and organization between your incident command system, reported dispensing, and the emergency operations center. That's that ICS EOC interface. What are the folks at the vaccination center doing? How are they coordinating requests with the emergency operations center? How are they then coordinating from a bunch of different cities or towns with the region that a bunch of cities and towns are in a multi-agency

coordinating center or a state-level MAC? And then how are they coordinating with the national agencies and emergency operations centers at Health and Human Services, the CDC, FEMA, et cetera, et cetera? That's what we need to look at. That's the connectivity we should have. And that's an org chart. Day-to-day, I propose, because there's variation across our country, and I know there's states' rights and all this kind of stuff, that all public health fall under or follow the local health district, which is a city or county health department, that falls under a state's umbrella and is supported by federal funding. Why? I think it could provide across the board increased

accountability, right? So if you're in a small town that's not connected to your state, you have less resources and less staff, probably less coordination. And there's more accountability for those objectives I talked about. If it's all connected, it's all tied to funding. It's a requirement, right? There's overhead. Now, the balance is when something happens in the local health district, not having the state folks come and micromanage you or lead from afar, that's not helpful because it's not helpful. But having more resources does make a difference. In addition to health departments, long-term care facilities, nursing

homes, right? Those have been really a bad place to be, unfortunately, because of mismanaged patient care. There's outbreaks in those places all the time, but I believe that there should be more federal funding directly to those or through the health district or tied to public health more so. Why is that? Because there's a gap in long-term care facility preparedness that has to be closed. The current environment is a haves-haves-nots, right? If a long-term care facility falls under the umbrella of a larger company with multi-tiers of care, meaning they go from, I'm just an older person that just wants an apartment in a facility with all the other folks, or I need some assistance,

or I'm a full nursing home, bed bound, that's a big company. They have money, they have staffs to help them be more prepared. So they're going to be more prepared. They're probably going to be also better at disease control, infection control, standards and readiness. But what about many other great folks that have the quote mom and pop level? Well, their preparedness is probably going to be minimal, right? There's a danger of lower cleanliness maybe. And that's not across the board. There's plenty of outstanding people who decided I'm going to help older folks and I'm going to help folks live. That's awesome. But often the standards are lower. They don't have as much resources.

And unfortunately, you know, they don't have the staff dedicated to their preparedness. So in addition to keeping their business open, keeping their residents right in their, in their where they live and safe and, and fed and happy or helping coordinate appointments or whatever they're doing for those folks, then tack on kind of that, that or whatever they're doing for those folks, then tack on kind of that seventh hat they're wearing that, oh, we also have to do an exercise to get some funding for this or that.

So let's give them funding. The government has funding. We spend on other stuff. Give it to long-term care facilities and other nursing home style places. That was the last of those third of the foundational five things. So we studied leaders of intent. We talked about some objectives. We talked about organization,

which kind of I tied to funding and how we could organize so that that long term care, I think should be more closely tied to public health. But right now it's a lot of, a lot of private entities. Now, what about resources? Those fourth of the foundational five got a lot of these because there's a lot of resources.

The United States government has resources, health and Human Services, the CDC, FEMA, we all have a bunch of funds to make stuff happen. Yes, funding waxes and wanes with each administration, regardless of party. So it's not even a political thing. But as a whole, there are billions of dollars sent to the various states across America. But are the billions of dollars sent to the states for public health preparedness used as efficiently as they should be? What does 2020 tell you? What does it tell all of us? Discussion-based exercises, incident command system training, additional practical application of some of the credentialing and other steps that I've talked about, they don't cost a lot of money, right? It's people's time,

it's hiring consultants, it's maybe snacks for the class or something. But is it worth doing that upfront than paying the price that we have over the past year? What about the private sector? Well, they own, what, over 80% of the infrastructure? Probably a good idea to always make sure they're looped in early and often for exercises. And the type of places I'm talking about that has to do with public health, even though disease can go everywhere, hospitals, healthcare in general, all the various flavors of healthcare, airlines, right, pretty important, manufacturing. That's some of the folks we need to make sure we're always reaching out to. They can also generally spend funds more freely than government entities whose hands are tied with what they can buy, like lunches for trainees or participants. And we all know a free box lunch from our favorite caterer helps get us to a class

