Jessi Marin Guarin posted Aug 27, 2023 7:31 PM
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Optimizing Medical Coding Practices: Ensuring Accuracy
and Efficiency
The correct payment, compensation, and information
collection all depend on precise medical coding, which is a critical
component of healthcare administration. This essay examines the
situation of Lenore, who had a straightforward birth, and considers
how that affected the assignment of codes. Additionally, it discusses
difficulties brought on by inadequate physician paperwork and offers
solutions for efficiently handling such circumstances.
The importance of accurate coding is demonstrated by
Lenore’s uneventful delivery, which was reported as having no
difficulties before delivery, throughout the birth, or after delivery.
The Result of Birth code [a Z code -(V37.0-V37.9)] indicates delivery
facts according to the ICD-10-CM coding system. In her situation,
choosing a code from this range would be dictated by the lack of
problems.
Additionally, a precise account of the occurrence depends on
the delivery’s code. Given that Lenore delivered normally, the code
would indicate the delivery method (vaginal) and other important
information. This situation emphasizes the need for thorough
documentation. Coders can select precise codes thanks to accurate
records, which ensures accurate billing and payment.
The duties performed by medical coders in a healthcare
institution with conflicting clinician recordkeeping are complex.
Coders cannot choose proper codes from insufficient data, which
may result in incorrect charges and an interruption in compensation.
Coders may find it difficult to assign the proper codes if a clinical
record is missing crucial individual or procedural information.
Additionally, insufficient evidence may result in codes that have too
few characters, making them incorrect. Revenue is impacted, and
rejections of claims may follow, aggravating operational difficulties.
Healthcare organizations should take a holistic strategy to
address the issues brought on by insufficient physician
documentation. First and foremost, it is crucial to support ongoing
and dynamic physician education. Physicians need to be aware of
how their decisions in documentation affect subsequent coding and
billing processes. This increased knowledge may function as a
motivator for more accurate recordkeeping procedures.
Implementing a clear and effective query process is also
crucial. By serving as a link between coders and doctors, this
procedure streamlines the exchange of information and
clarifications. Such a technique avoids potential delays while
speeding up the coding process. Additionally, healthcare
organizations ought to spend money on programs that specifically
increase documentation. These programs include training seminars,
workshops, and helpful critique loops to help doctors improve the
record of their procedures. The business can reap significant
rewards in terms of increased efficiency and accuracy by better
matching these processes with the need for correct coding.
Additionally, using sophisticated coding tools that include
prompts and alerts for inadequate documentation can dramatically
improve coder productivity. These tools act as navigational aids,
enabling developers to quickly find and fill in any gaps in the
specification. Finally, promoting collaboration across functions
among coders, doctors, and managers is extremely beneficial. A
sophisticated awareness of the difficulties each stakeholder faces is
fostered by frequent communication between several departments.
This coordinated effort will eventually end in the development of
more thorough and effective remedies for the complex problem of
insufficient evidence. Healthcare organizations can prevent problems
caused by insufficient documentation by putting these methods into
practice. This adds to better healthcare for patients and efficient
operations as well as improving the accuracy of the coding and
billing procedures.
In summary, the accuracy of medical coding serves as a
cornerstone in the complex web of healthcare management. Lenore’s
straightforward delivery serves as a case study for the beneficial
interaction between rigorous documentation and precise coding.
Additionally, the difficulties posed by insufficient medical
documentation highlight the necessity for strategic interventions.
Healthcare companies can negotiate the challenges of incomplete
documentation by adopting physician education, effective inquiry
methods, documentation refinement projects, technological tools,
and peaceful collaboration. This coordinated set of tactics not only
guarantees efficient payment and coding but also significantly
enhances the provision of first-rate treatment for patients and the
overall efficacy of the healthcare facility.
Jewel Sanders posted Sep 5, 2023 9:02 AM
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1.
2. Lenore delivers a healthy baby girl. Her medical
documentation indicates that she has had a normal
delivery with no complications antepartum, during the
delivery, or postpartum. How does this information
influence which codes you assign? [Tips: Think about
Outcome of Delivery code [a Z code -(V37.0-V37.9)] and
code for delivery].
3.
4.
5. You work for a healthcare organization where several
physicians are not providing specific information (i.e., the
location of the pain, etc.). Due to the issue, it is
impossible for the coder to complete their work. Keeping
in in mind that a code is invalid if it has not been coded to
the full number of characters available for that code. If
appropriate documentation is not provided by the
physician, the coder cannot complete their work, and the
insurance company will return the claim to request
additional information, thereby delaying payment. How
would you handle this situation? What would you do?
What would you recommend to correct the problem?
6.
Coding every single detail correctly is imperative as
we’ve learned thus far in class. Although it was a healthy
delivery, there are multiple details that must be coded
correctly. Lenore’s birth doesn’t specify whether she gave birth
vaginally or by cesarean, so those are two separate codes. If
she gave birth vaginally, we would use code: Z438.00 found in
ICD-10-CM; if she gave birth by cesarean section, we would
use code: Z38.01. Even with this being a perfectly healthy
delivery, we still need more details because these are two
completely different codes that need to be sent to insurance.
Furthermore, code Z37.0 is a single live birth so this would
apply to Lenore’s case as well. I would also like to add code
080 from ICD-1-CM to describe the details of her healthy
delivery (which we don’t have so we would have to reject the
claim till the physician provided us with these details). This
code signifies there were no problems throughout the entire
duration before, during, or after the delivery with a baby born
full term, which we were not told but for the purpose of this
assignment, I will assume. In the real world, we would want to
get more information regarding the details of Lenore’s birth.
This example just goes to show that there are various details
we need in the case of a childbirth, and this is just an
unproblematic birth!
Some other options for coding the outcome of the
delivery include Z37.0 through Z37.9 from the ICD-10-CM. A
few other options for outcomes are Z37.1 which signifies a
stillbirth and Z37.2 which signifies twins born. There are so
many things that may go wrong during a childbirth that need to
be coded correctly when submitted to insurance. Childbirth is a
complex situation so many details are needed before the coder
can submit a claim.
If a physician is failing to provide all of the details
necessary for coding, that is a problem because then there
could be issues with insurance if the coder is just making
assumptions like I did in the first example. In this instance, the
correct thing for the insurance company to do is reject the
claim till they get the details they need such as the location of
pain. This obviously slows down the process of paying the
medical bill because insurance is not going to pay it until
they’re sure they have all of the necessary details. I would
handle this problem by confronting the situation. I think the
most efficient way would be to send a mass email to all
physicians explaining the issue and why it is important that
we’re receiving all of the relevant information. I would also
explain how healthcare workers all need to work together to
take care of each patient and medical coders are a part of this
healthcare team. I would explain all of this very kindly in the
email because the physicians are very busy and likely didn’t
know they weren’t including all of the necessary information. I
would also attach a simple slideshow outlining all of the details
needed for each type of birth: vaginal, cesarean, stillbirth,
multifetal, in order for coders to have all the information to
accurately submit a claim. I would keep in mind that this may
need to be repeated every 6 months or so. The physicians
don’t know what they don’t know, if there are issues with
claims, the coders should reach out to them to address these
said issues. Like I mentioned, in healthcare everyone in the
team must work together as cogs to take care of each patient.
