Health Progress - November-December 2019

JOURNAL OF THE CATHOLIC HEALTH ASSOCIATION OF THE UNITED STATES

HEALTH PROGRESS NOVEMBER – DECEMBER 2019

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DISASTERS with Compassion

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100th ANNIVERSARY

DISASTERS

64 LOOKING BACK TO MOVE FORWARD RON HAMEL, PhD

DEPARTMENTS 2 EDITOR’S NOTE MARY ANN STEINER 72 MISSION AND LEADERSHIP Climate Refugees — The Forgotten Ones BRIAN SMITH, MS, MA, MDiv 75 ETHICS Listening Well for Symphonic Truth ALEC ARNOLD, MA, ThM 77 THINKING GLOBALLY Work Together to Improve Disaster Response BRUCE COMPTON

Illustrations by Carole Hénaff

79 COMMUNITY BENEFIT Caregivers Can Reach Out to Improve Health BARRY ROSS, RN, MPH, MBA

4 WIPE EVERY TEAR FROM THEIR EYES Nathaniel Blanton Hibner, PhD 8 GUNS, GERMS AND HEALTH CARE: LESSONS OBSERVED AND LEARNED Alexander Garza, MD 14 FLEXIBILITY, STAFF GENEROSITY KEY TO WEATHERING STORM Lance Mendiola, MS, CHFM, CHSP, CBO 19 SPIRITUAL CARE WHEN DISASTERS STRIKE David Lewellen 23 DISASTER LANDSCAPES IN HEALTH CARE: LEARNING EXPERIENCES FROM FLORIDA TO PERU Karen Reich, MSW, FACHE and Camille Grippon, MA

81 POLICY Models Changing to Better Meet Social Needs INDU SPUGNARDI

29 POPE FRANCIS — FINDING GOD IN DAILY LIFE 84 EXECUTIVE SUMMARIES 88 PRAYER SERVICE

30 CREATING A CULTURE OF EMERGENCY PREPAREDNESS Jeff Mosely, PE 35 BUILDING ‘MUSCLE MEMORY’ IN PUBLIC INFORMATION OFFICERS Brian Reardon 39 COMPASSION IN DISASTERS David G. Addiss, MD, MPH 45 THE HEALTH CARE LEADER’S ROLE IN SAFETY Kim Hollon, FACHE 50 REDUCING THE RISK OF A CYBER CRISIS Jarrett Kolthoff, GCFA, CISSP 56 HOW TO USE ETHICAL FRAMEWORKS FOR DISASTER PLANNING Carl Middleton, DMin, MDiv, MA, MRE 61 ‘I AM WITH YOU’ Mary L. Hill, BSN, MAHCM, JD

IN YOUR NEXT ISSUE

WHAT’S NEW IN HEALTH CARE

62 REFLECTION: THE WAY THROUGH Pam Franta, PhD

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EDITOR’S NOTE

C

ecil B. DeMille’s last great film epic was my first experience of a disaster movie.

Sr. Elizabeth Ann decided that all the children in her Catholic school would benefit from the story of God’s power and wrath against the Egyptians and the might of his saving hand for Moses and the Israelites. She sent a message home in the Friday folders that parents should take their children to see “The Ten Commandments” at our neighborhood movie house. Not many parents dared question Sr. Elizabeth Ann, so the following Sunday we filled the Brentwood Theatre.

Based on the book of Exodus, the movie featured disasters of every order in shocking Technicolor. Pharaoh’s cruel treatment of the enslaved Hebrews was religious violence and the slaughter of their infant boys ethnic cleansing. There MARY ANN were plagues and pestilence STEINER that spoiled the drinking water, infected the people, decimated their livestock and blighted their crops. Punishing hail, lightning and an unnatural darkness that persisted for days epitomized extreme weather events. There were miraculous rescues, heroic confrontations and finally the scene of the hapless Egyptians drowning in the Red Sea. I had nightmares for months.

Some of us know disasters of severe weather, eruptions of mass violence or rampant epidemics firsthand, but many more of us know them by the numbers. How many days, how many dead, how many inches of rain, how many acres burned, how much the cost, how many shooters and how many victims. And then the flooding of information: how many stories, how many clicks. Alexander Garza in his article (p. 8), addresses the distressing number of children killed by gunfire in St. Louis this past summer. Each time another child was slaughtered intentionally or by random gunfire, their picture was added to the composite of those who died before them, like a tile finding its unfortunate place in a mosaic. God bless the child.

We almost didn’t use the image on the cover of this magazine because some of us kept confusing what was meant to be a compass of compassionate action with a stopwatch for how much time there was to respond and rescue. In the end, it turned out to be a helpful ambiguity. Finding our way to the true north of compassion, discussed in David Addiss’ article (p. 39), goes hand-in-hand with

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the carefully calibrated plans of urgent response.

Catholic health care encourages a forward-bearing approach: We operate with a true hand of compassion as well as a steady hand of response.

When Moses first encountered the burning bush, God immediately told him to remove his sandals because the place where he was standing was holy ground. The ground we stand on, whether it’s burning, quaking, flooding or tainted with blood, is always sacred ground when we are doing God’s work in the healing ministry. Thanks to the articles that follow, there is much to learn about building cultures of safety, learning efficiencies of response, and attending to the social and environmental factors that play into the causes and consequences of disasters. As author after author points out, there also is much to be grateful for in the expertise, diligence and generosity of our colleagues, who guide the discernment of disaster response preparations and uphold the highest standards of care when many people are at risk.

Once again, we are fortunate to welcome a guest author who helps us celebrate Health Progress’ 100th anniversary. Ron Hamel, former CHA senior director of ethics, wrote a history of the development of the Ethical and Religious Directives for Catholic Health Care Services, often called the ERDs or the Directives, which is the document that offers moral guidance, drawn from the church’s theological and moral teachings, on the values, identity and clinical aspects of Catholic health care delivery. Many thanks to Ron for tracking the important decisions that shaped the ERDs and offering suggestions for the topics to be considered in a future seventh edition.

It’s my favorite season, with Advent soon to follow. “I know well the plans I have in mind for you,” says the Lord, “plans for your welfare and not for woe, so as to give you a future of hope.”

(Jer 29:11). We are always preparing the ways of the Lord.

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Produced in USA. Health Progress ISSN 0882-1577. November - December 2019 (Vol. 100, No. 6).

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Kathleen Benton, DrPH, president and CEO, Hospice Savannah, Inc., Savannah, Ga. Sr. Rosemary Donley, SC, PhD, professor of nursing, Duquesne University, Pittsburgh.

Fr. Joseph J. Driscoll, DMin, director of ministry formation and organizational spirituality, Holy Redeemer Health System, Meadowbrook, Pa. Marian Jennings, MBA, president, M. Jennings Consulting, Inc., Malvern, Pa. Tracy Neary, regional vice president, mission integration, St. Vincent Healthcare, Billings, Mont.

Sr. Kathleen M. Popko, SP, PhD, president, Sisters of Providence, Holyoke, Mass.

Laura Richter, MDiv, system senior director, mission integration, SSM Health, St. Louis.

Gabriela Robles, MBA, MAHCM, vice president, community partnerships, Providence St. Joseph Health, Irvine, Calif.

Michael Romano, national director, media relations, Catholic Health Initiatives, Englewood, Colo.

Linda Root, RN, MAHCM, chief mission integration officer, Ascension Michigan, Warren, Mich.

Fred Rottnek, MD, MAHCM, director of community medicine, Saint Louis University School of Medicine, St. Louis.

Becky Urbanski, EdD, senior vice president, mission integration and marketing, Benedictine Health System, Duluth, Minn.

Brian Yanofchick, MA, MBA, senior vice president, sponsorship, Bon Secours Mercy Health, Marriottsville, Md.

CHA EDITORIAL CONTRIBUTORS ADVOCACY AND PUBLIC POLICY: Lisa Smith, MPA COMMUNITY BENEFIT: Julie Trocchio, BSN, MS CONTINUUM OF CARE AND AGING SERVICES: Julie Trocchio, BSN, MS ETHICS: Nathaniel Blanton Hibner, PhD FINANCE: Rhonda Mueller, CPA INTERNATIONAL OUTREACH: Bruce Compton LEADERSHIP AND MINISTRY DEVELOPMENT: Brian P. Smith, MS, MA, MDiv LEGAL: Catherine A. Hurley, JD MINISTRY FORMATION: Diarmuid Rooney, MSPsych, MTS, DSocAdmin THEOLOGY AND SPONSORSHIP: Fr. Charles Bouchard, OP, STD

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DISASTERS

Wipe Every Tear From Their Eyes NATHANIEL BLANTON HIBNER, PhD

O

n Aug. 4, 2019, my hometown of Dayton, Ohio, became the second city in 24 hours to experience a mass shooter. Nine innocent lives were lost on the streets of the beautiful historic Oregon District — a neighborhood where I spent the first three years of my life and one that continues to hold an emotional connection to my family. news and in the morning The same darkness print, people in commustruck the city of El Paso, … It was as if an earthquake rent nities struck by disaster Texas, when a man opened The hearth-stones of a continent, have deeper concerns. As fire inside a Wal-Mart as And made forlorn people of faith, they quespeople went about their The households born tion God’s role: Why did weekend shopping. He Of peace on earth, good-will to men!

God allow such a thing to killed 22 people. In total, 31 And in despair I bowed my head; happen? This existential men, women and children “There is no peace on earth,” I said; crisis is not new to modern lost their lives in the two “For hate is strong, times. cities.

And mocks the song Consider the great In the days following, Of peace on earth, good-will to men!” earthquake that struck the news media and the pubThen pealed the bells more loud and deep: thriving city of Lisbon in lic searched to understand “God is not dead, nor doth He sleep; 1755. The city, having seen these disasters. They The Wrong shall fail, a surge in population, was raised questions about The Right prevail, a forest of tall, crowded the shooters’ upbringWith peace on earth, good-will to men.” buildings built upon one ings, their pasts and their — Excerpted from Henry Wadsworth another, overflowing with motives. Residents in the Longfellow’s “Christmas Bells” the masses. The structures, two cities began the promere shells of cheap matecess of mourning, coming together and standing up against hate and rials, could not withstand the trembling force of violence. Crosses, candles, stuffed bears were the quake. Fire broke out, a tsunami destroyed placed along the streets. Another mass shooting ships in the harbor and chaos spread. Tens of thousands of people were killed. in America.

The news of the disaster reached every corner Disasters, both man-made and natural, shake the very core of our identities. The rational part of of Europe. People were shocked by the gravity of our brains cannot neatly connect the event with the destruction. Leaders in other cities began to a why. Why did these men kill? Why did the tor- wonder how their community might fare if struck nado hit my house and not my neighbor’s? Why by a similar event. Another conversation started, as well. Philosophers and theologians began to did death appear today?

Beyond the questions debated on the nightly debate the meaning behind the devastation. They

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questioned the role of religion, the power of God, the existence of Providence, evil and salvation.

Accusations of heresy and blasphemy were made on both sides.

For some historians, the Lisbon earthquake was more than a natural disaster. The timing of the event coincided with intellectual and religious changes happening in Europe. It was a real-life example of a theoretical debate ignited by realworld events, thriving in universities and cafes.

The unexplainable occurrence shattered a sense of comfort, safety and rationality for many.

One important intellectual who publicly discussed the impact of the event was the philosopher known as Voltaire (nom de plume for François-Marie Arouet). Voltaire wrote a poem entitled, “Poème sur le désastre de Lisbonne,” or “Poem on the Lisbon Disaster,” in which he expressed doubt about the existence of a God who is considered all mighty and all good, but would still permit such a disaster. Voltaire challenged his contemporaries who said, “God is avenged. Their death is the price of their crimes,” or, “Yet, this misfortune … is another’s good.” Voltaire’s lament is not only about the physical destruction caused by the earthquake, but about a spiritual destruction that challenged the predominant philosophy and theology of the day. “One day, all will be well — this is our hope. All is well today — that is the illusion.” A theology whereby a disaster like Lisbon was just a part of God’s plan did not connect with the reality of the situation. Voltaire and others wanted more.

The question of the “why?” behind disasters has yet to be answered. At least not in a definitive way. Philosophers and theologians have attempted to understand the role of our God in a world that is filled with death and suffering.

However, since the time of Voltaire’s poem, I believe we are making progress. Maybe not on an answer, but surely in our understanding of the divine. For example, Voltaire and his contemporaries had an image of God as above the world, using (or refusing to use) his power to manipulate events on Earth. This view of God as an abstract, distant figure has lost its predominance in many theological circles and been replaced by a God who suffers with creation.

Holocaust survivor and Nobel laureate Elie Wiesel provides a vivid example of this suffering in God, in his book Night.1 He uses the gruesome hanging of three prisoners, to explain God’s presence in a new way:

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Then came the march past the victims.

The two men were no longer alive. Their tongues were hanging out, swollen and bluish. But the third rope was still moving: the child, too light, was still breathing...

And so he remained for more than half an hour, lingering between life and death, writhing before our eyes. And we were forced to look at him at close range. He was still alive when I passed him. His tongue was still red, his eyes not yet extinguished.

Behind me, I heard the same man asking: “For God’s sake, where is God?” And from within me, I heard a voice answer: “Where is he? Here he is — hanging here on this gallows...

Wiesel’s answer to the question “Where is God?” shatters the traditional theology of a God immutable by creation—a God that looks down from above and chooses not to interfere. Wiesel’s God is one that stands with the suffering and bears the pain along with those who suffer.

The concept of a suffering God expands in theology through the 20th century. Yet, it is a challenge for many people to accept. How can an almighty deity be moved by his simple creatures?

What power do we have over God? Surely, a God that can be moved by us is one that is not in control of us.

A suffering God challenges people’s understanding of the divine. It scandalizes and moves us to question what we may have learned through our upbringing in a certain faith. Like the death of Christ, the idea of a God who suffers today goes against the image of a Lord who has conquered all.

In Christ’s time it was believed that the Messiah would be a great warrior. Instead, he was a man born in a manger, killed on a wooden cross.

When the Lisbon earthquake struck, people were shocked by the natural forces at play. Yet, Voltaire and others noticed how the design of the city exacerbated the death toll. Today, society is shocked by the human forces that have accelerated natural disasters and the human actions that have a role in violent episodes. An awareness of humankind’s role in disasters is becoming more and more apparent.

As health care providers, our ministry is at the forefront of these events. Our emergency departments fill with those harmed by the firing of bullets or injured during the destruction of wildfires.

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DISASTERS

Nurses and physicians may feel an overriding sense of despair as the influx of patients does not wane, but instead continues like a steady river.

Perhaps our society is condemned to continue bearing these disasters. At times it can even feel like perhaps the God in whom we seek salvation has forgotten his people.

Disasters, both of natural and human-made causes, seem incomprehensible to our rational minds. When we mix the circumstances with a God that has the power to prevent them and chooses not to, our faith may stumble. Yet, if instead of a God outside the violence and the destruction, our God is one who sits with the victims, perhaps we can begin to see the irrationality of the event for what it is—a symptom of our fallen and incomplete world. People of faith yearn for the coming Kingdom of God. David Bentley Hart, an American theologian and philosopher, finishes his book, The Doors of the Sea, with a passage that I believe responds to our collective yearning for an answer.2 Hart recognizes that through Christ’s death on the cross, our God has a connection to human suffering: Now we are able to rejoice that we are saved not through the immanent mechanisms of history and nature, but by grace;

that God will not unite all of history’s many strands in one great synthesis, but will judge much of history false and damnable; that he will not simply reveal the sublime logic of fallen nature, but will strike off the fetters in which creation languishes; and that, rather than showing us how the tears of a small girl suffering in the dark were necessary for the building of the Kingdom, he will instead raise her up and wipe away all tears from her eyes — and there shall be no more death, nor sorrow, nor crying, nor any more pain, for the former things will have passed away, and he that sits upon the throne will say, “Behold, I make all things new.”

NATHANIEL BLANTON HIBNER is director of ethics for the Catholic Health Association, St. Louis.

NOTES 1. Elie Wiesel, Night (New York: Farrar, Strauss and Giroux, 2006).

2. David Bentley Hart, The Doors of the Sea: Where Was God in the Tsunami? (Grand Rapids, Mich.: William B. Eerdmans Publishing Company, 2005), 104.

QUESTIONS FOR DISCUSSION Nathaniel Blanton Hibner, director of ethics at the Catholic Health Association, discusses disasters in light of the problem of evil and suffering in a world created by a loving God. Disasters, he points out, shake the core of our beliefs in our fellow humans and in the goodness and power of a God who loves us.

Disasters disturb and distress us personally, but they also expose belief systems and cultural contexts to new scrutiny by theologians, philosophers, scientists and world leaders.

1. Once the scale of a disaster has been realized and emergency measures taken, how do you deal with the human toll, the suffering around you and the knowledge that you can only do so much?

2. Sometimes disasters seem more to do with evil, as in a mass shooting, and sometimes they have more to do with suffering, as in hurricanes that wreak havoc in people’s lives. How do you reconcile your personal beliefs with the work needs to be done? Does blame directed at bad actors get in the way?

Does shame about not being prepared, survivor guilt, or not being able to do more affect your ability to do what you can?

3. Hibner says that while we have not solved the questions of evil and suffering, we may have made progress in our understanding of God. Rather than a punitive God who rains down suffering, or an indifferent God who tolerates human sin and pain, we may be coming to know a compassionate God who suffers with us. How does this align or challenge your view of God? Talk about what you think of that.

4. What does your ministry do to care for staff when disaster strikes? What kinds of pastoral care are offered to the victims of disaster who end up in your facilities? What services does your ministry offer to the community at large? Is there more as an anchor institution you think it could be doing?

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DISASTERS

Guns, Germs And Health Care Lessons Observed and Learned

ALEXANDER GARZA, MD

I

n his classic book Guns, Germs, and Steel, Jared Diamond argues that the development of civilizations and their ascendency in the world was mostly influenced by geography, climate and access to natural resources, which gave greater protection from disease and improved the probability of succeeding. It was not by accident that Diamond included “guns” and “germs” as main characters in his book.

Although civilization has progressed on many fronts, particularly in the treatment of trauma and infectious diseases, guns, violence and germs continue to plague our communities. Harm inflicted on individuals from guns or germs can be random; however, in both cases there are unequal burdens on different populations and they are heavily influenced by social determinants. Health care, in particular Catholic health care with its mission to care for the poor and vulnerable, must continue to plan responses to small outbreaks of violence and disease, as well as larger scale disasters caused by them. In addition, we must mitigate the issues that place the vulnerable and marginalized at increased risk of suffering from guns and germs in the first place.

I have been in a position to observe and interact with guns, violence and germs throughout my career in medicine. From a paramedic, to an emergency medicine physician, a soldier deployed in conflict, a government executive at the U.S. Department of Homeland Security, a faculty member at a college for public health, and now as an executive in a large Catholic health care ministry. In each of these roles, the environments were

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different, but the underlying principles the same.

Guns, violence, and germs are formidable threats to be understood and countered. Understanding environment, risk and response are important for any population, government or health care system in dealing with these different yet similar threats.

GUNS AND VIOLENCE

Gunshot wounds and other acts of violence were not uncommon calls when I was a paramedic. The clinical side of taking care of trauma patients is fairly well established. As paramedics, the best medicine we could offer was getting them to the trauma center as quickly as possible. Many studies have shown that this alone can be a major determinant of survival. As a medical director for emergency medical services in Kansas City, Mo., my directive was that I did not care whether the crews started IV’s or not, but I did care if they took too much time on the scene. As an emergency physician, improving the odds for survival depended on clinical and systems training as well as being consistent with the delivery of trauma care. Everyone in the trauma bay has a role to play, from the trauma surgeon to the ER technician,

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and the success of the outcome depends on each gery resident’s apparent ambivalence to the fact person executing their part with rigor. If every- that these were children and victims. Although one caring for the trauma patient understands the they clearly had nonsurvivable wounds, he prosystem, and it is practiced and drilled and refined, ceeded to perform other medical procedures as if then the system can respond even in the face of a using their bodies for training. It was grossly disrespectful to them as human beings. I then left the mass shooting.

Gun violence can be short and intense as in trauma room to speak with the mother of the chilurban trauma, to overwhelming and prolonged, dren only to find her heavily inebriated. I couldn’t as in warfare. The victims can be indiscriminate in both. An outbreak The likelihood of suffering from the of gun violence in the St. Louis region disease of violence, particularly gun in 2019 has taken a particularly hard toll on children, with at least 17 killed violence, is more strongly associated as of Sept. 1. The likelihood of suffering from the disease of violence, with communities impacted by particularly gun violence, is more negative socioeconomic conditions, strongly associated with communities impacted by negative socioenvironment, poor education and economic conditions, environment, poor education and poverty rather poverty rather than genetics, diet or than genetics, diet or lifestyle. While lifestyle. a popular refrain is that zip codes can determine people’s risk of health issues or longevity, the point is sometimes lost sleep when I got home just thinking about what that zip codes are a surrogate marker for socio- had just happened.

I am not exactly sure why these patients have economic conditions. As much as we can reduce the risk of heart disease by proper diet, exercise stuck with me over the years. Perhaps it was and preventative treatment, violence needs to be because in looking at that child on the couch addressed in a similar fashion, through risk reduc- in her living room and seeing the devastation it brought to the family and the crowd that had gathtion and proper response.

Although I have taken care of thousands of ered outside, I realized that gun violence does not patients as a care provider, two victims of gun start and stop with the victim. It impacts families violence particularly stick with me. While work- and communities in ways we don’t see in the steing as a paramedic, my partner and I were dis- rility of the hospital. The second was because of patched to a shooting. The scene was chaotic, and our ability as caregivers to become callous to the the police were waving us in frantically. A high human element of trauma. Perhaps this is a coping velocity bullet had penetrated the front window mechanism, or perhaps bravado. Either way, we of a home, striking a small girl in the head. She need to constantly remind ourselves of the special had been asleep on the couch. With an expression relationship we hold as caregivers to our patients, of panic and staring intensely at the girl’s face, an particularly those in dire need of our abilities, and officer asked: “Is there anything you can do?,” but that all people are first humans created in God’s image. And last, caregivers are not immune to the he already knew the answer.

