Public Health Emergencies: HHS Needs to Better Communicate Requirements and Revise Plans for Assessing Impact of Personnel Reassignment
Published: 2017-01-09T00:00:00

Fast Facts:
In a public health emergency—such as a flu pandemic or natural disaster—staff at state and local health departments may need extra help responding. In such cases, personnel funded by certain Health and Human Services programs may be reassigned from their regular duties to help with emergency response.
While no state has needed to request this help yet, we looked at how HHS plans to approve reassignment requests and to analyze whether reassignment was helpful during the emergency. We found that, among other things, HHS had no plans to analyze the impact of any reassignments on emergency response. We recommended it develop such a plan.

Highlights:
section_title: Why GAO Did This Study
paragraphs: HHS provides funding to state, local, and territorial entities to help them prepare for and respond to public health emergencies, such as influenza pandemics and other threats. However, states have reported not having sufficient personnel to assist in public health emergencies. The Pandemic and All-Hazards Preparedness Reauthorization Act of 2013 (PAHPRA) authorized HHS to allow states and tribes to temporarily reassign personnel funded, in whole or in part, by HHS programs to aid in public health emergency response.
PAHPRA included a provision for GAO to examine the impact of the reassignment authority. However, the authority has not yet been used. Therefore, this report examines the processes HHS has in place to review states' and tribes' requests for temporary reassignment and evaluate the after-action reports states and tribes are to submit after they have used the authority. GAO reviewed HHS guidance and interviewed officials from HHS and five states selected based on their increased risks for public health emergencies and levels of prior federal grant funding received.
section_title: What GAO Found
paragraphs: The Office of the Assistant Secretary for Preparedness and Response (ASPR), within the Department of Health and Human Services (HHS), has primary federal responsibility for overseeing medical and public health preparedness and response and coordinating the reassignment of personnel in a public health emergency. ASPR has developed processes to review and approve states' and tribes' requests for personnel reassignment. Should ASPR receive a request for personnel reassignment, it would convene relevant officials from the HHS agencies and offices from which states were requesting reassignment, with the goal of the agencies and offices considering requests and ASPR communicating reassignment decisions within four days. However, ASPR's efforts to communicate these processes to the HHS agencies and offices that administer programs eligible for personnel reassignment have been limited.
Program officials—personnel responsible for day-to-day administration of programs eligible for reassignment—from two HHS agencies told GAO that they were generally unaware of the reassignment authority, ASPR's processes and time frames for reviewing and approving requests, or the program officials' expected role in approving requests.
ASPR officials said that the office did not conduct targeted outreach to HHS agencies and offices to inform them of its processes, requirements, or expectations, noting that these entities should be aware of them through other channels, such as during the vetting of guidance on the use of the reassignment authority through HHS. However, officials from one agency said program officials are typically not directly involved in the vetting process.
Conducting outreach to HHS agencies and offices on ASPR's reassignment requests, review processes, and time frames would be consistent with federal internal control standards for information and communication, and would improve HHS agencies' and offices' awareness of expected roles, thereby preventing potential delays in decision making in the event of a public health emergency.
ASPR has assigned responsibility for reviewing after-action reports to HHS agencies and offices—an expectation program officials were also unaware of—and does not plan to conduct its own evaluations of the reports. HHS requires states and tribes that use the authority to submit after-action reports containing information on how the reassignment assisted their emergency response. In assigning report review responsibility to HHS agencies and offices, ASPR officials said that the HHS agencies and offices will be better able to identify the effect of the reassignments on their programs and take corrective actions as needed. However, ASPR's approach does not address the need to comprehensively assess the impact of reassignment on emergency response across HHS. Conducting its own evaluations of the after-action reports would be consistent with the federal internal control standard for monitoring, and would allow ASPR to determine whether the reassignment authority provides helpful resources for states' public health emergency response, as well as assess the effect of the authority across all participating HHS agencies and offices.
section_title: What GAO Recommends
paragraphs: GAO recommends that HHS direct ASPR to (1) conduct outreach to HHS agencies and offices to inform them of ASPR's processes, expectations, and requirements for the reassignment authority; and (2) develop a plan to evaluate after-action reports to assess the authority's impact on emergency response and medical surge. HHS agreed with both recommendations and provided information on how ASPR plans to implement them.

