After Action Review of Elk River Spill is Long Overdue

Though West Virginia officials remain silent, Kanawha and Putnam County officials have conducted an instructive assessment

By Michael M. Barrick

CHARLESTON, W.Va. – On January 9, 2014, at about 10 a.m., fire departments in Kanawha County, the home to West Virginia’s state capital, where dispatched to two locations because reports of a “chemical odor” were being called in by citizens. It was at least four hours before emergency response officials realized they had a major public health crisis on their hands – the water for 300,000 people served by the Elk River was unsafe for human use.

It wasn’t until about 2 p.m. that Mike Dorsey, the emergency response coordinator for the West Virginia Department of Environmental Protection, determined that the release of the coal-mining cleaning chemical 4-methylcyclohexane methanol (MCHM) at a site owned by Freedom Industries along the Elk River had reached the water intake of the West Virginia American Water Company.

Elk River Basin in West Virginia

Elk River Basin in West Virginia

As disturbing as that incident was, what is equally disturbing is that the state of West Virginia has yet to publish an After Action Review, as promised by Governor Earl Ray Tomblin early last May. The delay is unconscionable. We do not know what lessons have been learned, so we can’t know what measures need to be taken to prevent such an event again. We do not know how to improve the response of appropriate agencies and organizations, and we don’t know what steps – if any – private industry has taken to improve their emergency operations plans.

While the event was certainly complex, Mountain State citizens have the right to expect that the report would have been concluded in a timely manner. It will be interesting to see if the report will be released before the anniversary in an effort to appease groups such as the Ohio Valley Environmental Coalition (OVEC), which is planning a month-long focus based on the theme, “Water Unites Us!” Even if the report is published in the next couple of weeks, OVEC, other groups and all citizens should be skeptical, for the long delay suggests that political considerations may be hindering its release.

KPEPC After Action Report
In the interim, though, citizens can turn to the After Action Report (AAR) of the Kanawha Putnam Emergency Planning Committee (KPEPC). The report, titled “West Virginia American Water Incident” was published Nov. 17. Kanawha and Putnam counties are two of the nine counties that were impacted by the spill. The two counties have a merged Local Emergency Planning Committee (LEPC) that conducted a thorough review of nine capabilities of the KPEPC Emergency Management Plan (EOP) relevant to the spill. While the KPEPC is clear in stating that the AAR is not intended to be an overview of the whole event (as the state’s should be), it nonetheless offers solid insight into numerous lessons learned and corrective actions that should be taken.

The Executive Summary states, “On January 9, 2014 a leak of MCHM into the Elk River contaminated the drinking water for most of the residents of Kanawha and Putnam Counties. Both Kanawha and Putnam Counties activated their Emergency Operations Centers (EOCs). For approximately the next 30 days the EOCs were involved in commodity distribution.”

The AAR assessed the following nine capabilities:
1. Planning
2. Public Information and Warning
3. Operational Coordination
4. Environmental Response/Health and Safety
5. Mass Care Services
6. Public Health and Medical Services
7. On-scene Security and Protection
8. Public and Private Services and Resources
9. Community Resilience

The AAR also states, “The purpose of this report is to provide supportive corrective actions in relation to the KPEPC (Emergency Management) Plan. Our goal is to identify actions taken and to identify strengths to be maintained and built upon, identify potential areas for further improvement, and support implementation of corrective actions.”

According to the report, once initial responders traced the odor, “…Freedom Industries employees characterized the event as a small spill that was under control.” Later, however, Dorsey “called (the) Kanawha County Office of Emergency Management reporting that the spill was more than originally thought.”

It continues, “When representatives from Charleston and Kanawha County Offices of Emergency Management arrived they were told the spill was more significant and that product was entering the water.” A West Virginia American Water company representative initially “…stated they thought they would be able to treat the contaminated water by using extra activated carbon in the treatment process which had already been initiated.”

However, the report notes, “Freedom Industries employees could not or would not give an estimate of the amount of product released. Initially, Freedom Industries only reported that they had a leak of Crude MCHM. Several times over the course of the incident the estimated quantity of material leaked increased. In addition, it became clear that the material leaked also contained other chemicals besides MCHM.”

Not surprisingly, communications issues were identified. “One of the challenges of this incident was the role of social media in shaping public opinion,” notes the report. It continues, “This was both good and bad. While many agencies attempted to use social media to provide information to the public, there was a great deal of misinformation or completely false information.”

To address this challenge, the report concludes, “Agencies should develop internal policies and procedures for use of social media to relay critical information. In addition, agencies should consider assigning staff members to monitor social media and when misinformation or incorrect information is presented, to be ready to counter with correct information.”

It notes also, “An issue during this incident was that there were inconsistent messages. A Joint Information Center (JIC) should have been established. …All officials and personnel involved in an incident, regardless of their home jurisdiction or discipline must ensure that any public statement is coordinated, in advance, with the other members participating in Joint Information System.”

It adds, “During the incident various departments from within the WV state government were in charge of the Public Information component of the incident. It was not clear how county governments could be engaged in the process. There is the need, however, for a method to enable county agencies to be kept in the loop of critical information.”

There were also command and control issues. The report notes, “To maintain command and control it is critical that an incident command post be identified. According to the Kanawha Putnam Emergency Management Plan, the Incident Command Post is a facility or area from which the IC (Incident Commander) and command staff operates. Ideally, the Incident Command Post will be located in a safe area away from the incident scene, yet close enough that the command staff can still safely observe tactical operations. In this incident that was not a clear ICP.”

Hence, it recommends, “During future incidents, an ICP needs to be established early during the incident response.” It continues, “In addition to not having a clear Incident Command Post, it was not apparent who had been named the overall Incident Commander. At the same time, however, it is clear that this incident should have been operating under a Unified Command.” It adds, “During all emergencies/incidents ensure that an Incident Commander is clearly identified. When necessary establish a Unified Command structure to better integrate the response capabilities of all involved agencies.”

Confusion about MCHM was also a challenge. “During the initial response phase of the incident there was a lack of information and misinformation regarding Crude MCHM. Different agencies were using slightly different versions of the Material Safety Data Sheet (MSDS) for Crude MCHM. Even worse was that the MSDS lacked information related to human health threats associated with the product.”

The report’s writers were also critical of Freedom Industries. “One of the most challenging aspects of this incident from both a response and a public notification aspect is that Freedom Industries, Inc. was not reliable in their releasing information. During the first week or so of the incident the amount of chemical released changed multiple times. Then it was released that in addition to the Crude MCHM additional chemicals were leaked.”