The second happened while I was working toll that these experiences take on them. We must as an attending emergency physician. EMS had recognize and take care of the second victims, the called ahead about a pair of children who were caregivers.

Guns, violence and to a lesser extent, germs, victims of a drive-by shooting. The paramedics who arrived were performing CPR. Though val- followed me to Iraq where I deployed as a Civil iant, it didn’t matter because both children suf- Affairs team chief and battalion surgeon with the fered fatal wounds to the head. Many things both- U.S. Army in 2003. A sad byproduct of warfare is ered me about this, for different reasons. One, of improvement in trauma care, which was certainly course, was because these were innocent chil- true in the Iraq and Afghanistan theaters. This dren, still in their pajamas; the second was the sur- included improved surgical techniques, equip-

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DISASTERS

ment and evacuation processes to get the injured ered the explosion from the IED as “the boom,” to definitive care more quickly. Although I was a and built strategies around it, we should think of physician, my job wasn’t to take care of the sol- gun violence in the same way. Although we have diers, but rather to rebuild health care through- become very good at treating the injured on the out three provinces in central Iraq. Resurrect- battlefield, just as we have become very advanced ing a functioning health care system would, in in treating victims of gun violence, victory is turn, help the community return to some degree when an IED is never placed to begin with. The of normalcy and hopefully show that coalition same is true of gun violence: Victory is when we forces were committed to the people, commonly can prevent it in the first place.

COIN strategy extends beyond the convenreferred to as “winning the hearts and minds.”

During this time, injuries from firearms were tional use of force against the enemy and focuses constant and devastating since most were caused equally on economic and societal approaches to by high velocity, military weapons. As the war con- defeat violence and counterinsurgency as it does tinued, an insurgency developed. Along with this, on combat and security operations. Domestic tactics changed from conventional to asymmet- environments with poverty and social injustice ric warfare and the use of improvised explosive also create environments similar to those in insurdevices (IEDs). The military reacted by develop- gencies that increase the probability to “recruit” ing a strategy of countering IEDs around the sin- people into violence, and similarly should be gular event of the explosion, colloquially called examined in the same light as an insurgency. If “the boom.” If you think of this as a continuum, then “left of boom” Although we have become very good at were things that prevented an IED attack, such as deterrence, detectreating the injured on the battlefield, tion and mitigation, and “right of just as we have become very advanced boom” were response, tracking the perpetrator, care for wounded and in treating victims of gun violence, more. victory is when an IED is never placed The IED, however, is merely a tool of the insurgency — that is to begin with. The same is true of to say, you can’t declare victory by defeating the IED, you have to gun violence: Victory is when we can defeat the insurgency. This led to prevent it in the first place. developing the doctrine of counterinsurgency or COIN, which teaches that when a population is stable, able to they were, then attention wouldn’t be just focused operate freely as a society and provide for its citi- on law enforcement activities or gun control, but zens, it is much less likely to resort to violence also on the foundational issues that create an enviagainst the population and coalition forces. The ronment for “recruitment” to violence. The U.S. whole purpose of COIN is to eliminate people’s government spent billions of dollars in recondesire to be engaged in violence and/or counter- struction due to war, with the goal of preventing insurgencies. Mine was just one of many teams a failed state. Perhaps these same tactics can be deployed with the goal to improve the society’s used domestically in our communities to counter infrastructure, which would, in turn, deny the a gun violence insurgency. insurgency its needed narrative and, consequently, decrease the probability of the insur- GERMS gency recruiting from the population.

While I was working as an emergency medical There are striking differences in how the technician in Kansas City, Mo., a reporter and U.S. military develops strategies to combat vio- photographer from the Kansas City Star Magazine lence and insurgencies in war zones, and how the rode along with my partner and me for a week to do domestic U.S. government responds to societal a story about emergency medical services. During violence in America — although both are threats that time, they saw what we saw, took notes and to stable societies. Just as the military consid- pictures, and interviewed us for the Sunday maga-

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zine. During the week, we were dispatched to a include active surveillance, effective vaccination house where parents had called 911 due to a rash programs, antibiotic stewardship and reduction contracted by their young son. Upon arriving, we of hospital acquired infections.

While serving as the chief medical officer at the observed that the family lived a spartan existence: their stove’s door open because it was used to heat Department of Homeland Security, I was involved a ramshackle apartment, they had only piecemeal in many national and international crises. Howfurniture and little or no food in their refrigerator. ever, the largest part of my work surrounded the It was clear they had no access to primary care, impact that infectious agents, whether deliberate otherwise why call an ambulance? By 911 stan- or natural occurrences, had on the nation’s secudards, this was hardly an emergency, however, rity. The most opportunistic biological weapon whether I knew it or not, it was an introduction generally is what makes a pathogen also difficult to the social determinants of health. The article to combat in the field. This includes easy dissemicame out under the banner of “Life, Death and the nation, effective transmission, difficulty in detecParamedic.” Within the article, in large bold print tion and no vaccine or effective therapy. From a was a quote from me stating, “If more physicians global perspective, if this is combined with an saw what we see every day, medicine would be ineffective public health response, or a weak govpracticed differently.” I still remember saying that ernment, it becomes a catastrophe.

The anthrax attacks came on the heels of the to the reporter while we were driving the boy to the children’s hospital. I caught quite a bit of flak 9-11 terrorist attack and were deliberate, directed from the emergency physicians about that quote. I attempts to disseminate high-grade anthrax. Five had to explain that they didn’t see what we saw out people were killed and at least 17 people were in the community. They only saw a kid with chick- injured as a result of these attacks. As a result, enpox who needed care in the ER. They didn’t see significant work was directed toward planning the apartment or the stove or the refrigerator with for biological weapons. To get “left of boom,” little food. Most agreed with my assessment, but we developed sophisticated programs to surveil areas of high population density for suspicious they felt powerless to do anything.

Infectious agents, although a different threat pathogens. But more important than the technolthan gun violence, still cause significant morbid- ogy was planning for how to prepare and respond, ity and mortality. Throughout history, disease or what we called the “concept of operations” or and pandemics such as the “Black Plague” and the CONOPS. When considering a wide-area disSpanish flu of 1918 that killed nearly one-third of semination, it is no longer just a health event, the earth’s population have proved formidable threats. Attempts to Infectious agents, although a different deliberately use infectious agents as offensive weapons also have threat than gun violence, still cause occurred throughout history, from significant morbidity and mortality. the catapulting of plague infected bodies at the siege of Caffa in 1346, but a security event with public health consethrough the anthrax mail attacks of 2001.

In many ways, however, infectious diseases are quences. We held tabletop exercises, bringing similar to gun violence. They affect the poor and together multidisciplinary teams including the vulnerable disproportionately and can span from police, EMS, health care, and public health, as small intense episodes, such as a case of menin- well as elected leaders, to discuss the response gitis or sepsis, to full-blown disasters, such as the to potential events. These same tactics also can be used within health care systems when dealing H1N1 pandemic or recent Ebola virus outbreaks.

Just as it should be with trauma, health care with significant infectious disease issues. During should be as prepared to handle infectious dis- the particularly virulent influenza season of 2018ease, whether it’s a single-event infectious disease 2019, SSM Health in the St. Louis region set up a multidisciplinary incident command structure. or a large-scale biological event.

Health care carries much more of the load This was important because everyone needed to for strategies against infectious disease than be at the table—from doctors to nurses and from does gun violence and can significantly mitigate microbiology lab technicians to supply chain staff. the threat of infectious disease. Such strategies We all knew what was happening and what the

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Guns, violence and germs are present in society every day and pose a significant burden on both our communities and our health care systems. They disproportionately afflict the poor and vulnerable. priorities were. This kept our health care system organized and directed efforts to keep our system operating with minimal disruptions.

However scary a deliberate biological attack seems, nature is a much more prolific at developing and spreading serious infectious disasters than any nefarious state actor. The 2004 Severe Acute Respiratory Syndrome (SARS) pandemic provides a good example of how disease is no longer isolated by geography and how serious illnesses can rapidly travel worldwide due to air travel. The Ebola crisis in Sierra Leone and Guinea in 2013 offers a similar lesson on how fragile states, local culture and environmental issues, when combined with a highly transmissible and

lethal infectious agent, can bring about devastating effects.

Guns, violence and germs are present in society every day and pose a significant burden on both our communities and our health care systems. They disproportionately afflict the poor and vulnerable and, just as suggested in Guns, Germs and Steel, they frequently impact the ecological environment where people live, as well as access to health resources that are predictive of who will and will not be susceptible. As Catholic health care providers, we must be both prepared to care for the victims and patients, but, just as important, our ministries also call us to work far left of the “boom” by mitigating negative influences and determinants for those our mission calls us to serve. It is through this approach that we can reduce the effects of guns and germs on societal success.

ALEXANDER GARZA is chief medical officer for St. Louis-based SSM Health, which has care delivery sites and clinical staff in Illinois, Missouri, Oklahoma and Wisconsin, including 23 hospitals, more than 290 physician offices, 11,000 providers and nearly 40,000 employees.

QUESTIONS FOR DISCUSSION Alexander Garza, MD, brings his experience from the military and medical work in poor urban areas to bear on what health care can do to reduce the incidence and consequences of disasters. He thinks Catholic health care has a special role to play not only in caring for victims and patients, but also in doing much more to mitigate negative influences and social determinants that contribute to those situations.

1. Has your ministry had to respond to a disaster – extreme weather, industrial accident, ongoing violence in the community or pandemic disease – that called for different levels of care, communication, stress on employees or anxiety? If so, please talk about what happened and how your organization or team responded. If not, discuss what protocols you have in place should a large-scale disaster strike your community.

2. Garza relies on tactical parlance to exhort health care to work “far left of boom.” What does that mean for your ministry in terms of strategy and operations, mission, pastoral care and community benefit? Be specific about what is already in place and what still needs to be done.

3. When he talks about disasters of disease and violence, Garza emphasizes the need for prevention as well as preparation. How does that play out in the communities your ministry serves? What resources do you need in terms of information, community relationships, financial investments and staff expertise to maximize your opportunities for prevention?

4. Extreme weather events, gun violence and infectious diseases don’t always land in communities that are particularly poor or vulnerable, yet the fallout of those events tends to affect people unequally.

Please talk about how your ministry builds that recognition into its disaster preparedness plans and how a preferential option for the poor might shape the priorities of response when a disaster occurs.

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DISASTERS

Flexibility, Staff Generosity Key to Weathering Storm LANCE MENDIOLA, MS, CHFM, CHSP, CBO

“T

ell me what you need, and we’ll get it there.” For three-and-half weeks in 2017, I found myself saying that over and over as we orchestrated a massive response to Hurricane Harvey. It took a team of dedicated people to get us through the storm, which devastated so much of the state of Texas and affected so many of the communities we serve. It stretched our strength. It challenged our employees. And the millions of gallons of water that fell for days on vulnerable towns and cities in Southeast Texas really tested us all.

Everyone knows that in times of disaster, preparation is key. But at CHRISTUS Health, we learned from previous storms that preparation also requires a much broader approach than many might realize. We do prepare our resources, from food and water to fuel for our generators, to ensure our potentially affected facilities will have enough to weather a storm, and we have planned as far ahead as possible, spending the last 10 years focused on strengthening our buildings to withstand Category 5 storms. But we also know we’ll have to decide quickly if we will cease non-essential medical procedures or move patients. We learned the hard way during Hurricane Rita in 2005 that when the federal government makes an emergency declaration, all patient transportation options are then controlled and directed by the government. We could no longer control when patients would be moved or how, or tell their families where they might end up. So now we begin discussing the possibility of and planning for the need to move patients as soon as a storm appears imminent.

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Our preparations for Hurricane Harvey began when the storm was still out in the Gulf of Mexico and forecast to make landfall near our six CHRISTUS Spohn facilities in Corpus Christi, Alice, Beeville and Kingsville, Texas. The three hospitals in Corpus Christi were expected to take a direct hit. Following our emergency plan, we activated our emergency operations and opened command centers in each of these hospitals and in our system office in Irving. We also created a plan for system leaders about when they could expect updates from the system command center. We learned that many new leaders, who wanted to be helpful and supportive, were reaching out to local leaders in affected areas, which was taking valuable time and energy away from their clearly designated emergency roles. This correspondence made clear that any communication for affected CHRISTUS Health facilities should be funneled through the system command center. Our communications from the command center included the latest weather information, as well as updates from the system office and CHRISTUS ministries.

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Local facility management, security, operations, supply chain and clinical teams committed to working around the clock. They secured our campuses (including a tower under construction), inventoried supplies, transported patients to consolidate them to a few select wings of the hospitals and leveraged resources, including additional staff, to serve those expected to be in harm’s way.

They closed clinics and urgent care centers and canceled non-urgent surgical procedures, transferring patients who would be most difficult to care for if the storm persisted while we still could, namely our NICU and dialysis patients.

A team of staff and physicians arrived at the six CHRISTUS Spohn hospitals and were checked in. Each received an armband, which is a harrowing and humbling experience. Associates write their names on these bands, so they can be iden-

The flooding, which was catastrophic, shut down Interstate 10, isolating the community and our hospitals in the area. Yet, we never closed. tified should the hospital sustain major damage and they are among the casualties. As a veteran, I know what it’s like to put yourself in harm’s way for a greater cause. But each time we go through the process of issuing armbands to our associates, I am in awe again of our amazing health care providers and their unending commitment to the patients we serve.

On Friday, August 25, Hurricane Harvey made landfall at 9:45 p.m. between Port Aransas and Port O’Connor, both on the Gulf of Mexico and about 90 miles apart. It was farther north than the original forecasts. We avoided a direct hit to our hospitals in South Texas, but we did not escape unscathed. The community hospitals in Kingsville, Beeville and Alice retained power, with the exception of a few surges and flickers. The Corpus Christi hospitals lost power but operated on generators. In the light of the following day, we saw that the damage to our CHRISTUS Spohn facilities was generally minor.

But Hurricane Harvey was not finished with

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the CHRISTUS community yet. Prior to the storm’s landfall, CHRISTUS Santa Rosa Health System in San Antonio and The Children’s Hospital of San Antonio, along with CHRISTUS Health Shreveport-Bossier in Northern Louisiana, had accepted nearly 100 patients from South Texas, including some of our more vulnerable dialysis and NICU patients. Harvey would pound San Antonio briefly with rain, affecting some of our staffing levels, before moving on and sitting for an extended time over Southeast Texas.

Most memorable for many was the effect to the Houston area, which received days of rain from Harvey. In downtown Houston, floodwaters covered part of the CHRISTUS St. Mary Clinic’s floors. But Sr. Rosanne Popp, DC, MD, and Sr. Kim Xuan Nguyen, DC, remembering the spirit of the sisters during the 1900 storm in Galveston, kept the clinic open daily.

In Beaumont, close to 30 inches of rain fell in one day, and rainfall along the upper Texas coast totaled some 60 inches in some parts. The flooding, which was catastrophic, shut down Interstate 10, isolating the community and our hospitals in the area. Yet, we never closed. Following our emergency plans, we set up a command center in Beaumont in the belly of CHRISTUS Southeast Texas–St. Elizabeth Hospital. Between daily status calls, people slept on cots, ate emergency food supplies and cared for patients.

We had to monitor not just critical infrastructure and water intrusion, but also the availability of a precious resource. Harvey caused the city of Beaumont to lose water supply, which was not restored for three-and-a-half weeks. Without water, we would be unable to clean rooms, flush toilets, sterilize equipment, maintain daily operations, provide patient care services and offer showers to staff or patients who were sheltered in place.

Luckily, years earlier, a local leader had applied for a FEMA grant to place two water wells on the campus of CHRISTUS St. Elizabeth. However, the wells were not created to support the water needs of an entire hospital and would require some serious engineering work to meet our needs. It took a large team including our facilities managers and our vendors and quite a bit of trial-and-error with additional holding tanks to develop a temporary system with enough water pressure. An auxiliary water distribution system also was developed to store and pump transported water to the hospi-

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tal. Once the wells were connected to the hospital patients from hospitals in the path of the storm to provide non-potable water for infrastructure and then required additional nursing support operations, we needed to continue to replenish to care for them. Of course these arrangements the water in them to supply our needs. Fortunately, required careful logistics and a variety of transa local city government provided an additional portation solutions in the air and on the ground.

12,000 gallons of water via U.S. Army Corps of The system team coordinated travel for each wave Engineers mobile tankers on a rotating schedule. of nurses, then followed them virtually, using Sometimes it was difficult to find enough licensed GPS and other digital monitoring, to ensure they drivers to operate them and enough mobile tank- arrived safely and were connected upon arrival to ers to meet our needs during a crisis — challenges the right departments and the right nurse superviwe had not anticipated. Potable water had been sors. We even went so far as to follow up with their stored on campus before the storm made landfall, families to make sure they were aware where their but other supplies such as food, linens and phar- loved ones were located since at times communimaceuticals had to be replenished through careful cation was limited. coordination. Some of our leaders in other locations wanted to proactively Not only did we work together to ride order or send supplies they had on hand, but I continued to remind them out the storm, but our local teams that when a need for a certain type of remained focused on continuing to supply was expressed, we would find a way to get it there. Our teams on the meet the needs of our communities. ground who were working roundthe-clock to respond to this crisis did Not only did we work together to ride out the not need trucks showing up at their loading dock at all hours, diverting their attention from more storm, but our local teams remained focused on continuing to meet the needs of our communicritical tasks.

When supplies were requested, our supply ties. Sometimes, however, we had to balance our chain team worked with our vendors and other limited resources with needs that seemed unendlocal facilities to send what was needed. However, ing. Before the storm hit, St. Elizabeth created a the roads around the hospital remained flooded, discharge lounge, a special part of the hospital to and the available routes were largely unavail- accommodate patients who were fully discharged able because of local disaster declarations. In but could not get to a safe location.

As local rescue crews (comprised of both these cases, our central command center had to supply letters signed by our CEO to each vendor professionals and volunteers) ventured out in transporting supplies, detailing what they were boats and helicopters to rescue Southeast Texans bringing and why we needed it so they could pass stranded in their homes, we experienced this phethrough various traffic checkpoints on their way nomenon once again. Rescuers continued to drop community members in need of shelter, food and to deliver their cargo.

The flooding also prevented many of our water in an open space next to St. Elizabeth hosemployees from reporting to the hospital to care pital. Unfortunately, though, we were limited on for patients. After a few days, we were in dire space, resources and staff to manage and care for need of nurses to relieve the staff in-house. So we an influx of our neighbors in need of non-medical put out a call system-wide for nurses, prioritiz- support. We couldn’t just turn them away, howing those who were located close by and trained ever. So we instead provided transportation for on the electronic medical record in the hospital. them to local shelters, where they could find the Over the following weeks, on just a few hours’ support they needed.

And in some cases, we provided a bit more. notice and with little idea of what they would face, a contingent of 50 registered nurses from across One day in the midst of our hurricane response, a CHRISTUS boarded planes and other aircraft 10-year-old and a 14-year-old were delivered alone bound for various CHRISTUS facilities in need. to St. Elizabeth, and staff provided dry clothes and This included hospitals on the Texas Gulf Coast activities and oversight for them as we moved as well as those in San Antonio, which accepted to find their father. We were able to locate him

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through our efforts on social media, and the fam- ments to treat cancer patients who needed their treatments and routine visits, but had been disily was reunited at the hospital that evening.

Unfortunately, the storm did more than just placed by the storm. And many of our CHRIStouch our communities; it touched our CHRIS- TUS ministries in Texas and Louisiana extended TUS family as well. A large number of our associ- special employment offers and support to the ates were impacted, from those who had to dis- displaced.

All in all, our response to Hurricane Harvey— card the contents of a full freezer due to power loss to those who lost every material possession or “Hurricane CHRISTUS” as we called it—lasted they owned. Local leaders estimated that approx- almost a month and touched almost every domesimately 30 percent of associates’ homes were tic CHRISTUS market. Luckily, damage to the affected by the storm or flooding. Speaking with CHRISTUS facilities was not severe, but some of employees in the latter group was humbling— it did require additional months of remediation.

In the end, the hurricane highlighted what many of them came to work anyway, because they wanted to care for our patients. “It’s just stuff,” makes our system, and Catholic health care, they said. “The important thing is that everyone exceptional: our teams came together to serve our communities in their times of need, regardless of in my family is safe.”

Many of our associates wanted to help their what these individuals may have been experienccolleagues and assist with meeting the needs, as well as our partners and Many of our associates wanted to other generous Catholic health syshelp their colleagues and assist tems. So human resources, finance and legal quickly set up a fund and a with meeting the needs, as well as donation mechanism to accept financial contributions and donations of our partners and other generous paid time off, as well as an application Catholic health systems. process for those in need. We mobilized additional HR and spiritual care resources to provide support for those impacted ing in their own lives at the time. One by one, they as well. The needs at times felt overwhelming, but forged ahead to live out our mission to extend the healing ministry of Christ in visible and excepso was the response.

Our associates committed almost $30,000 from tional ways, displaying the courage and committheir paychecks to support their CHRISTUS col- ment that sets Catholic health care apart each and leagues affected by the storm and donated almost every day of the year.

4,000 hours of time off. And when our employees’ needs eclipsed these amounts, associates donated LANCE MENDIOLA is CHRISTUS Health’s vice president of facilities management and construcagain.

Our facilities helped in other ways too. CHRIS- tion, located in Dallas. He is a retired Army chief TUS Spohn organized post-storm cleanup volun- warrant officer with one humanitarian and two teer days. The CHRISTUS St. Patrick Regional combat mission deployments. Mendiola has a Cancer Center in Lake Charles, La. (which is close master’s degree in public safety with a concentrato Southeast Texas) opened up extra appoint- tion in emergency management.

