Public Health Preparedness: HHS Should Take Actions to Ensure It Has an Adequate Number of Effectively Trained Emergency Responders
Fast Facts
Medical emergency responders (e.g. doctors and nurses) enrolled in a Department of Health and Human Services program can be called up and sent to help states and localities in a public health emergency.
But HHS doesn’t know if it has enough responders available with the critical skills and competencies needed for current or future emergencies. In 2017, for example, HHS had a responder shortage and relied on the Department of Defense to provide medical care.
Also, HHS needs to evaluate its training to ensure that it effectively prepares responders for national emergencies like the COVID-19 pandemic. Our 5 recommendations address these issues.
HHS Medical Emergency Responders at a Response Preparation Briefing
Response team personnel
Highlights
What GAO Found
Major natural disasters in the past 3 years, as well as the COVID-19 pandemic, have heightened attention to the nation's ability to respond to these types of emergencies. The Department of Health and Human Services (HHS) is responsible for leading the public health and medical response to emergencies. HHS responded to COVID-19, in part, by deploying responders enrolled in the National Disaster Medical System (NDMS). These individuals, such as doctors and nurses, generally work outside the federal government and are federal employees used intermittently. In 2018, HHS developed an enrollment target for NDMS of 6,290 responders, but GAO found HHS did not follow key principles of effective strategic workforce planning in developing this target. For example, HHS did not identify the critical skills and competencies needed of its NDMS workforce to meet current and future programmatic results. Specifically, HHS's target does not take into consideration three key areas: a workforce capable of responding to (1) a nationwide event or multiple concurrent events, (2) the needs of at-risk individuals, and (3) the availability of other medical responders. Consequently, HHS cannot be sure its target, if achieved, will provide an adequate number of responders with the skill sets needed to effectively respond.
HHS requires responders to take web-based training prior to deployment, such as characteristics of infectious diseases, and also offers optional in-person training, such as care delivery in a severe environment. However, HHS's process to evaluate its training does not align with key practices. As a result, HHS does not have assurance that it is effectively preparing responders for deployment, including keeping them and others safe during an emergency, such as COVID-19. For example, HHS requires a web-based course on donning and doffing personal protective equipment to protect against infectious disease, biological, and chemical threats. However, HHS does not know the training's effectiveness until responders have deployed; at which point, if ineffective, responders could potentially expose themselves to hazards. Further, HHS officials state their in-person training is most beneficial but more costly to provide, limiting its provision. A more effective training evaluation process would help the agency determine which in-person courses are most beneficial and should be prioritized, or even made mandatory, for effective and safe responder deployment.
Why GAO Did This Study
NDMS is the main program through which HHS enrolls responders to assist with the federal medical and public health response to public health emergencies. HHS deploys NDMS responders to provide, among other things, patient care and movement. During the 2017 hurricanes, NDMS had a shortage of responders that resulted in HHS relying on other departments, such as the Department of Defense, to provide medical care. As of December 2019, HHS had 3,667 NDMS responders.
The Pandemic and All-Hazards Preparedness and Advancing Innovation Act of 2019 included a provision for GAO to review HHS's responder surge capacity. This report examines (1) the workforce planning for NDMS responders to assist with public health emergencies, and (2) training provided to these responders.
To conduct this work, GAO reviewed agency NDMS planning documentation, including NDMS staffing decisions, team structures, and training materials; compared HHS actions to key workforce planning practices; and interviewed HHS officials.
Recommendations
GAO is making five recommendations to HHS, including to develop a workforce target that accounts for the critical skills and competencies that are needed to meet current and future programmatic results and to develop processes for evaluating its training to ensure an effectively trained workforce. HHS concurred with our recommendations and generally plans to take action.
Recommendations for Executive Action
| Agency Affected | Recommendation | Status |
|---|---|---|
| Office of the Assistant Secretary for Preparedness and Response | ASPR should develop an NDMS responder workforce target that aligns with the goals and objectives in ASPR's forthcoming strategic plan. (Recommendation 1) |
Open
HHS officials agreed with this recommendation. In December 2022, ASPR publicly released its 2022-2026 strategic plan. GAO considers this recommendation open until GAO receives and reviews supporting documentation provided by ASPR demonstrating that ASPR's NDMS responder workforce target aligns with the goals and objectives in ASPR's new strategic plan.
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| Office of the Assistant Secretary for Preparedness and Response |
Priority Rec.