I referenced how healthcare workers are like a cog
because it is imperative that they all work together to achieve a
task. Medical coders can be easily forgotten about but they are
very much so a part of the team and they shouldn’t have their
job made harder by physicians not providing them all of the
details they need. Medical coders are every bit as a part of the
team because they ensure that all details are included and
submitted accurately.
Emily Landewee posted Sep 4, 2023 1:30 PM
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The Importance of Correct Coding in Healthcare
Coding is such an important part of the healthcare world. While
some may believe it is only used to charge them outrageous
amounts of money, it can also help organize a patient’s health
information. This can involve things like their illnesses,
conditions, and treatments. I have seen coding mistakes
firsthand at my job. A patient will come in for a scan they
believe to be on their left leg because that is the one that they
are experiencing pain in. However, the doctor accidentally
ordered a right. The sonographers are not allowed to begin
scanning the patient until they check with the provider and
establish the correct order. Sometimes this can take a few
hours, delaying the patient’s scan. This is why it is so important
for the coding to be correct, because one wrong code can
drastically affect how the patient receives care. This paper will
examine two instances involving medical coding and my
proposed solutions to the problems.
The first example given is of a patient named Lenore who
delivered a healthy baby girl. Everything before, during, and
after her delivery has been indicated in her medical
documentation as normal and with no complications. This
information is very important when deciding which codes to
use. For example, a single liveborn infant that is delivered
vaginally would be represented by ICD-10 code Z38.00.
However, if this infant were born by a cesarean section, the
code would be Z38.01. There are also many other details that
can affect the coding process including the number of infants
born, the place in which the birth occurred, if the infant was
liveborn or stillborn, if the infant was full-term, etc. This shows
just how important the details are when it comes to coding.
Z37.0-Z37.9 are the ICD-10-CM diagnosis codes for outcome
of delivery. Some examples of these include single live birth
(Z37.0), twins both liveborn (Z37.2), and single stillbirth (Z37.1).
These codes are to only be used on the mother’s record. In
Lenore’s case, I would assign her the code Z37.0 since she had
a single live birth. I would also use ICD-10-CM Code O80 to
describe the normal delivery. This code is used for a normal
full-term delivery in which a single healthy infant is delivered
and there are no complications antepartum, postpartum, or
during the delivery. This perfectly describes the information
given about Lenore. Since ICD-10-CM Code O80 describes a
normal birth with no complications, the only appropriate
diagnosis code for outcome of delivery that can be used with it
is Z37.0 which is the other code I assigned to Lenore. If Lenore
had any complications or other circumstances to her pregnancy
and delivery, her coding would have been much different.
There are so many complexities when it comes to pregnancy
and delivery that there is an array of codes to describe each
and every situation. This is why all the details, large and small,
are important when deciding which codes to use.
The second example given is about a healthcare organization
who has physicians who do not list enough information for the
coders to do their jobs properly. They do not give out the
location of pain or any other specifics that allow the coders to
complete their codes. The insurance companies will return the
claim to request additional information before they pay,
therefore delaying it. If I were a member of this organization, I
would start by talking to the physicians about providing the
specific information needed for the coders. It is part of their
duties to provide this specific information in the patient’s chart
where those taking care of the patient can see it whether they
are a coder, nurse, etc. However, I do know that there is a
physician shortage everywhere these days, so many of these
physicians are overworked and see so many patients that they
do not have the time to document their notes properly or they
may not even get to spend as much time with a patient as they
need. If this were the case, I would offer to have an assistant
follow them around and take notes for them. Providing
worksheets that request certain information be filled out could
also be beneficial because then no little details that a coder
needs would be left out. These are just some of the solutions
that could help this organization.
A huge part of healthcare is everyone working together
cohesively to provide the best patient care possible. Something
the hospital I am employed at does to make sure everyone is on
the same page is to assign education modules. Every year, there
are general modules due, however, throughout the year, there
will be some random modules assigned. Recently, a module
about hand hygiene was assigned. Everyone in a hospital should
know when and how to wash their hands. However, since flu
season is coming around the corner, they implemented this
module to make the employees check their actions and bring
attention to something extremely important. It is not only
significant for the employee’s health, but for the health of their
patients as well. This is something that employees need to be
implementing in their daily jobs year-round to protect their
patients, their community, and themselves.
This brings me to another solution for the healthcare
organization issue above. To spread the word across the
healthcare organization, I would assign a healthcare education
module to all employees about the importance of healthcare
coding. Many may think that is something only the coder
should worry about, but in all reality, everyone plays a part in it.
I would have modules designed for different categories of jobs
and would put a lot of emphasis on the physicians’ modules
because they are the main cause for all of the confusion. I think
something that would also be beneficial in the module would be
mentioning how the coding process works and how it affects
the reimbursement the organization gets back from insurance
companies. I think that would help put more emphasis on their
roles and would make them realize that they need to include
more details for the coders to do their jobs correctly.
Every job is important in a healthcare system. Missing one
piece would make an organization fall apart. Coders are
extremely important in keeping patient information
documented correctly and organized. Their job is certainly not
easy, but with the help of physicians and other hospital staff
providing them the correct information they need, then they
will have a smoother coding process. Overall, I believe
everyone within a healthcare organization needs to look at the
big picture of their work, and that is providing the best care to
their patients.
References
Obstetric Coding in ICD-10-CM/PCS. Journal of AHIMA.
(n.d.). https://library.ahima.org/doc?oid=100639#:~:text=Outc
ome%20of%20delivery%20codes%20%28Z37.0%E2%80%93Z
37.9%29%20are%20intended%20for,on%20subsequent%20rec
ords%20or%20on%20the%20newborn%20record.
Obstetrics Coding and Documentation Reference
Guide. BlueCross BlueShield of Alabama.
(n.d.). https://providers.bcbsal.org/portal/documents/10226/3
06297/Obstetrics+Coding+and+Documentation+Reference+G
uide/8f5f1b65-1fd2-49a5-8708-6819a162098e?version=1.0
Outcome of Delivery Z37. ICD10Data.
(n.d.). https://www.icd10data.com/ICD10CM/Codes/Z00Z99/Z30-Z39/Z37-
Module 3 Discussion Paper
Contains unread posts
Alli Kallenbach posted Sep 5, 2023 11:51 AM
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The Importance of Coding in Health Care
Coding is a very crucial and tedious job in the world of health
care. It must be done accurately and precisely. In order for
correct payments to be made successfully to both the physician
and patient, the coding must be completed very professionally
as well as coding the correct information.