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Spiritual Care When Disasters Strike DAVID LEWELLEN

C

haplain Mary Reichert was roused from her sleep when her phone rang around 2:30 a.m. on June 12, 2016. A gunman had opened fire inside the Pulse nightclub, and dozens of casualties were arriving at Orlando Regional Medical Center, where she had finished a shift hours before. Extra chaplains were needed immediately.

Also, her supervisor passed along a circulating report that the gunman was inside the hospital. It turned out not to be true, but as Reichert drove to work she texted her son to say she loved him.

“I knew what I was supposed to do, and it didn’t feel right to say no,” she remembered. “Not from an employment perspective but from a human perspective.”

Inside the hospital were gunshot victims and family members who needed her help. Reichert “did what I was trained to do, and everything else went away.” She collected names and numbers for patients who had been admitted as Does, passing the information to the liaison officer, and as families arrived looking for loved ones, she tried to match the information to unknown patients. She sat with family members in a conference room, offering rosaries and a listening presence. She escorted people to the restroom through the locked-down corridors.

When Mary Reichert and her colleagues tended to people that night of the shooting, which ultimately left 49 people dead, they did what spiritual care workers train for in case of disaster. People who are injured, uprooted or suffer losses during a hurricane, a fire, a plane crash, or any other catastrophe will have spiritual needs as well as material concerns. Along with every other health care department, spiritual care staffs both plan in

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advance and then improvise in the moment, using therapeutic skills to minister to those in need of support.

AROUND-THE-CLOCK RESPONSE

Of the three major hospitals in Santa Rosa, Calif., only St. Joseph Health Sonoma County was far enough from the danger zone to remain open when wildfires blazed in northern California for two weeks in the fall of 2017. “A hospital is one of the few places in a community that is open 24/7,” said Katy Hillenmeyer, director of mission integration for St. Joseph Health Sonoma County. “It became a place that people gravitated to if they needed refuge.” And when residents fleeing the fires arrived, “chaplains were very important first responders. They weren’t just at bedsides. They were out in the lobbies and cafeterias and wait-

People who are injured, uprooted or suffer losses during a hurricane, a fire, a plane crash, or any other catastrophe will have spiritual needs as well as material concerns.

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ing rooms, extending themselves to people who hundred dollars, but a small contribution can be seemed disoriented or lost or in need.” Chaplains a help when people are handling unforeseen ciralso met with patients evacuated from the other cumstances and “long after the money is spent, it hospitals to St. Joseph, and hospital personnel communicates that we care about you.”

In meeting after meeting during the crisis went into shelters to treat people whose needs phase of the hurricane, Ford said, he was asked were less acute.

Joint Commission-mandated disaster drills, as for a reflection, a prayer, or a few words of encourwell as previous experience with fires and earth- agement, and he had to have something ready at quakes, helped St. Joseph respond, Hillenmeyer all times or be able to improvise. “In a disaster, our said. All chaplains in her department are trained chaplains just have to increase their awareness in critical incident stress management, a way to and up their game of what they already basically help first responders or caregivers process a trau- know,” Ford said. “Their ministry skill of listening was amplified by organizing listening circles. matic event soon after it happens.

“The disaster absolutely brought out the best Their gifts of compassion were used by showing in every one of our caregivers,” Hillenmeyer said. empathy and offering help to more associates than “People pitched in where they were needed. We normal, but responding and organizing as needed had doctors directing traffic, and executives and is an expectation in our culture at CHRISTUS painters cooking meals in the cafeteria. People Health.” who lost their homes still came in to work.”

Two weeks later, when the fires were under TIME-OUT FOR SELF CARE control, human resources undertook “welfare During a crisis, a chaplain may “arrive on a unit checks on every single one of our caregivers,” who where you could cut the tension with a knife,” were “dealing with the stress of the fire, insurance said Coletta Barrett, vice president of mission at claims, temporary housing, rebuilding.” One- Our Lady of the Lake Regional Medical Center in sixth of the hospital’s staffers lost their homes in Baton Rouge, La. Just by calling staffers together the disaster, Hillenmeyer said, and spiritual care for a brief moment of prayer, silence or mindfulprovided a listening presence for them. And while ness, “that 30-second time-out can do a lot to build the fires were still burning, St. Joseph’s converted resiliency.” office space into temporary apartments and set Hurricane preparation is a constant for Barup a housing task force to find anything available, rett’s system; she coordinates with Louisiana including hotel rooms, for displaced employees.

State University, the state health association, and Staff housing was also a priority for the other groups. Barrett and her team also use small CHRISTUS Southeast Texas system, after Hurri- disasters to prepare for big ones. The spiritual cane Harvey struck, paused, and then struck again in 2017. “No one expected Just by calling staffers together for that within a few days we would get six feet of water,” said Dan Ford, a brief moment of prayer, silence or regional vice president for mission. mindfulness, “that 30-second time“We literally had nurses coming in by boat and helicopter.” The hospital put out can do a lot to build resiliency.” up employees who couldn’t get home in unused patient rooms, and stocked — COLETTA BARRETT a “hurricane lounge” with snacks and games. “All of those things can be tools of spiritual care department responds to every trauma, heart care,” Ford said. attack or stroke code to assist those in immediate As the rebuilding effort began, CHRISTUS need and also “to know what our capacity is in expanded its emergency employee assistance the face of true disaster. We know we can surge fund in southeast Texas, and a committee with when we need to.” In those cases, “we’re not there representatives from mission, spiritual care, necessarily for the patient, but for the family and finance and human resources worked to “help as caregivers,” Barrett said. If 10 or 15 relatives are many as we could as quickly as we could.” Most getting upset in the emergency room, a chaplain of the awards provided people with just a few will find a conference room for them to have a

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When the Red Cross mobilizes for major disasters, its response includes spiritual care. As of 2015, the organization recognizes spiritual care as an integral part of its disaster response, on par with relief supplies and mental health. space where the chaplain can listen to whatever is on someone’s mind and respond appropriately.

A few months ago a police officer was shot, and 150 people gathered at the Baton Rouge hospital waiting for news, including the police chief, the mayor, the district attorney and others. Spiritual care staff made the decision to move the group from the emergency waiting area to the auditorium. The hospital chaplain was the first to know that the officer had died, and spent a few minutes with the police chaplain, “ministering to their minister” before making the announcement to the larger group.

When weather forecasts suggest a possible hurricane, the spiritual care department’s plan activates. Barrett said, “Unfortunately, we have it down to a science.” Some chaplains must plan to be onsite for as long as 72 hours, if necessary; others are sent home to be the relief shift. During Hurricane Barry in 2019, the hospital provided sleeping accommodations for 800 staffers at night and 600 during the day. During a very unexpected ice storm last winter, Barrett had to let staffers already working know, ‘You’re not going home,’” because the next shift couldn’t safely drive to the hospital.

RED CROSS INCLUDES SPIRITUAL CARE

When the Red Cross mobilizes for major disasters, its response includes spiritual care. As of 2015, the organization recognizes spiritual care as an integral part of its disaster response, on par with relief supplies and mental health — the culmination of decades of working with certified chaplains’ groups to assist people in the aftermath.

Some Catholic hospitals give their chaplains time off to respond to a disaster in another loca-

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tion, and capture it as part of the hospital’s community benefit work, according to Tim Serban, who has volunteered as part of the American Red Cross’ efforts to provide disaster spiritual care since 1999. Most Catholic health care systems do not have formal response teams in place to send to a disaster, but deploying a trained chaplain and those from other caregiving professions is “a unique opportunity to support response,” said Serban, chief mission officer – Oregon region, Providence Health & Services.

However, the Red Cross does not have enough board-certified chaplains, of any faith, on its rolls of willing volunteers to meet the needs in a disaster. Therefore, other chaplains, or local clergy, are also called upon, after they have completed Red Cross training about how to minister appropriately to survivors in a disaster situation. Chaplains learn about “psychological first aid,” a critical incident stress management process that is not psychotherapy, but provides a way to learn about stress reactions, vent emotions and refer people for additional help when needed.

They work with nurses, social workers and counselors to meet victims’ needs, whether locally after a house fire or traveling elsewhere in the nation after an event such as a hurricane.

That work can even extend to conducting memorial services. Groups that distribute supplies or meet other material needs have to sign a pledge to abide by Red Cross neutrality rules. The Red Cross’ priority is to “ensure no one’s vulnerability is taken advantage of,” Serban said — as part of that, proselytizing is not tolerated.

The Red Cross divides disaster phases into preparation, response, recovery and mitigation.

At the first stage, as organizations plan for disasters, trained chaplains can “help spiritual care teams anticipate what the needs might be,” Serban said. Response is the heated, harried phase that makes national news and includes the arrival of outside teams, including chaplains. The recovery phase is usually when outside chaplains go home, but ideally they will have first cooperated with local chaplains and faith leaders to plan for ways to tend to ongoing needs. The mitigation phase is considering lessons learned for use at other times and places.

TAKING THE LONG VIEW

After the immediate crisis abates, local chaplains still have to keep attending to the spiritual needs

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“We could not have cared for people as effectively as we did if we had not coordinated with community partners.”

— KATY HILLENMEYER

of victims, families, staff and sometimes community members, too. Following the Pulse nightclub shooting, Orlando Health gave its employees a chance to grieve and to process what had happened, through support groups and memorial events. “We’re more aware now of the importance of supporting staff members’ emotions,” Reichert said.

The hospital later published an e-book of the response to the disaster in every department.

(See it online at https://www.orlandohealth.com/ campaigns/g6iv8jkzop719). “Every single person was affected in some way,” she said, “no matter if they were there or not, or what their role was. It was a defining moment, and it brought the staff together as a community.”

The spiritual care department, which was used to getting the calls that no one else was sure what to do with, also responded to community members who wanted to help. “The event hits the news and everyone wants to do something,” Reichert said. “But we don’t know who you are, and you don’t know our protocols. You’re another person we have to worry about.” She learned how to say “thanks, but no thanks” to offers to come in and console victims and family members — and for callers who were stubborn, “I went back to my customer service training and just kept repeating the message.”

The Santa Rosa system, too, had to grapple

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with eager volunteers during the wildfires. Restaurants would drop off donated pizza or sandwiches at the hospital lobby. In those cases, “normal circumstances don’t apply,” Hillenmeyer said.

“You say OK, we have to take it on faith that people will use good judgment.” For people who wanted to volunteer to help area residents or hospital caregivers, “we had to have some sense of professionalism, and that they were not a security risk,” she said. “It was almost like an interview situation. If we got the sense that they were truly there to care for people, we found a way to put them to work.” Volunteers with verifiable licenses offered massage therapy, grief counseling and pastoral care in the weeks following the fires.

In conjunction with local mental health agencies, St. Joseph’s spiritual care department established support groups, in English and Spanish, “extending basic mental health first aid to one another,” Hillenmeyer said. “We could not have cared for people as effectively as we did if we had not coordinated with community partners.”

Almost two years after the fires, “the people who lost their homes are not back to normal,” Hillenmeyer said. But when another wildfire hit Butte County, about 150 miles northeast, in 2018, “it felt like déjà vu,” she said. St. Joseph took some transferred patients from the affected area, the local air quality got worse, and “we had to be prepared to jump back into the mode of crisis intervention.

Wildfires and quakes will be part of our lives as long as we live here. The capabilities we showed in our own disaster can also be put to the service of our neighbors in their once-in-a-lifetime occurrence.”

DAVID LEWELLEN is a freelance writer in Glendale, Wis., and editor of Vision, the newsletter of the National Association of Catholic Chaplains.

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DISASTERS

Disaster Landscapes In Health Care Learning Experiences from Florida to Peru

KAREN REICH, MSW, FACHE and CAMILLE GRIPPON, MA

W

e see daily examples in the news of disasters around the United States and elsewhere in the world. We further understand climate change is taking a toll on the earth. And disasters like hurricanes, floods, earthquakes and wildfires affect every aspect of providing health care. In the last two years alone, Catholic health care facilities have experienced major disasters in Florida, California and the Carolinas, just to name a few, and also have contended with responding to disasters in some international ministries like Mexico and Peru.

During 2017, Bon Secours Health System had to face disasters that hit at the heart of its ministry.

One disaster, Hurricane Irma, caused the evacuation of two facilities in St. Petersburg, Fla., Bon Secours Maria Manor and Bon Secours Place. The response posed significant challenges to patients and staff. The other disaster was more than 2,600 miles away from Florida. The floods in Peru that year directly impacted over one million people in that South American country where the Sisters of Bon Secours live, minister and provide health care to vulnerable communities. These very different disasters provided valuable organizational lessons about resilience and action. Health care’s complex systems for providing care can be fragile in times of disasters, and we must continue to thoughtfully develop disaster preparedness plans to secure ongoing operations while also increasing mitigation practices to prevent greater warming of our common home.

CARE OF OUR COMMON HOME

Pope Francis highlights the urgency to curb the warming of our common home in his encyclical, Laudato Sí. He states that “reducing greenhouse

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gases requires honesty, courage and responsibility, above all on the part of those countries which are more powerful and pollute the most.”1 Human beings have an ethical responsibility toward the natural world that sustains life itself. Curtailing the human-made effects on the earth’s climate requires moral choices and bold action from every sector of society, including the health care sector.

The challenge before society is not only to be resolute in the conviction that climate change is real but also to ensure that appropriate personal, organizational and societal action takes place in an accelerated manner. As a global family, we can no longer ignore the need for updated environmental regulation of industry and the need to end water and air pollution and backward energy practices.

The victims hit hardest are already among the most vulnerable in the world.

The U.S. health care sector has a particular responsibility. Health care is the second largest producer of greenhouse gases after the food industry, yet the gravity of its operations on the environment is still largely underestimated. At a basic level, health care facilities produce and emit greenhouse gases into the environment through

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DISASTERS

heating and cooling units and energy-intensive life-cycle of their products. For example, is there equipment, which rely on electricity powered by enough education that takes place within a busifossil fuels. Once the greenhouse gases build up ness to understand the effects of where materials in the atmosphere, they directly contribute to the that will be used come from and what happens when the material ends its utility or life-cycle? warming of the globe.

The use of fossil fuels and the health of the pop- If the use of such products affects the integrity ulation also are intimately connected. The Ameri- of the environment and life itself, should they be can Medical Association not only has agreed with used? Although there are numerous examples of the scientific evidence around climate change business decisions that happen every day that but also has urged physicians to play a critical have an implication on the environment, longrole in advocating for climate change mitigation. term consequences need to be weighed against According to The Lancet, mitigation strategies short-term gains. should include “the recognition by governments and electorates that climate change has enormous THE FRAGILITY OF HEALTH CARE: health implications.”2 LESSONS FROM FLORIDA Similarly, the AMA Journal of Ethics calls for From Aug. 30 to Sept. 6, 2017, Hurricane Irma medical advocates to promote “public and leg- caused major destruction in Barbuda, Saint Marislative support for international, national, and tin, Saint Barthelemy, Anguilla, the U.S. Virgin regional policies to mitigate climate change; Islands and the Florida Keys. It reached its peak encourage a co-benefits approach, which pro- intensity as a Category 5 Hurricane. It significantly motes policy and lifestyle measures to improve damaged many parts of Florida. Some islands public health; and expand medical curricula and were leveled, the Florida Keys experienced 90% awareness on climate and global change.”3 The of homes damaged, and millions across Florida stakes could not be higher for the medical pro- were without power.

Florida is home to Bon Secours Maria Manor fession. Its members will increasingly contend with “changing patterns of disease and mortality, and Bon Secours Place, both of which had to extreme weather events including flooding and be evacuated due to the hurricane. Luckily, the facilities experienced no significant infrastrucdrought,” and food insecurity.

Health care can have a negative effect on the ture damage from the storm. Bon Secours staff in environment, and the health care sector as part Florida did a heroic job in transporting medically of the global community has an ethical responsibility to achieve even greater Climate change needs to be strides to help curb the warming of the addressed in terms of protecting planet. Every ethically responsible business looks to minimize egregious harm people from harm and protecting when dealing with personnel matters, as an example, yet many fall short of holdthe ecosystem from irremediable ing their operations to the same standard destruction. when it comes to protecting the environment. One possible reason is because there is no consensus, in moral terms, about how frail residents and patients to St. Jude’s school and to deal with environmental issues. While some cathedral in St. Petersburg, which was on higher see it as a matter of right and wrong, others do not. ground.

Climate change needs to be addressed in terms Bon Secours was not anticipating an evacuaof protecting people from harm and protecting the tion. However, Pinellas County Disaster Manecosystem from irremediable destruction. While agement began redrawing evacuation zone lines every sector of society, and every industry, has an at the last minute in the aftermath of Hurricane environmental footprint and effect in the world, Harvey in Texas. There, some nursing homes had every industry should begin to fully understand sheltered residents in place, based on the informaits ethical environmental responsibility. Business tion they had, but media coverage soon showed leaders have a moral choice to discern about the some residents in waist-high water from a storm

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surge. The two Bon Secours facilities in St. Peters- needed, while also contending with our employburg found they were re-designated as being in an ees’ personal home evacuations and power outevacuation zone where facilities were required to ages. Many resources had been deployed to assist the hurricane response efforts in Texas, leading suddenly evacuate.

On the morning of Sept. 8, 2017, Bon Secours to a lack of generators and fuel supply throughin St. Petersburg began to execute its evacuation out Florida. Bon Secours struggled to relocate plan. Staff had already secured the facilities with new generators and to knit together several new protections to better withstand the storm. With fuel suppliers to total the 10,000 gallons needed the call to evacuate, 350 patients and residents were relocated from their “Evacuations should not be all or skilled nursing and assisted living residences. Moving vans carried food nothing. We need a much more and water for seven days, all patient nuanced and better-researched records and possessions — including the patients’ own mattresses, supunderstanding of who should plies, medications, medication carts, electronic medical records and assoevacuate before, and how people ciated technology. Everything except can be sustained appropriately.” the walls and floor was moved by a small team of staff. Despite having — KATHRYN HYER been notified about the frailty of some patients at Bon Secours, the county sent school buses for transportation, which before going into the night of the storm. The other lacked sufficient lifts and wheelchair accommo- challenge faced was the lag time before the activadations, resulting in strenuous physical labor for tion of temporary offsite generators; it required staff to assist those patients. Nonetheless, all the a two-hour manual procedure and involved the patients and residents were safely transported perfectly timed choreography of Duke Energy, the 10 miles across town to higher ground in only generator company and electricians.

Lessons learned from the experience led to eight hours.

Over the course of five days, 150 staff and 50 changes. As a result of Hurricane Irma, there family members and volunteers ensured that has been progress at the local level including quality of care was maintained and also that the automatic transfer switches, redundant venquality cadence of daily routines remained as dor capabilities and improved planning. But as normal as possible. While unfamiliar surround- Kathryn Hyer, PhD, director of the Florida Policy ings and mattresses on the floor of the cathedral Exchange Center on Aging at the University of and school made it difficult for patients as well South Florida, explains “evacuations should not as caregivers, compassionate care and a spirit of be all or nothing. We need a much more nuanced unity were palpable. “Eggs your way,” Tai Chi, and better-researched understanding of who yoga, bingo, Mass and choir were among the should evacuate before, and how people can be many activities that were enjoyed. And, when it sustained appropriately.”4 Hyer is a member of was time for a lockdown as the hurricane picked Bon Secours St. Petersburg Health System’s board up, Bishop Gregory L. Parkes of the Diocese of quality committee.

St. Petersburg came to the shelter, bringing added Hyer made eight recommendations from her comfort to all. ongoing research to improve the outcomes for the Even though the evacuation was successful elderly: and the patients were safe, Bon Secours faced 1. Require generators and fuel to support air challenges. Team members had to balance issues conditioning and other medical needs. that arose from providing care in a difficult physi2. Improve education about emergency plans. cal environment. These included operational and 3. More federal oversight in a facility’s evacuahuman matters, from the challenging logistics tion plan is needed. of working with vendors to get resources where 4. The decision to evacuate must take into

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account the size and severity of the storm, the ability of the facility to withstand wind and potential storm surge and the needs of the residents.

5. Require facilities be built to minimize flooding risk and allow residents to shelter in place if necessary.

6. Give nursing homes and assisted living communities priority in power restoration efforts.

7. Provide some litigation protection for facilities that abide by regulations and provide care during disasters.

8. Commit to ongoing geriatric education programs.

Hyer also noted that the country needs ongoing geriatrics training and consistent research funding to evaluate disasters. “We know that disasters will continue to occur, and we must be prepared.”5 This disaster not only showed the leadership in place at Bon Secours facilities but also highlighted the fragility of health care operations and the need for disaster preparedness.

DISASTER GUIDELINES: LESSONS FROM PERU

On March 15, 2017, Peru suffered through the worst flooding in recent history due to the abnormal warming of the Pacific Ocean. Half of the country, 12 coastal states, were severely affected by the disaster. Relief was very limited since 4,000 miles of roads and 514 bridges were compromised. Over one million vulnerable people were affected, over 153,000 homes were destroyed, over 460 hospitals were compromised, and many people were left homeless.

Since Bon Secours Health System was founded by the Congregation of Sisters of Bon Secours, Bon Secours was aware that there were many Catholic groups directly impacted in Peru during the floods, especially the Sisters of Bon Secours in: La Libertad (Trujillo), Piura (Los Ranchos), Ancash (Huacho), and Lima; the Sisters of the Incarnate Word were affected in Ancash (Chimbote).

Even though the decision to become actively involved in support of the communities in need was unwavering, it was also guided by disaster guidelines and best practices already established under the organization’s office of Global Ministries. Responding to a disaster abroad without such guidelines would neither have been helpful nor organizationally sound. As an example, the guidelines follow the humanitarian core mandate

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to “do no harm” or to minimize the harm organizations may be inadvertently doing simply by being present and wanting to assist.

