Tuesday, March 25, 2008

The Importance of Oversight

The Massachusetts state auditor's office recently completed a study of how the Massachusetts Department of Public Health (DPH) distributed federal grant money in 2004-05 - money that was intended to be used in preparation for bioterrorism or mass casualty incidents (MCIs). Much of the funding went toward the purchase of trailers that could be used in response to an MCI.

The study underlines the importance of oversight in preparedness.

The federal money was allocated to each of the state's five regional emergency medical services (EMS) councils, supervised by the DPH.

Now, I'm an advocate of taking a regional approach, giving autonomy to local areas. Massachusetts has followed this strategy not only with the EMS councils (a common organizational structure) but also in its state homeland security strategy. As a general rule, I think bottom-up is better than top-down.

The trick, however, is ensuring that all regions are contributing toward the larger goal. That's where Massachusetts' DPH stumbled. Initially, they didn't adequately oversee the regional EMS councils to ensure that the MCI trailers were contributing to the state's preparedness goals. The state auditor found that the DPH didn't meet that its memorandum of agreement (MOA) in a number of ways, including:

• All municipalities within the region had not been notified of trailer availability, location, and purpose.
• Trailer storage locations were not as stated in the signed MOA.
• Periodic drills and/or exercises that involve the use of the MCI trailer and equipment had not taken place.
• Periodic maintenance of the MCI trailers and equipment did not take place to ensure that the trailers were in a constant state of readiness.
• Reporting obligations regarding all trailer activities (i.e., deployment, maintenance checks, etc.) had not been met.

Preparedness was sorely lacking in a couple of instances:
In one instance, the MCI trailer was not at either the location specified in the MOA or at the secondary location that was added to a copy of the MOA. Moreover, once the Host Agency was able to determine where the trailer was located, it could not be accessed, since the only personnel with the keys were unavailable.

The second MCI unit that was visited was at the stipulated location and was accessible for our site survey. However, its contents had not been unpacked and sorted, nor had any of its equipment been tested for use. We eventually were able to locate the items on the inventory test list, although this involved the opening and unpacking of boxes. Again, the only exception was the storage pods. The trailer itself was kept outdoors, which made the condition of the medical supplies and equipment inside susceptible to weather/climate conditions. It did not appear that this trailer was in a state of readiness as required in the MOA.

As a result of the monitoring weakness, DPH was not aware that the provisions and responsibilities of the MOA between it, one regional EMS council, and two Host Locations had not been met with regard to the MCI trailers.
There were also problems with tracking how the money was spent:
Each coalition had established its own procedures for the spending and distribution of funds, using both the advance method and the reimbursement method;

When local spending took place outside of the host agency, it was difficult for the coalition to effectively monitor and control it.
After the audit, the DPH has fixed these mistakes. They've publicized the existence and location of the trailers, and each region has hosted a drill or exercise using them.

But the incident underscores the importance of oversight and - perhaps more important - communication. Without regular communication, it really doesn't matter at what level these decisions are made. Preparedness will suffer.

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