In one example, Lenore had a normal, uncomplicated birth—
antepartum, during delivery, and postpartum. Now it is time for
the coders to assign information for Lenore. This uneventful
delivery would be under the “Outcome of Delivery” Z code-
V37.0 in the ICD-10 CM. Z code- V37.0 is “Outcome of
Delivery” code for a single live birth. In Lenore’s case of her
delivery, she would be assigned the “Outcome of Delivery” Z
code- V37.0 because it is the only code applicable to her
situation. The code O80, which describes a normal pregnancy,
would be beneficial in assigning a code to Lenore. Z codeV37.0 is the only appropriate use with code O80. In this coding
system, the patient has to have the correct information needed
to fit the criterion of the code. There are a copious number of
codes out there for pregnancy-related conditions. It becomes
even more complicated when you add in a mother who may or
may not have pre-existing conditions. You also have to factor
conditions which may developed antepartum or postpartum. In
addition to the mother’s possible complications, you have to
factor in the baby’s. Whatever the other codes may be, the
health care facility and the coders have to do an accurate look
at all sides of the situation to understand the circumstances
before assigning a code. Even if it is something like an
uneventful delivery, there should always be someone to make
sure the code is assigned meticulously.
Furthermore, the codes must be very specific, as they hold
important information. This will tell us what kind of delivery
Lenore had (vaginal, cesarean) and if anything else that was
significant happened. As you can see, there are a vast number
of codes that coders could mistakenly use. If these mistakes
happen, they can interfere with billing. If there is a discrepancy,
Lenore’s insurance company might file a claim to request
information. In such a case, the coders would want to make
sure they have the correct code input. Even the slightest typo
could mean a completely different condition. However, it is
always important that the coders are given the correct
information, so they can assign the correct code to the correct
patient.
If physicians are not providing coders with the information
needed to complete their work, then they cannot do their job
sufficiently. As stated earlier, the slightest typo could mean a
completely different condition, and a code is made up of
complex characters. Coders cannot just choose a code if all of
the crucial information is not recorded. It would be based off of
insufficient data which would result in incorrect billing and
compensation. Even more so, the patient may not be able to
receive the full extent of his treatment if he is assigned to the
wrong code. His situation may be more drastic, but the doctors
were not providing enough specific information to the coders
for them to code correctly. If coded incorrectly, any patient’s
insurance company can file a claim to request information
about the patient. While it may seem that the coder is at fault, I
would disagree. How do we prevent this from happening again
in the future? I propose a few solutions to put in place.
One solution is to hold physicians accountable for withholding
information. The coders cannot do their jobs without
physicians, so they need access to special information. I know
there is a health care worker (nurses, lab technicians, etc.)
shortage, so it is very difficult to document everything when
you have many patients and extra responsibilities. Regardless of
the circumstances, coders should be able to get the correct
information needed to assign a code to a patient available.
Coders should also reach out to physicians to build a rapport.
By doing this, coders can work closer with the physician. The
physician in turn could learn a little about the importance of
coding. The physicians can even learn what coding is like
outside of patient information and learn about patient billing
and insurance reimbursement. Then, they could understand
how difficult and confusing it is when not all of the information
is present. This coding education would allow them to be more
mindful when documenting patient information. It is crucial that
they are knowledgeable about the coding process and are
confident that when they input information, it will make sense
to the coder.
Although after this, physicians and coders may now have better
relationships, I feel there will be confusion still. Physicians will
better understand the importance of coding, but there are
things that physicians understand that coders do not. For
example, each kind of specialty physician has its own set of
special medical terminology. While coders are very
knowledgeable, I think it would be a good idea to have the
coders learn more about medical terminology. This way they
could better communicate with physicians and may be able to
interpret any information that can be used for coding.
In summary, coding is a very important task, especially in health
care. Codes are used to keep information organized correctly
and accurately. Coders need very specific information in order
to get the patient’s code correct. As stated above, one wrong
mishap can lead to disaster— wrong diagnosis, wrong billing,
wrong payment, and the patient’s insurance company can file a
claim to request information. In Lenore’s case, she had an
uneventful delivery. The coders still have to assign the correct
code to her in order to ensure that she did not receive an
insufficient code. In turn, the coders must also make sure she
fits the criterion for this code. It is also difficult to assign
someone a code when not enough information about the
patient is given. When this occurs, coders and physicians
should begin to work together. Physicians need to make the
needed information more readily available. This way coders can
do their jobs correctly. While physicians get educated about
what coders do and their importance, coders can get educated
about how to better communicate with physicians when
accessing information. Everything in health care works as a
cohesive unit, so coding is an integral part of that unit that
cannot be overlooked.

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Theories of Psychotherapy and
Counseling: Concepts
and Cases
6th Edition
Richard S. Sharf
Chapter 6
Person-Centered Therapy
© 2016 Cengage Learning. All rights reserved.
© 2016 Cengage Learning.
All rights reserved.
Carl Rogers’s Four Phases
of Person-Centered Therapy
Developmental
–
forming his approach
Nondirective
–
focus on understanding the client and
communicating understanding
Client-centered
–
theoretical development of therapeutic
change
Person-centered
–
application to family, groups, and
political activism as well as the
individual
Slide 1 Chapter 6
© 2016 Cengage Learning.
All rights reserved.
Influences on Carl Rogers’s
Development of Person-Centered
Therapy
Early theological training
Otto Rank
–
creativity of individuals
Alfred Adler
–
value of the individual and good
relationships
Abraham Maslow
–
self-actualization
Martin Buber
–
“I-Thou”
Rollo May
–
existentialism
Slide 2 Chapter 6
© 2016 Cengage Learning.
All rights reserved.
Person-Centered View of
Psychological Development
Infancy
–
monitoring of pleasantness
of environment
Children
–
develop trust in their
reactions to the environment
Older children
–
develop a need for positive
regard from others
Older children and adults
–
develop a sense of self-worth
or self regard
Slide 3 Chapter 6
© 2016 Cengage Learning.
All rights reserved.
Person-Centered Theory
of Personality
Conditions of worth
–
lead to incongruence
Conditional regard
–
a sense of alienation
Psychological disturbance is related to the amount of incongruence
between individual experience and self-concept
Congruent relationships
–
Fully functioning person
–
Psychological maturity
–
Slide 4 Chapter 6
© 2016 Cengage Learning.
All rights reserved.
a sense of being heard and
understood
provide positive regard to
others and receive it from
others – a goal
openness, creativity, and
responsibility
Goals of Person-Centered
Therapy
Client determines goal
More deeply understand various aspects of oneself
Accept oneself and others
More self-direction which leads to better problem solving
ability and less defensiveness
Slide 5 Chapter 6
© 2016 Cengage Learning.
All rights reserved.
Necessary and Sufficient
Conditions
for Person-Centered Change
1. Psychological contact between two people
2. Client is incongruent
Therapist provides
3. Congruence and genuineness
4. Unconditional positive regard or acceptance
5. Empathy
The client perceives
6. Empathy and acceptance
Slide 6 Chapter 6
© 2016 Cengage Learning.