In addition, the organization followed CHA’s report on disaster response which says, “Disaster situations evolve quickly. Financial contributions enable relief agencies to purchase exactly what is needed when it is needed. Financial contributions also avoid the expense and environmental impact of transporting and storing donated goods.” It is also true that the desire to help through handson work or by supplying donations is generous and admirable; however, the help most needed by people impacted by disasters comes from trained, experienced relief and development professionals.6 Bon Secours Health System (now known as Bon Secours Mercy Health) did not support employees wishing to donate supplies or their skills to the Peru disaster since the scale of the disaster response needed was massive. The response was better supported through an established partnership with an international disaster relief organization. Bon Secours and one of its disaster partners, Americares, provided aid for six months from the onset of the disaster. Bon Secours supported the emergency effort with professional relief workers, medical mobile units, cash, distribution of water purification solutions and critically needed medicines. The aid response included over 6,500 patient encounters and served well over 50,000 people. The total response was valued at more than $8 million and included life-saving medications to treat dengue, and water purification to prevent more disaster-related illnesses.

Bon Secours also activated a program to match 100% of any cash donations received from any employee. The handful of medical professionals and experts deployed from the United States to Peru from the organization itself were rigorously screened and sent to fill specific short-term needs. They followed global guidelines the office of global ministries follows related to safety measures, ethical standards and professional protocols. The guidelines include: 1. All participants’ credentials and/or other required documentation will be properly submitted to the local Ministry of Health.

2. All participants will be briefed and educated on Bon Secours global ethical standards.

3. Participants will practice within the same

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professional and specialized skills abroad as they practice within the U.S. under their professional licenses.

4. Participants respect local authority at all times.

5. All participants will understand their role and responsibility and the local context of deployment.

6. All participants must attend the international formation and orientation sessions prior to departure and the debriefing meeting upon their return.

7. Each trip will be chaperoned by a country leader who has the ultimate responsibility and authority for the safety, coordination and organization of the participants, and the safety of the patients and families.

8. Each trip will have competent, and sufficient, interpreters to support the participants.

9. Under no circumstance is it acceptable to give money to patients and families. The participant can refer the case to the country leader for evaluation.

10. No participant shall purchase gifts directly from, or for, patients or families. The participant can refer the case to the country leader for evaluation.

11. Maintaining personal safety is paramount. A requirement of participating in the trip is to read, understand and abide by the safety protocols. In addition, it is prohibited to travel alone and outside the approved security system set in place by the country leader.

12. Participants shall maintain open lines of communication with the country leader, interpreters, patients, families and coworkers to avoid misunderstandings or negligence that can often lead patients not to receive proper care.

A CALL TO ACTION

In his encyclical, Pope Francis called for honesty, courage and responsibility. The disaster landscape is vast, and health care organizations must contend with many challenges. Areas for additional development include disaster preparedness and mitigation efforts by health care systems to lessen their harmful impact on the environment. There are many resources available for those who need to start from scratch, such as tools from Health Care Without Harm, Practice Greenhealth, and Premier Safety Institute. Several Cath-

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olic health care organizations have refined their disaster planning based on lessons learned from disasters like Hurricane Katrina and others. One such example is the U.S. command post set up by CHRISTUS Health.

What is upon all of us, as individuals and as a collective, is that the consequences of inaction both on disaster preparedness and climate change mitigation are far too great. There are many implications from inaction for people, society, industries and the world. The time to act is now in order to achieve a cultural transformation and to protect the generations to come. In a time of political denial, global unrest and personal strife, it is normal to see disasters as an abstract force that cannot be tamed. The health care sector’s highest order is to do no harm . Health care has opportunities to mitigate its impact on the environment and to prepare for what is to come.

KAREN REICH is president Bon Secours St. Petersburg Health System and Health System Senior Services. She is based in Florida. CAMILLE A. GRIPPON is system director global ministries. She is based in Marriottsville, Md. Both authors work as part of Bon Secours Mercy Health system.

NOTES 1. Francis, Laudato Sí (Washington, DC: United States Conference of Catholic Bishops, 2015).

2. Anthony Costello et al., “Managing the Health Effects of Climate Change: Lancet and University College London Institute for Global Health Commission,” The Lancet 373, no. 9676 (May 2009): 1693-733.

3. Andrew Jameton, “The Importance of Physician Climate Advocacy in the Face of Political Denial,” AMA Journal of Ethics 19, no. 12 (December 2017): 1222237, https://journalofethics.ama-assn.org/article/ importance-physician-climate-advocacy-face-politicaldenial/2017-12.

4. “Despite Recent Deaths, Evacuating Nursing Homes in Natural Disasters Isn’t Always the Safest Option,” University of South Florida summary related to the work of Kathryn Hyer, http://news.usf.edu/article/ templates/?a=8058&z=220.

5. “Despite Recent Deaths.”

6. Disaster Response: Considerations for Catholic Health Care, Catholic Health Association of the United States, 2013, https://www.chausa.org/disasterresponse/ resources.

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RealyEasyStar/ Fotografia Felici/Alamy Stock Photo

Finding God in Daily Life To Mary, Queen of Peace ‌ I entrust once again the anxieties and sorrows of the people who suffer in many parts of the world due to natural disasters, social tensions or conflicts.

Pope Francis to pilgrims gathered in St. Peter’s Square, Aug. 15, 2017

Creating a Culture of Emergency Preparedness JEFF MOSELY, PE

O

n the morning of July 10, 2019, the command center opens at Our Lady of the Lake Regional Medical Center in Baton Rouge, La. Tropical Storm Barry’s journey across the Gulf of Mexico is varying in intensity and direction. The local weather coverage, a constant companion in the command center for the next four days, is predicting with more confidence that the storm will become a hurricane before landfall near Morgan City, La. The on-land projected route takes Hurricane Barry west of Baton Rouge by midday Saturday.

More concerning is a projection of rain that could exceed 25 inches by the end of the weekend. At this point, our incident command center located in a room off the administrative offices has only partially activated the logistics and planning section chiefs, but that will soon change. An uneasiness begins to form in the incident command center as everyone there has been down this road several times before.

Our incident command members are keenly highly experienced in emergency preparedness aware that the weather predicted could lead to and response. traumatic stress for those on our team. Louisiana has endured more natural disasters than most HOSPITAL EMERGENCY PREPAREDNESS states, 72 declared disasters since 1953. Time in Hospital emergency preparedness is the process Louisiana is still measured as “before Katrina” or of being prepared for any adverse event, natu“after Katrina,” due to the loss and catastrophic ral or manmade, that can endanger the safety of damage from that 2005 hurricane. And just three patients, visitors or employees. At Our Lady of years prior in August 2016, Baton Rouge had one of its worst floods in Hospital emergency preparedness is recorded history. Over 30 inches of the process of being prepared for any rain fell in some parts of the region.

Approximately a third of the busiadverse event, natural or manmade, nesses and homes had some form of flood damage, including those that can endanger the safety of of many employees and patients of patients, visitors or employees.

Our Lady of the Lake. Our command center opens when the administrator on call makes the determination it’s needed. the Lake it is referred to as our “culture of preFor this situation, as Wednesday morning turns paredness.” The facilities operations departto afternoon, the incident command is coming ment is inevitably at the center of this preparedinto its full complement of section chiefs, who ness. Events that could affect safety (known as are hospital employees with particular areas of adverse safety events) come in many forms other expertise. There’s comfort in knowing they are than weather. They can include mass casual-

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ties, an active shooter or loss of critical utilities such as information systems or electronic medical record systems. In all these examples facilities operations has a prominent role, not only in the preparation, but also in managing adverse events as they are unfolding. This preparedness comes from intense training, policies and drills.

The Joint Commission requires as part of its hospital accreditation at least two drills per year. In 2018, we conducted four drills, plus had one actual event in which the incident command was activated. All emergency preparedness is structured within an emergency management program. The objective of the emergency management program is to identify processes for managing the effect of emergency events to hospital operations. These are highlights of the plan: A hazard vulnerability plan is completed annually to identify and prioritize potential natural, technological and/or human emergency events that may affect demand for or the hospital’s ability to respond to demand for services.

The process includes an evaluation of mitigation and preparedness activities of the physical plant, as well as response and recovery strategies.

The hospital uses an incident command structure that is compliant with the National Incident Management System structure. The Federal Emergency Management Agency’s National Incident Management System provides ways for government, nongovernmental organizations and the private sector to work together. The hospital’s command structure is consistent with the command structure in place at other health care facilities in East Baton Rouge Parish, the most populous parish in Louisiana. It includes the city of Baton Rouge.

Training for team members about incident command begins in general orientation and is included in annual education that can include classes, webinars and drills. Hospital leaders, including managers, directors, division directors and senior leaders are assigned incident command training. In the facilities department, team members learn utility loss protocols and preevent precautions.

All members of the command have other jobs at the hospital; we call in the section chiefs as needed, based on a potential disaster or emergency. Leaders with assigned roles in the com-

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mand structure also complete two courses, one on the National Incident Management System, and one on the National Response Framework.

These courses are for those who need a basic understanding of the National Incident Management System.

At Our Lady of the Lake, the role of the incident commander rotates to the administrator on call when an event happens. The person holding the role may change once the incident command is activated if specific competencies warrant a change in leadership.

Our Lady of the Lake has a designated emergency management coordinator who functionally resides in facilities services, reinforcing the close relationship between emergency preparedness and the built environment. This coordinator manages all emergency preparedness activities and chairs the emergency management committee. As part of our emergency management program, the hospital has a written emergency operations plan that describes the response procedures to follow when emergencies occur. This includes recovery strategies and actions designed to help restore the systems critical to providing care, treatment and services after an emergency. Each of these response plans includes facilities protocols and is required training by all team members. The code colors can vary between states and even between different systems in a region, so drills include work to familiarize people with the different code names and responses. Some of the key response plans are as follows: Code Gray — Inclement Weather (Hurricane, Tornado, Ice Storm, etc.)

Code Black — Bomb Threat Plan Code Red — Fire Plan Code Purple — Information Systems/ Telecommunications Failure Code Orange — Chemical Contamination Plan Code Green — Radiation Plan Code Yellow — Mass Casualty Incident Plan Code Silver — Active Shooter/Hostage After every drill and actual event, the hospital conducts an after-action review or “hot wash.”

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The purpose of this meeting is to learn what went puter workstations via emails and our intranet well and identify opportunities for improvement. home page.

Ongoing communication to staff is provided This is part of a sustainability program to ensure policies and procedures are followed and are still electronically with the team member text alert relevant. After Hurricane Gustav in 2008 caused system and regularly scheduled briefings for a 33-hour power outage at Our Lady of the Lake, department leaders, who give employees updates. the after-action review recommended increas- Medical staff communicates with patients and ing the emergency power through increased gen- their families. erator capacity to accommodate all power needs Hurricanes are unique in that they can give including the heating, ventilation and air condi- ample time for hospitals and health systems to tioning systems. Our Lady of the Lake was within three hours of evacuating Three years after the 2016 floods, patients due to lack of air conditioning when the power was restored. some in the Baton Rouge area are still Today, Our Lady of the Lake has five traumatized, so there is sensitivity 1,750 kilowatt natural gas generators that can handle the entire facility’s in all communications to our team power needs. It’s critically important: In 2018 a U.S. Senate inquiry faulted members. The goal is to not be too state and federal oversight agencies alarming, but still emphasize the for fatal heat strokes when nursing homes were without air conditionneed for a culture of preparedness. ing after several hurricanes that year.

No other essential system in the built environment is more important than emergency begin their preparations and are a good example power reliability and capacity. to use in describing the emergency preparedPerhaps every after-action review ever con- ness process. The actions of the emergency preducted will identify issues with communication paredness teams leading up to a hurricane event and recommendations for improving it. We have are methodical and slower paced than response several policies in place regarding communica- to other potential disasters, because more lead tions. The hospital prepares for how it will com- time is available. Also, hurricanes encompass all municate during emergencies, including plans for aspects of emergency preparedness from transnotifying staff when emergency response mea- portation, facilities, staffing and supplies. sures are initiated. As a result of feedback concerning communication gaps during events, Our THREE DAYS BEFORE HURRICANE BARRY Lady of the Lake rolled out a text alert system in A tropical storm watch (soon to be hurricane 2016. This system allows for carefully selected text watch) is issued for the Baton Rouge region. This communications to be sent to all those staff who means that a hurricane could be expected to pass opt into the alerts. Communication systems are through the Baton Rouge area within 72 hours. among the most important systems to be main- The administrator on call, an experienced Louisitained. For that reason, these systems including all anan with more than four decades of emergency information technology systems, are connected to preparedness experience, has assumed the role of uninterruptible power supplies. Equipment con- incident commander. For this event, the facilities nected to these supplies does not have a 10-second lead is the logistics section chief. The incident delay in power as do items strictly on emergency commander in consultation with the Lake’s chief power. Other forms of communication include: operating officer and other executive leadership When the hospital responds to a disaster sit- decide to activate a “Code Gray-warning.” The uation, personnel within the hospital are notified incident commander first initiates a partial actiby overhead paging that announces the appropri- vation of the command center including just the logistics, planning and public information officer ate emergency code.

Mass alerts are issued electronically to com- section chiefs. The public information officer, in

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consultation with other command staff and the chief operating officer, begins issuing early communications to staff. Three years after the 2016 floods, some in the Baton Rouge area are still traumatized, so there is sensitivity in all communications to our team members. The goal is to not be too alarming, but still emphasize the need for a culture of preparedness. The initial communications to all staff via emails and a called department head meeting indicate that we are watching the weather situation closely and to: Validate that your current department call tree is accurate and complete.

Confirm your supply inventory is adequate and appropriate.

Reinforce that our mission calls us to be a healing and spiritual presence. We encourage supervisors to support their team and provide the calming spirit they need.

The ever-present opportunity to request sign-ups for text alerts.

Facilities operations, in addition to these tasks, begin their 72-hour pre-hurricane protocol, which includes topping off diesel fuel tanks, clearing the hospital site of debris that could become projectiles and touching base with all of their supply vendors and contractors for standby support.

48 HOURS BEFORE

The weather reports related to Tropical Storm Barry indicate Baton Rouge may get 15-25 inches of rain, which concerns staff more than the wind.

It cannot be emphasized enough how difficult it is for dedicated, caring staff to concentrate on our patients’ needs when memories of their own personal hardships from 2016 are ever present in their minds, but they do! “The Lake,” as locals call the health care system, is a caring ministry dedicated to helping those most in need and the spirit of healing. With two days out from Hurricane Barry’s landfall, a lot of emphasis is on the logistics section of the incident command. If the “Code Gray-activation” is issued, hundreds of staff will be required to stay on site until the code is lifted.

The logistics section begins preparing a sleep plan for staff. Fortunately, a plan is already in place that utilizes conference and clinical exam rooms as sleep rooms. Our Lady of the Lake has 832 licensed beds but does not allow staff to sleep in unoccupied patient rooms during a Code Gray-

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activation. We also are connected to several medical office buildings with hundreds of exam rooms.

These medical office buildings are on the hospital’s emergency power, including air conditioning. Under the sleep plan, the outpatient clinics would be closed if a Code Gray is called and beds would be available. After the 2016 flood we gave every employee who had an office an air mattress to keep on site. Hundreds of others were purchased and stored by facilities operations. The planning section of the incident command works on a distribution plan to get air mattresses into office and exam spaces.

24 HOURS BEFORE

The confidence level that Tropical Storm Barry will hit landfall around Morgan City, La., is high.

The likelihood of 25 or more inches of rain hitting Baton Rouge is high. At this point the operations section of incident command is opened as well.

The planning section of the incident command finishes its activation plan, which outlines steps for core and support departments and personnel. Our Lady of the Lake, like some other institutions, no longer uses the terms “essential and non-essential” when describing core and support departments out of recognition that everyone’s job is important. Each core department, as well as the incident command itself, develops an A and B team to work in 12-hour shifts. Once Code Gray-activation is announced, all core teams are required to stay on site. The daily communications remind those core personnel to be prepared to stay by packing sleeping provisions, personal items and, most importantly, prepare things at home for their absence. Code Gray-activation was announced for 7 p.m. the evening before Barry is due to arrive.

HURRICANE BARRY ARRIVES

As expected, Tropical Storm Barry became Hurricane Barry on Saturday, July 13 at approximately noon, then shortly thereafter made landfall near Morgan City, La., as a Category 1 Hurricane. What happened next was not expected, and to this day is still not fully understood. Miraculously, the storm seemed to dissipate as it made landfall. It would later be attributed to a high-level dry air current that sheared the storm and dried up most of the moisture as it made landfall. The Baton Rouge area was spared the predicted rainfall and gusty

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winds. Later on Saturday afternoon, we were able to communicate that activation would be lifted by 7 a.m. Sunday morning and the recovery phase (relief teams) would begin. Relief teams take on shifts and give activated teams a rest. In prolonged incidents, relief team members may assume roles in the command center. Incident command was deactivated as well.

CONCLUSION

An after-action review was conducted the following Monday. Perhaps because the brunt of the storm never materialized or because we were prepared for the worst, there were very few issues raised. Facilities operations housed over 900 team members for two nights and received great reviews in the management of beds and bed locations.

These events shape who we are and how we manage our operations during a disaster. I recall

sitting in the incident command during the flood of 2016 watching heartbreaking news coverage about those who had lost their homes. I will never forget one gentleman whose neighbors had showed up en masse to help him save his personal belongings. He told the reporter that God doesn’t send money, he sends people. Those words will stick with me the rest of my life. When I spend days that can seem endlessly long in the command center, I see employees doing their jobs with a skill and compassion second to none. It reminds me that God really does send people to aid those most in need.

JEFF MOSELY is the vice president of construction and facilities operations for Our Lady of the Lake Regional Medical Center. Related facilities include more than 900 beds in four hospitals in Baton Rouge, La. In his role, he also supervises facilities emergency management for the region.

A Shared Statement of Identity for the Catholic Health Ministry We are the people of Catholic health care,

a ministry of the church continuing Jesus’ mission of love and healing today. As provider, employer, advocate, citizen — bringing together people of diverse faiths and backgrounds — our ministry is an enduring sign of health care rooted in our belief that every person is a treasure, every life a sacred gift, every human being a unity of body, mind, and spirit.

We work to bring alive the Gospel vision of justice and peace. We answer God’s call to foster healing, act with compassion, and promote wellness for all persons and communities, with special attention to our neighbors who are poor, underserved, and most vulnerable. By our service, we strive to transform hurt into hope.

AS THE CHURCH’S MINISTRY OF HEALTH CARE, WE COMMIT TO:

romote and Defend Human Dignity P Attend to the Whole Person v Care for Poor and Vulnerable Persons v Promote the Common Good

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ct on Behalf of Justice A Steward Resources v Serve as a Ministry of the Church

v

v

v

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Building ‘Muscle Memory’ in Public Information Officers BRIAN REARDON

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disaster situation calls for a consistent, coordinated and timely flow of information in order to give the greatest support to the response and recovery effort. The critical role of a hospital public information officer communicating accurate messages to internal audiences and the general public before, during and after a disaster is recognized by the U.S. Department of Homeland Security’s Federal Emergency Management Agency.1 To assist public information officers in their roles and to help them acquire practical knowledge, FEMA offers a series of free training courses and materials.2 To get a sense of the role that Catholic health system and hospital public information officers play in disaster preparedness and response, CHA surveyed a number of these professionals in the summer of 2019 to gauge their level of participation and training within their organization’s incident command system and/or emergency operations plan.3 Hospitals establish such systems and plans as part of FEMA’s National Incident Management System, which provides a consistent framework for incident management, regardless of the size or complexity of the incident.4

VIEW FROM THE FIELD

The CHA public information survey was completed by 31 colleagues from Catholic health systems and hospitals. The purpose of the survey was fourfold: to determine their level of involvement in providing input to the development and updates of their organization’s incident command system and emergency operations plan; to evaluate the frequency of their participation in disaster preparedness drills and briefings; to gauge how often they’ve staffed an activated emergency operations center during an incident; and to determine whether they’ve received formal training and the type of training provided.

What follows are the first six questions and

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summary of the answers (not all 31 respondents answered every question).

1. As a public information officer/communications official, how often do you participate in emergency preparedness drills? a. More than once a year – 17 b. About once a year – 7 c. Every two or three years – 1 d. Have not in three years – 2 2. Have you undergone formal training for emergency preparedness? a. Yes – 23 b. No – 4 3. What type of training program did you attend? a. FEMA – 9 b. State agency – 4 c. Local – 6 d. Red Cross – 1 4. How many times have you served in an Emergency Operations Center activated as the result of an event? a. More than five – 15 b. Two to four – 5 c. Once – 2 d. Never – 4

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5. Have you been involved in the creation or updating of your organization’s emergency operations plan? a. Yes – 21 b. No – 5 6. Have you participated in presentations to the Joint Commission or another regulatory agency on your organization’s emergency operations plan?

a. Yes – 4 b. No – 22 The final question in the survey was fairly open-ended as it asked if there was one thing about their role within the emergency operations structure that they wanted to share (such as lessons learned, helpful resources, and challenges).

In reviewing the survey responses, there are a few findings that should be of interest to Catholic health care leaders who oversee their organization’s incident command structure.

First, less than half of the public information officers who responded indicated they had gone through FEMA training. As noted earlier, there is no cost to attend the training and as one of the respondents said, “every hospital leader — PIO or not — should take advantage of the FEMA training opportunities.” According to Phil Politano, the course manager for FEMA’s Emergency Management Institute’s Public Information Academy, “all (of the institute’s) independent study courses are free. Courses conducted on our Emmitsburg, Maryland, campus are free of charge. There is a reimbursement schedule for students that mostly, if not completely, covers travel. Lodging is provided on campus.”

Catholic health care is apparently not unique when it comes to forgoing FEMA public information officer training. Politano reports that during the past four years, only 57 of the 812 students who enrolled in one of the FEMA courses for public information officers indicated they worked in health care. Politano adds, “We could always see more. I believe there is a challenge for hospital PIOs to receive our training opportunities due to lack of awareness and appreciation (for the value of the training) among leadership.”

