DUKE HEALTH CARE COALITION

ANNUAL EVALUATION & SCORE CARD Budget period 1 (07/01/17 – 06/30/18)

Mid-Year Report

Program effectiveness is evaluated by comparing the review of the program to current needs and stated objectives of the program with measurements made related to stated performance measures, and the degree to which current performance met those stated objectives.

1 Duke Healthcare Preparedness Coalition Evaluation & Scorecard July 1, 2017 – June 30, 2018

Dear Stakeholders: The mission of the Duke Healthcare Preparedness Coalition is to assist our regional partners and stakeholders in planning and mitigating for, responding to, and recovering from all-hazards disaster events. Through a robust program of training and exercises, we are working to facilitate stronger cooperation, collaboration, and communication within our stakeholder and partner agencies resulting in greater overall preparedness and resiliency. This ongoing report is a review of our programs and activities during the year. The Duke Healthcare Coalition is

growing stronger and with your support, becoming well-positioned to tackle future opportunities and challenges.

We have an aggressive work plan ahead that will significantly reinforce the Coalition’s growth and better position

our member’s preparedness. We sincerely thank you for your years of support and encourage you to continue

that support in the months ahead.

Kenneth A. Shaw, CEM, CHPA Douglas R. Young, CEM, NCEEM, VaPEM, MESH Duke Coalition Healthcare Preparedness Coordinator Person County Emergency Services Director Healthcare Coalition Chair

2 Duke Healthcare Preparedness Coalition Evaluation & Scorecard July 1, 2017 – June 30, 2018

Duke Health Care Coalition

2017 -2019 Steering Committee Membership Executive Committee Chair: Douglass Young, Emergency Services Director, Person County, NC Vice Chair Jason Zivica, Director, Emergency Preparedness and Business Continuity, Duke

University Medical Center Secretary Glen Labar Jr., Person County Emergency Medical Services Compliance Officer Treasurer Courtney Polomsky, Assistant Healthcare Preparedness Coordinator, Duke Healthcare

Coalition Caucus Representatives Hospital Hannah Davis, Infection Prevention, Risk, & Emergency Preparedness Coordinator,

Person Memorial Hospital EMS Javier Plummer, EMS Director, Vance County EMS Public Health Pat Gentry, preparedness Coordinator, Durham County Public Health Emergency Management J. David Marsee II, Sr. Emergency Management Coordinator, Durham County

Emergency Management Community Health Center Lou Ann Reaves, Administrative Assistant, Caswell Family Medical Center Skilled Nursing Facilities Rebecca Marion, Administrator, Croasdaile Village Nursing Home Home Health/Hospice Sarah Upchurch, Operations Manager, Liberty Home Care and Hospice

3 Duke Healthcare Preparedness Coalition Evaluation & Scorecard July 1, 2017 – June 30, 2018

Duke Health Care Coalition

Scorecard & Evaluation 2017 - 2018

Scope: The Duke Health Care Preparedness Coalition is a network of health care organizations, providers and regional partners committed to strengthening the health care system for emergencies. The purpose of the Coalition is to develop coordinated, effective medical and public health system response to all hazards through:

Effective communications systems and protocols, Strategic acquisition and management of resources, Collaborative prevention, mitigation, preparedness, response and recovery.

Membership in the Coalition is open to all health care providers and partner response organizations from the regional area consisting of Caswell, Durham, Granville, Person, Robeson, Vance, and Wake (Duke Raleigh Hospital only) who agree to work collaboratively and coordinate emergency prevention, mitigation, preparedness, response and recovery activities. The Coalition’s work to develop emergency preparedness and response systems and resources is of benefit to the entire community, not just Coalition members. Objectives: The Duke Health Care Coalition is designed to achieve the following objectives:

• Utilize the four phases of emergency management—mitigation, preparedness, response, and recovery—to frame its approach to wide range of community emergency events

• Utilize an all-hazards approach to emergency management that is applicable to any type of situation or event, whether pre-identified or not