The logistics of distributing water and others supplies presented challenges. “Many community organizations, volunteer fire departments, and governmental agencies were involved in the distribution of commodities during the incident. In most cases these sites stepped forward offering to provide assistance as water distribution locations.

“Some of the locations worked well and other presented challenges. Part of the selection process should include access and security considerations at each location.

“In the future, FEMA and the state are going to require the direct delivery of FEMA resources (i.e. trailer loads of water) directly to the distribution points. The practice will not allow for dropping trailers at a central location in the county and then relocating the trailers by county assets. FEMA wants the state to be responsible for all movement of the FEMA assets.”

The report recommends that emergency planners, “Develop a list of locations and contacts to potentially be used in future incidents. For each of the locations develop maps showing locations and provide directions.”

Also concerning was the impact upon vulnerable populations and the response of the public in general. “Public housing, assisted living, apartment complexes and other densely populated residential areas present many challenges…the residents in these buildings also have access or functional needs.”

Additionally, notes the report, “A great deal of money has been spent on educating the public on the importance of building self-sufficient for a minimum of 72 hours. Regardless of the amount of money thrown at the problem, the public does not comprehend or is unwilling to take any action.” Furthermore, “It was difficult to get the populous to start thinking about providing water on their own. Even when water was available in all of the stores and when the water was deemed safe, the population expected free water.”

Despite the many challenges and lessons learned, some positive capabilities were identified, including:
• Great support from community agencies. Local agencies provided manpower and resources to distribute over 15 million bottles of water;
• Support provided to the community by WV American Water;
• Cooperation between Federal, State, County and local agencies and businesses;
• Quick delivery of emergency supply of bottled and tanker loads of water by WV American Water within 4 hours;
• First arriving emergency supply of water by WV Division of Homeland Security and Emergency Management within 30 hours; and
• Social media and flow of public information disseminated through the media.

The officials responsible for this report are to be commended for a thorough and transparent assessment. Hopefully, the State of West Virginia will follow their lead.

© Appalachian Chronicle, 2014. Barrick is a lead author for an upcoming book by Springer Publishing on disaster evacuations and is a member of a consortium of Emergency Management experts with West Virginia University, the University of Colorado-Denver, the University of Oklahoma, and the University of South Carolina. He holds a Certificate in Community Preparedness and Disaster Management from the University of North Carolina School of Public Health and is the Safety Officer/Emergency Management Coordinator for Stonewall Jackson Memorial Hospital in Weston, W.Va. He writes from his home in Bridgeport, W.Va.

To learn more about the KPECP AAR, you can contact:
City of Charleston, Office of Emergency Management
Grant Gunnoe

Kanawha County Office of Emergency Management
Dale Petry

Putnam County Office of Emergency Management
Frank Chapman

Kanawha Putnam Emergency Planning Committee
Larry Zuspan, Administrator

Kanawha Putnam Emergency Planning Committee
Dr. Matt Blackwood, Chair of the Board of Directors

Incompetence and Complacency Increase Dangers from Fracking

Gas leak in Doddridge County, W.Va. is a sentinel warning

By Michael M. Barrick

The leak of approximately 120 gallons of natural gas liquids into the air in Doddridge County, W.Va. on October 9 should serve as a sentinel warning to those supporting the fracking industry and all of those impacted by it.

While it is true that the leak in the Smithburg area of Doddridge County is not related to fracking, that is not the point; rather, what we need to consider is the incompetence and complacency that led to the leak – and the response to it by those charged with protecting the public health and safety. In short, it shows that the gas industry cannot be trusted, and emergency response officials have a lot to learn and improve upon.

A vapor cloud led to a massive traffic jam, injuries to at least two workers, complacent remarks from gas company officials and admissions by emergency officials that they experienced serious communications breakdowns.

This is concerning, considering the rush by gas companies to build fracking sites all over northern West Virginia, in particular in Doddridge County. Naturally, gas company officials claim that fracking is safe. The evidence is quickly mounting to the contrary. From mutated amphibians to workers exposed to carcinogens – and much more – fracking is being proven to not be worth the jobs it is creating.

In response to the accident in Smithburg, a gas company official was quoted in the Clarksburg Exponent Telegram as saying, “During routine loading of natural gas liquids (NGLs) to a tractor-trailer at what’s called a ‘load out’ facility, a leak occurred.” Note the use of the word “routine.” That is a deliberate attempt to downplay the incident. For the workers injured, for the homes evacuated, and for the motorists stranded, it was anything but routine. This is the type of language we can expect from gas companies and all of those in the fracking industry as they destroy the environment and kill people.

The only response to such language is, “cowpatties.”

The gas official was also quoted as saying, “Two employees at the facility were evacuated by medical professionals. However, no one was injured.” Really? A first responder at the scene had a different response. The newspaper reported that he said, “…that two employees were treated at the scene for difficulty breathing.”

Who do you believe?

Also of concern is the acknowledgment by the director of the Doddridge County Office of Emergency Services (OES), Pat Heaster. He told the newspaper that he was not notified of the incident. For those unfamiliar with emergency response, that is an inexcusable lapse. It is the director of OES who is responsible for coordinating disaster response in a county. It is hard to do that when you don’t know there is a disaster.

It is also maddening that he blamed technology. “We’ve had problems with dispatch reaching pagers due to the topography and antennas. We must determine want went wrong with communications.” While technology is a problem in West Virginia, there are still landline telephones. And, one would suspect that police officials or other knows where he lives and from where he works. They certainly could have notified him.

Heaster promised that the Local Emergency Planning Committee (LEPC) would meet next week and discuss the problem. If the Doddridge LEPC operates as most others in West Virginia, I would not hold my breath. Or then again, maybe we should.

© Michael Barrick, 2014. Barrick is the founder of the Appalachian Preservation Project, LLC. He also works in healthcare as an emergency manager and holds a post-graduate certificate in Community Preparedness and Disaster Management from the University of North Carolina Gillings School of Global Public Health. He can be contacted via email at

Stubborn and Conflicted Public a Major Challenge to Disaster Evacuation

Public expects officials to be prepared for disasters, but often ignores directives

By Michael M. Barrick

“No one thought about leaving town ‘til death stared them in the face.”
– “Wasn’t That a Mighty Storm,” by Eric Von Schmidt

The decision to evacuate is often referred to as “a career killer” within the disaster management field. That is with good reason. Millions of people are often impacted by the decision. If the decision to evacuate turns out, in hindsight, to be a mistake, the politicians will hear about it at the polls. Knowing this, elected officials will quickly dismiss a cabinet level appointee and/or their functionaries without hesitation. Hence, a political decision affects future policy decisions, as subsequent disaster officials may hesitate to order an evacuation for fear of committing career suicide. In short, a management decision to not order an evacuation could potentially be a misapplication of policy because of political considerations or pressure.