and it does make the class better, right? If you're going to go to a class to get credentialed or get trained up and be prepared for this stuff, it's nice to take care of your people. Standard operating procedures instead of emergency operations plans is my other suggestion as a resource. Emergency operations plans, whether they fall under the public health realm or for a locality or anywhere, are pretty big documents, hundreds of pages. Could you or I pick up a 350-page document and action the items inside? Depends on how well it's written, right? Is it in the table of contents? Does that then take me to

a decision diagram or some other actionable thing? Do we really, in our emergency operations plans, care about the history of the locality we're writing that plan for? Or in a case like a pandemic, do we just want to know how many injection stations we can fit into our pre-planned vaccination site? I submit the latter. So if all of our plans could be picked up by someone that's never read our entire big bulky emergency operations plan, and instead we give them a, I don't know, 10 to 15 pager that has references and documents and diagrams, that's probably a good way to go. I know I've talked about that. That's what I do with my plans. And that's what I've seen others done with their plans. So again, administrative overhead, I think, has hampered

us. And I think part of our resources need to streamline that and make our plans more actionable. I propose as resources, we put more project management tools into emergency management and public health. SharePoint, JIRA, Project Online, all the other, there's so many different ones there, and I've got no endorsements for any of these folks. There's so many tools that are used effectively to manage multi-billion dollar projects in the private sector that should be incorporated into public health's antiquated IT infrastructure. If we could coordinate projects across states very effectively, like real-time stuff, and we had a good overall project monitoring, that would be very helpful as a resource. It would make sure the money's going where it needs to go.

Everyone's met their requirements. And there's some systems that exist. But it's more of a coordination than actually kind of a project or program or even portfolio. That could really help public health coordinate and prepare and respond. I think there should be nationally-led community health assessments as a resource for communities, for local health departments, and states. My exposure to these before and the concept of it, which is you get public health professionals led by either a public health nurse or an epidemiologist, a disease expert. They're going to go around the community, ask some standard questions, get a feel for the health of the community, come back, evaluate it. And that drives the programs.

From what I've seen, some folks saw they were neat. Some folks did them and it was like, wow, they did that. That's like an outlier instead of the norm across the country. So let's change that norm. With the re-awareness, again, not new, that there's health disparities or challenges for low income of all races to get access to healthcare and public health. Maybe this is the time where the public's not so opposed to having some public health folks come through their neighborhood and do a basic screening and ask them questions, and maybe they can help show them around their neighborhoods. Where is our balance of privacy versus preparedness versus driving?

We want to ask you these questions. We want to put together this assessment so we can come back to you with better care, better options, better programs, instead of some of the other nonsense that local, state, and federal governments spend money on. After all, those assessments is how we're going to get real ground truth on the health of our nation. Fifth, final category of the foundational five here, communications. I mean, as of this episode, March 2021, technology could help us close so many of the gaps we've re-identified or that have come up, right? There are government communication networks that exist both in public and private sector. We have Zoom, FaceTime, Teams, all these

different programs that we're doing business with, but what's the message from that, right? I feel like, you know, it changed in 2020. Mass, no mass, mass, et cetera. And that's not a mass debate, just a thing. And then the data, what's the data accurate? What's the source of truth. This is a tough one because our systems should be efficient because they follow a people process, right? Not that we put systems in and made people adjust to them. That's a standard tentative it project management, right? Learn what the people's process is, optimize the process where you can then get technology that fits it. But what's the source of truth when it comes to an outbreak and what we've learned in