• Define and prepare for the service needs created by the hazard impact on healthcare organizations in the community

• Identify required community resources needed for response and recovery and develop methods for acquiring and maintaining them

• Provide emergency response and recovery management and coordination between the lead regional hospital and OEMS during an event as well as integration with the broader response community

4 Duke Healthcare Preparedness Coalition Evaluation & Scorecard July 1, 2017 – June 30, 2018

Grant Management / Financials

Salaries / Fringe $230,260.00

Staff Travel $ 10,000.00

Office Supplies & Equip $ 5,000.00

Utilities $ 8,000.00

Operational other $ 95,406.00

In Kind $ 34,866.00

Total $383,533.00

5 Duke Healthcare Preparedness Coalition Evaluation & Scorecard July 1, 2017 – June 30, 2018

Grant Management / Financials

Approved/Revised Budget

Reimbursement to Date (September) Balance Committed Projected Unallocated

Administration = Salaries, fringes, travel, office supplies, and utilities $ 253,260.00 $ 47,288.58 $ 205,971.42 $ 3,342.65 $ 7,701.85 $ 194,926.92 Capability 1 - Foundation for Healthcare and Medical Readiness $ 33,406.00 $ 721.65 $ 32,684.35 $ 842.04 $ 827.96 $ 31,014.35

Capability 2 - Healthcare & Medical Response Coordination $ 5,000.00 $ 27.17 $ 4,972.83 $ 2,465.00 $ - $ 2,507.83

Capability 3 -Continuity of Healthcare Service Delivery $ - $ - $ - $ - $ - $ -

Capability 4 - Medical Surge $ 57,000.00 $ 6,530.83 $ 50,469.17 $ 4,075.54 $ 20,094.57 $ 26,299.06

Total $ 348,666.00 $ 54,568.23 $ 294,097.77 $10,725.23 $ 28,624.38 $ 254,748.16

Total Award $ 348,666.00 Per Cent Expended 15.65%

Expended to Date $ 54,568.23 Balance $ 294,097.77

Committed $ 10,725.23

Projected $ 28,624.38

Unallocated Funds $ 254,748.16

6 Duke Healthcare Preparedness Coalition Evaluation & Scorecard July 1, 2017 – June 30, 2018

7 Duke Healthcare Preparedness Coalition Evaluation & Scorecard July 1, 2017 – June 30, 2018

8 Duke Healthcare Preparedness Coalition Evaluation & Scorecard July 1, 2017 – June 30, 2018

Program Initiatives:

ID # Initiative Exact Goal and Activity Plan Notes / Quarterly Data Results

1

Regional Governance Update

The intent of this activity is to ensure appropriate governance and functioning of the HCC

Complete Coalition Assessment Tool

Review and Update Administrative documents (Bylaws, etc)

Approve MYTEP

Re-allocated budget as needed

Update scheduled December 2017

2

Regional Stakeholder Travel Support

Funding will be utilized to reimburse stakeholders and partners for attendance at national and state conferences related to healthcare preparedness and response, applicable training and education offerings, regional or state exercises, or program work groups as needed.

National Ebola Training Center

National Healthcare Coalition Conference

HSEEP Training

3

Licensed Care Facility Education and Outreach

Utilizing appropriate internal and vendor based subject matter experts, multiple workshops and training sessions will be conducted across the region to introduce basic emergency management principles, training on identification or risks and hazards, and analysis methodology for the specific home organization. These sessions will be offered using an in person format to Coalition stakeholders and will be scheduled in strategic locations across region to ensure participants from all counties have access to training. Training sessions will be open and marketed to all healthcare agencies.

See training summary Below

4

Healthcare Emergency Management Training and Education

The Healthcare Coalition will conduct courses on incident management and healthcare emergency management and response. Courses will be offered within locations that allow for increased attendance from geographic regional partners and managed through NC TERMS.