While there are opportunities to increase participation in formal training for public information officers, the survey indicates that partici-

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pation in annual (or more frequent) drills is the norm for Catholic health care communicators. As one survey respondent commented, “Drill, drill, and then drill some more. When the actual event happens, you go into autopilot with your training.”

When hospital staff participate in local disaster preparedness drills with law enforcement, emergency medical services, public health departments, and other hospitals and medical providers, FEMA’s Joint Information System provides the framework that allows them to “coordinate and integrate communication efforts to ensure that the public receives a consistent and comprehensive message.”5 One survey participant reinforced the importance of operating within the joint information system during a disaster by commenting, “communications planning is a team exercise — working in a silo or just within your own organization is not effective.” The coordination of communication required among different organizations during a disaster is another reason to have public information officers attend some form of FEMA training.

Administrators might consider the benefits of having public information officers attend meetings where the hospital’s emergency operations plan is being reviewed by The Joint Commission or other regulators. As the survey shows, only 15 percent of the respondents to that question said they have attended such meetings. Even if the public information officer is not required to present information on their role or the communications component of a plan, being present to hear the discussion can be another valuable part of their preparation.

The final takeaway from the survey is that a majority of public information officers have gained valuable experience working in an emergency operations center and contributing to their organization’s emergency operations plan.

This allows them to make adjustments to how they communicate in times of disaster. For example, several respondents commented that social media continues to play a larger role in disseminating information. “Twitter isn’t a huge audience for average daily posts, but in an emergency that is where media tend to get most of their information.

Things move too fast and Twitter was the way we were releasing updates throughout the event,” commented one public information officer. Other

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comments underscored the importance of having “analog” means of communicating and making sure to have important information in hard copy form in case of interruptions to the power supply or cellular service. As an example of this, CHRISTUS Health public information officers said during Hurricane Harvey they printed out updates that had been emailed and distributed hard copies to staff on the floors.

PERSONAL EXPERIENCE

patient information to the public about victims of the incident. In some scenarios, a relative of a victim would present at the front desk to ask about the patient’s condition. To keep us on our toes, the drill organizers had someone ask for an update, speaking in French. While Spanish interpreters were readily available during the drill, we did not have French-speaking staff available (at least to the best of my knowledge at the time). While I should’ve had our contracted phone translation service at the ready, I was caught off-guard. Following the drill, the phone number to the translation service was always part of the public informa-

I served as a hospital public information officer for HSHS St. John’s Hospital in Springfield, Ill., during my seven years as its community relations director. During my “Drill, drill, and then drill some more. first week on the job, I was oriented to the hospital’s emergency operaWhen the actual event happens, you tions plan and incident command go into autopilot with your training.” center. Over subsequent years I attended National Incident Manage— SURVEY RESPONDENT ment System training, took part in community-wide disaster drills, sat through table-top exercises and Joint Commit- tion officer call-sheet that our community relatee briefings, and worked in St. John’s emergency tions team carried around.

As a hospital public information officer, I operations center during various incidents.

St. John’s had a robust incident command struc- was fortunate to have the necessary training and ture that went beyond preparing and responding preparation that allowed me to function effecto major accidents, weather incidents, a presiden- tively within the hospital’s incident command tial visit, or flu outbreak. My public information structure. I knew who to contact, what informaofficer responsibilities kicked in on a regular basis tion was most critical to share, and how HIPAA when I received a page from the administrator on regulations, for example, affect what we can and call, with incidents ranging from a minor fender cannot share with the media and public. bender on campus to an assault on a member of the medical staff. Regardless of the severity of the CONCLUSION incident, I was trained on how to respond. The Often the role of a public information officer is knowledge I gained during drills and formal train- viewed somewhat narrowly as simply being the ing programs provided the needed “muscle mem- “mouthpiece” for an organization. Because many ory” for me to quickly obtain the necessary infor- public information officers have backgrounds in mation, and then write, format and deliver that journalism, public relations and mass communiinformation for internal and external audiences cations studies, they have the skill sets to serve with an understanding of how information from as highly effective communicators for their orgathe hospital fit within the context of the overall nizations. But in times of disaster, being able to message to the community. get the message right and get it out quickly is Every time we conducted a drill, I learned not enough. Public information officers need to something new. During one drill, I remember understand not only the “who, what, when and feeling pretty good about how our media com- where” but also the “how.” Because FEMA sets the mand center (which was kept separate from the national framework for how hospitals and other emergency operations center) was performing in organizations handle disasters, hospital pubrelaying information between the incident com- lic information officers can benefit greatly from mander and the mock media members. Part of the participating in training specifically designed for function of the media center was to provide basic their roles in times of disaster.

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RESOURCES

To learn more visit about FEMA training opportunities for public information officers visit: https://training.fema.gov/programs/pio/ To view FEMA’s public information officer training schedule, visit: https://training.fema.gov/ programs/pio/trainops.aspx BRIAN REARDON is vice president, communications and marketing, the Catholic Health Association, St. Louis.

NOTES 1. “NIMS Implementation for Healthcare Organizations Guidance,” Objective 11, January 2015, https://www.phe. gov/Preparedness/planning/hpp/reports/Documents/ nims-implementation-guide-jan2015.pdf.

2. “Basic Guidance for Public Information Officers (PIOs) National Incident Management System (NIMS),” Federal Emergency Management Agency, November 2007, https://www.fema.gov/media-librarydata/20130726-1623-20490-0276/basic_guidance_ for_pios_final_draft_12_06_07.pdf.

3. “Developing and Maintaining Emergency Operations Plans–Comprehensive Preparedness Guide (CPG) 101,” Version 2.0, FEMA, November 2010, https://www.fema. gov/media-library-data/20130726-1828-25045-0014/ cpg_101_comprehensive_preparedness_guide_ developing_and_maintaining_emergency_operations_ plans_2010.pdf.

4. National Incident Management System, Third Edition, FEMA, October 2017, https://www.fema.gov/medialibrary-data/1508151197225-ced8c60378c3936adb92c1a3ee6f6564/FINAL_NIMS_2017.pdf.

5. National Incident Management System, 42.

Upcoming Events International Outreach Networking Call Nov. 6 | 3:30 p.m. ET

Navigating the New Wired World: An Exploration of the Ethical Considerations of Online Searching for Patient Information Nov. 19 | Noon ET

Mission in Long-Term Care Networking Conference Call Dec. 3 | 3 p.m. ET

Faith Community Nurse Networking Call Dec. 10 | 3 p.m. ET

Human Trafficking Networking Call Dec. 12 | Noon ET

2020 International Outreach Networking Call Feb. 5 | 3:30 p.m. ET

Critical Conversations 2020 Feb. 12 – 13 Atlanta (Invitation only)

Diversity and Disparities Networking Call Feb. 19 | 1 p.m. ET

A Passionate Voice for Compassionate Care® chausa.org/calendar

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Compassion In Disasters DAVID G. ADDISS, MD, MPH

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ompassion is never more important — or more difficult — than in disaster situations.

Disasters trigger a deep sense of vulnerability. In the face of sudden, profound loss, we experience grief, disorientation and disbelief. All that we had leaned on and taken for granted is stripped away. Structures and routines that provided meaning no longer support us. In such moments, we depend on the compassion of others.

In their recent book, Compassionomics, Stephen Trzeciak, MD, MPH, and Anthony Mazzarelli, MD, JD, MBE, review the available scientific evidence on the power of compassion in health care settings. The results are striking. Not only does compassionate care result in a higher quality patient experience; it also enhances healing and immune function and leads to better clinical outcomes.1-4 Compassion provides measurable benefits to patients, health care workers and health systems. Comparable scientific data on disasters are lacking, but it is hard to imagine that the benefits of compassion in disaster settings would be any less important.

AWARENESS, EMPATHY AND ACTION

Compassion is more than a desire to help. Psychological research, neuroscience and multidisciplinary scholarship have yielded fresh insights into the nature and mechanisms of compassion.

In general, these findings point to three main elements: cognitive awareness that suffering exists; emotional resonance (empathy); and a commitment to alleviate the suffering (action). Disasters pose challenges to all three elements.

Cognitive Awareness Recognizing the presence of suffering in disas-

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ter settings is not difficult: the reality of suffering is everywhere. However, disasters typically are marked by chaos and confusion. The sheer volume of suffering can easily overwhelm our capacity to respond. Stability of mind and critical thinking are essential skills for effective, compassionate action in these settings.5 In addition, disaster response is characterized by frenetic activity, particularly during the early rescue phase. Time is of the essence. Responders are exceedingly busy, highly focused on the task at hand. While this is both understandable and necessary, an experiment at the Princeton Theological Seminary offers a cautionary note, with implications for compassion.6 Seminary students were assigned to hear either a talk on the parable of the Good Samaritan or an unrelated topic.

They were then told to proceed to another building on campus for their next assignment. Some of the students were instructed to take their time, while others were told that they needed to hurry.

Both groups of students had to pass by a man (an actor), slumped in the alley and shabbily dressed.

Overall, 40% of students stopped to offer help.

Surprisingly, this proportion was not significantly greater for those who had heard the parable. However, only 10% of students who were told they had to hurry stopped to help, compared to 63% who

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were time-relaxed. In disaster settings, urgent, highly-focused activity — itself motivated by compassion — may preclude responding to other invitations for compassionate action.

such if it is done with the intention of approving the shipment of life-saving medications, or drafting a proposal for a community health project, or writing an email to support a colleague going through a difficult time.

The multiplicity of compassionate actions is also described by “recipients” of compassion.

In a study by Shane Sinclair, MDiv, PhD, and colleagues, palliative care patients were asked how they experienced compassion from their health

Empathy Responding to suffering with compassion requires some degree of empathy, or emotional resonance: the ability to feel or imagine the pain of the other. But the magnitude and intensity of suffering in disasters can easily lead to empathic overload and personal disThe ability to remain present to tress. When this happens, rather than attend to the suffering of others, we suffering, to feel the pain of the other become fixated on our own distress, but not be overwhelmed by it, is a retreating into a pattern of fight, flight or freeze. Alternatively, we may skill that is taught to chaplains, but busy ourselves with activities (often not very often to public health or subconsciously) intended to alleviate our own distress, which may or may humanitarian workers. not address the suffering of others.

In the presence of intense suffering, emotional regulation is essential for compassion. care providers.8 Their responses revealed a rich, The ability to remain present to suffering, to feel nuanced understanding of the term. Patients did the pain of the other but not be overwhelmed by experience compassion through specific actions it, is a skill that is taught to chaplains, but not very taken to attend to their physical, emotional and often to public health or humanitarian workers. spiritual needs. But they also experienced compassion from providers who expressed interest in Action understanding them and their disease, or whose Action distinguishes compassion from empa- demeanor, affect and behavior communicated thy. Disasters focus the mind and demand urgent a capacity and willingness to be in relationship action. In disaster settings, the tools of compas- with them. Health care providers whose presence sion vary. For example, in the search for sur- embodied particular virtues, such as love, honesty vivors amidst the rubble of an earthquake, the and kindness, were also seen as compassionate. most effective tool of compassion — the means Thus, from the perspective of these “recipients,” through which compassion is enacted — may be compassion is comprised of a multitude of spea bulldozer. At other times, compassion may best cific actions, as well as attitudes, capacities and be expressed through human presence, sitting in virtues. silence and holding a hand of someone who has suffered incalculable loss. Wisdom is required to CRITIQUES OF COMPASSION discern the specific action(s) that will best serve. By way of better understanding compassion in Thus, in complex disaster settings, as else- disaster settings, it may be helpful to explore where, compassion “devolves into” millions what compassion is not. There are many possible of specific actions. In this sense, compassion is responses to suffering. The opposite of compas“comprised of non-compassion elements.”7 Each sion — also known as its “far enemy” — is cruof these actions is, at the same time, both an essen- elty. Compassion is usually — although not always tial component of compassion and an expression — readily distinguished from cruelty. Other of the compassionate impulse. Whether a specific responses to suffering, such as pity, may masact is compassionate depends both on the act itself querade as compassion, but they are, in fact, its and how it is performed. Turning on a computer “near enemies.” Compassion arises from a sense in an office setting is not inherently an act of com- of shared humanity, from solidarity, respect and passion. But it may undoubtedly be considered a profound awareness of interconnectedness. In

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contrast, pity is characterized by a sense of separation or distance between ourselves and others; it is a form of condescension. Compassion requires self-awareness; it demands that we be honest about our motives, needs, projections and distortions. Pity thrives on lack of awareness of self and other. It primarily seeks self-gratification.

Like the Pharisee in Luke 18: 9-14, pity declares, “I am glad that I am not like that unfortunate person.” In global health, humanitarian or disaster settings, pity may say, “I feel good when I help these poor people.”

Three critiques of compassion in global health and humanitarian work are relevant to relief work in disaster settings. They shine a light on the “near enemies” of compassion and call us to critically examine our motives and expectations.

Expression of superiority The first critique is that compassion is an expression of superiority. This view is articulated most poignantly by French anthropologist and sociologist Didier Fassin, MD, PhD, who argues that compassion “always presupposes a relation of inequality … When compassion is exercised in the public space, it is thus always directed from above to below, from the more powerful to the weaker, the more fragile, the more vulnerable.”9 Essentially, Fassin is describing pity rather than compassion. Further, people most severely affected by disasters are vulnerable and fragile in that moment — which is precisely why they are in need of compassionate action. Nonetheless, Fassin’s critique serves as a useful reminder. Are we acting from a place of solidarity, interdependence and compassion? Or can we detect subtle strains of self-gratification and superiority seeping into our work?

All about us A second critique is that what passes for compassionate action — especially in short-term medical or humanitarian missions — may have much more to do with the experience of the “giver” than benefit to the “receiver.” Short-term missions have become big business. Often with little preparation, no knowledge of local culture or language, an absence of coordination with government health officials, and no plans for longterm follow-up, students, medical teams and church groups descend on hospitals or communities to “help.” Terence Linhart, PhD, conveys the essence of this critique in the title of his paper,

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“They Were So Alive!: The Spectacle Self and Youth Group Short-Term Mission Trips.”10 Exactly who benefits from such adventures — or how — is not always clear. To address this problem, the Catholic Health Association has developed a suite of excellent resources for promoting self-awareness and critical reflection among church groups, medical teams and others interested in international service.11 At issue here is not the desire to help, but the a priori unquestioned assumption that one knows, without asking or further investigation, what will serve, as well as the over-identification of the ego with the role of “the helper.” In her book, The Need to Help, anthropologist Liisa Malkki, PhD, explores how Finnish International Red Cross professionals wrestle with the complex motivations that drew them to, and sustain them in, their work.12 They acknowledge a strong innate desire to help and to be useful, and they admit to feeling “fully alive” only when engaged in humanitarian missions. But they also eschew heroic narratives and reject the notion that this work somehow makes them special or confers self-importance.

Their experience suggests that self-reflection, humility and honesty regarding one’s needs and motives can help to insure against ethical blind spots and errors in judgment that arise from over-identification with humanitarian and global health work.13 Unstable emotion The third major critique of compassion in global health and disaster settings is that ethical decision-making, particularly in matters of public policy, must be rational, evidence-based and devoid of emotion. Emotion, particularly compassion, can introduce distortions that can interfere with equitable allocation of resources.

Compassion privileges the few whom we can see.

We are more likely to care about — and devote resources to helping — identifiable individuals or coherent groups of people in predicaments that are vividly described (or shown on television), a phenomenon known as identified person bias.14 Massive resources and extensive media attention are focused on the plight of a few boys trapped in a cave, while those same resources could save the lives of thousands of unidentified children if invested in primary health care.

Disaster situations highlight the challenge of identified person bias, particularly when triage is necessary. With triage, scant resources are allo-

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cated to those who will benefit most, rather than to self and others.

For those who wish to deepen their journey of those who are likely to die, even with help. Triage is equitable only if pre-established rules are fol- compassion as followers of Jesus, many resources lowed. A recent Radiolab episode featuring New are available to provide support and guidance.

York Times reporter Sheri Fink illustrated how Compassion is a major theme throughout the excruciating it can be when those rules demand Bible, especially in the writings of the prophets, that life-saving treatment be withheld from an the Psalms and the Gospels. Studying compassion individual one cares about.15 But to do otherwise in the life and work of Jesus, which compelled him violates the principle of equity. Thus, some argue both to heal individuals and feed multitudes, can yield invaluable insights for us today. As noted that compassion has no place in public policy.

However, humanitarian and global health work above, CHA has developed materials to guide becomes oppressive and untenable when stripped individual reflection and collective discernment of compassion. Dr. Abhay Bang, MD, MPH, a physician-researcher in The inclination to move toward, Gadchiroli district, India, reminds us rather than away from, suffering, or that, “Global health decisions without compassion become bureauto stand firmly in its presence with cratic, they become impersonal, they become insensitive. Global the intention of transforming it, must health operations without compasbe cultivated and practiced. sion may become autocratic.”16 The answer to identified person bias is not to banish compassion from decision-making regarding international short-term missions. in resource-limited settings, but, rather, to expand Frank Rogers, PhD, and Andrew Dreitcer, PhD, at the scope of compassion to include all persons, the Center for Engaged Compassion, Claremont including those who are unidentified — the “mul- School of Theology, have developed contemplatitudes” to whom the Gospel writers refer. Even tive-based compassion training that is particutriage, as emotionally and morally wrenching as larly accessible to Christians.17, 18 Such training it can be, does not negate the need to extend com- helps to cultivate cognitive and emotional stabilpassion to all persons as much as one is able. ity in the face of suffering. It also helps us to recognize the interpersonal assumptions and distortions that are inherent in the roles of “helper” and PRACTICING COMPASSION In disasters, many of those affected depend on “beneficiary.”

There are hopeful signs that global health and compassion for their very survival. At the same time, people who work in disaster relief are moti- the humanitarian sector are rediscovering the vated and sustained by compassion. The incli- “precious necessity of compassion.”19 For examnation to move toward, rather than away from, ple, the World Health Organization, with its new suffering, or to stand firmly in its presence with emphasis on people-centered health services, the intention of transforming it, must be culti- now considers compassion as essential for quality vated and practiced. Mature compassion requires universal health coverage.20 The Federal Ministry attending to and developing the requisite cogni- of Health in Ethiopia has identified compassion tive, empathic and action-based skills and capaci- as a core pillar of its national health sector transties that together allow compassion to naturally formation plan.21 The CHS Alliance, a network of emerge and flow in the presence of suffering. humanitarian and development organizations, is Mature compassion also demands self-aware- engaged in a deep exploration of compassion as a ness, critical reflection and honest appraisal of fundamental value linked to the core humanitarour motivations, rewards and expectations. These ian standard.22 practices serve as guardrails that prevent us from In summary, compassion is essential for qualsliding into the distortions of compassion high- ity disaster relief as well as for quality health care. lighted by the three critiques: pity, self-absorption But for both areas, more work is needed to realand preferentialism. Finally, mature compassion ize the power and potential of compassion. On the requires an acknowledgment of our own suffering one hand, we need to recover our compassionate and an openness to receiving compassion from impulse and commit to nurturing it at the individ-

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ual, organization and systems levels. But we also need to awaken to and appreciate the myriad ways in which we are already participating in the work of compassion. The need for this awakening, and for setting ourselves on a pathway toward mature compassion, has never been greater. We live in a world that paradoxically is more globalized and more polarized than ever before. For the foreseeable future, the frequency of disasters will continue to accelerate. Being able to respond to those disasters with compassion, wisdom and skillful means will make all the difference. As Roshi Joan Halifax, PhD, so rightly noted, “We live in a time when science is validating what humans have known throughout the ages: that compassion is not a luxury; it is a necessity for our well-being, resilience, and survival.”23 DAVID G. ADDISS is the director of the focus area for compassion and ethics, Task Force for Global Health. The Task Force is an international nonprofit working to improve the health of people most in need, primarily in developing countries.

NOTES 1. Stephen Trzeciak and Anthony Mazzarelli, Compassionomics: The Revolutionary Scientific Evidence that Caring Makes a Difference, (Pensacola, FL: Studer Group, 2019).

2. Jorge Fuentes et al., “Enhanced Therapeutic Alliance Modulates Pain Intensity and Muscle Pain Sensitivity in Patients with Chronic Low Back Pain: An Experimental Controlled Study,” Physical Therapy, 94, no. 4 (2014): 477-89.

3. Simone Steinhausen et al., “Short- and Long-term Subjective Medical Treatment Outcome of Trauma Surgery Patients: The Importance of Physician Empathy,” Patient Preference and Adherence 8 (2014): 1239-53.

4. Stephano Del Canali et al., “The Relationship Between Physician Empathy and Disease Complications: An Empirical Study of Primary Care Physicians and Their Diabetic Patients in Parma, Italy,” Academic Medicine, 87, no. 9 (2012): 1243-49.

5. Joseph Albanese and Jim Paturas, “The Importance of Critical Thinking Skills in Disaster Management,” Journal of Business Continuity and Emergency Planning 11, no. 4 (Summer 2018): 326-34.

6. John M. Darley and C. Daniel Batson, “From Jerusalem to Jericho: A Study of Situational and Dispositional

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Variables in Helping Behavior,” Journal of Personality and Social Psychology 27, no. 1 (1973): 100-108.

7. Joan Halifax, “A Heuristic Model of Enactive Compassion,” Current Opinion in Supportive and Palliative Care 6, (2012): 228–35.

8. Shane Sinclair et al., “Compassion in Health Care: An Empirical Model” Journal of Pain and Symptom Management, 51, no. 2 (2016): 193-203.

9. Didier Fassin, Humanitarian Reason, (Berkeley: University of California Press, 2012), 4.

10. Terence D. Linhart, “They Were So Alive!: The Spectacle Self and Youth Group Short-Term Mission Trips,” Missiology: An International Review, XXXIV, no. 4 (2006), 451-62.