The folk song about the Great Galveston Hurricane of 1900, referenced above, identifies the first core challenge facing the public health sector – the public. Though the song recalls a tragedy before modern communications and the 24/7 weather forecasting cycle, the public’s tendency to ignore warnings remains on full display. Just in the early months of 2014, Atlanta was paralyzed because the public failed to pay attention to the forecast which warned of the ice storm that left tens of thousands of Georgians stranded on roadways. Two weeks later, another winter storm, again predicted far in advance, left thousands stranded in the snow in and around Raleigh, North Carolina’s capital.

This first core challenge, however, is not without cause. It is related to the second core challenge – the public’s distrust of government. This applies not only to government, but also the politicians we elect to lead it and the employees to whom we entrust it. This is made evident by the fact politicians and the public alike refer derisively to public sector employees as “bureaucrats.” Unfortunately, the public has cause for being skeptical. Also in early 2014, 300,000 West Virginians learned that their water was unsafe to drink because their drinking supply – the Elk River – had been contaminated by the coal-mining cleaning chemical 4-methylcyclohexane methanol. The finger-pointing that began immediately after the incident could not engender confidence in public officials – both elected and appointed. Such distrust was only exacerbated, when, months following the spill, virtually nobody in authority was willing or able to answer the most fundamental question – is the water safe?

Cleary, these two core challenges are not only connected, they are also complicated. Even as hundreds of thousands of Georgians were making individual decisions about how to react to the forecasts of severe and dangerous weather – decisions that led thousands of people, including children, to be stranded – the mayor of Atlanta and governor of Georgia were harshly criticized for failing to provide clear leadership in anticipation of the ice storm. While one could argue that a resident living in the southeastern United States should anticipate many problems associated with an ice storm, the angry reaction to inaction by elected officials demonstrates that the public does have an expectation that government officials will provide guidance in anticipation of and response to disasters. The public may choose to ignore such warnings, yet the expectation is that warnings will be issued. Consequently, these two core challenges are intertwined. The public is not easily persuaded, but it still expects to be courted – even while death stares them in the face.

It was true in 1900 and it is true today. Emergency managers, in other words, must acknowledge they are serving a public that is stubborn and suspicious of governmental authority. These factors and the historical national devotion to individualism and property rights combine to further aggravate the public’s role in contributing to increased morbidity and mortality during disasters.

People everywhere – and certainly in the United States – are determined to continue to live in risk-prone areas. Admittedly, economic structures may leave the working class or impoverished with no alternative to living in a river valley; still, for whatever reason – whether stubbornness or powerlessness – the presence of people in areas prone to natural disasters is a challenge to disaster planning.

© Michael Barrick / The Barrick Report, 2014. Barrick is presently a lead author for an upcoming book by Springer Publishing on disaster evacuations and is a member of a consortium of Emergency Management experts with West Virginia University, the University of North Carolina, the University of Colorado-Denver, the University of Oklahoma, and the University of South Carolina. He holds a post-graduate Certificate in Community Preparedness and Disaster Management from the University of North Carolina Gillings School of Global Public Health. He offers consulting expertise on healthcare and community emergency preparedness.

Our Nation’s Gravest Threat – Mediocrity

We will solve nothing so long as we collectively shrug off challenges

By Michael M. Barrick

Does the Secret Service want President Obama dead? If you have even the slightest conspiracy theory streak guiding your thoughts, you might rightly think so in light of the ongoing security breaches at the White House and the juvenile behavior of the agency’s officers on foreign soil. However, I am not quite that paranoid. I am, though, quite disgusted and concerned. For, the root cause of the agency’s problems is incompetence. In short, it, like much of our society, has fallen prey to our gravest enemy – the momentum of mediocrity.

Let’s review.

This past Sunday’s Washington Post’s headline story announced, “Secret Service stumbled after shooting in 2011.” In summary, according to the article, a gunman shot several rounds at the White House on November 11, 2011. While some agents initially responded as trained – that is, recognizing and attempting to identify the threat – a senior officer ordered them to stand down, claiming no shots had been fired. Several days later, however, a worker at the White House discovered several locations where bullets had hit the White House on the south end of the second floor. As it turns out, someone had indeed opened fire at the president’s home from 700 yards away. Only by sheer dumb luck did the Secret Service eventually identify and arrest a suspect. He was captured only because he crashed his car leaving the scene. It took several days before he was arrested in Pennsylvania.

The following year, a team of Secret Service agents charged with protecting the president in Columbia during an overseas visit instead spent their time cavorting with prostitutes. Not only is this a completely inexcusable breach of their sacred duty, it left them open to blackmail.

Then, just last week, another man scaled the fence on the north end of the mansion, ran across the yard, entered the unlocked front door and gained entry to the presidential quarters.

These agents of the Secret Service clearly do not represent our brightest and best. Yet, they are supposed to. Whatever one thinks of President Obama, anyone who lived through the 1960s is acutely aware of the trauma inflicted upon the nation when the president is murdered. With terrorists unquestionably determined to destabilize our nation, there is no better way to accomplish that than to murder our president and his family. It is beyond comprehension that the Secret Service does not take such a threat seriously. Clearly they do not, no matter what its leaders say. It is obviously time to clean house, so that those living and working in the White House are protected as they should be.

The mediocrity is not limited to the national government though. It is also on display at the local and state levels as well.

West Virginia offers clear evidence of this.

This past summer, the Lewis County Firefighter’s Association and the Lewis County Commission decided to disband the county’s HazMat response team, even though two major highways run through it, crowded daily with trucks hauling materials, water and supplies for the fracking industry. The back roads are just as crowded and even more dangerous. Public officials simply shrugged their shoulders and have done nothing to correct the problem.

Yet, the Material Safety Data Sheet (MSDS) for Gas Pipeline Condensate reveals numerous potential health effects to the eyes and skin, as well as through ingestion and inhalation. There are also acute health and chronic health hazards. Additionally, medical conditions that are aggravated by exposure to it include respiratory, cardiovascular and nervous system conditions. Still, county officials do nothing.