See training summary Below

5

Regional Communications Testing

Coalition personnel will conduct monthly [VIPER, MED8\10, MSAT, WebEOC, SMARTT] tests with regional partners and stakeholders. This will assist in identification of necessary future planning or education support for regional partners and

See Performance measure / Indicator data

9 Duke Healthcare Preparedness Coalition Evaluation & Scorecard July 1, 2017 – June 30, 2018

stakeholders.

6 Program Communications

Develop Coalition website and general communication capabilities.

Website: WWW.northcarolinatrianglecoalition.org

7

Regional Exercise Development

The Healthcare Coalition will conduct a workshop/exercise series that will clearly identify the gaps in medical surge preparedness and response. This will include regional participation in the coalition surge test (CST).

Ongoing. Continuing the provisions of Healthcare in the Duke Region

Surge test scheduled in June

8

SMRS Operational Readiness

The intent of this activity is to maintain the operational readiness of regional SMRS packages and resources in order to respond effectively during an event. This activity will focus on the evaluation and replacement of supply caches, replacement of expired or useable items, and maintenance of equipment to ensure a safe, functional state of readiness

Ongoing. Inventory assessed and priority purchases are being developed

9

SMRS Operational Planning

Based on the established SMRS primary and secondary operational missions, Duke Coalition staff will develop and/or update regional level mission ready packages. This will include the identification of specialty equipment or resources.

Ongoing

10

Healthcare Emergency Response Training

The Healthcare Coalition / SMAT 400 will conduct courses on incident management and healthcare emergency management and response. Courses will be offered within locations that allow for increased attendance from geographic regional partners and managed through NC TERMS.

See training summary Below

11

Regional Response Plan Update

Based on recent regional events (real world, exercise, and drill) or identified through training or education, the Duke Coalition personnel and executive body of stakeholders will update the regional support plan to accurately describe and detail the function and support of the regional healthcare coalition.

Update scheduled for January 2018

10 Duke Healthcare Preparedness Coalition Evaluation & Scorecard July 1, 2017 – June 30, 2018

Performance Indicators:

11 Duke Healthcare Preparedness Coalition Evaluation & Scorecard July 1, 2017 – June 30, 2018

12 Duke Healthcare Preparedness Coalition Evaluation & Scorecard July 1, 2017 – June 30, 2018

Program accomplishments and Activities

Budget Period 1 Preparedness Training, Exercise, Planning and Events:

Date Scope

Exercise, Training, Planning or Event

(Stakeholder Lead) Short Description of Event

1 07/14/17 Durham Planning Dementia Inclusive Durham Action Team Meeting – Sponsored by Dementia Inclusive Durham

2 07/17/17 Region Planning FCC Steering Committee Meeting – Update to Regional NDMS plan

3 07/24 Durham Planning Durham County Access and Functional Needs Committee Meeting: Special and At risk population planning

4 07/28/17 Region Planning DHPC 17-01 Quarterly Meeting and Kick-off to Continuing the provisions of Healthcare in the Duke Region – Coalition Development and Regional Surge planning

5 08/02/17 Region Planning FCC Steering Committee Meeting – Update to Regional NDMS plan

6 08/03/17 Region Exercise Radiation Injury Treatment Network Tabletop Exercise – Sponsored by Duke University Hospital Radiation Countermeasures Center of Research Excellence

7 08/09/17 Region Planning North Carolina Triangle Coalition Planning Meeting- Collaboration between the three Coalitions of Duke, Wake , and UNC to more effectively serve their healthcare partners and the State Medical Response System (SMRS)

8 08/10/17 Region Planning Regional Long Term Care Disaster Planning Task Force meeting – Triangle J Council of Governments

9 8/21/17 Durham County

Training CMS Rules Lunch and Learn Sponsored by Durham County Office of Emergency Management. Coalition presented on rules interpretation and the “Four Core” Elements of the rule.