All rights reserved.
What the Client Experiences
in Person-Centered Therapy
Responsibility for self
The therapist’s empathy and unconditional positive regard
which stimulates
The process of exploring oneself
which allows the client to
Experience oneself
Experience therapeutic change
Slide 7 Chapter 6
© 2016 Cengage Learning.
All rights reserved.
Psychological Disorders:
Examples of the Person-Centered
Approach
Disorder
Therapist
Patient
Depression
Rogers, C.
Female graduate student
Grief and loss
Rogers, D.
7 year old boy
Anxiety/ phobia
Van Fleet, Sywulak,
& Sniscak
5 year old boy
Slide 8 Chapter 6
© 2016 Cengage Learning.
All rights reserved.
Current Trends in
Person-Centered Therapy
Application of person-centered principles to international
concerns regarding conflict and peace
Incorporating other theoretical models into person-centered
therapy
Constructionist trends – empathy with the individual in a cultural
context
Training trends – person-centered ideals applied to graduate
training
Slide 9 Chapter 6
© 2016 Cengage Learning.
All rights reserved.
Gender Issues in
Person-Centered Therapy
Can therapists truly understand clients of the other
gender?
Focus on intimacy in relationships
Therapists values and lesbian, gay, bisexual, or
transgendered clients
Slide 10 Chapter 6
© 2016 Cengage Learning.
All rights reserved.
Multicultural Issues and
Person-Centered Therapy
Person-centered therapy is practiced world wide, especially
in areas of conflict.
Are genuineness, acceptance, and empathy cultural values
that are limited to certain cultures?
Does Rogers’s emphasis on the individual, conflict with the
family values of some cultures?
Slide 11 Chapter 6
© 2016 Cengage Learning.
All rights reserved.
Theories of Psychotherapy and
Counseling: Concepts
and Cases
6th Edition
Richard S. Sharf
Chapter 7
Gestalt Therapy: An Experiential Therapy
© 2016 Cengage Learning. All rights reserved.
© 2016 Cengage Learning.
All rights reserved.
Influences on Perls’s
Development of Gestalt Therapy
•Kurt Goldstein
–
•Wilhelm Reich
•Sigmund Freidlander
•Alfred Korzybski
•Kurt Lewin
•Existentialism
–
•Gestalt psychology
–
•Laura Posner Perls
–
Slide 1 Chapter 7
© 2016 Cengage Learning.
All rights reserved.
holistic perspective, self actualization, importance of
language usage
bodily awareness within individuals
observation of balance and polarities
role of language in therapy
field theory, studying the whole field
phenomenology, direct experience of
existence
the whole is more than the sum of its
parts
respect for personal relationships
Gestalt Psychology
Psychological phenomena are organized by wholes rather
than by parts
Studied visual and auditory perception, mainly
Basic concepts
Field
Figure
Ground
Development of laws of perception
Gestalt psychologists critical of loose application of their
work by gestalt therapists
Slide 2 Chapter 7
© 2016 Cengage Learning.
All rights reserved.
Examples of Complete,
Incomplete, and Weak Gestalts
1
2
1
4
3
2
Slide 3 Chapter 7
© 2016 Cengage Learning.
All rights reserved.
5
6
7
Complete gestalt
8
9
5
7
Incomplete gestalt
6
Weak gestalt
9
8
Gestalt Theory of Personality:
Contact
Levels of Contact – Five layers of neurosis
_____________________________________________________________
Phony – inauthentic communication
_____________________________________________________
Phobic – avoiding emotional pain
_________________________________________
Impasse – afraid to change
__________________________
Implosive – awareness
of feeling
_________________
Explosive- authentic
Slide 4 Chapter 7
© 2016 Cengage Learning.
All rights reserved.
Gestalt Theory of Personality:
Contact Boundaries
Four types of boundaries for viewing I-boundaries
Body boundaries
Value boundaries
I – boundaries
Familiarity boundaries
Slide 5 Chapter 7
© 2016 Cengage Learning.
All rights reserved.
Expressive boundaries
Gestalt Theory of Personality:
Contact Boundary Disturbances
Introjection
–
Taking in views of others uncritically
Projection
–
Pushing out or dismissing aspects of ourselves
by assigning them to others
Retroflection
–
Bending back on ourselves – doing to ourselves
what we want to do to someone else or have
done to us
Deflection
–
Indirect or minimal contact – avoiding the issue,
not getting to the point
Confluence
–
Lessening the boundary between ourselves and
others
Slide 6 Chapter 7
© 2016 Cengage Learning.
All rights reserved.
Gestalt Theory of Personality:
Awareness
Contact within self and with others:
Awareness of
Sensations
–
Seeing, hearing, touching, etc.
Feelings
–
Emotional and physical
Future events
–
Wants and desires
Values
–
Social, spiritual, and relationship
issues
Slide 7 Chapter 7
© 2016 Cengage Learning.
All rights reserved.
Gestalt Theory of Personality:
The Present
Past (unfinished business)
PRESENT
Future
Slide 8 Chapter 7
© 2016 Cengage Learning.
All rights reserved.
Goals of Gestalt Therapy
Become fully aware of oneself – Perls
Develop awareness of one’s
•Body
•Feeling
•Environment
•Experiences
•Needs
•Skills
•Sensations (seeing, hearing)
•Power to care for oneself
•Actions and their consequences
•Fantasies
Slide 9 Chapter 7
© 2016 Cengage Learning.
All rights reserved.
Gestalt Therapy: Enhancing
Awareness
Basic Awareness Techniques
Statements and questions
Emphasis through repetition or exaggeration
Language usage
I not you
won’t not can’t
want not need
choose to, not have to
Nonverbal behavior
Self – “Be the angry part of you.”
Slide 10 Chapter 7
© 2016 Cengage Learning.
All rights reserved.
Others – “Be your father.”
Gestalt Therapy: Enhancing
Awareness
More Advanced Awareness Techniques
Feelings
–
Act out the emotion
Self-dialogue
–
Use of the empty chair to express polarities
Enactment
–
Dramatizing an experience or characteristic
Dreams
–
Acting out parts of the dream
Homework
–
Write dialogues, perform tasks
Avoidance
–
An active process that can be confronted
Creativity
–
Slide 11 Chapter 7
© 2016 Cengage Learning.
All rights reserved.
Gestalt Therapy: Risks
Because of the potential to hurt, therapists
need concern for client
focus on client not technique
need understanding of gestalt theory
apply the technique within the context of gestalt theory
Slide 12 Chapter 7
© 2016 Cengage Learning.
All rights reserved.
Psychological Disorders:
Examples of Gestalt Approaches
Disorder
Therapist
Patient
Depression
Strumpfel and
Goldman
Depressed woman
Anxiety
Naranjo
Anxious man
Posttraumatic stress
Serok
Holocaust survivor
Substance abuse
Clemmons
Mike
Slide 13 Chapter 7
© 2016 Cengage Learning.
