Executive Summary

Abstract: The Metropolitan Medical Response System (MMRS) program of the U.S. Department of Health and Human Services (DHHS) provides funds to major U.S. cities to help them develop plans for coping with the health and medical consequences of a terrorist attack with chemical, biological, or radiological (CBR) agents.

The DHHS Office of Emergency Preparedness (OEP) asked the Institute of Medicine (IOM) to assist in assessing the effectiveness of the MMRS program by identifying or developing performance measures and systems and then using those measures to establish appropriate evaluation methods, tools, and processes for use by OEP to assess both its own management of the program and local preparedness in the cities that have participated in the program.

Both the MMRS program and the local preparedness to cope with terrorism that it seeks to enhance can and should be improved by a comprehensive evaluation program. Since the nature of the threat of CBR attack and U.S. cities both undergo continual change, preparedness to respond to a CBR attack must also undergo continual change. Therefore, it is important to conceptualize preparedness as a continual process rather than the achievement of a single final plan. The evaluation of preparedness must necessarily, therefore, also be a continual process rather than a one-time event or even a series of events spaced at long time intervals.

This report provides a set of measurement tools and describes a process for evaluating the extent to which communities have implemented the plans required by the MMRS program and have begun to achieve real preparedness. Specifically, the committee lists 23 essential capabilities that form the basis for preparedness. For each of those capabilities, the committee provides a small set of pre-



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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program Executive Summary Abstract: The Metropolitan Medical Response System (MMRS) program of the U.S. Department of Health and Human Services (DHHS) provides funds to major U.S. cities to help them develop plans for coping with the health and medical consequences of a terrorist attack with chemical, biological, or radiological (CBR) agents. The DHHS Office of Emergency Preparedness (OEP) asked the Institute of Medicine (IOM) to assist in assessing the effectiveness of the MMRS program by identifying or developing performance measures and systems and then using those measures to establish appropriate evaluation methods, tools, and processes for use by OEP to assess both its own management of the program and local preparedness in the cities that have participated in the program. Both the MMRS program and the local preparedness to cope with terrorism that it seeks to enhance can and should be improved by a comprehensive evaluation program. Since the nature of the threat of CBR attack and U.S. cities both undergo continual change, preparedness to respond to a CBR attack must also undergo continual change. Therefore, it is important to conceptualize preparedness as a continual process rather than the achievement of a single final plan. The evaluation of preparedness must necessarily, therefore, also be a continual process rather than a one-time event or even a series of events spaced at long time intervals. This report provides a set of measurement tools and describes a process for evaluating the extent to which communities have implemented the plans required by the MMRS program and have begun to achieve real preparedness. Specifically, the committee lists 23 essential capabilities that form the basis for preparedness. For each of those capabilities, the committee provides a small set of pre-

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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program paredness indicators by which community preparedness can be judged and advice on a suitable method for gathering the necessary data with which a proper conclusion can be drawn. In summary, this report provides the managers of the MMRS program and others concerned about local capabilities to cope with CBR terrorism with three evaluation tools and a three-part assessment method. The tools provided are a questionnaire survey eliciting feedback about the management of the MMRS program, a table of preparedness indicators for 23 essential response capabilities, and a set of three scenarios and related questions for group discussion. The assessment method described integrates document inspection, a site visit by a team of expert peer reviewers, and observations at community exercises and drills. Among the many federal efforts to combat terrorism is the Metropolitan Medical Response System (MMRS) program of the U.S. Department of Health and Human Services (DHHS), which attempts to enhance the preparedness of major U.S. cities with regard to the health and medical consequences of an attack or threatened attack with chemical, biological, or radiological (CBR) agents. The DHHS Office of Emergency Preparedness (OEP) has been contracting with the most heavily populated U.S. cities since 1997 in an effort to improve those cities’ capabilities to respond to terrorism incidents on the scale of the September 11, 2001, attacks on the World Trade Center and the Pentagon. The central focus of this effort, the MMRS program, has been on unfamiliar chemical and biological agents, although many of the requisite capabilities for dealing with the consequences of those agents are necessary for an effective response to an attack with explosives or radiological agents as well or even for an effective response to natural disasters. The contracts, which OEP has signed with 122 cities as of the spring of 2002, provide funds for special equipment and a cache of pharmaceuticals and medical supplies, and in turn demand detailed plans on how the city will organize and respond to chemical and biological terrorism incidents. A large number of these cities have now produced acceptable plans, and OEP turned to IOM for assistance in evaluating the extent to which its efforts and these plans have actually prepared cities to cope with the consequences of mass-casualty terrorism with a CBR agent (i.e., are the cities now well-prepared, and how has OEP contributed?). CHARGE TO THE COMMITTEE OEP asked the Institute of Medicine (IOM) to assist OEP in assessing the effectiveness of the MMRS program by identifying or developing performance measures and systems and identifying barriers related to the MMRS development process. IOM was then to use those measures to es-

