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
- Support infection prevention and control (The Public Health Good Idea)
- Plan for a “best guess” and don’t forget that it is a guess (The Planning and Improvising Good Idea)
- Develop your own plan and partner in your response (The Community Collaboration Good Idea)
- Clarify organizational priorities and roles during an outbreak (The Business Continuity Good Idea)
- Talk with your staff and your community about their concerns (The We are People First Good Idea)
Five Good Resources
- Planning Guide for an Influenza Pandemic – Association of Ontario Health Centres(2008)
- “Non-profit response to catastrophic disasters.” Disaster Prevention and Management: An International Journal, vol.6, p551-561, Naim Kapucu (2007)
- The Flu Pandemic and You: A Canadian Guide, Vincent Lam and Colin Lee (2006)
- Understanding Voluntary Organizations in Health Emergency Management, Susan Phillips & Christopher Stoney (2006) – Public Health Agency of Canada
- “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)
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.