section_title: Letter
paragraphs: The Department of Health and Human Services (HHS) provides funding  to state, local, and territorial entities to help them prepare for and respond  to public health emergencies, such as influenza pandemics, natural  disasters, and other public health threats. After the H1N1 influenza  pandemic of 2009, states receiving HHS preparedness funds reported  that one barrier to their response efforts was not having sufficient  personnel to assist in the response. The Pandemic and All-Hazards  Preparedness Reauthorization Act of 2013 (PAHPRA) established a new  authority allowing the HHS Secretary to authorize state or tribal  governments to temporarily reassign—on a voluntary basis—state, local,  and tribal public health personnel funded, in whole or in part, by certain  federal programs to assist in public health emergency response. In order  for a governor or tribal leader to request personnel reassignment, the  HHS Secretary must have declared a federal public health emergency  that includes areas in the state or tribal area. PAHPRA also requires  governors or tribal leaders (or their designees) to submit certain  information with the reassignment request. HHS requires states and  tribes that use the reassignment authority to subsequently submit reports,  known as after-action reports, containing information on, among other  things, how the reassignment assisted them in responding to the public  health emergency; how, if applicable, medical surge capacity was  improved through reassignment; and the impact the reassignment had on  the funded programs from which personnel were reassigned.
PAHPRA includes a provision for GAO to review the impact of the  temporary reassignment authority on states’ and tribes’ public health  emergency response. However, to date, no state or tribe has requested to  use the reassignment authority. Therefore, this report examines the  processes HHS has in place to review states’ and tribes’ requests to use  the temporary reassignment authority and evaluate their after-action  reports on the use of this authority.
To determine the processes HHS has in place to review states’ and  tribes’ requests to use the temporary reassignment authority and to  evaluate their after-action reports on its use, we reviewed HHS guidance  and other relevant documents that provide information on the temporary  reassignment authority and compared the processes described in these  documents with federal internal control standards. We interviewed  officials from HHS’s Office of the Assistant Secretary for Preparedness  and Response (ASPR) about their plans for reviewing and approving  reassignment requests and for evaluating after-action reports on the use  of the authority. We also interviewed officials from two HHS agencies that  administered the largest number of programs eligible for reassignment.  Further, we interviewed officials from relevant stakeholder associations,  such as the Association of State and Territorial Health Officials and  National Indian Health Board, and five selected state departments of  health to obtain information on HHS’s coordination and communication  with them regarding the use of the authority, requirements for submitting  reassignment requests and reports on their use of the authority, and the  nature and extent of any HHS evaluations of the required reports. In  determining which states to select, we considered those states that (1)  received the largest amounts of federal grant funding in fiscal year 2015  to prevent terrorism and other catastrophic events, (2) are at higher risk  for natural disasters (e.g., hurricanes, tornadoes, and earthquakes) that  have the potential to result in public health emergencies, based on their  geographic location, and (3) have the largest American Indian and Alaska  Native populations (based on 2010 census information). The results of  our analysis are intended to be illustrative; they are not generalizable to  all state departments of health.
We conducted this performance audit from March 2016 to January 2017  in accordance with generally accepted government auditing standards.  Those standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives.
subsections: section_title: Background
paragraphs: Natural disasters and infectious disease outbreaks, such as hurricanes  Katrina and Sandy and the 2009 H1N1 influenza pandemic, have raised  concerns about the ability of health care systems to “surge”—that is, to  have the staff, resources, and equipment in place to adequately care for  increased numbers of injured or ill individuals, or individuals with unusual  or highly specialized needs. HHS has funded state, local, and territorial  entities to help assist them in building their medical and public health  emergency preparedness and response capabilities so that they can  more effectively address these emergencies. This funding has been  provided primarily through Hospital Preparedness Program (HPP) and  Public Health Emergency Preparedness (PHEP) program cooperative  agreements—administered by HHS’s ASPR and Centers for Disease  Control and Prevention (CDC), respectively.
