Dealing with an Influenza Pandemic

Find an updated version of Thomas Appleyard’s talk after the list of resources (originally published in the book, Five Good Ideas: Practical Strategies for Non-Profit Success).

An influenza pandemic raises difficult questions for organizations: How might an outbreak affect staffing capacity, the safety of clients, the viability of programs and services and the stability of funding? How can organizations make decisions and communicate to stakeholders in an environment of changing or conflicting information while dealing with high rates of management absenteeism? How can organizations match their response to the severity of the situation? While many guidelines exist for corporations and for hospitals, precious little has been established for small and medium-sized non-profit organizations – particularly those without a health focus. In this session, emergency management consultant Thomas Appleyard shared Five Good Ideas he learned in working with these organizations as they prepared for an influenza pandemic over recent years and responded to the H1N1 pandemic.

Five Good Ideas

1. Support infection prevention and control (The Public Health Good Idea)
2. Plan for a “best guess” and don’t forget that it is a guess (The Planning and Improvising Good Idea)
3. Develop your own plan and partner in your response (The Community Collaboration Good Idea)
4. Clarify organizational priorities and roles during an outbreak (The Business Continuity Good Idea)
5. Talk with your staff and your community about their concerns (The We are People First Good Idea)

Five Good Resources

1. Planning Guide for an Influenza Pandemic – Association of Ontario Health Centres(2008)
2. “Non-profit response to catastrophic disasters.” Disaster Prevention and Management: An International Journal, vol.6, p551-561, Naim Kapucu (2007)
3. The Flu Pandemic and You: A Canadian Guide, Vincent Lam and Colin Lee (2006)
4. Understanding Voluntary Organizations in Health Emergency Management, Susan Phillips & Christopher Stoney (2006) – Public Health Agency of Canada
5. “Emergency health care workers’ willingness to work during major emergencies and disasters.” The Australian Journal of Emergency Management, vol.22(2) p21-24, Erin Smith (2007)

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Updated presentation, published in the book, Five Good Ideas: Practical Strategies for Non-Profit Success.

Dealing with a large-scale emergency

Guidance for large or­gan­iz­a­tions who need to deal with large-scale emer­gen­cies is widely avail­able. Far less is avail­able for small or­gan­iz­a­tions, es­pe­cially small com­munity-based or­gan­iz­a­tions that have to re­spond to large-scale emer­gen­cies – such as pub­lic health emer­gen­cies – be­cause the needs of their cli­ents and com­munit­ies change as external cir­cum­stances do.

With an em­phasis on the early re­sponse phase dur­ing an emer­gency, these five good ideas are in­ten­ded to help fill this gap.

1. Per­form a risk as­sess­ment

Whether you are in the pre­pared­ness phase plan­ning for pos­sible fu­ture events, or in the re­sponse phase fig­ur­ing out what your or­gan­iz­a­tion will do today and to­mor­row, per­form­ing a risk as­sess­ment is es­sen­tial. This will al­low you to reflect on what an emer­gency might mean for your op­er­a­tions, cli­ents, part­ners, sup­pli­ers and com­munity.

Many tools can be used to struc­ture the risk as­sess­ment pro­cess. A com­monly used one is the HIRA – Haz­ard Identifica­tion and Risk As­sess­ment. With HIRAs, spe­cific haz­ards that may af­fect the or­gan­iz­a­tion (for ex­ample, in­flu­enza out­breaks, tor­nadoes or black­outs) are iden­ti­fied and po­ten­tial im­pacts are as­sessed. Mu­ni­cip­al­it­ies in Ontario are required to per­form HIRAs reg­u­larly. You may be able to get a copy of the HIRA for your area. One of the great be­ne­fits of con­duct­ing your own in­ternal HIRA is that it will help you visu­al­ize what your or­gan­iz­a­tion could look like as an emergency is un­der way. This visu­al­iz­a­tion step can be ex­tremely use­ful for plan­ning.

Em­ploy­ees may won­der as an emer­gency be­gins, “Will I come to work each day and find out what my job is as I ar­rive, or am I go­ing to do the same job I usu­ally do? Are people still go­ing to sit at their desks or will they be work­ing from home? Will there be screen­ers at the door ask­ing people about symp­toms?” Hav­ing the an­swers to these ques­tions – even if they are just a best guess – is very help­ful.

This can’t just be a the­or­et­ical ex­er­cise: ac­tu­ally do a sim­u­la­tion of how your or­gan­iz­a­tion would func­tion in emer­gency cir­cum­stances. If, for in­stance, you are pre­par­ing for a large-scale pub­lic health emer­gency, prac­tice the strategies you might use; if needed, have every­one in your of­fice go through the steps of put­ting on and tak­ing off per­sonal pro­tect­ive equip­ment, de­term­ine ex­actly where screen­ing sta­tions would be, prac­tice tak­ing someone’s tem­per­at­ure – the really prac­tical, skill-based things you’ll need to im­ple­ment in mo­ments of ac­tual emer­gency. You’ll find that it’s only when staff can truly visu­al­ize the types of scen­arios you might face that you can en­gage in deeper, richer and more col­lab­or­at­ive plan­ning for those cir­cum­stances.