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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program tablish appropriate evaluation methods, tools, and processes for use by OEP. In response to that request, IOM formed the Committee on Evaluation of the Metropolitan Medical Response System Program. The primary measure of effectiveness for any program is the extent to which it achieves its ultimate goals. Therefore, in Phase I of this project the Committee identified almost 500 preparedness indicators that might be used to assess the response capabilities of MMRS program cities at the site, jurisdictional, and governmental levels. Those indicators are described in the committee’s Phase I report (Institute of Medicine, 2001) and are reprinted as Appendix E of this report. In Phase II, the committee used the preparedness indicators established in Phase I to develop usable evaluation methods, tools, and processes for assessing both program management by OEP and the capabilities of the local communities necessary for effective response to CBR terrorism. Those methods, tools, and processes are the subject of this report. CHEMICAL, BIOLOGICAL, AND RADIOLOGICAL WEAPONS There are thousands of chemicals that may result in morbidity or mortality for humans at some dose. In the present context, “chemical agents” are generally considered to be a relatively short list of chemicals that have at some time been “weaponized” for military use. Some of these agents have no other use (e.g., nerve agents and mustard gas); other agents such as chlorine and ammonia are in wide use in industry. Often classified by the site or nature of their effects in humans as nerve, blister, choking, vomiting, and tear agents and incapacitants, many of these chemicals are poorly understood by civilian hazardous materials technicians and other emergency responders, medical personnel, and law enforcement officials. The agents listed below have been the primary focus of efforts to prepare for chemical terrorism, in part because of their toxicities but to a greater extent because of the health care community’s unfamiliarity with these agents: Nerve agents Tabun (GA) Sarin (GB) Soman (GD) GF VX Vesicants (blister agents) Mustard (H, HD) Lewisite (L) Phosgene oxime (CX)

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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program Blood agents Hydrocyanic acid (AC) Cyanogen chloride (CK) Arsine Methyl isocyanate Choking agents Phosgene (CG, DP) Chlorine Ammonia Biological agents with adverse effects on human health include viruses, bacteria, fungi, and toxins. The distinguishing feature of biological agents other than toxins is their ability to propagate—exposure to an extremely small amount can lead to an overwhelming infection, and in some cases the victim may even become a source of infection for additional victims. This propagation within the exposed person (that is, incubation) takes time, however, so the effects of viruses, bacteria, and fungi may not become apparent until days or weeks after the initial exposure. There may be no obvious temporal or geographical concentration of victims to help medical personnel arrive at a diagnosis and make law enforcement personnel suspect a crime. Diagnosis of infection in individual patients will also be rendered more difficult because most of the agents considered to be likely threats are very rarely seen in U.S. cities and the initial symptoms that they produce (fever, headache, general malaise) are also characteristic of those produced by many common diseases. As difficult as it was to contain the spread of anthrax from just a few spore-filled letters in the autumn of 2001, the fact that the letters announced the presence of anthrax spores actually made the diagnosis and response far easier than if, for example, the perpetrator had covertly introduced spores into the air-handling system of a sports arena or airport. The victims in that case would have dispersed, perhaps very widely, by the time they became ill, and many might have died before an accurate diagnosis could have been made. As in the case of chemicals, would-be terrorists have a large number of potentially harmful biological agents from which to choose. Indeed, the tools of biotechnology might even be used to make some biological variants that have not previously existed, so to suggest that would-be terrorists will only use agents that have been the focus of military weapons programs would be folly. The agents that have been developed as biological weapons were carefully selected for their suitability as weapons, however, and few civilian American physicians have experience in either the diagnosis or treatment of the diseases caused by those agents. For that reason, these agents have been the focus of counterterrorism training and