HPP and PHEP generally fund activities to achieve specified  preparedness goals. Accordingly, ASPR and CDC officials indicated that  this funding is primarily available to support the development of  preparedness capabilities and capacity and may be available to support  emergency response activities in certain circumstances only. This  limitation led to some states’ concerns about the lack of sufficient  personnel to assist in the 2009 H1N1 response.
Appendix I provides additional information on the impact of HHS’s  cooperative agreement funding on state and local medical surge capacity  in public health emergency response.
HHS also administers programs that provide funding to state and tribal  governments that, among other things, allows them to hire public health  personnel to carry out certain activities, such as tuberculosis prevention  and control activities. These personnel could be eligible for reassignment  under PAHPRA in cases where the respective state or tribe was  attempting to increase their ability to surge. Specifically, personnel eligible  for reassignment under the authority include state, local, and tribal  personnel funded in whole or in part through programs authorized under  the Public Health Service Act. HHS has identified about 100 Public Health  Service Act-authorized programs across the department that are eligible  for the reassignment authority—including, for example, CDC’s  tuberculosis program and the Health Resources and Services  Administration’s (HRSA) Ryan White HIV/AIDS program. Personnel  eligible for reassignment may include administrative or leadership staff;  environmental health specialists; epidemiologists; medical officers and  nurses; safety and health specialists; mental and behavioral health  personnel; and technical, logistical, or other support personnel. Public  health emergency activities in which these personnel might assist include  identifying and transporting patients to health care facilities or alternate  care sites, managing mass fatalities, and helping to distribute medical  countermeasures from federal and state caches.
subsections: section_title: Requirements for the Temporary Reassignment Authority
paragraphs: The HHS Secretary delegated responsibility for reviewing and approving  state and tribal requests for voluntary temporary reassignment to the HHS  agency or office responsible for administering the program from which  staff may be reassigned, with HHS’s ASPR responsible for coordinating  the review process. If approved, reassignment authorizations are valid for  no more than 30 days or until the HHS Secretary determines that the  public health emergency no longer exists, whichever comes first.
HHS has issued guidance regarding the circumstances in which the  reassignment authority can be used, its requirements, and an overview of  federal, state, and tribal responsibilities under the authority. The guidance  for the temporary reassignment authority, which was developed by an  intradepartmental workgroup led by ASPR, outlines the information states  and tribes are required to submit when requesting use of the authority,  such as the number of personnel to be reassigned, the federal program  from which they are requesting reassignment, and assurance that the  state’s or tribe’s current public health workforce cannot adequately and  appropriately address the emergency without additional personnel. The  guidance also notes that states and tribes that use the reassignment  authority will be directed to submit after-action reports to ASPR within 120  days of the termination of the authorization. HHS published a notice of  availability of the proposed guidance in the Federal Register in October  2013, providing a 60-day public comment period. According to ASPR  officials, HHS finalized the guidance in August 2015; HHS published the  notice of the availability of the final guidance in the Federal Register in  April 2016. ASPR also posted the guidance on its website.
section_title: ASPR’s Processes for the Reassignment Authority Were Not Well Communicated, and It Does Not Plan to Assess the Authority’s Impact on Emergency Response
paragraphs: HHS’s ASPR has developed processes for HHS agencies and offices to  review and approve states’ and tribes’ requests to temporarily reassign  federally funded personnel in public health emergencies and to review the  after-action reports these entities are required to submit on the effect of  the personnel reassignment. ASPR’s initial efforts to communicate  information about these processes to states, tribes, and HHS agencies  and offices were limited, though the office has begun to improve  communication efforts to state and tribal public health officials. In addition,  rather than conducting its own evaluations, ASPR plans to assign  responsibility for reviewing after-action reports to the HHS agencies and  offices that administer the programs from which personnel were  reassigned, but which are generally not responsible for assessing the  impact of the reassignment authority on public health emergency  response.