11. Catholic Health Association, International Outreach Overview, https://www.chausa.org/ internationaloutreach/Overview.

12. Liisa H. Malkki, The Need to Help: The Domestic Arts of International Humanitarianism, (Durham, NC: Duke University Press, 2015).

13. David G. Addiss, “Spiritual Themes and Challenges in Global Health,” The Journal of Medical Humanities 39, no. 3 (2018): 337–48.

14. J. Glenn Cohen, Norman Daniels and Nir Eyal, eds., Identified Versus Statistical Lives, (Oxford: Oxford University Press, 2015).

15. “Playing God,” Radiolab, reported by Sheri Fink and produced by Simon Adler and Annie McEwen, August 21, 2016, http://www.radiolab.org/story/playing-god/ 16. Task Force for Global Health, Compassion in Global Health, Richard Stanley Productions, (2011) https:// www.youtube.com/watch?v=ydn0H60K3Nk. 17. Frank Rogers, Practicing Compassion (Nashville, Tenn.: Upper Room Books, 2015).

18. Andrew Dreitcer, Living Compassion: Loving Like Jesus (Nashville, Tenn.: Upper Room Books, 2017).

19. Joan Halifax, “The Precious Necessity of Compassion,” Journal of Pain and Symptom Management, 41, no.

1 (January 2011): 146–53.

20. World Health Organization, WHO Global Learning Laboratory for Quality UHC, https://www.who.int/ servicedeliverysafety/areas/qhc/gll/en/ 21. Federal Democratic Republic of Ethiopia Ministry of Health, Health Sector Transformation Plan, October 2015, https://www.globalfinancingfacility.org/sites/ gff_new/files/Ethiopia-health-system-transformationplan.pdf.

22. CHS Alliance, www.chsalliance.org.

23. Halifax, “The Precious Necessity of Compassion,” 152.

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The Health Care Leader’s Role in Safety KIM HOLLON, FACHE

J

oin me in a thought experiment: You are a railroad track operator with the job of pulling a manual lever to switch a train from one track to the other. A train is barreling toward disaster, but you can pull a switch to move it to a safer track. You aren’t properly trained, and so you fail to do so. A number of people die as a result. It is easy to see in this straightforward example that the operator is at least partly at fault for the harm that results.

In health care, when we fail to establish systems that protect our patients, it is less evident, but just as impactful.

The safety and quality of care is heavily influenced by the organization’s leadership, what we focus on and how we develop systems that help people make the best choices. The knowledge leaders need to attain high reliability in health care is not uniformly understood, not something I was taught, nor have I witnessed at any other facility. Information and education from other industries are available for us to learn from, however we must adapt what we learn to fit our industry.

My journey toward high reliability has been circuitous. My aim has been constant, but the path of my education from mentor to mentor has been a winding road. As a consequence, there are times that I wonder what new management concept or standard might move health care system teams toward zero harm more quickly. I know from experience that if I had known years ago what I do now, lives could have been saved and suffering avoided. Technically, the education on high reliability may always have been available to me, but it certainly wasn’t easily found or adapted.

I have been a C-suite executive of a hospital or health system for over 30 years. I have been hardworking and conscientious, focused on caring for our vulnerable populations, improving quality and providing value, always with an understand-

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ing of the privilege we have to serve the sick. But if I am brutally honest with myself, I have been among the leadership of an industry that has been aware of significant safety problems since at least 1999 when the Institute of Medicine published To Err Is Human: Building a Safer Health System.1

SLOW PROGRESS ON WELL-KNOWN ISSUE

When I first read that 44,000 to 98,000 people died unnecessarily on an annual basis in U. S. hospitals, I was shocked, certain there must be problems in the study, and that it couldn’t possibly reflect problems in our hospital. I quickly purchased the book and read it cover to cover, trying to understand the research and recommendations. I became convinced that we had to do something, but I didn’t fully understand the recommendations and found few local peers who had better answers for what to do, or who had even read the study. A year later, I spoke to 100 young executives about quality improvement and asked how many of them had read To Err Is Human. Only one person raised a hand. That was the first of many times I have discussed quality or safety with health care leaders and boards across the country and realized that they lacked up-to-date knowledge about the importance of our role in ensuring the safe

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and high-quality treatment of patients under our care, we had a moral obligation to change how we managed, making it easier for our staff to reach care.

Looking back, I only thought I understood my zero harm.

Staying the course through a system-wide, norole. That’s because I thought we were focused on quality and safety and that we held people exceptions-allowed leadership method change accountable for it. I knew from data that our qual- tested my resolve many times. Approximately ity measures were better than average. I believed I 20 percent of our leadership team chose to leave was that trained railroad worker who daily pulled rather than change their leadership style. The the lever to avert an unintended consequence. I change for all levels of management —asking prided myself on the quality improvement that them to spend leadership time improving their understanding of the root causes of problems and our teams had accomplished.

When I had the opportunity to join and lead waste, then coaching staff who perform the work Massachusetts-based Signature Healthcare, I to design their own improvements — has been took to heart the philosophy of Lean, a well- hard but also transformative, both personally and known management approach, and began a com- for our organization.

We have encouraged employees to take ownprehensive transformation of our strategic planning, daily operating systems, communication, ership of how they improve processes related to process improvement, inventory management their jobs. We have implemented over 6,000 sugand human resource systems. In many organi- gestions per year. We have removed chaos from zations, Lean management is implemented as a our environment through standardization, using process improvement technique or set of tools, visual cues to reduce the chance of mistakes and and few consultants would recommend a system- a robust standardized problem-solving method, wide blitz-implementation of Lean to this degree. generating exceptional improvements in quality.

However, I was eager to take what I was learn- Our patients very rarely suffer from infections, ing and apply it across the entire organization. So, pressure ulcers, falls with injuries and other forms we started shift-related daily huddles, transpar- of hospital-acquired conditions. In our ambulaent public posting of our departmental goals, per- tory areas, we have dramatically improved diaformance metrics, workplace standardization, a betic and hypertension control, cancer screening standard problem-solving method to determine the root cause and counWe standardized a significant ter measures, a suggestion system, and a monthly meeting process. We portion of all leaders’ work to standardized a significant portion of include engaging their team in daily all leaders’ work to include engaging their team in daily improvements to improvements to our processes and our processes and outcomes by using outcomes by using Lean concepts Lean concepts and tools. I mandated that all leaders learn and adopt a new and tools. way to manage, turning their personal management systems upside down.

They focused on observing employees and the rates, admission rates per 1000 population and processes they used in accomplishing work. They readmissions. For many public measures we are took note of variation and waste, then coached in the top 10% of performance, remarkable for an staff to improve the staff’s own work rather than underfunded safety net health system. As a result of our improvement, the hospital and its medical making changes from top down.

Relearning how to lead after 30 years of suc- group began to receive a number of awards and cess was difficult for me and all of our team. Many recognition for quality. I believed we were becomof my closest allies continued to ask during those ing a highly reliable organization. Until … I realimplementation years why we were changing ized that was just not true. everything we did, as the systemic change was hard on the organization. I responded that as long A CULTURE OF SAFETY as any of our patients received less than perfect One Saturday morning in 2013, the day before I

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was to run a marathon, I read High-Reliability ture in an organization had just as much impact Health Care: Getting There from Here. The article on errors as the physical and computer processes opened a new area of learning and transformed used to perform work. As the CEO, I was the archihow I see my role as leader.2 The next day while tect and chief inspector of organizational and culrunning, I mulled over the author’s message that tural defenses, a job I was completely unaware of hospitals will never approach the state of high and untrained for. In some ways, I felt as though I reliability without implementing a robust pro- had figuratively been asleep at the switch.

As I began to grasp the importance of this new cess improvement method, technology to help prevent errors and a culture of safety. I knew we role, I saw how systems theory impacted almost had a great learning system and really good technology for error prevention. I As I learned more about highbelieved we had a great culture, but I had no idea what a culture of safety was. As I reliability and human error models, admitted to myself that I had no working it dawned on me that my belief that model for a culture of safety or how to establish it, improve it and measure it, I a hospital could be error proof and had to acknowledge that my leadership checklist its way to zero harm was was falling well short of what it should be. I think this might be the first time I fundamentally flawed. realized that I was the railroad worker who had failed to pull the lever that moved the train from the damaged track, and that everything: it was a new lens through which to failure was allowing harm to happen in spite of all observe the health care delivery system. I began to read more widely and talked to experts about difthe process improvements we had implemented.

As I learned more about high-reliability and ferent aspects of safety: safety management syshuman error models, it dawned on me that my tems, safety in health care, safe cultures, cognibelief that a hospital could be error proof and tive biases, human error theory and the design of a checklist its way to zero harm was fundamentally culture of safety. I also began to think more deeply flawed. I began to admit I had not thought deeply about how Signature’s leadership team organized about human errors, their causes, and how they for safety, including my personal biases regarding are influenced by the organization. I had heard of the relationship between boards and the CEO as James Reason’s Swiss Cheese Model of error-pre- it relates to safety and quality.

Typically, when I heard consultants say boards vention, but I thought his model related to process set the expectation for quality and are important improvement.3 Here’s how I explained Reason’s model, using a to high-reliability, I scoffed at the notion, thinkmedication example: If a physician orders a med- ing that this was a clever way for governance conication on the computer, it prevents misreading sultants to gain more work. In fact, I have often the doctor’s handwriting. When the pharmacist challenged people to explain exactly how a board reviews the order, he or she can prevent mistakes impacts quality. Typically, I’ve found the explain dosage. When the nurse pulls the medication nation lacking any implementable details. My from the dispensing system, it has safeguards to personal experience is that board members are make sure it is the correct one, and finally, when interested in quality and serving the community, the nurse scans the barcode on a patient’s wrist- but their knowledge of medicine as a discipline band and on the medication at the time of delivery, and health care as an industry is limited, and their the double check ensures the right patient, right understanding of quality and safety is rudimenmedication, right time and right dose. I thought tary. I couldn’t imagine, with such limited knowleach of those systems represented a defense sys- edge, how they could set a very high bar for safety.

In thinking more deeply about how Signature’s tem or one of Reason’s “slices of cheese.” (Each “slice” is considered a barrier to prevent a prob- board could add energy to our pursuit of zero lem, but still contains potential holes in it, like harm, I decided we needed to talk more openly Swiss cheese.) Reason believed that the way we about constructive dissent in quality discuslead and influence behavior, thought and cul- sions and how executives and physician leaders

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can shut down probing questions. For about six ing a practice that no one enters a patient’s room months, we shortened all of our routine quality without protective eyewear. They did not believe business matters and focused our board quality they could successfully enforce it. For months we committee discussions on how the board mem- struggled with how to establish a policy about bers could become better coaches of the execu- protective eyewear, when our employees and tives and physician leaders, and how we would managers did not perceive the risk as high. We measure success. Through trial and error, we also also discovered that if employees wore eyewear developed a checklist of questions that are asked for long periods of time, it needed to be comfortat the end of each meeting, aimed at reducing the able and protect the eyes from splashes that might power distance and inviting any unspoken ques- come from different angles. Comfortable eyewear tion. The result of this work has been surprising; for staff who routinely wore glasses also became our team has become less defensive in answering a concern. We removed the perceived barriers to challenging questions and our board has begun to wearing eye protection by researching options ask much better questions that help us think differently.

Reducing barriers to doing the In addition to rethinking how I work with the board quality comright thing, increasing employee mittee, I’ve begun asking very differrecognition of perceived risk, and ent questions when we experience employee or patient harm. I now reinforcing use through co-worker see human error that causes harm is almost always a consequence of the coaching were all organizational organizational system. Human error influences on human error, and is not the cause, but a consequence of the system. We ask a lot more quesall belong to leaders to design and tions about what exactly is the “sysimplement. tem” and what we can do as leaders to change that system. More often than not, it is the system that is missing essential safe and providing attractive and appropriate eyewear supervisory practices because most health care that staff were more likely to wear. But we continmanagers have developed their leadership habits ued to have injuries from lack of use. within health care. And health care has few examAfter solving for the perceived barrier to ples, if any, of high-reliability at the institutional wearing glasses, we began to work on the low perceived risk of injury by making certain that level. any time someone was injured anywhere within our system, everyone learned about the injury, A CLOSER LOOK A great example of how supervision impacts how it happened and, in particular, whether safety can be found by examining eye injuries the employee had any perception of splash risk in health care. Two years ago, our most frequent before the procedure. As we improved our leadmode of injury was splashes of different fluids in ership systems of communicating injury stories, the eye. The injuries rarely caused any significant we found improved compliance. Now whenever harm, but they were early warning signs that we there is an eye injury, we ask, “Does the manager have a system for the safety coaches to observe for were not practicing safety.

In reviewing the injuries, we noticed that in protective eyewear use on all shifts, and are results almost all instances, the employee did not antici- reported to the team on a frequent basis?” Reducpate the splash and did not anticipate any personal ing barriers to doing the right thing, increasing risk. We provided goggles for occasions when employee recognition of perceived risk, and reinemployees emptied containers, opened tubes in forcing use through co-worker coaching were all the lab or other “risky” processes, but employees organizational influences on human error and all did not have protective eyewear with them at all belong to leaders to design and implement. Signatimes, to use at a second’s notice. When we began ture leaders have become much better at examto discuss this as a leadership team, our manag- ining our behaviors, looking for the omission of ers were initially not supportive of implement- these types of activities and preventing errors

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from becoming a consequence of our leadership failure.

As I have changed my leadership style and our organization starts to change its collective leadership and culture, we have had surprising success. Since our initial Leapfrog safety grade of B, we have had straight A’s at each six-month rating.

After several years of straight A’s we implemented a safety management system and integrated it into our Lean management system, and reinforced it with standard leader work. To my surprise, we reduced our serious patient safety events by over 80% and have maintained that level of improvement for over three years. Experiencing that dramatic decline in harm affirmed what I was beginning to understand — that implementing a culture of safety and robust process improvement are both necessary to reach zero harm. If anyone had told me 10 years ago that we could reduce our serious safety events by 80% I would not have believed it, because I had no mental model of how different an organization could be.

Knowing what I know now, I have begun to think about the holes in our defense systems outside of the health care system that could affect patient safety. The organizations and systems that influence how we lead in health care are flawed.

We do not adequately teach safety science in our graduate management programs; our industry educational development systems are not providing the right level of in-depth education to support change; our regulatory agencies have not caught up to best practices in safety management; the media does not understand the intersection of safety and leadership in ways to help hold health care accountable; and insurers and employers do not know how to judge a safe organization. There are no certifications for health care boards in safety, and the state and national health care asso-

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ciations seem more interested in protecting the status quo than establishing meaningful measures or processes to speed up the transfer of reliability practices.

With enlightened self-interest, boards should begin to call for increased public accountability, transparency and more rigorous external oversight. Just as the greatest athletes know they reach their potential only through a coach who can extract the most of their natural talent, we must increase the pressure for change through external influence. When we think about how vulnerable that makes our institutions, we should judge that vulnerability against the vulnerability of our patients, who are suffering harm at unacceptable rates. If our industry has not solved this problem in 20 years on its own, it will not likely solve it in the next 20. Our patients can’t wait on us to improve at our current pace.

KIM HOLLON is president and chief executive officer of Brockton, Mass.-based Signature Healthcare. Signature Healthcare is comprised of a safety net community hospital and integrated medical group serving a diverse and socio-economically challenged population, south of Boston.

NOTES 1. Institute of Medicine, Linda T. Kohn, Janet Corrigan and Molla S. Donaldson, eds., To Err Is Human: Building a Safer Health System, (Washington, D.C.: National Academy Press, 2000).

2. Mark R. Chassin and Jerod M. Loeb, “High-Reliability Health Care: Getting There from Here,” Milbank Quarterly 91, no. 3 (September 2013): 459–90, https://doi. org/10.1111/1468-0009.12023.

3. James Reason, A Life in Error: From Little Slips to Big Disasters, (Burlington, Vt.: Ashgate, 2013): 74-75.

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DISASTERS

Reducing the Risk Of a Cyber Crisis JARRETT KOLTHOFF, GCFA, CISSP

A

true crisis facing health care in America stems from cyber criminals, who target the health care industry with greater frequency than any other sector of the economy.

Protecting information is vital. Patients rely on the medical establishment not only for care, but for survival. The amount of sensitive personal data stored by America’s medical establishment is vast.1 Combine this personal data with detailed financial information and you have a treasure trove of assets that can be easily marketed on the “dark net,” (the portion of the internet not open to public view) in such a fashion that virtually anyone, anywhere can purchase them for a few cents per file.

According to specialty insurer Beazley, 41% of all cyber incidents tracked by the company in 2018 occurred in the health care field. Of particular concern, 34% of all ransomware attacks and 27% of all business email compromises were carried out on health care providers, with business email compromise attacks skyrocketing by a whopping 133% from 2017 to 2018.2 (A ransomware attack generally involves locking or taking a victim’s electronic data, then demanding a ransom to restore access to it.)

When it comes to ransomware, organized cyber criminals and sophisticated hackers have narrowed their focus, with a significant concentration on small and medium-sized organizations, because they are commonly underfunded and poorly prepared for a cyber incident. According to Beazley’s statistics, 71% of ransomware attacks tracked were perpetrated against small and medium-sized organizations, with an average ransom demand and/or payment of just over $116,000.3 With threats escalating and the severity of cyberattacks mounting, the calls for greater accountability and preparedness will most likely

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result in higher fines and even individual lawsuits seeking punitive damages which could be crippling to the health care industry as a whole.

When personal information is disclosed, routine steps like credit monitoring are not satisfactory to those who have experienced harm from a breach. In some cases following a security

According to specialty insurer Beazley, 41% of all cyber incidents tracked by the company in 2018 occurred in the health care field. breach, there have been lawsuits seeking damages similar to those sought in some malpractice cases. Consequently, substantial measures need to be taken to minimize cyber-risk within health care, including the implementation of practices to prevent breaches, precise strategic and tactical planning, and procedures to be followed in the event of breach.

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INVOLVING THE BOARD

tions, particularly in the health care field. The Before delving into breach prevention and miti- moment compliance standards are written and gation measures, let’s look at why organizations released, they’re instantly outdated, making have to designate cybersecurity as a priority. The cybersecurity all the more challenging.

As laws change, individual board members boards of directors and executive teams of every health care operation in the United States need now can be held personally and fiscally accountto place cybersecurity on par with patient care in able for losses resulting from cybersecurity practerms of importance. Without proper cybersecu- tices that are not deemed to be “reasonable and rity in place, patient care and safety are at serious, prudent.” This fact alone should be motivation for cybersecurity standards that go beyond comoften mortal risk.

Once cyber criminals have accessed a health pliance, but there are still boards and organizacare organization’s networks, operating systems tions that don’t pay enough attention to these and controls, the opportunity for harm escalates on an alarming scale.

A board member with cybersecurity Medications and dosage levels can training and/or background is no easily be changed and altered. MRIs, CAT scans and X-rays can be maniplonger a luxury, but an absolute ulated to show tumors, blockages, fractures and other conditions where necessity for every hospital and they do not exist. Life support equiphealth care-related business. ment can be reprogrammed or terminated, resulting in patient deaths.

A board member with cybersecurity training issues until they’re faced with a significant cyber and/or background is no longer a luxury, but an incident. absolute necessity for every hospital and health Boards and executive teams must prioritize care-related business. Cybersecurity has now sur- cybersecurity as part of an organization’s overall passed malpractice as the most serious and sig- risk assessment strategy. Then they can deternificant threat to medical operations and medical mine the amount of risk exposure they are willing liability. A single cyber incident could inflict cata- to accept in relation to cost of protection, prevenstrophic financial damages and also permanently tion and the potential for loss across a number of erode brand value, brand trust and patient confi- different categories. dence, resulting in millions, even billions, of dollars in long-term losses.

HIRE CYBERSECURITY EXPERTS Some boards may hesitate at “bringing the In-house information technology departments geeks to the table.” But without board oversight and security departments at most health care and a cybersecurity champion on the board, cyber facilities are stretched to the limit in terms of criminals and cyber terrorists may seek out and personnel, budget and workload. There’s always target your organization first, assuming a greater something that needs to be done and a minor probability of vulnerabilities and gaps in your emergency that needs to be remedied. So adding infrastructure. cybersecurity onto these groups’ responsibilities may be an undue burden.

Keeping up with the latest changes and develCOMPLIANCE EQUALS COMPLACENCY There are various federal and state cybersecu- opments in how cyberattacks are executed is a rity protocols that organizations need to follow, full-time job. Staying abreast of evolving cyber including HIPAA health care data privacy and crime methods with the implementation, monisecurity requirements. But most regulations are toring, tracking and updating required by an loosely worded, leaving room for substantial indi- effective cybersecurity operation may be too big vidual interpretation of rules and application of a task to handle with in-house staff. To make matters even more difficult, attracting and retaining standards.

Compliance standards simply cannot keep top-level cybersecurity engineers to work at the pace with the constant changes and shifts in how level required by health care providers becomes cyber criminals attack companies and organiza- expensive and time consuming. Some organiza-

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tions may need to support their in-house departments with the expertise of outside cybersecurity experts.

TACTICS TO HELP PREVENT A BREACH

In addition to the big-picture issues to consider, there are some street-level tactics that can help prevent a breach. Some of the ideas presented here are for information technology teams, while other items require only simple changes.

Incorporate a dedicated “update and patch” team. For larger operations, hiring a dedicated

stopped, or a new way to help secure patient care equipment, or little things every employee can do to help keep data and patients safer. By communicating and sharing, you can keep cybersecurity top-of-mind and reinforce its importance.

Provide a personal benefit to employees during cyber training. Consider offering cybersecu-

rity training at a mealtime and provide a meal for employees. The cost of food is small, compared to what a single incident response would cost.