All rights reserved.
Current Trends in
Gestalt Therapy
Integrating concepts from
self psychology
object relations
relational psychoanalysis
other psychoanalytic approaches
Attention to issues such as shame
Slide 14 Chapter 7
© 2016 Cengage Learning.
All rights reserved.
Gender Issues and Gestalt
Therapy
Leadership of gestalt therapy by both men and women
Gestalt therapy can help women develop a sense of
empowerment
Gestalt therapy can help men become more aware of emotions
and blocks that interfere with different roles
Slide 15 Chapter 7
© 2016 Cengage Learning.
All rights reserved.
Multicultural Issues and
Gestalt Therapy
Experiments designed to help individuals deal with their culture
Bicultural clients can see the two cultures as a polarity – two
chair technique
Gestalt therapy can arouse deep emotions in individuals whose
culture discourages emotionality
Apply gestalt therapy to treat social needs
Slide 16 Chapter 7
© 2016 Cengage Learning.
All rights reserved.
Theories of Psychotherapy and
Counseling: Concepts
and Cases
6th Edition
Richard S. Sharf
Chapter 8
Behavior Therapy
© 2016 Cengage Learning. All rights reserved.
© 2016 Cengage Learning.
All rights reserved.
Behavior Therapy:
Early Research
Classical Conditioning: Focus on antecedents of behavior
UCS
UCR
CS
CR
A neutral conditioned stimulus is presented just prior to the
unconditioned stimulus. Similar responses then are given
(unconditioned response, conditioned response) to the
conditioned stimulus.
Originator: Ivan Pavlov
Slide 1 Chapter 8
© 2016 Cengage Learning.
All rights reserved.
Behavior Therapy:
Early Research
Operant Conditioning:
Focus on antecedents and consequences of overt
behavior
Reinforce correct responses
Ignore incorrect responses
Shape behavior by controlling amount, frequency, and
conditions under which reinforcement occurs
Originators: E.L. Thorndike and B.F. Skinner
Slide 2 Chapter 8
© 2016 Cengage Learning.
All rights reserved.
Behavior Therapy: Contemporary
Research
Social cognitive theory: Covert behavior, includes role of thoughts
and behavior
Triadic Reciprocal Interaction System
Behavioral Actions
SELF-SYSTEM
Personal Factors
Originator: Albert Bandura
Slide 3 Chapter 8
© 2016 Cengage Learning.
All rights reserved.
Environment
Behavior Theory: Concepts Derived
From Operant Conditioning
Positive reinforcement – The introduction of a stimulus
increases the likelihood that behavior will be repeated
Negative reinforcement- An undesirable consequence of a
behavior is removed, increasing the likelihood the behavior
will be performed again.
Extinction – the process of no longer presenting a
reinforcement
Generalization- transferring the response from one type of
stimuli to similar stimuli
Discrimination- responding differently to stimuli based on cues
or antecedent events
Shaping- gradually reinforcing parts of a behavior to more
closely approximate the desired behavior
Slide 4 Chapter 8
© 2016 Cengage Learning.
All rights reserved.
Behavior Therapy: Concepts
Derived From
Observational Learning
Attending to a model
Retaining information about the model
Motor reproduction – Reproducing the behavior of the model
Motivational processes – Repeat reinforced behavior
Vicarious
Self-reinforcement
Self-efficacy – perceptions of one’s ability to perform in different
situations
Slide 5 Chapter 8
© 2016 Cengage Learning.
All rights reserved.
Goals of Behavior Therapy
Changing target behaviors – ones that can be defined clearly and
accurately
Goals preferably arrived at in collaboration with clients by
evaluating goals and possible outcomes
Goals for clients who can not choose raise ethical questions
Slide 6 Chapter 8
© 2016 Cengage Learning.
All rights reserved.
Behavioral Assessment
Assessing discrete behaviors and their antecedents and
consequences through the use of
Behavioral interviews – specific questions
Behavioral reports and ratings – e.g., BDI
Behavioral observations – natural or simulated
Physiological measurements – blood pressure, heart rate,
respiration
Slide 7 Chapter 8
© 2016 Cengage Learning.
All rights reserved.
Behavioral Therapies: Overview
Imaginal
In vivo
Virtual reality
Slide 8 Chapter 8
© 2016 Cengage Learning.
All rights reserved.
Gradual
Flooding
Systematic
desensitization
Implosive therapy
Behavior Therapy: Systematic Desensitization
Relaxation
–
Anxiety hierarchies
–
Relax body by learning a variety of
relaxation methods
a ladder of graded degrees of anxiety
using a subjective units of
discomfort scale (SUDs).
Example: Fear of exams
1.
2.
3.
10.
Slide 9 Chapter 8
© 2016 Cengage Learning.
All rights reserved.
Five minutes before the psychology mid-term (80)
Walking to the psychology mid-term (70)
Midnight before the psychology mid-term (65)
Thinking about last year’s math final (20)
Desensitization
Relax the client
Present a neutral scene
Present scenes of increasing anxiety
Relax the client if the client becomes anxious
Return to a less anxious scene
Continue to move slowly up the hierarchy
Behavior Therapy:
Imaginal Flooding Therapy
Develop scenes that the client imagines and are anxiety
producing to the client
Repeat the scenes again and again in the therapy hour
Rationale: Fear will be extinguished
Slide 10 Chapter 8
© 2016 Cengage Learning.
All rights reserved.
Behavioral Therapy:
Modeling Techniques
Types of Modeling
Live- Watching a model
Symbolic- Watching films, DVDs, photographs, or pictures
Role playing- Acting the part of someone or oneself in
different situations
Participant modeling- Therapists model behaviors and guide
the client in using them
Covert modeling- The client imagines a model that the
therapist describes
Slide 11 Chapter 8
© 2016 Cengage Learning.
All rights reserved.
Meichenbaum’s Self-Instructional
Training
•
Model appropriate behavior
•
Have client practice behavior
•
Client repeat’s instructions to self
•
Instructions may be taped
•
Records of practicing the instructions may be made
Slide 12 Chapter 8
© 2016 Cengage Learning.
All rights reserved.
Meichenbaum’s Stress
Inoculation Approach
•Conceptual phase
–
Gather information; teach client
how to think about problem
•Skills acquisition
–
Teach skill such as relaxation,
cognitive restructuring, or selfreinforcement
•Application
–
Rehearse statements, visualize
scenes, practice behavior
Slide 13 Chapter 8
© 2016 Cengage Learning.
All rights reserved.
Psychological Disorders:
Examples of Behavioral Approaches
Disorder
Therapist
Client
Anxiety
Brown, O’Leary and
Barlow
Claire
Depression
Hoberman and Clarke Jane
ObsessiveCompulsive
Riggs and Foa
June
Phobia
Johnson and
McGlynn
Six-year-old girl
All research-supported therapies
Slide 14 Chapter 8
© 2016 Cengage Learning.