subsections: section_title: ASPR Has Developed Processes to Review Reassignment Requests and After-Action Reports
paragraphs: ASPR, as the designated HHS coordinator for the reassignment authority,  has developed processes for implementing the reassignment authority  and reviewing the after-action reports states and tribes are to submit.  When states and tribes request to use the reassignment authority, ASPR  will coordinate with the relevant HHS agencies and offices that administer  the funding programs from which personnel are requested to be  reassigned to review and approve requests and communicate decisions  back to states and tribes. In September 2016, ASPR finalized a written  procedure to supplement the April 2016 reassignment guidance. This  procedure provides additional information on HHS’s roles, responsibilities,  and time frames for reviewing and approving reassignment requests.  According to the procedure, ASPR anticipates that HHS’s review and  approval process will take as many as four business days: one day for  ASPR to forward the request to the relevant HHS agencies and offices,  two days for these agencies and offices to review the request and  communicate the decision back to ASPR, and one day for ASPR to  communicate that decision to the requesting state or tribe. ASPR noted  that the review and approval process could be expedited as necessary.  For the after-action reports, officials told us that ASPR plans to assign  responsibility for their review to the HHS agencies and offices from which  personnel are reassigned.
section_title: Efforts to Communicate Processes to Stakeholders Have Been Limited
paragraphs: From the time the reassignment authority was established in 2013  through early 2016, ASPR provided limited information about states’ and  tribes’ requirements for submitting reassignment requests and HHS’s  processes and anticipated time frames for reviewing and approving them.  ASPR’s initial communications provided general information only on the  availability of the reassignment authority. In addition to publishing the  availability of the 2013 proposed guidance on the reassignment authority  in the Federal Register, ASPR and CDC jointly developed supplemental  information for HPP and PHEP awardees in 2014 that included  information about the availability of the reassignment authority, the  eligibility of states and tribes to request this authority, and the publication  of the proposed guidance. More recently, ASPR officials noted that they  included information on personnel reassignment during an exercise at a  2015 preparedness summit convened by the National Association of  County and City Health Officials, and presented information about the  reassignment authority during a 2015 homeland security conference.
ASPR’s initial communication efforts, however, may have not reached a  broad audience of states and tribes, or contained up-to-date information.  For example, public health officials from all states or tribes may not have  attended the 2015 preparedness summit or participated in the exercise. In  addition, while some public health officials may attend homeland security  conferences, these events are typically targeted to homeland security,  law enforcement, and emergency management officials. These officials  may be located in separate departments from public health officials,  depending on how the state is organized, and are unlikely to be the  officials who would be requesting personnel reassignment or submitting  after-action reports. ASPR officials told us that the office also provided  the attendees at the June 2015 homeland security conference with  information contained in the 2013 proposed guidance; however, ASPR  subsequently updated the guidance to include certain changes that were  issued in the 2016 final guidance. For example, the final guidance  contains information about ASPR’s process for coordinating and  reviewing reassignment requests and approvals, anticipated time frames  for doing so, and expectations for HHS agencies to participate in the  approval process. The final guidance also increased the amount of time  states and tribes have to submit after-action reports from 90 to 120 days  after the personnel reassignment period ends, and provides notice that  submitting required after-action reports is tied to the award of program  funds. ASPR officials told us that the availability of the authority was not  dependent on the publication or finalization of the guidance, and that  states and tribes would become familiar with processes and requirements  as a result of using the authority in actual public health emergencies.