Practice. Practice. Practice. All the theoretical planning you do as part of your cybersecurity program is useless until its tested in a real-world environment. For your front-line IT and cybersecurity teams, call in your cybersecurity provider and host tabletop exercises on how to stop a simulated cyberattack. Once you see your strategies and tactics in action, you can evaluate, improve, change and even overhaul your procedures. Finding out what works and what doesn’t is much better in practice than when you’re actually being attacked.

A 2017 Privacy and Security Awareness Report showed that 78% of health care employees showed some lack of preparedness with common privacy and security threat scenarios.4 That’s why employers should practice cyber emergency drills, similar to fire drills. Create a variety of

team that handles only updates and patches is money well spent. Given the number of computers, devices and types of equipment in the average hospital or large-scale organization, updating and patching can’t be handled part-time. From updating and patching, to the overwhelming task of tracking every piece of software and equipment, to monitoring update notices, the work of a dedicated update and patch team will quickly become one of the most valuable functions in your organization.

Create a cybersecurity culture. Cybersecurity is everyone’s responsibility, not just the members of a team or a committee or a department. Everyone in your organization is impacted by cybersecurity so everyone should also be part of the solution, not part of the problem.

Get everyone involved and excited.

Get everyone involved and excited.

Offer recognition and rewards to those who provide ideas or create programs Offer recognition and rewards for improving cybersecurity at the to those who provide ideas or employee level. Keep people aware. And provide avenues for education and for create programs for improving making employees realize their value in cybersecurity at the employee the process of organizational security.

A simple weekly email blast, a monthly level. Keep people aware. newsletter and intranet postings, along with regular recognition events are a great way to keep your organization cyber safe possible scenarios and have employees practice and to let employees know that you value how emergency protocols. they’re making a difference.

Create departmental-level cybersecurity teams. Depending on the size of your organiza-

tion, have an executive-level cybersecurity team or leader, such as a chief information security officer, communicate weekly or bi-weekly to departmentally-based teams to share the latest on cybersecurity. Don’t make it all nuts and bolts tech talk, as that could get repetitive and even boring. Consider including updates on how cyberattacks were

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STEPS EMPLOYEES CAN TAKE

There are a myriad of little things employees can do to help prevent breaches: Protect personal and mobile devices. Mobile devices are your most vulnerable point of entry.

With personal smartphones and tablets used to regularly access networks, all employee devices should be registered, protected with encryption and antivirus software, and more, depending on

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your facility. Through a mobile device manager, should do first: an organization can register and protect even Enlist your cybersecurity provider immedipersonally owned devices. Work to make mobile ately. Dealing with a breach is not a do-it-yourself devices as safe as possible. project. Asking anyone but an expertly trained Be password strong. Stolen passwords are an cyber engineer to mitigate a breach is akin to askeasy gateway for cyber criminals to breach your ing a pastry chef to disarm a nuclear warhead. system. Stress that employees use strong pass- Expert incident response is critical to ending words with a long variety of characters, numbers your breach quickly and effectively, so leave it to and symbols. Use verification techniques for professionals. added security when someone is accessing work Don’t turn off computers, networks or sysaccounts, such as multi-factor authentication with tems. Most malware has built-in “kill switches” security questions and out-of-band notifications that can trigger when equipment is shut down in a for logins. Have employees change passwords manner meant to end a breach. The result can lead regularly. And finally, make the sharing of passwords a violation of work policy An independent backup free from with appropriate consequences. Passwords should never be shared. malware or ransomware could Limit access. Everyone doesn’t be the ticket to saving valuable need access to everything. Strictly limit access to sensitive data and informaassets that might not otherwise be tion that doesn’t apply to an employee’s job description. Software, apps and recoverable. other additions to your network should be handled only by designated information tech- to permanent destruction of networks, systems nology team members, not random personnel. and data. Call in the pros and let them do what And for vendors requiring network access, issue they do best, or you could face catastrophic loss. restricted access and time-limited credentials Quarantine all devices, networks and sysbased on exactly what the vendor needs to com- tems. Respond to a breach as you would to a plete the work. highly contagious communicable disease. NothTeach proper cyber hygiene. Most people ing new comes in or goes out in terms of informahave never been taught good cyber hygiene. Plac- tion technology. Until you determine the point of ing sensitive information in emails or leaving per- breach, what you’re facing and how to eliminate sonal data in email attachments are just two easy the chance of the malware spreading to uninfected ways to open doors that can allow criminals to equipment, you need to quarantine everything, steal information. Encourage employees to keep including personal devices used by staff and venonly critical immediate data on their computers dors, who have network and system access. and devices. Everything else can be backed up or Enlist your legal and communications teams. stored on the cloud.

Once you’ve been breached, you want to share Backup, backup, backup. Keep information accurate information and mitigate damage on backed up in multiple places for added security. multiple fronts. Bring in your legal representaBackup offline on multiple devices. Backup on the tive to make sure you release information in comcloud and backup in designated areas of the orga- pliant fashion and to the proper authorities and nization’s networks. An independent backup free agencies. Once that happens, you’ll have strict from malware or ransomware could be the ticket protocols to follow. Have communications ready to saving valuable assets that might not otherwise to handle informational or news releases to necessary parties and the media, if needed. be recoverable.

Always stay one step ahead of what is required by law and manage the situation. Even more WHAT TO DO IF YOU DISCOVER A BREACH Most breaches aren’t discovered for an average of importantly, always present yourself profes18 months. Once you become aware of a breach, sionally and keep the interest of outside parties time is of the essence. The faster you move, the impacted by the breach at the forefront of everyless damage you face. But you have to do every- thing you do. thing right from the beginning. Here’s what you Have digital forensics at the ready. After your

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cybersecurity partner mitigates the breach, call in the digital forensics team. It’s critical to learn as much as possible about the breach, where and how it occurred, damages caused and how much data and other assets may have been stolen.

CONCLUSION

It’s disheartening that health care, an industry based on helping those in greatest need, has become a prime target for criminal enterprises.

Many of us live with a false sense of security when it comes to health care cyber crime. We use personal devices, laptop and desktop computers, and various types of equipment dependent on information technology networks or systems when we’re working. The natural assumption is that “we’re all protected” by someone, somewhere, who has responsibility for making sure criminals are “locked out.” But in reality, we are all just as responsible for cybersecurity in our own way as those with cybersecurity as part of their job function. The better we all plan, prepare and respond will lead to improved safety not only for the health

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care industry, but for the patients who place their lives in our hands every day.

JARRETT KOLTHOFF is the chief executive officer of St. Louis-based SpearTip Cyber Counterintelligence.

NOTES 1. For more information, see Karim Abouelmehdi, Abderrahim Beni-Hessane, Hayat Khaloufi, “Big Healthcare Data: Preserving Security and Privacy,” Journal of Big Data 5, no. 1 (2018), https://link.springer.com/ article/10.1186/s40537-017-01107.

2. “Beazley Breach Briefing,” Beazley website, March 21, 2019, https://www.beazley.com/news/2019/beazley_ breach_briefing_2019.html.

3. “Beazley Breach Briefing.”

4. Elizabeth Snell, “78% of Healthcare Workers Lack Data Privacy, Security Preparedness,” Health IT Security website, Feb. 6, 2018, https://healthitsecurity.com/ news/78-of-healthcare-workers-lack-data-privacysecurity-preparedness.

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How to Use Ethical Frameworks for Disaster Planning CARL MIDDLETON, DMin, MDiv, MA, MRE

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ver the past several years natural disasters have been both expensive and deadly. In addition to natural disasters there have been acts of domestic terrorism in schools, churches, synagogues and mosques. In recognition of the significant and increasing effect that disasters can have on hospital care in the United States as well as on Catholic missions overseas, Catholic Health Association members gathered in the summer of 2018 for “When Disasters Strike: A Special Convening for International and Domestic Response,” a forum for sharing insights and lessons learned. Participants and panelists with vast and varied experience discussed the numerous effects that Catholic health care should anticipate in a disaster.

Participants described a resounding sense of religious and moral obligation to help during a disaster, a commitment shared across individuals and their organizations. This discussion led to a conversation regarding a discernment process and ethical framework to assist health care and aid organizations when making decisions related to natural disaster response.

As a theologian and ethicist, I have continued to think about the subject since that gathering. In my role at both the local and national levels, I have served on disaster planning committees, served on the incident command team during Hurricane Harvey, have completed the Incident Command System Training and the FEMA Healthcare Leadership for Mass Casualty course. These experiences have enabled me to suggest an ethical framework for the disaster planning discernment and identify the key ethical values and questions that pertain to disaster decision-making.

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Disasters often require some combination of triaging, allocating and rationing of resources because the demand is far greater than the supply. Recent disasters that have involved Catholic health facilities and systems reinforce the importance of preparedness for all types of disasters. A discernment process and ethical framework are needed to provide guidance in decision-making for a wide variety of disasters.

DISCERNMENT PROCESS

Catholic health care systems have their own discernment processes that can be used as a model for disasters/humanitarian crises. A discernment process from a faith-based perspective would typically include clinical, organizational and public health ethics. A disaster planning committee can use a discernment process as a way to organize their work.

Prior to implementing the discernment pro-

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cess and ethical framework, they would need to go through a selection process to identify a team of people with appropriate expertise and experience who will be involved in disaster planning discernment. It is important to include a mission leader and an ethicist in the planning process and to serve on the Incident Command Team.

Though the terminology might change, these are the typical elements of a discernment process: an analysis phase, a resolution phase and an evaluation. After describing the steps of each phase, I will suggest elements of an ethical framework for disaster planning discernment.

The Steps of the Analysis Phase Begin with prayer and reflection.

Define the issues, identifying key facts, factors and stakeholders.

Establish the facts of the issue: who, what, where, when, why and how.

Clarify who will own the decision.

Frame the perspectives, by identifying your own perspective and appreciating the perspectives of others.

Identify who will be affected by the decision.

Identify all possible alternatives.

Brainstorm options, including doing nothing, and determine the pros and cons of each.

ETHICAL GOALS

In their book, Emergency Ethics: Public Health Preparedness and Response, Hastings Center Fellows Bruce Jennings and the late John Arras formulated seven ethical goals designed to inform both the content of preparedness plans and the process by which they are devised, updated and implemented in an emergency situation and its aftermath. A disaster planning committee can evaluate their disaster plan in light of these seven goals.

Harm reduction and benefit promotion.

Emergency preparedness activities should protect public safety, health and well-being. They should minimize the extent of death, injury, disease, disability and suffering during and after an emergency.

Equal liberty and human rights. Emergency preparedness activities should be designed to respect the equal liberty, autonomy and dignity of all persons.

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Distributive justice. Emergency preparedness activities should be conducted so as to ensure that the benefits and burdens imposed on the population by the emergency and by the need to cope with its effects are shared equitably and fairly.

Public accountability and transparency.

Emergency preparedness activities should be based on and incorporate decision-making processes that are inclusive, transparent and sustain public trust.

Community resilience and empowerment.

A principal goal of emergency preparedness should be to develop resilient, safe communities.

Emergency preparedness activities should strive toward the long-term goal of developing community resources that will make them more hazardresistant and allow them to recover appropriately and effectively after emergencies.

Public health professionalism. Emergency preparedness activities should recognize the special obligations of public health professionals and promote competency of and coordination among these professionals.

Responsible civic response. Emergency preparedness activities should promote a sense of personal responsibility and citizenship.1 Decision-makers should assess who among the staff is willing to: serve during a crisis; work collaboratively with stakeholders and professional staff in advance to establish practice guidelines; work collaboratively to develop fair and accountable processes to resolve disputes; and provide support to ease the moral burden of those with the duty to care.

ETHICAL DILEMMAS

Catastrophic events raise the potential for many serious ethical dilemmas and quandaries. FEMA’s instructor manual for Catastrophe Readiness and Response provides examples of some issues where ethics are relevant for a disaster planning committee: How do we ethically determine allocation and distribution of benefits and burdens before, during and following a catastrophic event?

How do we resolve or determine the fairness of unintended consequences?

How much participation by the public or [by] affected individuals in the planning and preparing for catastrophic events is required [in

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order for it] to be “ethical”?

How do we determine roles of responsibility and duty in catastrophe response? Who is responsible for responding? What types of responses are required? Who pays for response?

What is the nature and extent of professional duties and responsibilities during catastrophe response? Must emergency responders put themselves in danger? Is there an ethical duty to attempt a rescue even when doing so might put the first responder’s own life in danger?

How do private responsibilities relate to public duties? Is government “ethically” required to be proactive? More or less active than individuals and families?

How do we determine to whom a duty is owed (our “moral community”)? Is assistance provided on a purely first-come, first-served basis? How do we deal with especially vulnerable populations? Do the elderly and infirm receive additional resources or fewer? What about the poor? Immigrants? Prisoners? (Author’s note: See Part One of the Ethical and Religious Directives for Catholic Care Health Services.)

How do we ethically set policy and enforce limitations on individual rights, for example, curfew, quarantine, confinement, mandatory evacuation? Does autonomy trump public safety, or vice versa?

In emergency conditions can due process be suspended or modified? Might other constitutional rights be suspended?

• Can the government impose limitations on personal and family movement (e.g., can families be prevented from returning to their homes and neighborhoods, from exercising their property rights, when conditions are rendered unsafe?)

• How do we deal with residents who refuse to follow an order to evacuate? What is the ethical responsibility to them? Legal ramifications?

How does this impact the concerns for first responder safety?

What duty is owed the public in terms of messaging and communication about impending catastrophic events? How is this balanced with the need to avoid “panic” or “overreaction” on the part of the public? What role does the mass media play in communicating warnings and other information to the public? What role should it play (i.e., what is the ethical thing for the media to do?)2

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The Steps of the Resolution Phase Analyze the values: What values are at stake?

What are the significant value conflicts?

What values are being affirmed, and what values are being negated?

Conduct prayerful reflection upon the alternatives in light of your mission and values.

Determine what is the right thing to do for the right reason.

Decide: Identify which alternative/option best advances your mission, values and core strategies.

Choose your path among the possible alternatives.

Implement the decision: Develop a process for carrying it out.

Determine how and when the decision will be communicated to all stakeholders.

ETHICS ALGORITHM

The FEMA training manual’s section on ethics states: “There are no simple, formulaic schemes for making ethical choices, particularly in the catastrophe setting. There are, however, ways of thinking about key values, ethical principles and theories that can help preparedness planners devise strategies for emergency response. These involve a systematic approach to applying basic ethical principles and theories to any particular situation. One can create an ethics algorithm that, if consistently applied to planning for any particular kind of emergency, at least can provide reasonable confidence that ethical issues raised by an emergency are well-considered.”3 The ethics algorithm might be constructed as follows: 1. Who are all the possible interested parties?

Think broadly — include not only persons and categories of persons but institutions/organizations/ professions/communities.

2. What is the full range of duties and obligations of each potentially interested party, or at least the primary interested parties? Think of parties as not only individuals but also institutions and groups.

3. How might various duties and obligations of each of the various parties’ clash/conflict?

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4. What might be short-term and long-term consequences, both good and bad of each possible course of action? How confident are you of your predictive accuracy?

5. What ethical principles are at stake? (Possible ethical principles include respect for persons, beneficence, non-malfeasance, justice, truth telling, liberty, opportunity and reciprocity). Which ones are in tension?

6. What might be the intentions of the various players? Evaluate the praiseworthiness or lack thereof, of the motives of the people, organizations and/or institutions involved.

7. What appears to be the full range of possible courses of action?

8. Weed out those possible courses of action that appear not to be justifiable based on potentially bad consequences, inability to meet duties and obligations, and/or the ethical soundness, or lack thereof, of intentions.4 9. Another important resource is the World Medical Association’s set of ethical principles and procedures with regard to triage outlined in its Statement of Medical Ethics in the Event of Disasters.5

Values Analysis: What Values Are Affirmed, in Conflict or Negated

Some of the values to be considered for values analysis in a Catholic Healthcare Disaster Plan might include the following: Reasonableness: Decisions should be based on reasons (including evidence, principles, values) that stakeholders can agree are relevant to meeting health needs during a disaster.

Responsiveness: Leaders should revisit and revise decisions as new information emerges throughout the crisis.

Duty to provide care: The duty to provide care and to respond to suffering is inherent to all health care professionals’ codes of ethics.

Equity: During a crisis, tough decisions will need to be made when resources are limited.

Individual liberty: Restrictions to individual liberty may be necessary to protect the public from serious harm.

Privacy: In a crisis it may be necessary to override this right to protect the public from serious harm.

Proportionality: Requires restrictions to individual liberty and measures taken to protect the public from harm.

Do no harm: A foundational principle of

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ethics is the obligation to protect the public from serious harm.

Common good: During a crisis, people, especially those most vulnerable, need to have the basic necessities, food, shelter, water, clothing, etc.

Reciprocity: Requires that society supports those who face a disproportionate burden in protecting the public good and takes steps to minimize its impact.

Solidarity: A disaster requires collaboration between local, regional, national and global partners.

Stewardship: Trust, ethical behavior and good decision-making are utilized in allocation and rationing decisions.

Trust: Early engagement and transparent communication with stakeholders.6

EVALUATION PHASE

Evaluate whether the solution addressed the defined problem.

Determine if your actions produced the desired outcomes.

Document and use lessons learned for future planning and response.

In evaluating a disaster plan, the Army’s afteraction review is arguably one of the most successful organizational learning methods yet devised for evaluation and performance improvement, especially in light of disaster planning. The process involves all persons involved regardless of title or role to share and learn in order to have continuous improvement. I suggest that an afteraction review be conducted at the end of each day of the disaster by the incident command team.

The assessment allows both employees and leaders to discover and learn what happened and why.

Don Clark’s “After Action Review” article outlines the steps.7

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Steps and Guidelines For Conducting An After-Action Review Some standard questions to include in an after-action review: 1. What were our intended results?

2. What were our actual results?

3. What caused our results (lessons learned)?

4. What will we sustain or improve?

5. What are some upcoming activities that will allow us to use our lessons learned?

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CONCLUSION

For hospitals and health systems that have discernment processes, the disaster planning process needs to be evaluated through a collaborative effort by Incident Command Team, the ethics committee and the disaster preparedness committee. They should make sure the process is relevant to making decisions, especially triage and allocation decisions that have to be made during a disaster or crisis. As James Childress writes: “Yet we need rules such as a capacity triage plan, established in advance of emergencies, so that everyone will know how to respond…Although rules of triage must be formulated with the best medical information available, they are not merely medical in nature. They also reflect important moral values.”8 CARL MIDDLETON is a retired health care executive, theologian/ethicist and senior mission leader with 45 years of ministry experience in Catholic health care.

2. Anna Schwab and Timothy Beatley, Catastrophe Readiness and Response, FEMA Initial Ethics Training, Session 4 (2019): 16.

3.Anna Schwab, Catastrophe Readiness, 12.

4. Schwab, Catastrophe Readiness, 12.

5. “WMA Statement on Medical Ethics in the Event of Disasters,” World Medical Association website, Revised October 2017, https://www.wma.net/policies-post/ wma-statement-on-medical-ethics-in-the-event-ofdisasters/.

6. Alison K. Thompson et al., “Pandemic Influenza Preparedness: An Ethical Framework to Guide DecisionMaking,” BMC Medical Ethics 7, no. 12 (Dec. 4, 2006), https://bmcmedethics.biomedcentral.com/ articles/10.1186/1472-6939-7-12.

7. “After Action Review,” Donald Clark, Big Dog and Little Dog’s Performance Juxtaposition website, May 1, 1997, http://www.nwlink.com/~donclark/leader/leadaar.html.

8. James F. Childress, “Disaster Triage,” American Medical Association Journal of Ethics 6, no. 5 (May 2004), https://journalofethics.ama-assn.org/article/ disaster-triage/2004-05.

NOTES 1. Bruce Jennings et al., eds., Emergency Ethics: Public Health Preparedness and Response, (Oxford: Oxford University Press, 2016).

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Chad Lubbers

Image of the cross in wood found in lobby of Avera Heart Hospital after the Sept. 10 tornadoes.

‘I Am With You’ MARY L. HILL, BSN, MAHCM, JD

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he image of a cross in the wood is a visual reminder of God’s enduring promise, “I am with you.” We first encounter the promise in the Book of Genesis when God called Abraham to leave his home, his relatives and his country to venture through foreign lands. In the face of Abraham’s unknown future, God didn’t promise familiarity; rather, God promised to be with Abraham, guiding and blessing his journey toward founding the great nation of Israel.

Many centuries later, God restated the promise when He called a reluctant and plainspoken Moses to lead the Israelites from captivity. In response to Moses’ objections, God didn’t promise confidence; rather God promised to be with Moses, speaking through him to a hard-hearted Pharaoh and the wayward people.

God’s promise took on special significance with the coming of Emmanuel, which literally means, “God with us.” Jesus incarnated the promise and showed us how to build God’s Kingdom through acts of love, mercy and service. In the midst of the world’s suffering, Jesus didn’t promise contentment; rather, he was with us, transforming even death through the power of his Resurrection. And, at the conclusion of his earthly ministry, Jesus commended the promise to all generations proclaiming, “I am with you always, until the end of the age.”

We can see God’s enduring promise revealed through the faithfulness of our founding sisters who, inspired by the Gospel ministry of Jesus and his command, “Go and do likewise,” traveled to Dakota Territory to teach, heal and accompany. Although the journey has not been easy, God has been with the sisters as their ministries flourished into Avera, the largest women-founded organization in South Dakota. In the face of the many difficulties experienced throughout Avera’s history — harsh prairie conditions, epidemics, economic hardship, war and severe weather — God has been with Avera, inspiring and enabling it to be Christ’s healing compassion.

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Thus, as Avera continues to encounter the inevitable challenges attendant to health care ministry, we rest in the assurance that God is with us always, guiding and empowering us to bring hope and healing to our world.

AVERA: WHO WE ARE

Avera, a Catholic health care ministry rooted in the Gospel, is a response to Jesus’ command, “Go and do likewise.” In accord with its mission, Avera endeavors to positively impact the lives and health of persons and communities by providing quality services guided by Christian values.