10 08/23/17 Statewide Planning NC OEMS HP&R Quarterly Meeting: North Carolina Hospital Preparedness Program Quarterly Update

11 08/30/17 Region Training DHPC 17-02 Duke Healthcare Coalition Risk Assessment Webinar: Web-based introduction to the Regional Risk assessment template and process

12 08/31/17 Region Exercise DHPC 17-03 Operations Based workshop and exercise hosted by Tammy Lynn Center and conducted by All Clear Emergency Management for DHPC. Participants

13 Duke Healthcare Preparedness Coalition Evaluation & Scorecard July 1, 2017 – June 30, 2018

receive training on the conduct of exercises followed by a CMS compliant exercise. AAR included.

13 09/07/17 Durham Planning Durham County Terrorism Task Force Meeting

14 09/08/17 Durham Planning Dementia Inclusive Durham Action Team Meeting – Sponsored by Dementia Inclusive Durham

15 09/27/17 Region Planning North Carolina Triangle Coalition Planning Meeting- Collaboration between the three Coalitions of Duke, Wake , and UNC to more effectively serve their healthcare partners and the State Medical Response System (SMRS)

16 10/09/17 Region Planning Regional Long Term Care Disaster Planning Task Force meeting – Triangle J Council of Governments

17 10/10/17 Region Planning DHPC 17-04 Joint SMAT/MRC Team Meeting: Organizational Meeting and update to program

18 10/12/17 Region Planning DHPC 17-09 Regional Risk Assessment Workshop: Completion of initial Risk Assessment

19 10/13/17 Region Training DHPC 17-07 CMS Compliance Workshop: DHPC hosts training led by consultant to cover tips and recommendations to successfully navigate CMS compliance. Training concludes with a review of stakeholder documents.

20 10/27/17 Region Planning DHPC 17-08 Quarterly Meeting and Continuing the provisions of Healthcare in the Duke Region – Coalition Development and Regional Surge planning

21 11/08/17 Durham Training EOC/ESF-8 Training: EOC training sponsored by Durham County Emergency Management

22 11/09/17 Vance Planning Maria Parham Active Shooter Exercise Planning: Sponsored by Maria Parham and Vance County Emergency Management

23 11/10/17 Region Exercise DHPC 17-14 Operations Based workshop and exercise : Conducted by All Clear Emergency Management for DHPC. Participants receive training on the conduct of exercises followed by a CMS compliant exercise. AAR included.

24 11/14/17 Durham Planning Dementia Inclusive Durham Action Team Meeting – Sponsored by Dementia Inclusive Durham

25 11/16/17 Region Training CMS Rules Interpretation: Conducted by DHPC for the State Ombudsman program

26 11/20/17 Vance Planning Maria Parham Active Shooter Exercise Planning: Sponsored by Maria Parham and Vance County Emergency Management. Focus on Hospital needs

27 11/27/17 Vance Planning Maria Parham Active Shooter Exercise Planning: Sponsored by Maria Parham and Vance County Emergency Management.

28 11/28 – 11/30

Statewide Planning NC OEMS HP&R Quarterly Meeting: North Carolina Hospital Preparedness Program Quarterly Update

14 Duke Healthcare Preparedness Coalition Evaluation & Scorecard July 1, 2017 – June 30, 2018

29 11/30 Vance Exercise Maria Parham Active Shooter TTX: Sponsored by Maria Parham and Vance County Emergency Management.

30 12/07/17 Durham Planning Durham County Preparedness Committee Meeting: Public Health Preparedness planning

31 12/08/17 Vance Exercise Maria Parham Active Shooter Full-scale Exercise: Sponsored by Maria Parham and Vance County Emergency Management.

Evaluation of Effectiveness

Strengths Weaknesses Opportunities/Needs Concerns

Stakeholder engagement

Institutional support

Availability of response assets

• Coordinated Health plans for large scale (regional) disasters ( Fatality Mgt., Mass Sheltering)

Regional Patient placement and

bed availability plans &

coordinating structure

Established indicators for Crisis

standards of care

Evacuation and Patient Tracking

capability

Continued outreach to previously

underserved healthcare agencies

Changes in emergency management events and their management complexity

Ongoing sustainability outside of federal funding.