Public health officials from the five states we reviewed were unaware of  ASPR’s planned processes for reviewing reassignment requests and  after-action reports, and most noted that additional direct outreach to  provide information or required request forms would be useful. While  these officials were generally aware of the reassignment authority  provided by PAHPRA, none of them were aware that the reassignment  guidance had been finalized in April 2016 until we shared this information  with them in summer 2016. Officials from three of these five states were  also not aware of the 2013 proposed guidance, which had established  specific requirements for submitting requests and after-action reporting  responsibilities. Officials from three states we reviewed said that they  generally anticipated having enough personnel to respond to public health  emergencies and would likely not need to request further assistance.  However, officials from one of these states, as well as officials from the  two remaining states in our review, told us that they would potentially use  the authority in protracted public health emergencies that were at least  several weeks in duration or catastrophic enough to overwhelm state  resources. For example, officials from one state believed that the  authority would be useful in protracted emergencies even with their  estimation that it would take 10 to 14 days both for the state to prepare  the reassignment request and for HHS to approve it.
Since the time that we spoke to selected states for this review, ASPR has  developed additional information and documents for the reassignment  authority and plans to increase its communication efforts. For example, in  addition to the September 2016 written procedure to guide HHS’s review  and approval processes, ASPR finalized a personnel reassignment  request template in October 2016 and posted it on the ASPR temporary  reassignment website. ASPR officials told us that the office included the  reassignment authority and guidance as part of a discussion on grants  management at a late October 2016 meeting for state directors of public  health preparedness held by the Association of State and Territorial  Health Officials. ASPR officials also said that they planned to provide  information about the reassignment authority and guidance at the next  annual National Association of County and City Health Officials  preparedness summit scheduled for April 2017, and during regular  meetings that ASPR and CDC hold with HPP and PHEP awardees.
ASPR provided limited information to the HHS agencies and offices that  administer eligible funding programs about the processes for reviewing  and approving requests, reviewing states’ and tribes’ after-action reports,  or specific details about requirements for reassignment requests or after- action reports. The federal internal control standard for information and  communication states that effective communication with internal parties is  necessary to achieve an entity’s objectives. This standard calls for  management to communicate information down and across reporting  lines to enable personnel to perform key roles in achieving objectives.  ASPR officials told us that HHS agencies and offices should be aware of  the requirements for reviewing and approving states’ and tribes’ requests  because ASPR vetted the proposed guidance throughout the department.  ASPR officials also said that HHS agencies and offices had the  opportunity to review the final guidance, which incorporated public  comments, during the vetting process that occurred from 2014 to 2016. In  August 2016, ASPR finalized language regarding the availability of the  reassignment authority for eligible funding programs and requested that  HHS disseminate this language to HHS agencies and offices for them to  include in their future funding opportunity announcements. In addition,  ASPR officials told us that it vetted its September 2016 written procedure  through HHS. ASPR plans to continue to provide information about the  authority to HPP and PHEP awardees in regular meetings but has no  plans to provide additional information to the HHS agencies and offices  that administer other programs eligible for reassignment.
HHS program officials who are likely to be asked by ASPR to review and  approve temporary reassignment requests and review after-action reports  may not be aware of their responsibilities for these activities through such  vetting of the guidance, and these officials may not have seen either  version of the guidance or the written procedure. For example, HRSA  officials we interviewed said that program officials are not directly involved  in their agency’s vetting process, which usually occurs at the senior  management level. ASPR officials told us they would contact relevant  HHS grants management staff, including program officials, when they  received a reassignment request. However, the agency has not created a  roster of specific program officials: those grants management and other  staff responsible for day-to-day management of eligible funding programs  who would be charged with approving reassignment requests. Instead,  ASPR officials said the office would coordinate with the other HHS  agencies and offices that may be able to help facilitate the approval  process with their agency’s grants management staff and program  officials. In addition, neither the final guidance nor the written procedure  provides direction on how HHS agencies and offices are to review states’  and tribes’ after-action reports.