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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program other preparations. The specific agents that MMRS cities are directed to consider in their planning are those responsible for anthrax, botulism, hemorrhagic fever, plague, smallpox, and tularemia. The term “radiological weapon,” in distinction to nuclear weapon, refers to a weapon that would disseminate radioactive materials by means other than an uncontrolled fission chain reaction. The so-called dirty bomb, which consists of radioactive material wrapped around conventional explosives, is the best-known example. Exposure to excessive amounts of radiation does not make one radioactive, but in the short run it can produce skin reddening and loss of hair, nausea and vomiting, diarrhea, sterility, tissue fibrosis, organ atrophy, bone marrow failure, and death. These effects are not instantaneous, so radiological terrorism would present some of the same challenges for clinical diagnosis and law enforcement as biological terrorism. Some of these effects may be transient, but the genes of some exposed individuals may also damaged, leading to cancer or birth defects in their offspring that are manifest only years later. Decay of the commonly used radioactive materials is very slow, so contamination is a serious clinical concern. Although not invisible, a finely ground or powdered agent could be detected and removed only with the aid of special equipment for detection and decontamination. Activities required to cope with a radiological incident may resemble those required to cope with either a chemical incident or a biological incident, depending on whether the attack is overt (perhaps a conventional bomb wrapped in highly radioactive material) or covert (introduction of radioactive dust into an air, water, or food supply). THE MMRS PROGRAM Perhaps because the immediate stimulus for the MMRS program was an incident involving the release of a military nerve agent in the Tokyo subway in 1995, the first two Metropolitan Medical “Strike Teams” were essentially enhanced hazardous materials (hazmat) teams; and their plans, training, and equipment focused on the demands of coping with potential events involving chemical agent. Some of the other early MMRS program cities changed the strike team concept by integrating strike team capabilities into existing fire department, emergency medical services, and police training and organizational infrastructures. In addition, their plans incorporated local public health officials; nongovernmental organizations; state agencies, including the National Guard; federal military and nonmilitary officials; and private health care organizations. OEP soon amended the initial contracts to focus more attention on coping with a covert release of a biological agent and changed the name of the program to the Metropolitan Medical Response System. The new name emphasizes that the pro-

