Decision Making During the First Hours of a Response: Lessons from the NYC Threat Response Guides

2. <?xml version="1.0"?><AllQuestions /> <?xml version="1.0"?><AllResponses /> <?xml version="1.0"?><Settings><answerBulletFormat>Numeric</answerBulletFormat><answerNowAutoInsert>No</answerNowAutoInsert><answerNowStyle>Explosion</answerNowStyle><answerNowText>Answer Now</answerNowText><chartColors>Use PowerPoint Color Scheme</chartColors><chartType>Horizontal</chartType><correctAnswerIndicator>Checkmark</correctAnswerIndicator><countdownAutoInsert>No</countdownAutoInsert><countdownSeconds>10</countdownSeconds><countdownSound>TicToc.wav</countdownSound><countdownStyle>Box</countdownStyle><gridAutoInsert>No</gridAutoInsert><gridFillStyle>Answered</gridFillStyle><gridFillColor>255,255,0</gridFillColor><gridOpacity>50%</gridOpacity><gridTextStyle>Keypad #</gridTextStyle><inputSource>Response Devices</inputSource><multipleResponseDivisor># of Responses</multipleResponseDivisor><participantsLeaderBoard>5</participantsLeaderBoard><percentageDecimalPlaces>0</percentageDecimalPlaces><responseCounterAutoInsert>No</responseCounterAutoInsert><responseCounterStyle>Oval</responseCounterStyle><responseCounterDisplayValue># of Votes Received</responseCounterDisplayValue><insertObjectUsingColor>Red</insertObjectUsingColor><showResults>Yes</showResults><teamColors>Use PowerPoint Color Scheme</teamColors><teamIdentificationType>None</teamIdentificationType><teamScoringType>Voting pads only</teamScoringType><teamScoringDecimalPlaces>1</teamScoringDecimalPlaces><teamIdentificationItem></teamIdentificationItem><teamsLeaderBoard>5</teamsLeaderBoard><teamName1></teamName1><teamName2></teamName2><teamName3></teamName3><teamName4></teamName4><teamName5></teamName5><teamName6></teamName6><teamName7></teamName7><teamName8></teamName8><teamName9></teamName9><teamName10></teamName10><showControlBar>All Slides</showControlBar><defaultCorrectPointValue>0</defaultCorrectPointValue><defaultIncorrectPointValue>0</defaultIncorrectPointValue><chartColor1>187,224,227</chartColor1><chartColor2>51,51,153</chartColor2><chartColor3>0,153,153</chartColor3><chartColor4>153,204,0</chartColor4><chartColor5>128,128,128</chartColor5><chartColor6>0,0,0</chartColor6><chartColor7>0,102,204</chartColor7><chartColor8>204,204,255</chartColor8><chartColor9>255,0,0</chartColor9><chartColor10>255,255,0</chartColor10><teamColor1>187,224,227</teamColor1><teamColor2>51,51,153</teamColor2><teamColor3>0,153,153</teamColor3><teamColor4>153,204,0</teamColor4><teamColor5>128,128,128</teamColor5><teamColor6>0,0,0</teamColor6><teamColor7>0,102,204</teamColor7><teamColor8>204,204,255</teamColor8><teamColor9>255,0,0</teamColor9><teamColor10>255,255,0</teamColor10><displayAnswerImagesDuringVote>Yes</displayAnswerImagesDuringVote><displayAnswerImagesWithResponses>Yes</displayAnswerImagesWithResponses><displayAnswerTextDuringVote>Yes</displayAnswerTextDuringVote><displayAnswerTextWithResponses>Yes</displayAnswerTextWithResponses><questionSlideID></questionSlideID><controlBarState>Expanded</controlBarState><isGridColorKnownColor>True</isGridColorKnownColor><gridColorName>Yellow</gridColorName></Settings> <?xml version="1.0"?><AllAnswers /> Decision Making During the First Hours of a Response: Lessons from the NYC Threat Response Guides Mitch Stripling Director, Emergency Planning Unit NYC DOHMH Office of Emergency Preparedness and Response

3. Introduction: Objectives • Attendees will be able to: • Define the problem of decision-making in the acute phase of an emergency response. • Describe criteria necessary to evaluate any document meant to be used during an emergency response. • Explain the benefit of the Threat Response Guide Decision Aid model for their jurisdiction • Design a three step strategy to apply the model in their jurisdiction.