Our interviews with officials from selected CDC and HRSA programs  confirmed that these officials were not aware of the reassignment  authority and the related guidance, ASPR’s expectations regarding rapid  convening of program officials to make decisions on reassignment  requests, or their responsibilities for reviewing after-action reports. While  officials from CDC’s and HRSA’s public health emergency response  offices told us that they were aware of the authority and the guidance,  they acknowledged that they had not discussed any information regarding  the authority with the agencies’ program officials. HRSA’s emergency  coordinator told us that he is generally familiar with the purpose of after- action reports. As such, while HRSA does not have a plan to review the  after-action reports, the agency is aware that it can use these reports to  determine what effect, if any, personnel reassignment had on meeting the  program’s original goals, identify any needed corrective actions, and  execute those actions, according to this official. However, without more  specific outreach on the part of ASPR about decision making for  reassignment requests, reporting requirements, and its process for  reviewing after-action reports, HHS officials that administer the funding  programs may be unaware of their expected roles in reviewing and  approving reassignment requests and reviewing after-action reports,  which may negatively affect states’ and tribes’ public health emergency  response.
section_title: ASPR Does Not Plan to Evaluate the Impact of the Reassignment Authority on Public Health Emergency Response
paragraphs: ASPR will not be able to fully assess the impact of personnel  reassignment on public health emergency response because it does not  plan to conduct its own evaluations of states’ and tribes’ after-action  reports. Instead, according to ASPR officials, it plans to assign  responsibility for reviewing these reports to the HHS agencies and offices  that administer the programs from which personnel were reassigned,  because ASPR believes that these other HHS agencies and offices are  better able to identify the effect of the reassignment on their funding  programs and take corrective action as needed.
However, ASPR is the federal office with primary responsibility for  overseeing medical and public health preparedness and response.  Therefore, its assigning of sole responsibility for reviewing after-action  reports to other HHS agencies and offices is contrary to the federal  internal control standard for monitoring, which calls for management to  evaluate the results of monitoring activities to identify internal control  issues and for the oversight body to conduct evaluations across the  organization and take corrective action. Because some of the  information that ASPR requires states and tribes to report—specifically,  those elements related to the effect of personnel reassignment on  emergency response and medical surge capacity—is generally outside  the responsibility of the other HHS agencies and offices, this information  may not be fully or appropriately monitored and assessed across the  department if ASPR does not conduct its own evaluations. Specifically,  without evaluating after-action reports to determine the impact on  emergency response, ASPR will not be able to comprehensively  determine whether the reassignment authority is useful in providing  resources for states and tribes to respond to public health emergencies  and improve medical surge. ASPR will also be unable to provide technical  assistance to states and tribes related to improving their use of the  authority, if needed, or seek any necessary changes to the authority or  the guidance.
section_title: Conclusions
paragraphs: Given the need to respond quickly to public health emergencies that have  the potential to overwhelm states’ and tribes’ medical and public health  resources and severely delay the provision of critical medical services for  affected individuals, HHS agencies and offices should have a thorough  understanding of their responsibilities in reviewing requests to use the  temporary reassignment authority. Therefore, HHS and, specifically,  ASPR, would benefit from conducting targeted, timely outreach to other  HHS agencies and offices to provide information on HHS’s processes,  expectations, and requirements for using the authority prior to any further  federal public health emergency declarations. In addition, given its  responsibility for federal medical and public health preparedness and  response, ASPR would benefit from conducting its own comprehensive  evaluations of states’ and tribes’ after-action reports on the effect of the  authority on public health emergency response, including medical surge.
section_title: Recommendations
paragraphs: To help ensure that HHS agencies and offices fully understand the  requirements and processes for the temporary reassignment authority,  their responsibilities under the authority, and that ASPR is adequately and  comprehensively assessing the effect of the authority on public health  emergency response and medical surge, we recommend that the  Secretary of HHS direct ASPR to take the following two actions:
ASPR should conduct outreach to HHS agencies and offices that  administer programs eligible for the reassignment authority to inform  them of their responsibilities and ASPR’s expected time frames for  reviewing and approving states’ and tribes’ requests for personnel  reassignments, and inform them of their responsibilities and ASPR’s  expectations for reviewing states’ and tribes’ after-action reports.