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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program gram is intended to enhance the capabilities of existing systems that involve not just hazmat personnel, law enforcement personnel, emergency medical services personnel, public hospitals, and the American Red Cross but also public health agencies and laboratories, private hospitals, clinics, independent physicians, and other private-sector organizations. This emphasis on enhancing existing systems rather than creating new, and perhaps competing, CBR weapon-specific systems was strongly recommended by a previous IOM committee as a first principle in efforts to prepare for CBR terrorism (Institute of Medicine, 1999). EXISTING EMERGENCY RESPONSE SYSTEMS A previous IOM study (Institute of Medicine, 1999) pointed out that despite the justifiable emphasis on the novel aspects of a possible terrorist attack with a chemical or biological agent, frameworks for responding to incidents of both types already exist. It argued that strengthening existing mechanisms for dealing with unintentional releases of hazardous chemicals, for monitoring food safety, for detecting and responding to infectious disease outbreaks, and for coping with natural disasters with large numbers of casualties is preferable to building a new system focused solely on potentially devastating but low-probability terrorist events. The all-hazards approach currently advocated by emergency managers requires the availability of systems capable of responding not only to high-probability hazards but also to unexpected events. Those systems include individuals and organizations, means for communication and collaboration among those entities, procedures for the monitoring of public health on a regular basis, and the availability of appropriate equipment to protect responders and save life and property. No universal standard currently exists to define the concept of an “adequate” capacity of municipal emergency management, and U.S. metropolitan areas have a wide range of capabilities The core of emergency management is at the local or regional level and follows a bottom-up approach. Historically, local medical and public health personnel have been the first to notice and respond to rare or unique symptoms and slowly developing trends among victims. In addition, local leaders are the ones most likely to understand local priorities and the implications of critical decisions for their communities. In parallel to the fact that the core of emergency management is at the local level, one of the distinguishing features of the MMRS program is that it is not just a new or better way of providing federal aid to stricken communities but is also a way to help communities themselves deal both with the initial stages of a disaster and with the subsequent influx of outside assistance. Therefore, strengthening existing systems not only improves the

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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program emergency response to terrorist incidents but also improves the emergency responses to other disasters. OTHER FEDERAL PROGRAMS TO STRENGTHEN LOCAL CAPABILITIES The federal government is prepared to provide a substantial amount and diverse forms of assistance to communities stricken by a disaster. With a few exceptions, however, none of this assistance will be available to the affected community until at least 12 to 24 hours after it is requested (and the request itself may not come for hours or even days after the initiating event, be it an earthquake, a flood, or the release of a CBR agent). In contrast, as noted above, the MMRS program provides proactive, pre-disaster assistance; it is not a federal response. It provides funds for the purchase of special CBR agent-specific equipment, supplies, and pharmaceuticals for local law enforcement, fire department, and emergency medical personnel, while it demands substantial integrated planning by the local partners. An important element of that planning and an important consideration in any attempt to measure the impact of the MMRS program is the fact that at least four other federal entities provide additional equipment and CBR agent-specific training: the U.S. Department of Justice Office of Domestic Preparedness (formerly the Office of State and Local Domestic Preparedness Support), the Federal Bureau of Investigation, the Centers for Disease Control and Prevention, and the Federal Emergency Management Agency. In past years, the U.S. Department of Defense was a major source of training and equipment for the largest U.S. cities. Chapter 3 describes these programs, in which nearly all MMRS program cities participated. A significant consequence of this multitude of programs of special importance to the work of the Committee is that it effectively precludes unequivocal assignment of credit for local preparedness. FEEDBACK TO OEP ON PROGRAM MANAGEMENT Part of the charge to the committee concerns the performance of OEP staff in their administration of the MMRS program. That is, how can OEP determine at the program (i.e., national) level whether the strategies, resources, mechanisms, technical assistance, and monitoring processes provided to the MMRS development process are effective? The question of effectiveness obviously cannot be fully answered independently of some measure of the capabilities of the MMRS program communities, but it is nevertheless possible to make some judgments about OEP’s administration of the program by asking whether its contracts cover all the activities

