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Management in Practice

How do we manage disasters?

Healthcare is a field known for its complexity and fragmentation. Managing a massive cross-sectoral healthcare project is always a challenge. Coordinating the healthcare response to a disaster puts a strained system under even more pressure. John Piescik ’81 looked into the way the healthcare system responds to disaster for MITRE a not-for-profit company that operates three federally funded research and development centers. His findings may have implications well beyond healthcare, providing a means to manage solutions to some of the complex problems facing society.

Q: MITRE is researching disaster preparedness?

We were engaged to help with a congressionally mandated review of how effective the National Disaster Medical System is and what gaps exist.

Our report is still under review, but it gets into an interesting set of questions: what happens if different disaster scenarios from terrorist attacks to hurricanes, earthquakes, or low-yield nuclear explosions unfold? What are the medical capabilities in various regions? It sounds like a simple topic but in order to address it you need to look at the response capabilities on paper and how much it might degrade once a disaster happens.

Emergencies strain resources and break systems. Hospitals flooded out in New Orleans, and all of a sudden instead of being part of the solution they were part of the problem because their patients needed to be evacuated. What we do in many respects is help our clients see where a system is going to break. That is classic engineering thinking: model it, see what’s going to break, and fix it.

Q: What are the key issues for the healthcare system in responding effectively to a disaster?

One issue is that there are so many independent parties to be coordinated. We talk about having a national response capability but constitutionally we have federal, state, and local governments, and all kinds of private entities, so the concept of a national plan is challenging.

Then execution in an emergency becomes even more challenging because your plans break down in the face of reality. There’s the old saying in the military that no plan ever survives contact with the enemy. And disaster plans don’t survive contact with a disaster, though if you have them, you are better prepared.

Q: What does having the plan enable you to do better?

Planning enables you to buy materials, train people, raise public awareness when appropriate, and practice and improve your response through drills and simulations. There is a whole set of logistical questions. If you start with health impacts, how fast do they occur? How fast do they have to be addressed? How fast can we move assets into place? If we have displacement of a population and people have left behind their prescription medications, how do we restore a health maintenance capability?

You would not expect it, but that gets you into questions like, “Would we be better off with electronic health records in an emergency situation?” One of the things that came out of Katrina was that the answer is yes. Patients in the VA system who had to be moved had electronic records that weren’t destroyed. Many other people had paper records; those were lost in flooding.

Katrina and Rita were probably the largest tests of post-9-11 response planning that we have had, so far. There is a huge volume of congressional testimony and reports as well as media coverage. And we interviewed people involved in coordinating aspects of that response.

There was an idea that doctors and nurses can flock to the disaster to volunteer and they can all help. One of the really prominent findings was that unless they are organized into teams and come with their own materiel in more of a deployment model, volunteers often create difficulties in the early stages.

There is a sequence to a coordinated response. It has to be thought through. There are so many entities potentially involved that you have to have preexisting institutional arrangements, contracts, and in many cases relationships to make it work properly.

Everybody is going to have a day job that they are doing steady-state. But in a steady-state world, people get comfortable with moving at a certain pace and not really gearing up for an emergency situation. When you have an emergency, it is the same people responding. So how do you flip a switch and change from Clark Kent into Superman?

Some of it is that they will work longer hours and be heroic, but a lot depends on the support systems working, getting the right equipment and the right medicine and the right information where it needs to be, coordinating all facets of what goes on during an emergency. Command and control in an emergency is really important. As you get outside of traditional emergency responders you have to figure out how to achieve scalable command and control that involves people who aren’t regularly drilling together.

The mere fact that we know we will need x amount of a resource type doesn’t mean that some guy won’t be enforcing a road block mindlessly and preventing it from coming through. The real stories from Katrina were, in many cases, just breakdowns of communications.

Q: Where are you taking this work?

This got me interested in how you really coordinate planning across boundaries, across state and federal and nonprofit- and private-sector lines. What makes programs that seek massive change that crosses organizational boundaries, which I call “megachange,” succeed or fail? There is a sort of sociopolitical cloud cover that you want to see through to map the terrain ahead of a massive change program.

We’ve modeled some key variables and hope to work on a methodology for something we call stakeholder workshops. This is an engagement process where we’d take the information from this map, make it available to a representative group of stakeholders, engage them in plotting a course for this change that can meet most people’s objectives. The idea is to engage the stakeholders earlier than is traditionally done in getting a path staked out because otherwise you may have to wait for a legislative process that might take years to play out.

There are whole classes of policy issues where engaging knowledgeable stakeholders to kick around possibilities can expedite decision-making. What happens if you try to do this as a policy maker on your own is you will a) think of a smaller universe of things that could be done and b) make assumptions that are unrealistic.

What you really want to do is find cooperative strategies as early as you can. Then as you move through the process revisit your assumptions periodically with all the stakeholders and see what needs to be adapted to make it work better.

Q: Where might this be applied in future years?

It certainly has applications in emergency preparedness and response, in joint military operations and data sharing in the intelligence field, the air traffic system, education or healthcare reform. In any major national issue these days, you are getting beyond single-agency solutions because the low-hanging fruit has been plucked in most cases.

Q: How can this work impact business more broadly?

First, I think management education should prepare executives to be conscious of the implications of disasters and emergencies for their business, including continuity of operations planning, work force protection, and their roles in responding to emergencies as good corporate citizens. Why not work through a disaster case? Second, managers in the public and private sectors need to better understand the challenges of leading cross-boundary change.

Interview conducted and edited by Ted O’Callahan.