ASPR should develop a plan to evaluate states’ and tribes’ after- action reports to assess the impact of the reassignment authority on  states’ public health emergency response and medical surge and to  provide technical assistance as necessary.
section_title: Agency Comments and Our Evaluation
paragraphs: We provided a draft of this report to HHS, and its comments are reprinted  in appendix II. In its comments, HHS concurred with both of our  recommendations. For the first recommendation that ASPR should  conduct outreach to HHS agencies and offices that administer the  programs eligible for reassignment, HHS told us that ASPR intends to  continue to provide information on reassignment procedures through the  information posted on its website and sharing language to describe the  applicability of the authority to specific grants with HHS agencies and  offices that administer the eligible programs. In addition, ASPR plans to  continue to provide reassignment information during regular meetings  with HPP and PHEP awardees and public health preparedness meetings  with relevant stakeholder associations. We encourage ASPR to expand  its outreach beyond including reassignment information in eligible funding  announcements to include those HHS agencies and offices that  administer eligible programs other than HPP and PHEP.
For the second recommendation that ASPR develop a plan to conduct its  own evaluations of after-action reports, HHS provided information on  ASPR’s corrective action process for learning from and improving on past  emergency response and told us that ASPR plans to incorporate reviews  of states’ and tribes’ after-action reports into these corrective action  reviews in the future, as applicable. In addition, HHS provided technical  comments, which we incorporated, as appropriate.
We also provided relevant sections of the draft report to state  departments of health for the five states in our review (California, Florida,  New York, Texas, and Washington) and incorporated their technical  comments, as appropriate.
We are sending copies of this report to the Secretary of Health and  Human Services and appropriate congressional committees. In addition,  this report is available at no charge on the GAO website at  http://www.gao.gov.
If you or your staff have any questions about this report, please contact  me at (202) 512-7114 or curdae@gao.gov. Contact points for our Offices  of Congressional Relations and Public Affairs may be found on the last  page of this report. GAO staff who made key contributions to this report  are listed in appendix III.
section_title: Appendix I: Examples of the Impact of Federal Preparedness Funding on Medical Surge Capacity and Public Health Response
paragraphs: In mass casualty public health emergencies, such as natural disasters,  infectious disease outbreaks, or intentional attacks, health care facilities  and public health departments would need the ability to surge—that is, to  have the staff, resources, and equipment in place to adequately care for  increased numbers of injured or ill individuals or individuals with unusual  or highly specialized needs, including identifying alternate care sites and  managing personnel and volunteers. The Department of Health and  Human Services (HHS) provides funding through Hospital Preparedness  Program (HPP) and Public Health Emergency Preparedness (PHEP)  program cooperative agreements to assist state and local public health  agencies in building their public health emergency preparedness and  response capabilities, including for medical surge. To provide examples  of the impact that HPP and PHEP funding has had on awardees’ medical  surge capacity, we reviewed literature, interviewed public health officials  from five selected states, and reviewed information from the HHS Office  of the Assistant Secretary for Preparedness and Response (ASPR)  website. Examples from the literature review are from peer-reviewed  sources.
subsections: section_title: Examples from the literature review
paragraphs: We reviewed literature published between 2011 through May 2016 from  multiple U.S. sources, including scholarly and peer-reviewed materials;  government reports; trade or industry articles; books; conference papers;  association, nonprofit, and think tank publications; working papers; and  congressional hearings and transcripts. We identified two peer-reviewed  articles that provided examples of how HPP or PHEP funds assisted in  public health emergency response. In one article, representatives from  the North Dakota Department of Health reported on how HHS funding  helped it prepare for and respond to river floods in 2009, 2010, and 2011,  including in the areas of medical surge, medical material management,  and volunteer management. For example, to manage medical surge,  North Dakota had previously used HPP and PHEP funding to purchase  kits to convert buses into emergency transport vehicles that allowed for  wheelchair and stretcher transport, which the state used in its response to  the 2011 floods. According to the article, these converted buses were less  costly than ambulances used in previous floods. In addition, North Dakota  had previously implemented a patient tracking database, which required  all hospitals, long-term care facilities, and emergency medical services  responders in the state to agree to use a triage and tagging process. The  database and triage process provided unique identifiers and transport  requirements for each patient, as well as identifying patients requiring  priority placement, such as those patients undergoing dialysis. During the  2011 floods, North Dakota used the database to document patients’  evacuation to alternate health care facilities and then to discharge (or  death). In the area of volunteer management, North Dakota had  previously used HPP funding to contract with licensure boards to provide  regular and automatic uploads of licensure information from licensure  databases, which allowed the state to expand its pool of volunteer health  professionals during the 2011 flood response from those volunteers  previously registered with the state. In addition, in 2011, North Dakota  improved its credentialing process to allow for rapid, provisional  credentialing of “spontaneous” medical volunteers—those volunteers who  showed up to response sites to assist but were not previously registered  in the volunteer database.