Meanwhile, in the state capital of Charleston, no elected or appointed official is willing or able to hold those local officials accountable. Calls to those responsible for public health and safety, environmental protection and emergency management go unanswered or unattended. Every official I spoke with in Charleston regarding this matter said there is nothing they can do. This inaction is unconscionable in light of the fact that 300,000 West Virginians had their drinking water contaminated by a spill of the coal-mining cleaning chemical 4-methylcyclohexane methanol into the Elk River last January.

All of this can only be characterized as a momentum of mediocrity. Eventually, it will be deadly.

As we ponder these issues and wonder if there is any hope of reversing the trend, we might want to consider the thoughts of Derek Jeter, the New York Yankee baseball player who just retired after a stellar career. When Sports Illustrated asked him whether a teammate who was complacent about losing could change, Jeter replied, “I don’t think so. Either something means something to you or it doesn’t. I don’t think you can teach someone to have something mean something to them, do you know what I mean?”

Sadly, I think too few of us do. And that is why the momentum of mediocrity poses a grave threat – a greater threat even than the Islamic State, Iran, North Korea, Ebola or any of our other enemies or threats.

© Michael Barrick, 2014. Learn more about him here.

Adjusting the Mindset about Using Lethal Force in Hospitals

For those trained to save lives, the thought of taking one is unfathomable

By Michael M. Barrick

Those working in hospitals – whatever their position – have generally entered healthcare because they wish to improve and save lives. Consequently, the thought of using lethal force to stop a violent person – as recently happened in Pennsylvania – is unfathomable to most healthcare workers.

It is, however, the new reality.

This is the implicit truth for the hospital planning an “Active Shooter” drill. Considering the number of assaults, attacks and shootings in hospitals in recent years, any hospital serious about ensuring the safety and security of its patients, staff and visitors must prepare for the reality of a shooter in their facility. That also means they must also accept the reality that they or the police may have to use lethal force against the person presenting a threat.

So, to prepare for such a scenario – regardless of how remote one hopes or believes it is – requires the writing of a drill, functional exercise or perhaps even a full scale exercise involving the whole community.

Writing the plan is the “easy” part compared to adjusting our mindset about the potential need for “neutralizing” the threat. Of course, writing such an exercise is not easy, because the options available to healthcare workers are very limited when one considers how open and accessible most hospitals are. Faced with an increasingly violent society, hospital administrators, emergency managers, and community partners truly do face numerous obstacles in figuring out how to respond quickly and effectively to someone who poses a mortal threat. However, no matter how well-planned and executed an active shooter exercise may be, the first challenge is coming to terms with the fact that those charged with saving lives may have to take one.

How can we adjust our thinking to include that possibility? It begins with acknowledging that the possibility of such an event is real. Because such events are essentially random, it is a very difficult threat to rank in a Hazard Vulnerability Analysis (HVA). But ranked it must be. As with any risk identified in a HVA, many things must be considered. The first thing to acknowledge is that hospital staff may be reluctant to identify a threat, let alone react to it.

So, re-training our minds is the first step. Of course, this does not mean cavalierly accepting that we or police may have to use lethal force; rather, it demands of us that we truly begin with the first step of emergency management – mitigation. This includes robust training for ALL staff on crisis prevention and intervention. It includes training in self-defense. It includes training in recognizing potential threats. It means changes in policy to include intake questions which might help identify a domestic problem that could manifest itself within the hospital. It means ensuring that de-escalating a potentially violent situation is every employee’s priority.

Ultimately, it means including every possible employee in an active shooter exercise. As they see through such a drill the potential tragedy that could unfold, they will come to understand that the best way to avoid the unfathomable is to acknowledge that it can happen. From that acknowledgment will come two conclusions – the risk is real and it is dangerous to ignore it.

© Michael M. Barrick, 2014.

Key Assumption Guides Judge in New York City Case

Local government responsible for disaster planning – including for vulnerable populations

By Michael M. Barrick

Note: This is the second installment in a series of articles regarding emergency management and vulnerable populations. Read the first installment here. Additionally, I wish to thank James Farrell with the Upshur County, W.Va. Office of Emergency Management for first bringing this case to my attention.

Emergency planners are responsible for ensuring compliance to laws from various local, state and federal government agencies. This has been the case for roughly 40 years, but true collaboration and cooperation among emergency responders and planners didn’t start occurring until after the terrorist attacks of September 11, 2001 and then Hurricane Katrina four years later.Evacuation 1

Even today, planning and cooperation is sporadic at best. Lessons have been learned, but primarily the hard way – through mistakes caused by the lack of preparedness.

Apparently, many in the emergency preparedness community are slow learners. This has been made painfully obvious by Judge Jesse M. Furman, United States District Judge for the Southern District of New York. As I recently reported, advocates of the disabled successfully argued before Furman that New York City’s emergency planners violated the Americans with Disabilities Act (ADA) by failing to plan for and accommodate the needs of the city’s vulnerable populations during Tropical Strom Irene.

The failure amounted to “benign neglect” according to Furman. While some may consider the decision another case of federal overreach in local affairs, the millions of Americans who are disabled will no longer be ignored by emergency planners. Indeed, regardless of one’s political philosophy, one would hope that any and all emergency planners would carefully consider vulnerable populations as they plan for disasters that will impact their communities. First, because it is the humane and responsible course of action, but also because experience teaches that the needs of vulnerable populations prior to, during and following a disaster are extensive and real. The community healthcare structure will be impacted by meeting the needs of the disabled. The only question is whether the response will be proactive or, as is most common, reactive.

Case Background
The case was brought against the City of New York and then-Mayor Michael R. Bloomberg by the Brooklyn Center for Independence of the Disabled, the Center for Independence of the Disabled, New York, and two individuals. Prior to trial, Furman certified the lawsuit as a class action lawsuit on behalf of all disabled people – as defined by the ADA – in New York City.