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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program necessary for effective response. The committee in fact identified a number of shortfalls in this regard. Perhaps more valuable sources of feedback on this issue are OEP’s contractors, that is, the MMRS program communities, which can provide information about the extent to which they used OEP technical assistance and resources in fulfilling the terms of their contracts, their perceptions of its value, and the extent to which fulfilling the terms of the contract actually improved community preparedness. To this end the committee provides an initial evaluation tool: a questionnaire survey for administration to OEP’s primary point of contact in each MMRS program community. The initial section of the proposed survey, which could be administered at any point in the course of the contract or after the completion of the contract, solicits input on the extent to which an MMRS program community used OEP-provided resources in fulfilling the terms of its contract and how useful it found those resources for that purpose. The survey then queries the respondent about the perceived abilities of the community in a number of functional areas that the committee believes are essential to preparedness. It concludes with several open-ended questions regarding remaining barriers to preparedness for a terrorist attack with a CBR weapon and changes in the day-to-day and disaster-oriented operations of the public safety, public health, and health services agencies in the community. FEEDBACK TO OEP ON PROGRAM SUCCESS Regardless of how the MMRS program is managed by OEP, the ultimate test of the program’s worth lies in how well it has helped local communities prepare for the consequences of a massive terrorist attack with CBR weapons. The survey described above begins to answer that question by soliciting the opinions of the MMRS program communities themselves. Complementing that approach are the committee’s recommendations for an independent and systematic assessment of the response capabilities of the large metropolitan areas that have participated in or that will participate in the MMRS program. Those recommendations call for a three-part process composed of periodic review of documents and records, on-site assessment by a team of peers, and observation of community-initiated exercises and drills. Together the three components provide the means for assessing 23 essential capabilities necessary for any community to respond effectively to the wide variety of CBR terrorism incidents that it may suffer.

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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program Essential Capabilities The committee believes that effective response to incidents involving CBR weapons of any sort will require every community to make plans and develop expertise in 23 distinct activities. No single activity is necessarily more important than the others, and the specific characteristics and importance of these 23 essential response capabilities vary with the type of agent, as do the relative importances of the various capabilities, but together they form a comprehensive picture of the preparedness of the community. Relationship development (partnering) Communication system development Hazard assessment Training Equipment and supplies Mass immunization and prophylaxis Addressing the information needs of the public and the news media First responder protection Rescue and stabilization of victims Diagnosis and agent identification Decontamination of victims (at site of exposure or at hospital or treatment site) Transportation of victims Distribution of supplies, equipment, and pharmaceuticals Shelter and feeding of evacuated and displaced persons Definitive medical care Mental health services for responders, victims, caregivers, and their families Volunteer utilization and control Crowd and traffic control Evacuation and quarantine decisions and operations Fatality management Environmental cleanup, physical restoration of facilities, and certification of safety Follow-up study of responder, caregiver, and victim health Process for continuous evaluation of needs and resources Because not all of these capabilities are addressed in the MMRS program contracts, and the Committee was seeking to measure not contract compliance but actual preparedness, the Committee chose to build its evaluation program on these 23 essential capabilities rather than the 12 “deliverables” demanded by the MMRS program contracts. Consistent

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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program with the committee’s earlier endorsement of an all-hazards approach, all are relevant and necessary elements of responses to disasters of all kinds, natural and technological, deliberate and inadvertent. For each of these 23 capabilities, the committee derived one or more measures or preparedness indicators that could be sought in any community. Preparedness Indicators The products demanded of the communities with MMRS program contracts are for the most part written plans, and although written plans are certainly necessary elements of preparedness, they are in most cases only the beginning of a continuous process. Some elements of these plans can be implemented only during or after an actual incident or a very realistic exercise; but many require advance preparations, such as the purchase of equipment, hiring and training of personnel, or even changes in the way in which routine operations are conducted (for example, citywide electronic surveillance of emergency department visits or 911 calls). Even though these advance preparations and their documentation are necessary for preparedness, they are not the same sort of performances that might be assessed in an actual mass-casualty event (whether it involves CBR terrorism or not) or a drill or field exercise. Measures related to advance preparations are generally easier and cheaper to access, however, and can provide a measure of effective response capability or potential (although in the absence of regular acts of mass-casualty-producing CBR terrorism, no data can validate the relationship between the selected indicators and actual performance). Preparedness indicators thus fall into the following three categories: Inputs are the constituent parts called for, implicitly or explicitly, by a given deliverable (personnel; standard operating procedures; equipment and supplies; or schedules of planned meetings, training, and other future activities). Processes are evidence of actions taken to support or implement the plan (minutes of meetings, agreements prepared, training sessions conducted, or the numbers or percentages of personnel trained to use CBR agent detection equipment). Outputs are evidence of the effectiveness of actions taken to support or implement the MMRS plan (establishment of a stockpile of antidotes and antibiotics appropriate for the agents that pose the greatest threat and demonstration of critical knowledge, skills, and abilities in tabletop exercises, full-scale drills, or surrogate incidents such as deliberate scares and false alarms, unintentional chemical releases, naturally occurring epidemics, or isolated cases of rare diseases).