All rights reserved.
Current Trends in
Behavior Therapy
•Behavioral activation therapy
•Eye movement desensitization and processing
•Dialectical behavior therapy
•Ethical issues
Slide 15 Chapter 8
© 2016 Cengage Learning.
All rights reserved.
Behavioral Activation
Therapy
1. Designed to treat depression
2. Based on positive reinforcement
3. Goal to change behavior which will change depressed
mood
4. Techniques increase clients activities
5. Therapist and clients plan a schedule of gradual
behaviors
6. Clients use a daily activity sheet
Slide 16 Chapter 8
© 2016 Cengage Learning.
All rights reserved.
Eye-Movement Desensitization
and Reprocessing (EMDR)
1.
2.
3.
4.
5.
Client history
Explanation of EMDR
Gather baseline data
Desensitization phase
Increase positive cognitions- eye movement processing
introduced
6. Body scan performed
7. Client maintains a log of distressing thoughts or images
8. Process reevaluated and reviewed
Slide 17 Chapter 8
© 2016 Cengage Learning.
All rights reserved.
Dialectical Behavior Therapy
•
Individual Therapy
• Therapeutic skills
• Validation and acceptance strategies
• Problem-solving and change strategies
• Dialectical persuasion
• Group Skills Training
Slide 18 Chapter 8
© 2016 Cengage Learning.
All rights reserved.
Gender Issues in
Behavior Therapy
Behavior therapy can be viewed in a social or
environmental context
Are gender stereotyped behaviors reinforced?
Are gender stereotyped behaviors modeled?
Slide 19 Chapter 8
© 2016 Cengage Learning.
All rights reserved.
Multicultural Issues in
Behavior Therapy
Environmental factors (including culture) interact with
behavior
Specify vague expressions of distress in culturally specific
terms
Use cultural norms to specify treatment strategies
Be aware of cultural definitions of what constitutes deviant
behavior
Slide 20 Chapter 8
© 2016 Cengage Learning.
All rights reserved.

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Hospitals Rising to the Challenge:
The First Five Years of the U.S. Hospital Preparedness Program
and Priorities Going Forward
Evaluation Report | March 2009
Sponsored by the U.S. Department of Health and Human Services under Contract #HHSO100200700038C
The Center for Biosecurity is an independent, nonprofit organization of the University of Pittsburgh Medical Center (UPMC).
The Center’s multidisciplinary professional staff, with experience in government, medicine, public health, bioscience, law, and
the social sciences, works to affect policy and practice in ways that lessen the illness, death, and civil disruption that would
follow large-scale epidemics, whether they occur naturally or result from the use of a biological weapon. Experts at the Center
publish research findings regularly and are consulted by government agencies, businesses, academia, and the media for independent analyses of issues pertaining to national and global epidemic preparedness and response.
Center for Biosecurity of UPMC
The Pier IV Building
621 E. Pratt Street, Suite 210
Baltimore, Maryland 21202
443-573-3304
http://www.upmc-biosecurity.org
Acknowledgments
This work was commissioned by the U.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response (ASPR), under Contract No. HHSO100200700038C. This report would not
have been possible without the more than 100 dedicated and committed hospital and state preparedness planners and other experts who contributed their time to provide the Center for Biosecurity project team with critical
insight into the state of U.S. hospital preparedness, or without the participants of the June 2008 Issue Analysis
Meeting in Baltimore, Maryland. The project team would also like to give special thanks to the leadership and
staff of the ASPR Office of Preparedness and Emergency Operations components of the Hospital Preparedness
Program and State and Local Evaluation for their guidance and support in the development of this report.
Suggested Citation
Toner E, Waldhorn R, Franco C, Courtney B, Rambhia K, Norwood A, Inglesby TV, O’Toole T. Hospitals Rising
to the Challenge: The First Five Years of the U.S. Hospital Preparedness Program and Priorities Going Forward.
Prepared by the Center for Biosecurity of UPMC for the U.S. Department of Health and Human Services under
Contract No. HHSO100200700038C. 2009.
Hospitals Rising to the Challenge:
The First Five Years of the U.S. Hospital Preparedness Program
and Priorities Going Forward
Evaluation Report | March 2009
Project Team
Center for Biosecurity of UPMC
Eric Toner, MD (Principal Investigator)
Senior Associate
Richard Waldhorn, MD (Co-Principal Investigator)
Distinguished Scholar
Crystal Franco (Project Manager)
Senior Analyst
Brooke Courtney, JD, MPH
Associate
Kunal Rambhia
Analyst
Ann Norwood, MD, COL, USA, MC (Ret.)
Senior Associate
Thomas V. Inglesby, MD
Deputy Director and Chief Operating Officer
Tara O’Toole, MD, MPH
Director and Chief Executive Officer
Project Contacts: Eric Toner, MD, and Richard Waldhorn, MD
Hospitals Rising to the Challenge | March 2009
Contents
List of Tables and Figures……………………………………………………………………………………………………………iii
Executive Summary……………………………………………………………………………………………………………………. v
I. Project Overview
Summary………………………………………………………………………………………………………………………………. 1
Methodology…………………………………………………………………………………………………………………………. 2
II. State of U.S. Hospital Preparedness Prior to the Hospital Preparedness Program
Historical Context…………………………………………………………………………………………………………………… 7
Pre-HPP Hospital Preparedness Research…………………………………………………………………………………. 11
III. History of the Hospital Preparedness Program
Legislative and Funding History………………………………………………………………………………………………. 17
Program Guidance (FY2002–FY2008)……………………………………………………………………………………….. 19
Impact of Guidance Evolution on Data Collection and Reporting………………………………………………… 20
Hospital Preparedness Research Conducted after HPP Implementation……………………………………….. 21
IV. Key Findings
1. Disaster preparedness of individual hospitals has improved significantly
throughout the country since the start of the HPP………………………………………………………………….. 23
2. The emergence of Healthcare Coalitions is creating a foundation for
U.S. healthcare preparedness. ……………………………………………………………………………………………. 36
3. Healthcare planning for catastrophic emergencies is in early stages; progress
will require additional assistance and direction at the national level…………………………………………. 46
4. Surge capacity and capability goals, assessment of training, and analysis of
performance during actual events and realistic exercises are the most useful
indicators for measuring preparedness………………………………………………………………………………… 55
V. Conclusions
1. The HPP has improved the resilience of U.S. hospitals and communities and
increased their capacity to respond to “common medical disasters.”………………………………………. 57
2. The HPP should focus on building, strengthening, and linking Healthcare
Coalitions to lay the foundation for a national disaster health and medical
response system……………………………………………………………………………………………………………….. 58
3. Administrative adjustments to the HPP could improve the program’s
effectiveness and efficiency. ………………………………………………………………………………………………. 59
4. To prepare the nation to respond to catastrophic emergencies, HHS should
provide continued leadership to assist states in their efforts to address the many
procedural, ethical, legal, and practical problems posed by a shift to disaster
standards and ACFs that is required when demand for care overwhelms available resources……… 60
5. Catastrophic emergency preparedness is a national security issue and requires
the continued funding of the HPP………………………………………………………………………………………… 61
Center for Biosecurity of UPMC
i
Hospitals Rising to the Challenge | March 2009
Appendix A. List of Acronyms……………………………………………………………………………………………………. 63
Appendix B. Center for Biosecurity Descriptive Framework for Healthcare
Preparedness for Mass Casualty Events: The Framework and Crosswalk of
Elements of Preparedness………………………………………………………………………………………. 65
Appendix C. Map of Working Group Participants Contacted for Participation…………………………………. 79
Appendix D. HPP Guidance Terminology by Year…………………………………………………………………………. 81
Appendix E. Summary of HPP Program Guidance: FY2002–FY2008………………………………………………. 83
Appendix F.