The plaintiffs argued that the city failed to adequately address the needs of people with disabilities in its planning for and response to emergencies. Essentially, the judge concurred, though he did acknowledge that New York City in many ways has a robust emergency preparedness program. Yet, Furman did conclude “…that the City has violated the ADA … by failing to provide people with disabilities meaningful access to its emergency preparedness program in several ways.” He listed six specific areas in which the city failed to comply with the ADA in emergency planning and response. Those include:

(1) “The City’s evacuation plans do not accommodate the needs of people with disabilities with respect to high-rise evacuation and accessible transportation;
(2) “its shelter plans do not require that the shelter system be sufficiently accessible, either architecturally or programmatically, to accommodate people with disabilities in an emergency;
(3) “the City has no plan for canvassing or for otherwise ensuring that people with disabilities — who may, because of their disability, be unable to leave their building after a disaster — are able to access the services provided by the City after an emergency;
(4) “the City’s plans to distribute resources in the aftermath of a disaster do not provide for accessible communications at the facilities where resources are distributed;
(5) “the City’s outreach and education program fails in several respects to provide people with disabilities the same opportunity as others to develop a personal emergency plan; and
(6) “the City lacks sufficient plans to provide people with disabilities information about the existence and location of accessible services in an emergency.”

Ruling Rooted in a Maxim of Disaster Management
Judge Furman, early in the text of his ruling, states clearly what all emergency planners hold as a maxim of disaster management. Said the judge, “The task of planning for, and responding to, emergencies and disasters is one of the most important, and challenging, tasks any government faces. Emergencies can take many forms — from power outages, to hurricanes, to terrorist attacks — and a government, particularly a local government, must be prepared for them to strike at almost any moment.” In short, as all experienced emergency planners know, “All disasters begin and end locally.”

Concept of ‘Benign Neglect’
Furman did acknowledge “Notably, there is no evidence that these failures are a result of intentional discrimination by the City against people with disabilities.” He added, though, “But, the ADA … seek(s) to prevent not only intentional discrimination against people with disabilities, but also – indeed, primarily – discrimination that results from ‘benign neglect.’” As a result, concluded Furman, the ADA requires “affirmative accommodations to ensure that facially neutral rules do not in practice discriminate against individuals with disabilities.”

Unique Remedy
Perhaps in part because of the lack of intentional discrimination, and because Furman, by his own admission is not expert in emergency management and preparedness, issued a unique remedy. He left it to the plaintiffs and defendants to develop a solution. He explained, “Given the complexity and potential expense involved, there is no question that crafting an appropriate remedy would be better accomplished by those with expertise in such matters and through negotiation, whether court-supervised or otherwise, than by Court order.” So, he ordered, “The parties are therefore directed to meet and confer – in person and with representatives of the Department of Justice, if the elect to participate – about the most productive means of resolving the question of remedies through alternative dispute mechanisms.”

However, Furman added, “…the Court will impose remedies if the parties cannot agree on them…”

Local Implications
This case is 119 pages long. The evidence presented in trial seems to support Furman’s decision. Of course, others may disagree and it may be some time before a final resolution to this case is determined. I strongly encourage emergency planners to take the time to read it. Because Furman’s ruling applies only to New York City, it would be tempting for emergency planners across the nation to pay scant attention to it. That would be a mistake. Furman’s ruling could well become the law of the land. However, one thing is certain now – most communities are probably no better prepared to meet the needs of the disabled in a disaster than is New York City.

That is my experience in West Virginia, which with an aging and relatively unhealthy population, has a high number of vulnerable people. This may be mitigated some by the rugged individualism that is characteristic of the people of Appalachia; still, when disaster strikes, the topography and geography of the mountains isolate the people from one another – and emergency responders – during a disaster.

As a member of a two-county Local Emergency Planning Committee, where I first learned of this case thanks to Mr. James Farrell, I began asking members what we were doing to define, identify and make contact with disabled people. I asked not to accuse local emergency planners of not doing their job, but because hospitals are required by its accrediting agency – The Joint Commission – to make provisions for vulnerable populations in its emergency plans. I wanted to gather information to determine what gaps and vulnerabilities we might have, as a hospital, to meet the needs of the disabled. What I learned instead was that not only does our hospital have its works cut out for it in preparing to meet the needs of the disabled, our entire community does. Then, as I traveled the state, and called upon my colleagues in other states, I discovered that local communities are doing very little, if anything, to plan and prepare for the needs of the disabled in a disaster.

There is no excuse for this. We have simply grown complacent.

ADA Definitions
The ADA defines a person as disabled if he or she has a physical or mental impairment that substantially limits one or more major life activities, or has a record of such impairment, or is regarded as having such an impairment. A physical impairment is defined by the ADA as “any physiological disorder or condition, cosmetic disfigurement, or anatomical loss affecting one or more of the following body systems: neurological, musculoskeletal, special sense organs, respiratory (including speech organs), cardiovascular, reproductive, digestive, genitourinary, hemic and lymphatic, skin, and endocrine.”

Needless to say, that is a rather comprehensive list. In fact, in New York City, it constitutes roughly 900,000 people. Here, in central West Virginia, as many as one in four people may fit that definition. But we don’t know where they are. Even in our little town of Weston, with just roughly 5,000 souls, we don’t know who in one of the low-income high rises needs oxygen or mobility assistance. We don’t know who will need medicines if they are isolated from pharmacies for days. We don’t know who will need assistance eating or drinking, or access to dialysis. In short, we don’t even know what we don’t know.

Again, while I find that disturbing and am confident we have folks here willing to honor their obligation to the most vulnerable among us, I am also fearful that we just aren’t taking it seriously. As of this writing, it has been roughly three months since I first suggested a questionnaire be sent to local authorities and agencies who deal with vulnerable populations to see if there are ways we can identify and locate them should they need and desire assistance when disaster strikes. Of the dozens it was sent to, only a handful of folks have responded.

So, many of those charged with caring for people in disasters may not want to tackle the shortcomings identified by Judge Furman in his ruling. However, most of those who are disabled or considered vulnerable almost certainly want and expect help during a disaster. Otherwise, folks would not have made a federal case out of it.

We can only hope that the parties on both sides of this case reach a remedy that will benefit not only the people of New York City, but disabled Americans everywhere. We must hope that. Otherwise, a judge who knows nothing about disaster preparedness and management will impose a remedy. That may be less than desirable, but it is more than doing nothing.

That is our choice as emergency planners. We all know disasters begin and end locally. We know that all those within our jurisdictions are our responsibility. Certainly, we don’t need a judge to tell us that. Or do we?

© Michael Barrick / Barrick Report, 2014.

Does Your Community Neglect Vulnerable Populations?

Ruling by federal judge forcing emergency managers to consider the question

By Michael M. Barrick

Note: This is the first installment in a series of articles regarding emergency management and vulnerable populations.