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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program The best evidence for preparedness will almost always be outputs, which are the end products of processes undertaken with inputs. A variety of circumstances, including the timing of the assessment, may make collection of output data impossible or impractical. In this circumstance, evidence for preparedness must be sought among inputs and processes. All three types of indicators are, however, merely surrogate or proxy measures of MMRS effectiveness that are based on the judgments of knowledgeable students of the field but that have never been truly validated (and that cannot be truly validated, short of an actual mass-casualty CBR terrorism incident). For each of the selected performance indicators, the committee then provided its opinion on what would constitute acceptable evidence of preparedness (preparedness criteria). Box ES-1 provides an example of one such indicator, with the associated criteria for preparedness, and Figure ES-1 shows the overall approach to analyzing preparedness. The approach taken by the committee calls for a combination of evaluation of documents submitted to OEP by the community to be evaluated, direct observation of drills and exercises, and on-site questioning by a site-visit team. The indicator set therefore includes some components that may be evaluated through written materials, some that demand on-site questioning or observation, and some that can best be judged by observation of a community drill or exercise. Exercises and Drills The committee members began their task with the common view that, in the absence of regularly occurring CBR terrorism incidents, the plans produced by MMRS program cities might be best evaluated by large-scale field exercises that would simulate such an incident and more specialized drills that would test the performances of specialized portions of the overall response plan. This approach was ultimately rejected as too expensive in terms of the financial costs for OEP and in terms of time for local emergency response and medical personnel, difficult to tailor to 100 different locales, and in the case of a covert release of a biological agent, impossible to simulate realistically and ethically. Several committee members also observed that in their experiences the planning rather than the conduct of exercises had proven to be of greater value to the community. Since one of the MMRS program contract deliverables in fact calls for a schedule of exercises and another calls for collection and distribution of after-action reports, the committee opted to incorporate these exercises into the overall evaluation plan. Observers, preferably members of the team that will subsequently conduct a site visit to the community in question, should attend large-scale exercises and significant drills before they

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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program BOX ES-1 Example of Preparedness Indicator for One Essential Capability, First Responder Protection Essential Capability First Responder Protection Preparedness Indicator Demonstration that appropriate types and quantities of personal protective equipment and supplies have been purchased and are readily accessible to both traditional first responders and hospital and clinic staff. Preparedness Criteria Amount and location of procured personal protective equipment are consistent with MMRS program planning document’s presumed incident size and methodology for determining equipment needs. Inspection of at least two sites confirms the presence of equipment in specified inventory. Equipment should be readily accessible and clearly labeled at a site with appropriate temperature and humidity controls. Emergency and security staff have immediate access to personal protective equipment. Equipment is stored in an area without a lock. If it is stored in a locked area, staff can locate the key without assistance. On-duty personnel should be able to put on breathing apparatus (e.g., masks or respirators) without coaching. Respiratory fit test (e.g., with banana oil or peppermint oil) should confirm that the breathing apparatus seals completely. On-duty personnel should be able to put on chemical protective apparel without coaching. When suited, personnel should be heavily sprayed with water to demonstrate that the suit excludes outside elements (no water penetrates body suit). plan a site visit. Despite the drawbacks mentioned in the previous paragraph, many of the essential capabilities can be more accurately analyzed in this fashion, and some can only be evaluated in this manner. Site Visits and Peer Evaluators Although the details of any site visit to some extent will be specific to the site being visited, the committee envisions a typical site visit consist-