Another article described how HPP funding helped various North Carolina  organizations, such as North Carolina’s Wake County Department of  Emergency Medical Services and hospitals in the Raleigh-Durham area,  prepare for and respond to an explosion at an industrial plant in June  2009. Under the HPP component of surge planning for burn injuries, the  burn surge program developed by North Carolina included providing  education for those clinicians working outside of burn centers, planning  for emergency medical services surge, medical triage, and regional  hospital coordination. As a result of this planning, all 68 individuals injured  during the explosion were evaluated at the three level I trauma centers  and three community hospitals in the Raleigh-Durham area by the end of  the day. According to the article, the state’s planning efforts contributed  to an effective response and positive patient outcomes, including  improvements in response times from prior public health emergencies.
section_title: Examples from interviews with state public health officials
paragraphs: Officials from all five states in our review provided examples of how HPP  or PHEP funding assisted in public health emergency response.
According to officials from the Florida Department of Health, after the  June 2016 shooting at the Pulse nightclub in Orlando, Florida, which  resulted in 50 fatalities, the department activated its emergency  mortuary operations response system, a public-private partnership  that had been previously established by HPP and PHEP funding.  Officials told us that the department received the request for  resources at 8 a.m. on the morning after the shooting and had  mortuary response volunteers onsite 90 minutes later to assist with  autopsies and victim identification.
After an explosion at a fertilizer plant in West, Texas, in 2013, the  state was able to assemble dozens of ambulances, set up a field  hospital, and convene clinicians to treat casualties in a matter of hours  through capabilities and systems previously established by HPP and  PHEP funding, according to an official from the Texas Department of  State Health Services.
In addition, public health officials from the three other states in our  review—California, New York, and Washington—provided information  on how HPP and PHEP funding helped support emergency response.  Specifically, these states were able to use HPP and PHEP funding to  establish systems and purchase resources to coordinate evacuations  of health care facilities during wildfires in California and Washington  and hurricanes Irene and Sandy in New York; access provider  networks to provide timely behavioral health care after the December  2015 mass shooting in San Bernardino, California; and coordinate  and manage volunteers to assist with victim identification after a  March 2014 landslide decimated a town of 43 people in Washington.
section_title: Other sources of information
paragraphs: ASPR also collects examples of how HPP funding has enhanced medical  and public health emergency response on its website. For example, HPP  funding has been used to establish communications systems, systems for  tracking and triaging patients, and coalitions of health care facilities to  assist in the response to the May 2015 derailment of an Amtrak train in  Philadelphia; to purchase interoperable communications equipment to  assist in making evacuation decisions during wildfires in Colorado in  2013; and to establish a drive-through seasonal influenza vaccination site  in Virginia in October 2015.
section_title: Appendix II: Comments from the Department of Health and Human Services
section_title: Appendix III: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact:
paragraphs: Elizabeth H. Curda, (202) 512-7114 or curdae@gao.gov.
section_title: Staff Acknowledgments:
paragraphs: In addition to the contact named above, Karen Doran, Assistant Director;  Shana R. Deitch, Analyst-in-Charge; and Shaunessye D. Curry made key  contributions to this report. Also contributing were George Bogart, Sarah  Gilliland, and Drew Long.