Are emergency managers in your community doing all they can to care for the most vulnerable among us? If not, then they are guilty of “benign neglect” according to U.S. Judge Jesse M. Furman of the Federal District Court of Manhattan. Ruling in a case brought by advocates of the disabled following Tropical Storm Irene, the judge concluded last year that New York City failed to meet the needs of its roughly 900,000 vulnerable citizens. According to the judge, the failure to meet the needs of its most vulnerable citizens resulted from poor planning in anticipating and responding to special needs, inadequate public communications, inadequate sheltering plans and locations, and other failures from flawed assumptions. He argued, “… a government, particularly a local government, must be prepared for (disasters) to strike at almost any moment.”

Taken together, this constituted “benign neglect” argued Furman. Though a fresh turn-of-words by the judge, the concept is not a new phenomenon. Lawmakers are reluctant – or ill-equipped – to enact laws that would mitigate the threat of natural disasters. For instance, following Hurricane Katrina and other hurricanes from the 2005 season, the U.S. Department of Transportation (DOT) concluded that two of the primary causes of poor evacuation decision-making and implementation were poor communication among principle stakeholders and the inability to meet the needs of vulnerable populations. Also cited were poor planning, inadequate response and rescue operations, and poor sheltering plans.

Nearly a decade later, it would seem little has been learned. Instead, inertia seemed to be the primary response to these findings. According to Judge Furman, the primary impediments to effective evacuation identified by the DOT remain. Why so? While one would hope that Judge Furman’s discoveries about New York City’s shortcomings in meeting the healthcare needs of its most vulnerable citizens is unique to those who brought suit, experience reveals otherwise. The conditions in New York are pervasive in urban and rural areas alike. As Furman noted, “The task of planning for, and responding to, emergencies and other disasters is one of the most important, and challenging, tasks any government faces.” Too often, those responsible for the health and safety of the public fail to understand the full scope of their jobs, in particular professional collaboration. The public has been neglected because those charged with guarding lives have neglected their most basic and sacred duties – to know what is required of them and do it. While there are many reasons for this, it adds up to benign neglect.

Furman concluded, “…the city’s plans are inadequate to ensure that people with disabilities are able to evacuate before or during an emergency; they fail to provide sufficiently accessible shelters; and they do not sufficiently inform people with disabilities of the availability and location of accessible emergency services.” Yet, Furman acknowledged, “… ultimately, there are limits to what the government can do on its own: Not only must a local government be prepared, but its residents must also prepare themselves.”

Nevertheless, Furman has ordered community planners to not only educate the public, but also to include vulnerable citizens, their allies and advocates in emergency planning. “One way in which emergency planners can help ensure that the needs of people with disabilities are incorporated sufficiently into emergency plans is to include people with special needs in the planning process,” argued Furman. He said also, “Planners must compensate for their increased vulnerability by addressing, specifically, the needs of people with disabilities during the planning process” and, “Emergency planners must plan ahead to effectively provide services and communities with people with disabilities before, during, and after an emergency.” Failure to do so has dire consequences, he asserted. “Indeed, the National Council on Disability … has opined that the failure to address the specific vulnerabilities of people with disabilities in emergency planning ‘often leads to increased injury and death rates among this segment of the populations during disasters.’”

So clearly, emergency managers do not have the luxury of assuming that residents will prepare themselves; in fact, argued Judge Furman, one cannot assume that residents even know how to prepare themselves. The question that remains to be answered, then, is, “Will residents, once educated, prepare themselves?” One hopes the answer is yes, but based on history must infer that the true answer is no. Any other conclusion can be tragic.

The uncomfortable reality is that benign neglect exists. Most onerous, it is, by definition, the failure of policy makers and emergency management experts to do what is required of them. They have failed to protect and care for the public’s health. Indifference and ignorance by policy makers, resignation by planners and managers in the face of regulatory and bureaucratic obstacles, and a body politic largely indifferent to the concept of emergency preparedness are all root causes of benign neglect.

Its existence is undeniable; its persistence disturbing. Its elimination, essential.

© Michael M. Barrick / The Barrick Report, 2014.

The Alphabet Soup of Hospital Disaster Exercise Design

Numerous oversight agencies force a comprehensive list of capabilities and objectives

By Michael M. Barrick

When a hospital participates in a community-wide exercise, one of its first tasks is to explain to its community partners the vast scope of capabilities and objectives a hospital must assess in order to satisfy the numerous agencies which have oversight responsibilities of hospital disaster preparedness.

Emergency checklistNot only are hospitals required by The Joint Commission (TJC) to have multiple drills annually, a reality that requires a great deal (but necessary) work by the hospital and community, they also must design disaster exercises that satisfy requirements of the U.S. Department of Health and Human Services (DHHS) and the U.S. Department of Homeland Security (DHS). Finally, the objectives of participating agencies must also be incorporated into the exercise. In fact, it is often the hospital’s exercise plan which must be subordinate to the overall community or regional plan. However, that does not mean the hospital does not need to write its own plan. Indeed, even though exercise partners might not first understand why the hospital writes its own exercise plan, once the partners see the various objectives and capabilities that a hospital must assess, they will understand.

Specifically, a hospital needs to incorporate the following standards or guidelines into a disaster exercise:
• TJC Emergency Management Standards and Elements of Performance
• Core Capabilities as identified in the Hospital Preparedness Program (HPP) of the Office of the Assistant Secretary for Preparedness and Response (ASPR) of the U.S. Department of Health and Human Services (DHHS)
• The NIMS Healthcare Implementation Objectives for Healthcare Organizations of the DHS
• Assessment of the exercise will be conducted according to the DHS Homeland Security Exercise Evaluation Program (HSEEP)

Of course, virtually any exercise will have objectives to assess effective implementation of the hospital’s Emergency Operations Plan (EOP). Because the EOP should include sections on crisis communications, as well as resources and assets, safety and security, staff management, patient management and utility management, implementation of the EOP should lead not only to internal responses, but communication and collaboration with community partners also.

For instance, a regional drill dealing with a water crisis could reasonably contain the objectives outlined below. While at first glance this may seem to be too many objectives to measure, the truth is that they simply account for actions which will likely be taken. And, the objectives could conceivably be boiled down to shorter expected actions or outcomes. Finally, it is important to list all possible objectives so that leadership, partners, and anyone else reading an exercise document can understand the complexity of a disaster situation. In any event, here is a list of objectives from an actual exercise.