ASPR should develop an NDMS responder workforce target that accounts for the critical skills and competencies that are needed to meet current and future programmatic results, such as a workforce target that considers (1) a nationwide event or multiple concurrent events, (2) the needs of at-risk individuals, and (3) the availability of other medical responders. (Recommendation 2) |
Closed – Implemented
HHS officials agreed with this recommendation. In February 2023, ASPR officials provided documentation demonstrating that they believe the NDMS responder workforce target of 6,290 NDMS personnel accounts for two large-scale catastrophic events, the hospital needs of at-risk individuals, and the availability of other responders. This fulfills the intent of the recommendation.
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| Office of the Assistant Secretary for Preparedness and Response | ASPR should develop strategies to fill gaps to achieve its revised workforce target. (Recommendation 3) |
Open – Partially Addressed
HHS officials agreed with this recommendation. As of February 2023, ASPR officials stated that ASPR is working to increase its NDMS responder workforce to meet its overall goal of 6,290 NDMS responders. According to agency documentation, as of February 8, 2023, NDMS had 4,239 responders available for rostering. ASPR has had direct hiring authority to aid hiring NDMS responders since June 2019 and continues to have this authority available through September 30, 2023. ASPR is working through the legislative process to request a permanent hiring authority. According to officials, this authority is the nexus and policy that has aided enhanced NDMS hiring. Further, officials stated that as part of their efforts to utilize the direct hire authority, there is a NDMS Hiring Team within the Shared Services Branch of ASPR's Division of Human Capital that works in partnership with NDMS on hiring through the authority. Officials also noted that the fiscal year 2023 President's Budget request proposed an additional $50 million above fiscal year 2022 NDMS funding levels to, in part, support hiring additional NDMS responders. When we reported on this issue, ASPR had direct hiring authority for NDMS responders, and as of December 2019, had 3,667 enrolled responders. Therefore, GAO considers this recommendation open until ASPR provides documentation demonstrating that relying on the direct hiring authority as its primary strategy has been successful or provides documentation on other strategies it is employing to address gaps and meet its NDMS responder workforce target.
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| Office of the Assistant Secretary for Preparedness and Response | ASPR should develop a process to evaluate the web-based and in-person training provided to NDMS responders using GAO-identified key practices for evaluating training. (Recommendation 4) |
Open
HHS officials agreed with this recommendation. As of February 2023, ASPR officials continue to work on implementing this recommendation. The fiscal year (FY) 2023 President's Budget request proposes an additional $50 million above fiscal year 2022 NDMS funding levels. According to ASPR officials, if funded at the specific requested level, NDMS will be able to evaluate training and make required adjustments based on collective feedback. At current levels, and if funding is not provided as requested, NDMS is unable to implement these actions. GAO will continue to monitor ASPR's action in this area to address the recommendation.
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| Office of the Assistant Secretary for Preparedness and Response | ASPR should develop a process or approach to prioritize various in-person training needs for its NDMS responders while taking into account budget constraints. (Recommendation 5) |
Open – Partially Addressed
HHS officials agreed with this recommendation. As of February 2023, ASPR continues to work on implementation this recommendation. In August 2022, ASPR conducted its first in-person training summit to provide hands-on training for NDMS responders, focusing on new hires to ensure basic skill sets to conduct post-disaster response operations. Over 1,400 NDMS personnel received training on new equipment, field and life support equipment, and classroom training on emerging threats, aeromedical evacuation, and disaster medicine. According to ASPR officials, the benefits of this in-person training proved its value during the October 2022 Hurricane Ian response to Florida to which ten NDMS teams were deployed. According to ASPR officials, the training plan developed for the summit was focused on the needs and skills for new NDMS hires, due to funding constraints, but will be adapted based on the needs of participating NDMS employees. Officials noted that this training plan will lay the foundation for the process and approach used to provide other training sessions when funding is available. ASPR recognizes that skills are perishable and require continuous opportunities to maintain proficiency. Once funding is available, ASPR will ensure hands-on training is available to the entire NDMS responder workforce. According to ASPR officials, as of October 2022, NDMS has no allocated training funds to support other in-person training sessions. According to officials, the fiscal year 2023 President's Budget request proposes an additional $50 million above fiscal year 2022 NDMS funding levels to, in part, support increased individual NDMS responder and team training to ensure mission readiness, including added hands-on and online training for new NDMS responders. ASPR officials stated that NDMS has a draft training strategy for fiscal year 2023 based on the requested funding level included in the fiscal year 2023 President's Budget. However, ASPR did not provide GAO with a copy of the draft strategy to know if or how it takes into account budgetary constraints. GAO will continue to monitor ASPR's action in this area to address the recommendation.
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