4. Threat Response Guide Project Participants • Primary Authors/Planners: Joel Ackelsberg; AminaAssefa (OEM); Jessica Cole; Melissa D’Souza; Jose Florez; Meghan McGinty; Susan Miller;  Megan Pribram (OEM); Colin Stimmler; HailuTedla • Major Contributors Subject Matter Experts: Nancy Clark; Erik Finkelstein; Erich Giebelhaus; Scott Harper; Carmela Hinderaker; Scott Hughes; Mickey Jones; Ray Lynch; Andy Karam; Pam Kellner; Jian Liu; Tom Mauro; Mark Misener; Andrea Paykin; Jeannine Prudhomme; Allison Scaccia; Lew Soloff; Sally Slavinski; Kate Uraneck; Elaine Vernetti

5. Prologue: The Problem Stress State (Yerkes-Dodson Law adaptation (Bourne & Yaroush, 2003)

6. Emergencies affect Cognition

8. What is puzzling is that after years of research…local government continues to be surprised when standard procedures in lengthy, detailed plans are irrelevant in the real disaster.(Hoetmer, 1984) Good planning is not the same thing as good management. (Quarantelli, 1996)

10. What do we do now?

11. Benefits of Checklists • Enhance the performance of procedural responses to emergencies . • Improve patient outcomes in complex procedures .

13. Checklists ≠ Imagination

14. Enter The Decision Aid

15. Why the Decision Aid? • Promote Improv/Flexibility/Original Thinking • Offload Cognitive Demands of Emergency Details • Provide Information Salient to All-Hazards Response • Support Leadership-based performance outcomes

16. What should it be?

17. Proposal: Any Decision Aid meant to be used by leadership during an Emergency should meet these criteria.

18. Look at criteria A and B in your handout. Do these describe important guidance for a leader in an emergency? What would you put in a Decision Aid to help meet these criteria?

21. Threat Response Guide Model

22. All-Hazard IN Scenarios

23. Context improves decision-making

24. Generic Functions

25. Focus on questions

26. All-hazards based task assignment

27. Communications Priorities

28. City, State and Federal

29. Tactical task and resource data

30. Graphical Reminders

31. Planning P Reminders

32. Designed with Usability in Mind

33. Limitations • Not yet in a field-ready handbook or electronic wiki • Not tied to linked procedures a la pilot handbooks.

34. Look at the Threat Response Guide. Does it serve as a useful Decision Aid? Three Up – Three Down.

36. Threat Response Guide Project Participants • Primary Authors/Planners: Joel Ackelsberg; AminaAssefa (OEM); Jessica Cole; Melissa D’Souza; Jose Florez; Meghan McGinty; Susan Miller;  Megan Pribram (OEM); Colin Stimmler; HailuTedla • Major Contributors Subject Matter Experts: Nancy Clark; Erik Finkelstein; Erich Giebelhaus; Scott Harper; Carmela Hinderaker; Scott Hughes; Mickey Jones; Ray Lynch; Andy Karam; Pam Kellner; Jian Liu; Tom Mauro; Mark Misener; Andrea Paykin; Jeannine Prudhomme; Allison Scaccia; Lew Soloff; Sally Slavinski; Kate Uraneck; Elaine Vernetti

37. Explosive TTX (Fall 2010) • “We need to get the TRG completed and it needs to accurately reflect our roles, responsibilities, and capabilities.” • “Do not exercise a TRG that has not even been vetted yet with ICS leadership.” • “Style/Voice not consistent” • “Do not use the TRG as a check-list for the IC, as suggested at the exercise. It should be used as a tool to understand the incident specific issues. The IC's should be sufficiently knowledgeable about the various sections roles not to need that detailed in a TRG.”

38. Chemical TTX (Spring 2011) • “TRG was helpful” • “Separate out objectives from tasks.” • “This is one of the better TRGs, in part due to its brevity” • “Recommend this be abbreviated - at least offer a "Quick Start Guide" so that recommended action steps are spelled out clearly (Step 1, Step 2, etc.) and are separated from the reference components.” • “Include an Acronym Guide - many times acronyms were used - sometimes incorrectly - to describe various system and agency functions.”

