Public Health Preparedness: HHS Should Take Actions to Ensure It Has an Adequate Number of Effectively Trained Emergency Responders

GAO-20-525 Published: Jun 18, 2020. Publicly Released: Jun 18, 2020.
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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

Response team personnel

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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.

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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.

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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 October 2022, ASPR officials noted that the agency's 2022-2026 strategic plan was in final development. 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 alignment of ASPR's NDMS responder workforce target with the goals and objectives in ASPR's strategic plan.
Office of the Assistant Secretary for Preparedness and Response
Priority Rec.
This is a priority recommendation.
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)
Open
HHS officials agreed with this recommendation. In October 2022, ASPR officials stated that its NDMS responder workforce target was based on several studies over many years and post major deployments. Such assessments were completed between 2007 and 2015, using the worse-case scenarios to define response requirements. These requirements then informed the maximum effort of what would be needed for the NDMS workforce, including the workforce needed to support two large-scale catastrophic events at the same time. GAO considers this recommendation open until GAO receives documentation of the assessments completed to inform ASPR's NDMS responder workforce target (which could include any assessments ASPR has completed that take into account NDMS responder needs during the COVID-19 pandemic), to determine if they fulfil the intent of the recommendation.
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
HHS officials agreed with this recommendation. In October 2022, ASPR officials stated that ASPR is working to increase its NDMS responder workforce to meet its overall goal of 6,290 NDMS personnel (to comprise 69 NDMS response teams). According to officials, as of October 28, 2022, NDMS has 3,965 responders available for rostering. Officials stated that the fiscal year 2023 President's Budget request proposes an additional $50 million above fiscal year 2022 NDMS funding levels to, in part, support hiring additional NDSM responders. GAO considers this recommendation open until ASPR provides documentation on the strategies it is employing to address gaps and meet its NDMS responder workforce target.
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 October 2022, 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.
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
HHS officials agreed with this recommendation. As of October 2022, ASPR officials continue to work on implementing this recommendation. ASPR officials stated that in August 2022 NDMS conducted its first in-person training summit to provide hands-on training for 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, 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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