EM.02.02.01: As part of its Emergency Operations Plan, the hospital prepares for how it will communicate during emergencies.

Elements of Performance (EP)
• EP 1: Staff notification of EOP activation
• EP 2: Staff notification of instructions and activities
• EP 3: Notification of external authorities
• EP 4: Communication with external authorities
• EP 5: Communications with patients and families
• EP 6: Communications with media
• EP 7: Communicate with providers of essential services

EM.02.02.03: As part of its Emergency Operations Plan, the hospital prepares for how it will manage resources and assets during emergencies.
Elements of Performance (EP)
• EP 3: Obtaining and replenishing non-medical supplies
• EP 6: Monitor quantities of resources and assets

EM.02.02.05: As part of its Emergency Operations Plan, the hospital prepares for how it will manage security and safety during an emergency.
Elements of Performance (EP)
• EP 7: Controlling entrance into and out of the facility

EM.02.02.07: As part of its Emergency Operations Plan, the hospital prepares for how it will manage staff during an emergency.
Elements of Performance (EP)
• EP 5: Managing staff support needs

EM.02.02.09: As part of its Emergency Operations Plan, the hospital prepares for how it will manage utilities during an emergency.
Elements of Performance (EP)
• EP 3: The hospital identifies alternative means of providing water needed for consumption and essential services
• EP 4: The hospital identifies alternative means of providing water needed for equipment and sanitary purposes
• EP 7: The hospital identifies systems that are essential, such as for heating and cooling, and steam for sterilization

EM.02.02.11: As part of its Emergency Operations Plan, the hospital prepares for how it will manage patients during an emergency.
Elements of Performance (EP)
• EP 4: The hospital plans for managing a potential increase in services for vulnerable populations
• EP 5: The hospital manages the personal hygiene and sanitation needs of its patients
• EP 7: The hospital identifies systems that are essential, such as for heating and cooling, and steam for sterilization

EM.03.01.03: The hospital evaluates the effectiveness of its Emergency Operations Plan.
Elements of Performance (EP)
• EP 7: Monitor the effectiveness of communication
• EP 8: Monitor resource allocation
• EP 9: Monitor management of safety and security
• EP 10: Monitor management of staff roles
• EP 11: Monitor management of utility systems
• EP 12: Monitor management of patient clinical and support activities
• EP 14: Document opportunities for improvement
• EP 16: Implement plans for improvement

Adoption (1) – “Adopt NIMS throughout the healthcare organization to include appropriate departments and business units.”
Preparedness: Planning (4) – “Participate in interagency mutual aid and/or assistance agreements, to include agreements with public and private sector and nongovernmental organizations.”
Preparedness: Training and Exercises (7) – “Promote and integrate, as appropriate, NIMS concepts and principles (i.e., the Incident Command System) into all healthcare organization-related training and exercises.”
Communications and Information Management (8) – “Promote and ensure that hospital processes, equipment, communication, and data interoperability facilitates the collection and distribution of consistent and accurate information with local and state partners during an incident or event.”
Command and Management (10) – “Manage all emergency incidents, exercises, and preplanned (recurring/special) events with consistent application of ICS organizational structures, doctrine, processes, and procedures.”
Command and Management (11) – “Adopt the principle of Public Information, facilitated by the use of the Joint Information System (JIS) and Joint Information Center (JIC) ensuring that Public Information procedures and processes gather, verify, coordinate, and disseminate information during an incident or event.”

1. Healthcare System Preparedness
2. Healthcare System Recovery
3. Emergency Operations Coordination

Capability 1: Healthcare System Preparedness
Function 2: Coordinate healthcare planning to prepare the healthcare system for a disaster
Coordinate with emergency management to develop local and state emergency operations plans that address the concerns and unique needs of healthcare organizations. Plans should encompass the ability to deliver essential healthcare services during a response.
• Task 2: Engage healthcare partners to coordinate healthcare planning efforts with local and state emergency operations planning to integrate healthcare organization priorities and unique needs into response and recovery operations.

Function 3: Identify and prioritize essential healthcare assets and services
Identify and prioritize healthcare assets and essential services within a healthcare delivery area or region (Healthcare Coalition area). Coordinate planning to protect and enhance priority healthcare assets and essential services in order to ensure continued healthcare delivery to the community during a disaster.
• Task 1: Identify and prioritize the essential healthcare assets and services of the community.
• Task 2: Coordinate planning and preventative measures to assist with the protection of prioritized healthcare assets and essential services.
Function 4: Determine gaps in the healthcare preparedness and identify resources for mitigation of these gaps
Perform resource assessments and develop plans to assist healthcare organizations address gaps associated with planning, training, staffing, and equipping that improve resource availability during response and recovery.
• Task 1: Perform a resource assessment by analyzing healthcare organization needs and evaluating exercises, training, and actual incidents or events to determine gaps and corrective action.

Function 6: Improve healthcare response capabilities through coordinated exercise and evaluation
Coordinate an exercise, evaluation, and corrective action program to continuously improve healthcare preparedness, response, and recovery. Exercises should assess and validate the effectiveness and efficiency of capabilities and the adequacy of policies, plans, procedures, and protocols.
• Task 1: Coordinate and implement capability based exercises that test disaster planning efforts.
• Task 2: Utilize a coordinated evaluation method to evaluate exercises and actual incident responses.
• Task 3: Address findings from gap analysis and subsequent corrective actions to revise planning, training, and exercises to minimize response gaps.

Capability 2: Healthcare System Recovery
Function 1: Develop recovery processes for the healthcare delivery system
Identify healthcare organization recovery needs and develop priority recovery processes to support a return to normalcy of operations or a new standard of normalcy for the provision of healthcare delivery to the community.
Task 1: Assess the impact of an incident on the healthcare systems ability to deliver essential services to the community and prioritize healthcare recovery needs.

Capability 3: Emergency Operations Coordination
Function 2: Assess and notify stakeholders of healthcare delivery status
Assess the incident’s impact on healthcare delivery in order to determine immediate healthcare organization resource needs and the status of healthcare delivery during an incident response.
• Task 1: During an incident, implement information sharing processes that supports ongoing communication to inform local incident management of the operational status and resource needs of healthcare organizations.
• Task 2: During an incident, implement information sharing processes that supports ongoing communication to inform healthcare organizations about the status of the incident and of healthcare delivery in the community.
• Task 3: During an incident, implement coordinated information sharing processes that provide relevant and timely healthcare messages to the community and other stakeholders through a Joint Information System (JIS).