39. Coastal Storm TTX (June 2011) • “Referring to the TRG and other materials seemed to help Leadership ask the proper questions and make the right decisions.” • “There was a disconnect between what was written on the TRG and what people were saying in the exercise. Honestly, I don't think that these processes are clear.”

40. Hurricane Irene (August 2011) • The Coastal Storm Threat Response Guide (TRG) was useful • Agree or Strongly Agree: 58.5% • Neutral: 30% • Most neutrals based on “Never saw it” • Most issues with proper distribution and difference from citywide plan

41. Radiological Functional (December 2011) • Did you refer to existing plans (i.e. Radiological Dispersal Device Threat Response Guide, Community Reception Center Plan, Radiological Emergency Operations Plan, and Radiological Response and Recovery Plan)? • Yes: 40.3% (27) • No: 59.7% (40) • 85% of those who referenced something, referenced the TRG. • “What I learned from Hurricane Irene/Tropical Storm Irene was to read the TRG first!! I did this and it was helpful.”

42. Major Lessons • We tried to listen and fix comments across the board • Treat it as a Decision Aid, not a Checklist, but prioritize the directive elements • Distribute it early, often, and beyond top leadership • Discuss study of mid-level leadership being as important as top-level • Focus on connecting to the outside system • Brevity is vital • Don’t analyze the TRGs as a “plan” but in terms of how they are used within the systems framework of an incident. • Ensure easy distribution to unexpected people; this is why it’s on standard paper • Get highest-level approval first

44. Would this be useful for your jurisdiction? If so, three things your would do to implement it.

45. Bibliography • Authority, C. A. (2006). Guidance on the Design, Presentation and Use of Emergency and Abnormal Checklists. (CAP 676). West Sussex, UK: TSO (The Stationery Office) Retrieved from http://www.caa.co.uk/docs/33/CAP676.PDF. • Burian, B., Barshi, I., & Dismukes, K. (2005). The challenge of aviation emergency and abnormal situations. NASA Ames Research Center. California. • Burian, B. K. (2004). Emergency and abnormal checklist design factors influencing flight crew response: A case study. • Burian, B. K. (2006a). Aeronautical emergency and abnormal checklists: expectations and realities. • Burian, B. K. (2006b). Design Guidance for Emergency and Abnormal Checklists in Aviation. • Burian, B. K. (2011). [14 Factors and Checklist Items]. • Burian, B. K., Dismukes, R. K., & Barshi, I. (2003). The emergency and abnormal situations project. • Degani, A. (1992). ON THE TYPOGRAPHY OF FLIGHT-DECK DOCUMENTATION. (NASA CONTRACTOR REPORT # 177605). Ames Research Center, CA. • Falzer, P. R. (2004). Cognitive schema and naturalistic decision making in evidence-based practices. [Evaluation Studies]. J Biomed Inform, 37(2), 86-98. doi: 10.1016/j.jbi.2004.02.002 • Pritchett, A., Nix, D., & Ockerman, J. (2001). Empirical Evaluations of Pilot Planning Behavior in Emergency Situations. Paper presented at the Human Factors and Ergonomics Society Annual Meeting • Quarantelli, E. L. (1997). Ten criteria for evaluating the management of community disasters. Disasters, 21(1), 39-56. • Verdaasdonk, E., Stassen, L., Widhiasmara, P., & Dankelman, J. (2009). Requirements for the design and implementation of checklists for surgical processes. Surgical Endoscopy, 23(4), 715-726. doi: 10.1007/s00464-008-0044-4 • Wyatt, J. (2000). Information for Patients. Journal of the Royal Society of Medicine, 93, 467-471. • Yannacci, J., Roberts, K., & Ganju, V. (2006). Principles from Adult Learning Theory, Evidence-Based Teaching, and Visual Marketing: What are the Implications for Toolkit Development? • Yukl, G., Gordon, A., & Taber, T. (2002). A Hierarchical Taxonomy of Leadership Behavior: Integrating a Half Century of Behavior Research. Journal of Leadership and Organizational Studies, 9(1), 15-32.

46. Remember to Connect!Email me if you’d like editable, redacted TRGs.mstripli@health.nyc.gov