A prob­lem with HIRAs, how­ever, is that we are no­tori­ously poor at pre­dict­ing haz­ards. Think about the events we didn’t see com­ing (SARS, the 2003 black­out) and the (so far) non-events that we thought were com­ing (the avian in­flu­enza pan­demic, Y2K). Of­ten what goes into HIRAs is in­form­a­tion about past events. It is im­port­ant to look at these and identify what was learned, but it’s also im­port­ant to ask how the or­gan­iz­a­tion and com­munity have changedsince those events, and what that might mean for the re­sponse re­quired.

While we’re pretty bad at pre­dict­ing haz­ards, we’re bet­ter at pre­dict­ing con­sequences for our or­gan­iz­a­tion and communit­ies. This means we can shift our think­ing from spe­cific con­tin­gency plan­ning to broader scen­ario plan­ning. There are com­mon con­sequences to a whole range of emer­gen­cies that small or­gan­iz­a­tions may face: high staff absent­ee­ism; dis­rup­tion in sup­ply lines; heightened risk of staff ill­ness, in­jury or death; heightened risk of cli­ent ill­ness, in­jury or death; dis­rup­tion of IT re­sources; sig­ni­fic­ant prop­erty dam­age; loss of re­cords; in­ab­il­ity of cli­ents to ac­cess the in­ter­ven­tions es­tab­lished; or even in­creased threats to health equity caused by these same in­ter­ven­tions. Plan­ning can be done based on these cat­egor­ies of ef­fects rather than spe­cific haz­ards.

2. Fa­cil­it­ate the com­munity’s de­vel­op­ment of ro­bust solu­tions

One of the factors that will de­term­ine whether work­ers come to work dur­ing an emer­gency is whether they trust the inform­a­tion provided by their em­ployer. Em­ploy­ers can build that trust by talk­ing about em­ployee con­cerns.

Ask­ing about con­cerns – an in­her­ent part of the risk as­sess­ment pro­cess – helps de­velop or­gan­iz­a­tional trust. This organ­iz­a­tional trust ac­tu­ally is a ro­bust solu­tion – by which I mean an ef­fect­ive prob­lem-solv­ing strategy in a large range of scen­arios.

When think­ing about ro­bust solu­tions to emer­gency man­age­ment prob­lems, more and more lit­er­at­ure is stress­ing the im­port­ance of pay­ing at­ten­tion to the com­plex­ity of events. My fa­vour­ite sen­tence in the emer­gency man­age­ment literature comes from an art­icle by Preeta M. Baner­jee and Joseph T. Ma­honey re­gard­ing the Columbia space-shuttle ex­plo­sion. They de­scribed the “re­cov­ery win­dow” as the un­cer­tain period of time after it was real­ized that some­thing was go­ing ser­i­ously wrong. They said: “In highly un­cer­tain situ­ations . . . en­ter­tain­ing hunches, reas­on­ing by ana­logy, imagin­ing po­ten­tial scen­arios, and ex­per­i­ment­ing with novel, ill-defined al­tern­at­ives be­come es­sen­tial.”

Com­pared to merely com­plic­ated events, com­plex events re­quire less em­phasis on ex­pert in­put and more em­phasis on mul­tiple per­spect­ives. En­ga­ging stake­hold­ers in activ­it­ies such as the ones de­scribed above not only makes the process more in­clus­ive, it be­comes es­sen­tial emer­gency man­age­ment prac­tice. Com­plex events re­quire at­tent­ive sense-mak­ing skills and watch­ful­ness.

3. Fo­cus on oc­cu­pa­tional health and safety

In Ontario, the Oc­cu­pa­tional Health and Safety Act trumps the Emer­gency Man­age­ment and Civil Pro­tec­tion Act. It’s impossible to talk about re­spond­ing to an emer­gency without talk­ing about oc­cu­pa­tional health and safety, be­cause occu­pa­tional health and safety must be your top pri­or­ity. For health emer­gen­cies, this in­cludes pay­ing care­ful at­ten­tion to in­fec­tion pre­ven­tion and con­trol.

One ma­jor strategy for pre­vent­ing and con­trolling in­fec­tion dur­ing a com­munity out­break is hand­wash­ing. It is the corner­stone of in­flu­enza pan­demic re­sponse be­fore a vac­cine is avail­able, and there is a lot of evid­ence that we aren’t any­where near as good at hand hy­giene as we think we are. One of the reas­ons people say they don’t want to wash their hands fre­quently is be­cause their skin may get cracked and chapped. Provid­ing hand mois­tur­izer for staff and clients has been shown to in­crease rates of hand­wash­ing. Sim­il­arly, it has been great to see hand-san­it­izer dis­pensers stay up after the H1N1 crisis was de­clared over. In all our or­gan­iz­a­tions, let’s make sure we don’t lose this mo­mentum.