the last year? It's tough because, you know, we just got we need to cross check our information anyway. Right? CNN, Fox, NBC, the CDC, World Health Organization, there's so many places to go. What I will say is it's probably good to cross-check what a air quote reporter says on TV because now they're kind of their own personalities as opposed to unfiltered news, objective news, right? And I think they try and be more of the feature than the facts that they speak about. So the technology exists for us to communicate in so many different ways. Our challenge is to filter out what's not accurate, right? And to work on our combined messaging with our good public information officers and joint

information centers and joint information systems, right, that are coordinating messages, not I'm going to send a message, you're going to send a message, you're going to send a message, and it's not the same. That's just not good. And our messages have to be real. I mentioned earlier the health, underlying health conditions. This is direct from the CDC site, right? Focused on COVID, but it's not just for COVID. If you have cancer, chronic kidney disease, chronic obstructive pulmonary disease, or COPD, Down syndrome, heart conditions such as heart failure, coronary artery disease, cardiomyopathies, immunocompromised state, right? It's weakened from solid organ transplant, obesity or severe obesity, pregnancy, sickle cell, or a smoker,

or have type two diabetes, you're at increased risk of having poor outcome from, I say insert disease. It's not just COVID. Having any of these decreases the ability to fight off diseases. And some of these, particularly in the area of obesity, we don't like to talk about as much, or smoking. Smoking's a right, some folks say. I don't smoke. I did as much, or smoking. Smoking is a right, some folks say. I don't smoke. I did chew tobacco for a long time. So I understand the addiction to the nicotine.

But we have to keep it real. If you're going to do some of these, if you're going to not be healthy because you're just not being healthy, then you're going to get sicker. And it sucks. If you're smoking, and that gives you COPD, or that it gives you lung cancer, that's worse. Now, I'm a cancer survivor, right? Was it from chewing tobacco? Was it from trying some cigarettes when I was younger? Who knows? Sometimes people just get it.

So some of these you can't prevent, right? Genetics, like diabetes, sickle cell, some of those things you can't. That's tough. But for everything on that list that we can, the big ones for me, right, have to do with the obesity, the smoking, other things that we can do a lot about, we have to be real and focus on them. And as I've said before, everyone should exercise and eat as healthy as possible. Right? I exercise regularly, many other people do, and still have time to enjoy some tasty fast food because it's good. I've made excuses, but I know there were excuses.

I made excuses for it. And there are excuses that many able-bodied people make for not being active. So I'll just submit these examples. Have you all heard of Jim Abbott? Jim Abbott was born without a right hand, yet he ended up playing professional baseball. Have you ever on YouTube or somewhere else seen somebody in a CrossFit gym that has one leg and one arm snatch weight off the ground and do it over their head while they're balancing? Have you heard about Kyle Maynard? He was the first quadruple amputee to ascend Mount Kilimanjaro without

the aid of prosthetics. That's an over 19,000 foot climb with no hands or feet, real or prosthetics. Do we still think we can't stay active? To me, there is so much more that I could say and document. And as someone that's kind of on the sidelines watching the field that he used to be in center stage and talk to and hear from some of my best friends and colleagues and others that are out there fighting the fight. We've got to be objective with ourselves. This is the time as we are vaccinating more and more and we're coming out of this that we have real talk with ourselves as a nation, as states, as localities, as organizations. The key is we have to accept that we screwed some things up, that we didn't all prepare like we should have. We have to take ownership of this and then do our best to make it right.

We cannot again let politics over the next years take center stage. Instead, we must have a resolute focus on the readiness and safety of our frontline people, our most vulnerable, and prepare the next generation to more readily face the invisible monster that is disease. Public health is hard, but it's not impossible. We do have plans for this. We should know how to scale. We must prepare and do better next time. I hope you all are out there doing better than you were yesterday. I appreciate every second of the episodes that you've listened to that you've shared. I hope together we come out of this dark cloud of pandemic stronger, more prepared, healthier as a people.

I hope we work together in that process. And of course, so that we can all make progress. Stay safe out there, everyone. Wash those hands and Godspeed.