Summary of Studies on Hospital Preparedness Since the Establishment
of the HPP by Year…………………………………………………………………………………………………. 87
Center for Biosecurity of UPMC
ii
Hospitals Rising to the Challenge | March 2009
List of Tables and Figures
Table 1. Number of Virtual Working Group Participants by Sector………………………………………………….. 4
Table 2. Studies on Pre-HPP Hospital Preparedness by Year………………………………………………………….. 12
Table 3. Hospital Preparedness Program Funding: FY2002–FY2009……………………………………………….. 18
Figure 1. Timeline of Significant Events for Healthcare Preparedness: 1989–2007……………………………… 9
Figure 2. Percent HPP Hospital Participation by Reporting States, Municipalities,
and Territories: 2006 (n = 58)………………………………………………………………………………………… 19
Figure 3. Percentage of Hospitals with Redundant Communications Capabilities by
Number of HPP-Participating States, Municipalities, and Territories: 2006
(n = 58)………………………………………………………………………………………………………………………. 30
Figure 4. Percent Hospital Use of Corrective Actions/Improvement Plans Following a
Drill or Exercise by Number of HPP-Participating States, Municipalities, and
Territories: 2006 (n = 58)………………………………………………………………………………………………. 36
Figure 5. HHS Medical Surge Capacity and Capability (MSCC) Framework………………………………………. 39
Figure 6. Multi-Agency Coordination (MAC) Model for Regional Healthcare
Emergencies ………………………………………………………………………………………………………………. 42
Figure 7. Percentage of HPP-Participating States, Municipalities, and Territories with
a Functional ESAR-VHP System that Allows Volunteer Health Professionals
to Register for Work in Hospitals or Other Facilities during Emergencies: 2006
(n = 62)………………………………………………………………………………………………………………………. 45
Figure 8. Administrative and Clinical Adaptations to Resource-Poor Situations…………………………………. 48
Center for Biosecurity of UPMC
iii
Hospitals Rising to the Challenge | March 2009
Executive Summary
Executive Summary
Hospitals are the backbone of the healthcare response to common medical disasters (i.e., mass casualty events
that occur with relative frequency, overwhelm a single hospital, and require a communitywide health response)
and, in particular, to catastrophic emergencies, such as an influenza pandemic or large-scale aerosolized anthrax
attack. The need for hospitals to be prepared to respond to disasters has increasingly become a priority for hospital leaders. They have been influenced by events such as the 2001 terrorist attacks and Hurricane Katrina and
the increased emphasis placed by accreditation organizations and regulatory agencies on the importance of such
disasters.
Established by the U.S. Department of Health and Human Services (HHS) in 2002, the goal of the Hospital
Preparedness Program (HPP)1 is to enhance the ability of hospitals and healthcare systems to prepare for and
respond to bioterror attacks on civilians and other public health emergencies, including pandemic influenza and
natural disasters. Current HPP priorities include strengthening hospital capabilities in the areas of interoperable communication systems, bed tracking, personnel management, fatality management planning, and hospital
evacuation planning. Past priorities include improving bed and personnel surge capacity, decontamination capabilities, isolation capacity, pharmaceutical supplies, training, education, drills, and exercises.
The HPP was initially administered by the Health Resources and Services Administration (HRSA). Congress directed the transfer of the HPP to the Office of the Assistant Secretary for Preparedness and Response (ASPR) under
the 2006 Pandemic and All-Hazards Preparedness Act (PAHPA).2 All 50 states, as well as the District of Columbia,
the nation’s three largest municipalities (Chicago, Los Angeles, and New York City), the Commonwealths of Puerto
Rico and the Northern Mariana Islands, three territories (American Samoa, Guam, and the U.S. Virgin Islands),
Micronesia, the Marshall Islands, and Palau, have received over $2 billion in HPP funding through grants, partnerships, and cooperative agreements since 2002.
In 2007, ASPR contracted with the Center for Biosecurity of the University of Pittsburgh Medical Center (UPMC)
(Center) to conduct an assessment of U.S. hospital preparedness and to develop recommendations for evaluating
and improving future hospital preparedness efforts. The first deliverable was the Center’s Descriptive Framework
for Healthcare Preparedness for Mass Casualty Events,3 which is a description of the most important components
of preparedness for mass casualty response at the local and regional hospital and healthcare system levels (Appendix B). Hospitals Rising to the Challenge: The First Five Years of the U.S. Hospital Preparedness Program and
Priorities Going Forward is the second deliverable under the contract. It is the Center’s assessment of the impact
of the HPP on hospital preparedness from the time of the program’s establishment in 2002 through mid-2007, as
well as our preliminary recommendations for improving the state of U.S. hospital preparedness going forward.
This evaluation report is based on extensive analyses of the published literature, government reports, and HPP
program assessments, as well as on detailed conversations with 133 health officials and hospital professionals
representing every state, the largest cities, and major territories of the U.S.
1
2
3
The original name of the program was the National Bioterrorism Hospital Preparedness Program (NBHPP).
Public Law No. 109-417.
Toner E, Waldhorn R, Franco C, et al. Descriptive Framework for Healthcare Preparedness for Mass Casualty Events. Prepared by
the Center for Biosecurity of UPMC for the U.S. Department of Health and Human Services under Contract No.
HHSO100200700038C. 2008.
Center for Biosecurity of UPMC
v
Hospitals Rising to the Challenge | March 2009
Executive Summary
Key Findings
Disaster preparedness of individual hospitals has improved significantly throughout the country
since the start of the HPP.
Since 2002, individual hospitals throughout the U.S. have made considerable progress in disaster preparedness.
For the most part, hospital senior leadership is actively supporting and participating in preparedness activities,
and disaster coordinators within hospitals have given sustained attention to preparedness and response planning
efforts. Hospital emergency operations plans (EOPs) have become more comprehensive and, in many locations,
are coordinated with community emergency plans and local hazards. Disaster training has become more rigorous
and standardized; hospitals have stockpiled emergency supplies and medicines; situational awareness and communications are improving; and exercises are more frequent and of higher quality.