Function 3: Support healthcare response efforts through coordination of resources
Coordinate resource allocation for healthcare organizations by assisting incident management with decisions regarding resource availability and needs.
• Task 1: Implement processes that assists local and state incident management to identify resource gaps and allocate available resources for healthcare organizations when requested during a response.

Undeniably, this is much to evaluate in any exercise. Nevertheless, if a hospital is going to deal with a water shortage, all of these elements will, at some point, come in to play. Yes, regulations require that these elements be measured; more importantly, it’s the right thing to do. Until all of the objectives are truly identified, the hospital won’t know its breaking point. Better to learn it in an exercise than during the real deal.

© Michael M. Barrick, 2014

Michael Chertoff: Poor Disaster Response Erodes Faith in Government

By Michael M. Barrick

CHAPEL HILL, N.C. – Poor disaster response erodes citizens’ faith in all of government, former U.S. Department of Homeland Security (DHS) Secretary Michael Chertoff said in a commencement address on May 17. Mr. Chertoff, who led DHS from 2005 – 2009 for President George W. Bush, made his remarks to the 20th graduating class of the Community Preparedness and Disaster Management certificate program of the University of North Carolina.

Mr. Chertoff also alluded to gaps in leadership, poor crisis communications and a lack of cooperation across agencies and disciplines as other core challenges facing those working in emergency and disaster management.

His remarks were delivered to those who are charged with overcoming those and other challenges. In addition to the graduates, several alumni were also present. Graduates and alumni represented numerous professions, including emergency management, fire service, law enforcement, emergency medical services, public health, hospitals, the military, the private sector, FEMA, volunteers, veterinarians and others.

Mr. Chertoff referred to Hurricane Katrina and more recent disasters such as the ship capsize in South Korea and the coal mine disaster in Turkey as examples of disasters that were made worse by poor response. He pointed out that when government doesn’t effectively meet one of its most basic functions – disaster preparedness and response – then people simply fail to trust government. That leads public reluctance to heed official warnings, and can also lead to safety and security problems due to the breakdown of order.

The United States is unique in its response because there is no chain of command for disaster response such as that which guides the military, Mr. Chertoff noted. As an example, he said, “The president can’t tell a governor what to do. In many instances, the governor can’t tell local responders what to do.” So, he continued, “That makes crisis communications all that more important.” Such communications don’t occur in a void, though, he noted. They are rooted in strong relationships among professionals, built upon cooperation and collaboration. It is also dependent upon people equipped and empowered to make decisions. “You must be decisive. You may make a mistake, but you are in a field that demands decisive leadership.”

With a nod to the mantra of the CPDM program, Mr. Chertoff added, “All disasters begin and end locally.” Consequently, he noted, the graduates are equipped to begin their careers in emergency management so long as they don’t lose sight of the key leadership roles they play in each of their communities.

About Mr. Chertoff
In addition to serving as DHS Secretary, Mr. Chertoff served as a Federal Judge on the U.S. Court of Appeals for the Third Circuit from 2003 – 2005 and Assistant Attorney General of the United States, Criminal Division from 2001 – 2003. Before that, he served as a federal prosecutor, investigating and prosecuting organized crime. Since leaving government service, Mr. Chertoff has co-founded The Chertoff Group, which specializes in risk identification, crisis management and strategic counsel on global security solutions.

About the UNC CPDM program
The CPDM graduate certificate program is the University of North Carolina’s comprehensive online disaster management program located in the Gillings School of Global Public Health. Developed in 2004 by one of the top departments of Health Policy and Management in the country, the CPDM certificate program has admitted over 350 students and has received high praise from professionals in the field.

UNCI am one of those graduates fortunate enough to be asked to speak to the benefits of the program at the commencement. I was privileged to share that, as a graduate of the program, “You are equipped to act in a crisis, even if it’s your first day on the job; you can build a coalition that is wide in scope, even if you are new to the community and not vested with official authority; and, you can lead efforts in your community to identify vulnerable citizens that will end up in our hospital anyway if we don’t prepare for their needs in a crisis.”

All of those have happened to me, just in the past 10 months at the hospital where I work in West Virginia.

I emphasized then – and now – that it is because of the UNC CPDM program that our hospital is able to lead healthcare system disaster response in our community, region and state. My own professional growth has accelerated because of the program. Of course, the program undeniably provided excellent instruction and practical use of basic emergency management processes, such as developing an HVA, writing an EOP, utilize HICS, and setting up a command center. But it offered something more – more vital perhaps. That is, confidence in a crisis, awareness of valuable community partners, and the knowledge to identify root causes to community risks.

© Michael Barrick / The Barrick Report, 2014. Contact him at

The New Reality: Hospitals Must Pay More for Disaster Preparedness

Disaster response is a cost of doing business

By Michael M. Barrick

The new reality about disaster response for hospitals is this: If you are going to be in business to care for the sick and injured– whether one at a time or in a mass casualty incident – get ready to pay for it. That’s the message as hospitals learn that federal grant funding for disaster preparedness is being reduced. The lack of terrorist attacks on the homeland and changing priorities in Congress has caused the grant money to slow to a trickle.

MoneyThis is causing hand-ringing in some hospitals. It shouldn’t. This news isn’t surprising. It is a discussion that has been going on for years in emergency management circles. In short, it should not be a surprise to hospitals that incurring the costs of patients – whether they come in one at a time or in groups – rests with the hospitals. So be it; disaster response is now a cost of doing business.

The timing couldn’t be better. Deregulation is the mantra of hospital leaders across the nation. Those of us in hospital leadership positions now have an opportunity to demonstrate that we can do the right thing without micromanagement from the government. We know the right thing to do. We’ve been trained. We’ve adopted NIMS and HICS. We’ve exercised. We’ve worked with more and more partners. We’ve learned about and drilled the NDMS and SNS. We continue to improve. So, this reduction in grant funding for disaster preparedness is a critical moment. Improvement will continue only with continued funding. Dithering over the matter is not an option. Grant money may dry up; disasters, however, will keep on happening.

The cost of caring for those injured in disasters is shifting more and more to hospitals. Whether one thinks that’s right or wrong, it is the new reality. The hospitals that budget for it now will be ready in the future. Let’s all hope we live in a community with hospital leaders that understand this new reality.

© Michael Barrick / Barrick Report, 2014.


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