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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program FIGURE ES-1 Relationships among essential capabilities, preparedness indicators, preparedness criteria, and data collection methods. All communities are evaluated for capabilities in 23 domains, the 23 essential capabilities listed above. Each capability is measured by reference to a set of 1 to 10 preparedness indicators (Table 8-1). For each preparedness indicator, evaluators draw a conclusion on preparedness based on the extent to which the community meets one to seven indicator-specific preparedness criteria (see Chapter 8). Data from the community are gathered by document inspection, on-site interviews, or observation of exercises and drills, as specified in the criteria.

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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program ing of a 3-day evaluation that would include individual interviews and observations, two 3-hour scenario-driven group discussions that would take place simultaneously on the afternoon of Day 3, a briefing of the community (i.e., some very general feedback on the assessment team’s observations and conclusions), and a formal report based on the collected observations of the assessment team. The assessment team should consist of five individuals collectively experienced in a variety of disciplines and professions. They should be, and be perceived as, peers of the individuals being assessed. To this end the committee recommends a fire department representative familiar with hazmat operations; a city- or county-level emergency manager; a local public health officer familiar with surveillance systems; an individual with extensive managerial, operational, and clinical experience in the field of prehospital emergency medical services; and an acute-care medical practitioner, who could be a nurse or a physician, with clinical experience in infectious diseases or emergency medicine and mass-casualty operations. At least three of the five members should have some current or previous involvement with the MMRS in their own communities. The scenario-driven group discussions, each facilitated by two on-site evaluators, will require 12 to 15 representatives from the community’s safety and health institutions to discuss questions about the community’s response to a fictional CBR terrorism incident. The goal of this portion of the site visit is to give the community an opportunity to demonstrate the existence of a well-understood process to coordinate all necessary capabilities to respond to a mass-casualty CBR terrorism incident, specifically the ability to acquire, process, and appropriately distribute information required to effectively manage critical incident functions. The fact that the evaluators will conduct two simultaneous discussions will insure that this ability is not confined to a single individual or a single department. CLOSING REMARKS The IOM committee’s Phase I report suggested several activities or areas that might be useful additions to future contracts with additional cities (Institute of Medicine, 2001). Among these are a preliminary assessment of the community’s strengths and weaknesses and provisions for the use and management of volunteers, for the receipt and distribution of materials from the National Pharmaceutical Stockpile, for decision making related to evacuation and disease containment, for the provision of shelters for people fleeing an area of real or perceived contamination, for postevent follow-up on the health of responders and caregivers, and for postevent amelioration of anxiety in the community at large. Nevertheless, the committee has been favorably impressed by the program’s focus

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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program on empowering local communities, as opposed to creating yet another federal team to rush to the community at the time of an incident, and the program’s flexibility in allowing each community to shape its system to its unique circumstances and requirements. A carefully done evaluation program of the sort described in this report should make the program even better. Not only does it seem that the resources are now available for the continuing financial relationship suggested by the committee, but it also seems that a consensus now exists on the need for shared responsibility among a wide variety of governmental and nongovernmental agencies to achieve the goals of the MMRS program. When the committee began this project the future success of the MMRS program depended on voluntary cooperative efforts to prepare for possible but seemingly improbable events. As the project concludes, the committee believes that OEP must be empowered to take a stance that fosters voluntary collaboration but must be willing and able to enforce integration of local, state, and federal services as a pressing societal need for coping with inevitable future acts of terrorism. The importance of the MMRS program effort is no longer equivocal, questionable, or debatable. The philosophy that it has developed has become an essential and rational approach that can be truly successful only with a rigorous and continuing evaluation and improvement program. The enhanced organization and cooperation demanded by a well-functioning MMRS program will permit a unified preparedness and public health system with immense potential for improved responses not only to a wide spectrum of terrorist acts but also to mass-casualty incidents of all varieties.

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