The emergence of Healthcare Coalitions is creating a foundation for U.S. healthcare preparedness.
One of the most significant factors contributing to strengthened healthcare preparedness is the emergence of
Healthcare Coalitions, which, since the establishment of the HPP, have involved collaboration and networking
among hospitals and between hospitals, public health departments, and emergency management and response
agencies. These coalitions represent the beginning of a coordinated communitywide approach to medical
disaster response. If they can continue to be developed and strengthened around the country, coalitions would
logically become the foundation of a more robust national disaster health and medical response capacity, as
envisioned in Homeland Security Presidential Directive 21 (HSPD-21),4 to respond to catastrophic emergencies
in which one community’s Healthcare Coalition could come to the assistance of another’s coalition. The HPP has
played a critically important role in catalyzing the creation of these coalitions, which did not exist in most communities before the program’s establishment.
Healthcare planning for catastrophic emergencies is in early stages; progress will require additional
assistance and direction at the national level.
The U.S. healthcare system is not currently capable of effectively responding to a sudden surge in demand for
medical care that would occur during catastrophic events, such as those described in the Department of Homeland Security (DHS) National Planning Scenarios.5 Emergencies of this magnitude would overwhelm the medical
capabilities of communities, regions, or the entire country and require drastic departures from customary healthcare practices. Such a “phase shift” in the provision of care to disaster standards would be unlike anything that
has ever been done in the U.S. It also is extremely difficult to plan for because it involves the development of
clinical standards of care for disasters and a process for implementing such standards, both of which raise complex clinical, legal (federal and state), and ethical issues. Most hospitals and states have begun to address this
problem and have found the Agency for Healthcare Research and Quality (AHRQ)/ASPR guidance documents,6,7
to be very useful, but none are adequately prepared. While many issues related to developing and implementing
disaster standards are ultimately state responsibilities, continued national leadership and direction are essential
for sustained state and local progress in catastrophic emergency planning.
4
5
6
7
The White House. Homeland Security Presidential Directive/HSPD-21. October 18, 2007.
http://www.whitehouse.gov/news/releases/2007/10/print/20071018-10.html. HSPDs were issued by President Bush
to communicate decisions about the nation’s homeland security policies.
U.S. Department of Homeland Security (DHS). National Preparedness Guidelines.
http://www.dhs.gov/xlibrary/assets/National_Preparedness_Guidelines.pdf. September 2007.
Agency for Healthcare Research and Quality (AHRQ), Assistant Secretary for Preparedness and Response (ASPR). Altered
Standards of Care in Mass Casualty Events. Prepared by Health Systems Research Inc. under Contract No. 290-04-0010.
AHRQ Publication No. 05-0043. Rockville, MD: Agency for Healthcare Research and Quality. April 2005.
Phillips SJ, Knebel A, eds. Mass Medical Care with Scarce Resources: A Community Planning Guide. Prepared by Health
Systems Research, Inc. under Contract No. 290-04-0010. AHRQ Publication No. 07-0001. Rockville, MD: Agency for
Healthcare Research and Quality 2007.
Center for Biosecurity of UPMC
vi
Hospitals Rising to the Challenge | March 2009
Executive Summary
Surge capacity and capability goals, assessment of training, and analysis of performance during
actual events and realistic exercises are the most useful indicators for measuring preparedness.
The most useful metrics for measuring individual hospital preparedness were those that were clearly defined and
not overly burdensome for hospitals. Useful HPP metrics included numerical surge capacity and capability goals
(e.g., targets for staff, supplies, and space), training of personnel, and performance during actual events and
structured exercises. Measuring individual hospital preparedness should also be based on the Joint Commission
Standards for Emergency Management, which already significantly overlap with HPP guidances. Assessment
of Healthcare Coalition preparedness should be based on the ability of coalitions to perform critical coalition
functions, such as providing situational awareness during an event and maintaining and operating reliable and
redundant communications systems.
Conclusions
The HPP has improved the resilience of U.S. hospitals and communities and increased their capacity
to respond to “common medical disasters.”
Prior to 2002, most hospitals did not have adequate plans to handle common medical disasters, much less
catastrophic emergencies comparable to the National Planning Scenarios. Over the course of six years, the HPP
has catalyzed significant improvements in hospital preparedness for common medical disasters. Hospitals have
implemented communications systems, incident command system concepts, stockpiles of medicines and supplies, situational awareness tools, and memoranda of understanding for sharing assets and staff during disasters.
The HPP should focus on building, strengthening, and linking Healthcare Coalitions to lay the
foundation for a national disaster health and medical response system.
The development of Healthcare Coalitions has been the single most important step toward preparing the U.S.
healthcare system to respond to catastrophic disasters that require the healthcare assets of an entire region or the
country. A national system of functional Healthcare Coalitions capable of responding to such disasters is unlikely
to develop without further federal support and guidance. To be able to respond collectively to these types of
catastrophes, the coalitions would need to be coordinated and linked with each other through a nationwide
system that could effectively call upon and coordinate all necessary national assets. The development of such a
system would clearly need to be integrated with existing federal and state disaster response programs and with
the development of a more robust national disaster health and medical system, as outlined in HSPD-21.8
Administrative adjustments to the HPP could improve the program’s effectiveness and efficiency.
These changes include: transitioning the HPP grant to a multi-year project cycle, where awardees would have at
least two years to complete grant work; streamlining and coordinating all federal grants that contain guidance for
hospitals and public health agencies; creating or adopting a healthcare-specific National Incident Management
System (NIMS) training program for use by hospitals and public health agencies that participate in the HPP; and
continuing to phase in the Homeland Security Exercise and Evaluation Program (HSEEP) standards for hospital
exercises and drills in the HPP guidance.
8
The White House (2007).
Center for Biosecurity of UPMC
vii
Hospitals Rising to the Challenge | March 2009
Executive Summary
To prepare the nation to respond to catastrophic emergencies, HHS should provide continued
leadership to assist states in their efforts to address the many procedural, ethical, legal, and
practical problems posed by a shift to disaster standards and alternate care facilities (ACFs) that is
required when demand for care overwhelms available resources.
Hospitals and Healthcare Coalitions are struggling with how best to prepare for catastrophic emergencies that
may require a shift to disaster standards of care. While many of these issues must ultimately be addressed
and resolved at the state and local levels, states continue to struggle with some fundamental issues, including
developing clinical guidelines and procedural or legal frameworks for shifting to and using disaster standards.
HHS should continue to provide leadership and direction on these issues by: creating a resource for planners
across the U.S. to share information on approaches, guidelines, and tools for disaster standards that have been
developed by states, medical experts, professional societies, and others; convening a working group specifically
focused on implementing disaster standards of care and ACFs and on exploring the developme

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