approach to disaster planning and response is therefore required to integrate all of the values and response capabilities necessary to achieve the best outcomes for the community as a whole.

Successful disaster response depends on coordination and integration across the full system of the key stakeholder groups: state and local governments, EMS, public health, emergency management, hospital facilities, and the outpatient sector. Vertical integration among agencies at the federal, state, and local levels also is crucial. At the cornerstone of this coordination and integration is a foundation of ethical obligations—the values that do not change even when resources are scarce—and the legal authorities and regulatory environment that allow for shifts in expectations of the best possible care based on the context of the disaster in which that care is being provided.

Conceptualizing a Systems Approach to Disaster Response

This section broadly outlines a systems framework for disaster response of which CSC is only one, albeit a critical, aspect. However, the development and implementation of CSC plans are the means to mount a response to an incident that far exceeds the usual health and medical capacity and capabilities. Therefore, the same elements that come together to build any successful disaster response should also be used to develop robust CSC plans and guide their implementation.

A systems approach is defined as a “management strategy that recognizes that disparate components must be viewed as interrelated components of a single system, and so employs specific methods to achieve and maintain the overarching system. These methods include the use of standardized structure and processes and foundational knowledge and concepts in the conduct of all related activities” (George Washington University Institute for Crisis, Disaster and Risk Management, 2009, p. 59).

The systems framework that the committee believes should inform the development and implementation of CSC plans (see Figure 2-1) is based on the five key elements of planning set forth in the 2009 letter report. These key elements served as the starting point for the development of the committee’s recommendations in that report and are foundational for all disaster response planning.

The two cornerstones for the foundation of this framework are the ethical considerations that govern planning and implementation and the legal authority and legal environment within which plans are developed. Ethical decision making is of paramount importance in the planning for and response to disasters. Without it, the system fails to meet the needs of the community and ceases to be fair, just, and equitable. As a result, trust—in professionals, institutions, government, and leadership—is quickly lost. The legal authority and legal environment within which CSC plans are the other cornerstone of the framework’s foundation. The legal authority and environment support the necessary and appropriate actions in response to a disaster. Between those two cornerstones of the foundation are the steps needed to ensure that the development and implementation of CSC plans occur. They include provider and community engagement efforts, development of a process that permits individual communities to identify regionally coordinated and consistent indicators that denote a change in the usual manner of health care delivery during a disaster, and the triggers that must be activated in order to implement CSC. These lead to the top step, the implementation of clinical processes and operations that support the disaster response. All of these efforts are supported and sustained by an ongoing performance improvement process, an important element of any systems approach to monitor demand (ensuring situational awareness), evaluate the impact of implementation actions, and establish/share best



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