Is it Time To Regionalize Preparedness?

Is it Time To Regionalize Preparedness?

The Federal Emergency Management Agency (FEMA) coordinates the Nation’s response to disasters through ten standardized administrative regions; the U.S. Department of Health and Human Services (HHS) does the same for health emergencies; each state Emergency Management Agency (EMA) and health department coordinates through a regional structure; EMA’s in large counties and municipalities divide their jurisdictions into geographically defined sectors, and fire and police departments have long used battalions and districts to manage operations. So why are such principles absent in preparedness?

Why do we not practice as we play? 

The State Has Got It

During lunch with a local health department director in the fall of 2012, I was told, “I do not understand how this regional system is supposed to help us.” I had recently left my position as the Chief of the State Health Department’s Division of Disaster Planning and Readiness, where I had spent three years, uncomfortably, aligning the regions of the State’s Public Health Emergency Preparedness (PHEP) Program and Hospital Preparedness Program (HPP).  Change is not always appreciated.

The seven unified regions were to support the development of regional Emergency Support Function #8 Teams that would coordinate regional preparedness activities.   And during response the teams would serve as Multi-Agency Coordination System (MACS).  She was not a fan of the effort. The Director’s health department serves a rural/urban county with a major state university that is surrounded by rural counties with few resources.   So I asked, “what if your university and the surrounding neighborhoods had been Joplin?”  “Well maybe, but the State…," she chopped back.

Yes, when a county and municipality is overwhelmed by a disaster, they can reach to the State Emergency Management Agency (EMA) - and wait.  You see, states are not as nimble as one’s neighbors.  Imagine a fire department waiting for the state to send a second alarm, instead of relying on established mutual aid agreements with neighboring departments.  How about a private hospital waiting for the state to deliver 18 gauge needles and a few cases of Normal Saline IV Fluid? 

By design, state EMAs are resource coordinators who seek first to quickly deliver local and regional assets, before those of the state.   And, like the federal government, they run disasters through a bureaucratic regional structure –a structure that ensures command and control, span of control, unity of effort, and financial accountability. 

The System

The principles of command and control, span of control, and unity of effort are inherent under the National Response Framework (NRF) and the National Incident Management System (NIMS).  But, such principles are absent in preparedness.  The irony is that federal preparedness programs are intended to make states and less dependent on the federal government, counties less dependent on states, municipalities less dependent upon counties, and the private healthcare system less likely to need public assets and facilities to manage medical surge.

You see, preparedness is really just PreSponse and PreCovery.  So why is there no regional layer to preparedness as there is in response?  Why do we not assess, plan, train, and exercise regionally?  Why do we not practice as we play?

The answer is simple; it is easier not to. Response is all hands on deck, whereas preparedness is other duties assigned.

It is far easier not to build and manage a regional preparedness coalition; it is far easier to avoid the conflict that occurs when jurisdictional interests collide in a contentious meeting; it is easier to assume that the hospital and long-term care center are required to, and will, handle their own problems, and it is easier to pretend that the private sector is a non-factor in public sector preparedness. 

Preparedness must embrace multidisciplinary engagement; it must engage the public, private, and not for profit sectors; it must cross jurisdictional borders; and it must mirror the operational realities of response.  In the catastrophic, operational reality does not run directly from the state Emergency Operations Center (EOC) to the local EOC.  Regional coordination is necessary to maintain a manageable span of control and allow for the nimble movement of regional assets.

Capability Alignment vs. Operational Alignment

So, how do we align preparedness activities with the operational realities of response?   Actually, the ball is already rolling in the healthcare sector.  First, lets understand capability alignment.

In 2012 the Assistant Secretary for Preparedness and Response (ASPR) and the Center for Disease Control and Prevention (CDC) initiated a new five-year project period that aligned the preparedness efforts of the public health and healthcare systems.  They did so in concert with FEMA to ensure that the Public Health Preparedness Capabilities: National Standards for State and Local Planning and the Healthcare Preparedness Capabilities: National Guidance for Healthcare System Preparedness would align as neatly as possible with the Nation’s Core Capabilities outlined in the National Preparedness Goal (NPG).

Yes, capability alignment is a great step forward. But, aligning preparedness capabilities is not the same as aligning preparedness with response and recovery.  Aligning capabilities helps ensure that regardless of which federal agency delivers the funding, all are working on related objectives toward the achievement of one goal –the NPG. Capability alignment does not unite people, build relationships, save money, or integrate people, planning, and operations. To do so requires a regional approach to preparedness, a team approach. 

Which takes us back to the 2012 alignment of PHEP and HPP.  ASPR’s National Healthcare Preparedness Program has taken the leap to promote regionalization through its cooperative agreements with the states. In 2012, they went beyond capability alignment to preparedness alignment by requiring grantees to require sub grantees to develop regional Health Care Coalitions (HCC).

In December, at the National Healthcare Coalition Preparedness Conference in Denver, Ms. Melissa Harvey, Acting Director of the National Healthcare Preparedness Program, announced that 459 health care coalitions were operating at the close of FY 2014. The models being used are varied, some being operated by hospitals, others by public health departments, and still others by hospital associations. But, the trend for urban and suburban coalitions is to establish independent 501c3 or 501c6 not-for-profit corporations to serve multi-county regions.

FEMA is now offering directed funding opportunities to state emergency management agencies to support formalization of independent regional preparedness coalitions operating in Urban Area Security Initiative (UASI).

In Iowa, preparedness officials at the State’s Health Department have opted to deliver both PHEP and HPP funding to their coalitions, which reduces the administrative burden and provides greater flexibility at the local level.   And more states are talking about routing PHEP funding through established regional healthcare coalitions to promote better collaboration between healthcare and public health.

Ms. Harvey pointed out in Denver that there is no perfect model that fits every state, or even every region in a state, which is why ASPR has given the states latitude with their coalition strategies.  She went on to say that the number of coalitions and their governance structures will continue to evolve as coalitions merge and restructure in an attempt to find the right balance between demographics, funding, and effectiveness. 

In his keynote at the National Health Care Coalition Preparedness Conference, Admiral Thad Allen stated, "if you've seen one coalition, you've seen one coalition." Well said! 

I leave you with a thought to ponder. Is a Hospital Coalition not a component of an HCC, is an HCC not component of an ESF-8 Coalition, and if so, is an ESF-8 Coalition not a component of a Whole Community Coalition?

Would it not be more efficient to build one preparedness coalition for each region?  Would it not make sense if coalitions aligned with the regions that each state will use in response?

 Stay tuned. This is important stuff!

About Karl Schmitt

Karl is the passionate Founder of  It is his Vision to reduce human suffering and loss of life caused by disasters and the responses to them, and his Mission to align the disaster preparedness programs of healthcare institutions with those of emergency management, public health, and others in the public, private, and not-for-profit sectors who care for the physical, mental, and spiritual health of people each day.  You can learn more about him here. He can be reached at

Karl Schmitt, MPA

Karl Schmitt, MPA

Karl is the Passionate Founder & CEO of bParati. He is on a mission to build a national network of effective, sustainable healthcare coalitions. More...

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Karl Schmitt, Passionate Founder & CEO, bParati

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