In many or­gan­iz­a­tions people are still en­cour­aged and given in­cent­ive to come to work when they are ill with a cough or fever. (Some re­cent re­search says that 84 per­cent of em­ploy­ees feel pres­sured to come to work when they are sick.) We need to change the cul­ture sur­round­ing sick leave – if we can’t get this right between in­fec­tious dis­ease out­breaks, we’ll never get it right dur­ing one. People who are com­ing to work when they have a cough and fever are do­ing far more harm than good. We need to sup­port the idea that it is prefer­able to stay home while ill through policy and through example from lead­er­ship, and by simply telling people to go home.

4. De­velop your own emer­gency re­sponse plan and part­ner­ships

It’s worth spend­ing time in a plan­ning pro­cess to fo­cus ex­clus­ively on your daily func­tions. Dur­ing this stage, make it against the rules to think about what other or­gan­iz­a­tions will do. No one is al­lowed to ask: What if the TTC shuts down? What if Lo­blaws can’t ac­cess any food at all? What if the shel­ters shut down? This is the time to work on a plan in your own or­gan­iz­a­tion. What are the risks you think you may face? How can you ad­dress some of the com­mon con­sequences that were iden­ti­fied in the risk as­sess­ment?

But there is an­other crit­ical stage, both be­fore and dur­ing an emer­gency, when it’s time to look up from your plan and see what is go­ing on in the com­munity around you, and part­ner with oth­ers. (Whether it’s the right thing or the wrong thing, we know from the re­search that most emer­gency part­ner­ships de­velop dur­ing the re­sponse to emer­gen­cies rather than be­fore.)

In Toronto, we star­ted to hear about H1N1 in late April 2009, on a Wed­nes­day. By Thursday, re­ports really star­ted pouring in about what was hap­pen­ing in Mex­ico City. That week­end there was a lot of talk among the com­munity health centres in Toronto about what it was go­ing to look like to walk into these or­gan­iz­a­tions on Monday. People star­ted to visu­al­ize their re­sponses. By Sunday an on­line group was es­tab­lished, and dozens of people from across the sec­tor were log­ging on, ask­ing ques­tions of each other and col­lab­or­at­ing on re­sponse strategies. It was never in a plan that com­munity health centres would col­lab­or­ate in this way – the part­ner­ships emerged as the situ­ation un­fol­ded.

De­vel­op­ing your own plan – that’s es­sen­tial risk man­age­ment. Form­ing part­ner­ships dur­ing a re­sponse – that’s essential emer­gency man­age­ment.

5. Plan for busi­ness con­tinu­ity

Al­though a lot of the busi­ness-con­tinu­ity lit­er­at­ure is writ­ten for large or­gan­iz­a­tions, small or­gan­iz­a­tions may face more sig­ni­fic­ant busi­ness-con­tinu­ity threats be­cause of their greater de­pend­ence on spe­cific in­di­vidu­als. It is there­fore worth think­ing through busi­ness-con­tinu­ity strategies for all of the con­sequences you identify in your plan­ning pro­cess.

Take the time to es­tab­lish: What are the things that we ab­so­lutely must keep do­ing, from a ser­vice per­spect­ive, or that we must start do­ing dur­ing an emer­gency? Ask: How man­age­able is this list of activ­it­ies dur­ing peri­ods of high absentee­ism? Lots of or­gan­iz­a­tions say they need to keep do­ing everything, but must re­cog­nize that they’re go­ing to be able to serve fewer people. You need to de­cide how you will triage.

An­other im­port­ant step is fig­ur­ing out the be­hind-the-scenes op­er­a­tional activ­it­ies that must con­tinue or start dur­ing an emer­gency. Payroll, for ex­ample, must al­ways con­tinue. If you don’t have payroll, you don’t have an or­gan­iz­a­tion.

Hav­ing come up with a man­age­able list of es­sen­tial ser­vices and be­hind-the-scenes op­er­a­tions, you can fig­ure out the staff you’ll need in place to meet these min­imal re­quire­ments – a skel­eton or­gan­iz­a­tional chart. This al­lows you to determ­ine whether you can ex­pect to have enough staff with suf­fi­cient skills to fill these roles dur­ing an emer­gency, and what train­ing you might need to provide to your core staff.

Once you’ve out­lined these es­sen­tial emer­gency tasks and de­term­ined who will be play­ing what roles, you may want to con­sider shar­ing this in­form­a­tion with your fun­ders. Tra­di­tion­ally, there has been very little dia­logue between fun­ders and non-profit or­gan­iz­a­tions re­gard­ing sus­pen­sion of pro­grams, re­deploy­ing staff and the need for new pro­grams during an emer­gency. Fun­ders can be drawn into your stake­holder en­gage­ment pro­cess as de­cisions and guesses are made re­gard­ing the need for new ser­vices and the ser­vices and pro­grams that are es­sen­tial to main­tain in an emergency. They may have valu­able in­sights and sup­port to of­fer.