As a ministry of the Catholic church, Avera distinguishes itself by service to and advocacy for those persons whose social condition puts them at the margins of society and makes them particularly vulnerable to discrimination. Avera rejoices in the challenge to be Christ’s healing compassion in the world and operates in a way that enables persons served to experience their own dignity and value.

This reflection by MARY L. HILL, executive vice president of mission, Avera Health, Sioux Falls, S.D., was written in response to a reporter’s question about Avera’s mission in the aftermath of tornadoes that hit the city on Sept. 10, 2019. An image of the cross was spotted in a piece of wood debris left behind. The reflection has been adapted and reprinted with permission from Avera Health.

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REFLECTION

The Way Through PAM FRANTA, PhD

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hough I have not encountered the type of disasters that cause catastrophic damage or loss of life, I have learned profoundly from my own brushes with disaster. In January of 1977, my husband and I were traveling from St. Louis to Chicago after a funeral.

The winter had been brutal with snow and bit- We could do little to help ourselves, dependent on ter cold. As we drove through Springfield, the sun the grace of others.

Eventually a highway patrolman came to came out, raising the temperature above freezing.

Mounds of snow on the shoulder began to melt, inform us the highway was closed. He drove us to running onto the highway. As we continued north, the National Guard Armory where the Red Cross the wind picked up and the temperature dropped, and Salvation Army provided cots, blankets and creating a whiteout and turning the road to a sheet food. Others there were just as dazed as we after of ice. Visibility was poor, but we could still see being rudely plucked from our journeys. The gratblue sky above the blowing snow. First one car itude I felt was immense, knowing that strangers slid off the road into a snowbank, and several oth- had come together to make us sandwiches and ers followed. It was not long before a semi-truck offer us safety. While in no way comparable to the slipped to the shoulder. Its trailer tilted, sending tragic disasters of floods, fires, hurricanes, and its contents into the wind. Posters meant for gro- even more frightening, violent situations, this cery store windows wrapped around highway experience taught me some profound truths. signs and covered windshields.

Shortly after that, we too went Unable to help ourselves, we must rely off the road. While grateful not on the generosity of others. Humbled to be hurt, we were stunned to be stopped so quickly. by our vulnerability and others’ With temperatures in the single digits, we knew we couldn’t compassion, we feel gratitude. remain there. David climbed out The wisdom of religious tradition knows what to survey the damage. After moving to the front of the car, he was soon thigh-deep in snow. By the is desirable in the face of disaster. Whether caused time he returned inside, his breath had frozen and by natural forces, a catastrophic event, illness or covered his beard with ice. Tying a handkerchief accident, one feels a tremendous sense of loss and fear of the unknown. Unable to help ourselves, we on the driver’s door handle, we waited.

Young and inexperienced, we had none of the must rely on the generosity of others. Humbled by provisions recommended for winter car trips. We our vulnerability and others’ compassion, we feel took the basics of warmth, food, water and safety gratitude. At the same time, those who minister to for granted. We were stuck. As we sat, we prayed people in need open themselves to a spirit of joy the prayers learned in childhood, a comfort when that arises from the act of giving.

Not all people are moved to humility quickly, one’s thoughts are being hijacked by fear. “Train the young in the way they should go; even when however. I recently heard a reformed white old, they will not swerve from it.” (Proverbs 22:6) supremacist describe his behavior during the

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height of his activism. After nights of perform- as the Israelites were tested at Meribah in the ing at rallies, he would go to work hungover desert (Exodus 17: 7). They saw their difficult cirand underfed. The next day his black coworkers cumstances as a sign that the Lord had neglected offered to share their lunch with him. The impact them. Forgetting about the manna, they homed in of their unconditional love moved him more than on immediate circumstances. The challenge for anything else. The wisdom of Christianity heals all of us is to see beyond the suffering and pain, to the suffering of others. “Love is patient, love give thanks so we can find and offer hope.

Since that whiteout, I have served as a responder is kind. It is not jealous ... it is not rude, it is not quick-tempered, it does not brood over injury. to disasters for the American Red Cross. The peoIt bears all things, believes all things, hopes all ple I met were challenged and humbled, stressed things, endures all things. ... Love never fails.” (1 Corinthians 13:4-8) “Love is patient, love is kind. It is not In the Buddhist tradition the “tonglen” refers to the practice of jealous ... it is not rude, it is not quicktaking in the suffering of others and giving back joy, grounded in tempered, it does not brood over humility, acceptance and compasinjury. It bears all things, believes all sion. Desmond Tutu in The Book of Joy acknowledges that all culthings, hopes all things, endures all tures “admire those who are other things. ... Love never fails.” regarding.”

The gifts that have been — 1 CORINTHIANS 13:4-8 bestowed on us, our time, treasure or talents, are not meant only for our gratification. Catholic tradition says we are by their losses and, though sometimes angry, meant to share them, giving glory to God and wit- usually grateful for survival and the kindness of nessing his love. Through this, our own lives are strangers. The lesson I have learned about how to renewed, since “whoever refreshes others will be get through these experiences is to be present to those in need. Even in the midst of my own losses, refreshed.” (Proverbs 11:25) Jonathan Cahn, the messianic rabbi, author and the opportunity is to remember that the blue sky pastor, describes in the Book of Mysteries (Day 42) exists above the blowing snow and “to raise the “How to Multiply Bread.” Referring to Jesus, he cup of salvation and call on the name of the Lord.” says, “He looked up to heaven and gave thanks. He (Psalm 116:13) Isaiah calls us to a different kind of “fasting,” gave thanks and the miracle happened. That’s the secret. That’s the key to miracles....You don’t look to share our bread with the hungry, shelter the at how little you have or how big your problem oppressed and homeless, and not turn our backs is or how impossible the situation is. You don’t on our own. If we do this, the “light shall rise in the panic, you don’t complain, and you don’t get dis- darkness”..and give plenty, even on the parched couraged over not having enough. You take the land. He will renew our strength and we “shall be little you have, whatever good there is, no matter like a watered garden, like a flowing spring whose how small or inadequate it is, and you do what waters never fail.” (Isaiah 58:10-11) My prayer is that all of us would more freMessiah did. You lift it up to the Lord and you give thanks for it. And the blessings you have will mul- quently be at our best in embodying that message, providing hope and encouragement for each tiply, if not in the world, then in your heart.

The more you give thanks, the less you will other to find the “way through.” hunger, and the more full and blessed you will be ... Give thanks even for what is not enough, and it PAM FRANTA is a licensed psychologist who works in senior leader coaching and development will multiply to become what is enough.”

In the midst of disaster, we are all tested, just at Edward Jones in St. Louis.

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HEALTH PROGRESS

The Ethical and Religious Directives

Looking Back To Move Forward RON HAMEL, PhD

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n its 1920 inaugural issue, Hospital Progress stated as its mission: “to become the medium through which the best thought and practice in hospital service to the sick will be worked into the lives of those who are consecrated to this service.” Despite an ever-changing health care environment over the past 100 years, the journal now named Health Progress has indeed communicated some of the best thought and practice on numerous facets of health care delivery in Catholic facilities. One of the ongoing areas of focus has been health care ethics. In fact, one of the earliest issues published the “Surgical Code for Catholic Hospitals for the Diocese of Detroit” which outlined acceptable and unacceptable surgical procedures from a Catholic ethical perspective. Since then, there have been hundreds if not thousands of articles and columns devoted to a vast range of ethical issues encountered in Catholic health care. To name just a few, these have included euthanasia and assisted-suicide, endof-life care, reproductive matters, genetics, transplantation, environmental responsibility, organizational ethics issues, and the Ethical and Religious Directives for Catholic Health Care Services (ERDs), the ethical code that provides moral guidance on aspects of health care delivery for Catholic health care facilities.

Any one of these areas is worthy of exploration because the articles that addressed them helped shape the practice in Catholic health care facilities, generated theological-ethical dialogue and debate, and even influenced the various iterations of Catholic health care’s ethical code, especially earlier versions. But if there is one theme that runs through a century of Health Progress, explicitly and implicitly, it is the ERDs. There are a good number of articles dealing explicitly with the code and numerous other articles that are indirectly tied to the ERDs in that they explain, elaborate upon, attempt to clarify or even propose alternative approaches to particular directives.

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In a 1947 issue of Hospital Progress, Rev. Lawrence Skelly wrote: “Whatever else may be said, certainly there is a need, a crying need, of a certain, definite, concise, clear cut Catholic Code for our Catholic hospitals. . . . Certainly if there should be one distinguishing mark of a Catholic hospital, it should be its code of ethics—else why do we exist?”1 While one might not totally agree with Fr. Skelly’s claims, there is no doubt that it underscores the importance of “the code” for Catholic health care. And this journal, along with the Catholic Health Association itself, has played a critical role in the various iterations of the ERDs.2

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Perhaps this is most true with regard to the 1971 revision and the development of its successor published in 1995, the majority of which still constitutes the current edition of the ERDs. The 1971 revision, Ethical and Religious Directives for Catholic Health Facilities, generated a “storm of violent criticism.”

Moral theologian Rev. Thomas J. O’Donnell, SJ, described the reaction in a 1972 issue of Hospital Progress: A storm of violent criticism has broken on the American health and hospital scene on the occasion of the U.S. Bishops’ approval, last November, of the new Ethical and Religious Directives for Catholic Health Facilities. The Directives are criticized as being meaningless for our modern day, as hopelessly ill-suited to the ecumenical dimension of our pluralistic society, of being irrelevant regarding what the Catholic hospital should or should not do, and beyond the scope of what the American hierarchy should or should not teach.3 Between August 1972 and March 1973, Hospital Progress published seven articles concerning the 1971 revision, pro and con, including a highly critical report from a commission of the Catholic Theological Society of America titled “Catholic Hospital Ethics.”4 Hospital Progress documented both sides of the heated debate and spurred further dialogue and debate across Catholic health care about what the Directives should be.5 In doing so, it is plausible, if not likely, that Hospital Progress contributed at least indirectly to the substantial revision in 1995. Since this was such a pivotal turning point in the conceptualization of the Directives, it is worth explor-

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ing in greater detail. The current ERDs remain substantially the same as the 1995 version, despite three subsequent revisions in 2001, 2009 and 2018.

Although the 1995 version was generally very well-received and has served Catholic health care effectively, it is 24 years old. Much has happened in American society and the church, in health care generally and in Catholic health care in particular, as well as in the life sciences, medicine and technology since its publication. Perhaps the Directives are due for a thorough update. If so, what are some of the areas to which a revision might need to attend?

THE 1971 CODE AND ITS CRITICS

Apparently, due to varied and liberal applications of the Directives in some dioceses across the country during the 1960s, especially with regard to contraception and sterilization, the executive committee of the Catholic Health Association board of trustees asked the National Conference of Catholic Bishops (the former name of the United States Conference of Catholic Bishops) to draft and promulgate a set of Directives that would apply to the entire country.6 The hope was that such an authoritative document would resolve the problem of what some perceived as “geographical morality.” Instead, the November 1971 publication of the new Directives resulted almost immediately in severe attacks.

Two of the strongest critics were Rev. Richard McCormick, SJ, STD, and Warren Reich, PhD. Though their critiques were not published in Hospital Progress, the journal did publish an exchange of views with Eugene Diamond, MD, who was critical of their assessments. 7 The first of Diamond’s opinion pieces in December 1972 appeared along with responses to Diamond from Reich and McCormick.8 The second set of exchanges appeared in February 1973.9 In the same February 1973 issue of Hospital

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Progress was the Catholic Theological Society of America Commission’s Report on “Catholic Hospital Ethics.” The commission began the study in June 1971. It was accepted by the Board of Directors on September 1, 1972, and was first published in The Linacre Quarterly in November 1972.10 Reich was a member of the commission and McCormick a consultant. Their critiques of the 1971 Directives are clearly reflected in the report that centers its critiques on four areas: the pluralistic context in which Catholic health care operates, the Catholic presence in health care, the code and ethical decision-making, and the role of conscience and dissent. The Catholic presence in health care is a less important critique and will not be considered here.

First, the theological society commission observes that the preamble to the 1971 edition presented a defensive response to the fact that the church’s healing ministry was operating in a highly pluralistic society and was serving people of many different faith traditions and moral beliefs. The preamble’s lack of a recognition of pluralism was especially troubling given Vatican II’s acknowledgement of and engagement with pluralism in its Declaration on Religious Freedom and in Gaudium et Spes/the Pastoral Constitution on the Church in the Modern World (report paragraphs 11-15). And what were judged to be the implications of pluralism for Catholic health care? The commission asks whether “Catholic hospitals, on religious and ethical grounds, [can] continue to justify the refusal of certain health services which are legally permitted, commonly accepted in the medical world, and, at least in some cases, not morally harmful according to the judgment of many prudent men?” (paragraph 17).

The concern here was that “in trying to retain a Catholic identity through institutional ethical policies we may violate the rights of others, neglect or harm the social good, and force an abdication of Catholic institutional presence in the hospital world” (paragraph 19). Striking a balance between maintaining Catholic identity and addressing the situation of pluralism was acknowledged as a challenge.

Second, the commission critiqued the Directives for their approach to ethical decision-making. Four major themes emerged here.

The preamble was found to be not only defensive, but also legalistic. The commission observed that “a number of important elements

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which constitute a Christian theology of moral law are unfortunately lacking in the Preamble of the U.S. bishops’ Directives, which offers a predominantly legalistic dimension to the Directives” (paragraph 39). In particular, they had in mind the absence of any influence of significant magisterial and theological developments in the areas of law, conscience and freedom that began to emerge in the mid-1950s (paragraph 42). This resulted in the new Directives containing many more moral prescriptions (norms prohibiting or commanding specific behavior) than ethical principles (general statements of moral values that provide guidance) and a greater insistence on their certitude and binding power than in the previous Directives, without acknowledging that these moral norms are not infallible and do not all enjoy the same degree of certitude and binding power (paragraph 41). The new code essentially was a listing of what could not be done in a Catholic health care facility.

Along similar lines, the commission was critical of the bishops for deleting a principle from the 1955 code having to do with the resolution of doubt regarding the application of a particular norm to a concrete situation (paragraph 42).

This further reinforced the legalism, the binding force of the norms and the insistence on certitude. The report maintained that the principle should still be in effect, not only for clinicians, but also for the patient “who has the first and most basic responsibility to make decisions on his own behalf” (paragraph 42). They further suggested that “today’s situation of pluralism in particular should prod us to more openness and candor, both in acknowledging what can be permitted on occasion even in the face of a general prohibition which the Catholic community is reluctant to abandon, and in firmly supporting the prohibitions of which we are deeply convinced and which seem to strike more deeply to the roots of our faith identity” (paragraph 41).

In contrast to the legalistic tone of the preamble to the 1971 Directives, the commission noted the very different tone of the Preamble to the Canadian Catholic Medico-Moral Guide: “The Guidelines … should be read and understood not as commands composed from without, but as demands of the inner dynamism of the human and Christian life …. Their application to a particular situation will usually

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The central moral agency of the patient must be acknowledged and his freedom should be maximized, though not to the exclusion of other considerations. The patient has the right to the fullest amount of information (medical and ethical) necessary for informed and responsible consent, and often he has the right to determine medical practice in his regard on the basis of his consent or dissent—but this latter right is not without limit (paragraph 49).

entail a great deal of prudence and wisdom ….

The Guidelines should serve to enlighten the judgment of conscience. They cannot replace it” (paragraph 39, italics in the original).

The commission suggested that this approach is far more reflective of a true Christian approach to law and morality. “For the Christian, the moral law is not conceived primarily as a restrictive force but as a liberating force, its function is to guide and inform Christian love and hence Christian compassion, care and healing; and to aid conThird, and finally, the commission turned to scientious judgments in an atmosphere of freedom” (paragraph 38). And this is due to the fact conscience, cooperation and dissent. The fundathat the law of the Christian is Christ Himself. He mental issue here was patients’ (Catholic and nonis the law of our lives. For this reason, “the moral Catholic) and clinicians’ exercise of a sincere and law is not held principally to be a legal enact- well-formed conscience which the commission ment, codified and promulgated with penalties believed they have the right to do, within limits, imposed” (paragraph 38). This understanding of on the basis of the right to religious liberty and the law, the drafters of the report believed, should nature of conscience. The challenge for the Cathinfluence the approach to the moral standards for olic hospital was whether it would allow patients, or patients and their physicians, to follow a course Catholic hospitals.

Finally, the commission was highly critical of of action dictated by conscience, but contrary to the new Directives’ approach to decision-making, some portion of the Directives. The commission which they believed should be a shared respon- proposed that these types of situations should be addressed using the principles of a thesibility. They strongly disology of cooperation (paragraph 54). agreed with the preamble’s They went on to explain: claim that the local bishop has ultimate authority when Today a theology of cooperation it comes to evaluating the must be formulated and interpreted morality of new scientific in light of the Church’s affirmation developments and debated of the right of religious liberty, its questions. They did not acceptance of pluralism in prinquestion the importance of ciple, and its teaching of ethical the bishop’s role in hospinorms with varying degrees of affirtal policy and practice, but mation according to a scale of moral rather his competence to be values. … Norms, no matter how the sole arbiter, “the sole ultiO RG A N I Z AT I O N A L E T H I C S detailed, cannot supply the answers. mate authority” (preamble To arrive at decisions concerning to the 1971 Directives). The cooperation requires a good ethimajority of bishops simply cal sense, consultation with those directly are not moral theologians and do not have experinvolved, and a knowledge of the local situtise in the life sciences or in medical ethics. “This ation (paragraph 55). unqualified statement of the local bishop’s competence in medical ethics,” the commission stated, It was the position of the commission that, “has been questioned on theological grounds, on legal-medical grounds, and for reasons of com- given church teaching on conscience and the right mon sense” (paragraph 46). Instead, the commis- of legitimate dissent, in some cases and for moral sion called for broad consultation, especially at the reasons, moral decision-makers might licitly local level, so that “all who have a stake are per- deviate from concrete, non-infallible Directives, mitted and encouraged” to share in the decision- provided certain conditions are fulfilled.11 making process, especially the patient.

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November - December 2006

Health Progress

Organizational Ethics

ALSO IN THIS ISSUE:

Reducing Cardiac Arrest and Hospital Mortality Nursing and the Common Good

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and thorough revision of the 1971 Directives with input from a wide range of individuals with appropriate competencies. In addition, they made a number of other recommendations, among them less attention to sex and reproduction, and addressing a number of other issues like service to the poor and underserved; end-of-life issues; the necessity of informed consent; transplantation; human experimentation; and genetic counseling.

A REVISED CODE OF ETHICS — 1995

to be a major concern for Catholic health care.

It cannot be reduced to observance of the ERDs nor to refusing to provide a handful of procedures judged to be immoral, though these are certainly a part of Catholic identity. Rather, a robust description of what constitutes Catholic identity, even though not a comprehensive and definitive description, would be most helpful to the ministry as would a somewhat more detailed explanation of what it means to be a “ministry” and a “ministry of the Church.” As Catholic health care transitions to increasing lay leadership, these are fundamentally important concepts that need to be grasped and lived out if Catholic health care is going to survive and flourish.

While it took 24 years, the 1971 Directives were revised. Published in 1995 after broad consultation over a six-year period and 11 major drafts, the revised Ethical and Religious Directives for Catholic Health Care Services, was dramatically different from the preCatholic identity has been and vious version. Many of the critiques levelled against the 1971 code were continues to be a major concern for taken seriously by the drafters and their consultants. As we know, that Catholic health care. It cannot be 1995 edition was more theological/ reduced to observance of the ERDs scriptural and less legalistic; provided theological/philosophical nor to refusing to provide a handful rationales for conclusions; began by of procedures judged to be immoral, focusing on core values of Catholic health care and key characteristics though these are certainly a part of of Catholic health care organizations; incorporated social justice considerCatholic identity. ations; employed human dignity as a central and unifying theme; focused Second, the Catholic Theological Society of more on the patient as decision-maker; dealt with a broader number of clinical issues; and included America report called for greater attention to cona section on partnerships, to name just a few science. This did not really get developed in the 1995 edition. There are only a couple of passing improvements. references to conscience. Yet conscience is a central reality in Catholic moral theology and in the LOOKING TO THE FUTURE It has now been 24 years since such a thorough- teachings of Vatican II.12 And each and every day, going revision. As previously noted, in the inter- there are hundreds if not thousands of conscience vening years, there have been many significant decisions made in Catholic health care facilities developments on many fronts relevant to Catho- by administrators, clinicians, patients and their lic health care. Given this, perhaps it is time for families, and many others. Ironically, the 1949 and an update of the current edition, one that is not 1955 editions explicitly address the exercise of as drastic as the 1995 revision, but one that bet- conscience in two types of situations: in matters ter reflects and addresses what has transpired that are legitimately debated by theologians and over 24 years. As someone who has lectured and in cases of doubt when the code does not speak written extensively on the ERDs over 17 years and to an issue or where its application is unclear. In participated in three revisions, I offer a few top- these situations, the physician is supported in folics that might be considered in the next revision, lowing his or her conscience and doing what is recognizing that the ERDs cannot address every in conformity with sound medical practice.13 Perrelevant topic and issue. haps we have something to learn from our neighFirst, Catholic identity has been and continues bors to the north about addressing the role of con-

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Fourth, several parts of the current edition science in moral codes for Catholic health care.

The 1970 edition of the Canadian Catholic Med- could be updated. For example, Part One, “The ico-Moral Guide (the Canadian equivalent of the Social Responsibility of Catholic Health Care U.S. Ethical and Religious Directives) states that Services,” would be enhanced by one or more the application of the guidelines “to a particular directives relating to care of the environment. It is well-known that health care is one situation will usually entail of the worst contributors to environa great deal of prudence and mental degradation. Environmentally wisdom. … The Guidelines responsible health care should be a should serve to enlighten distinguishing mark of every Cathothe judgment of conscience. lic health care organization. It is the They cannot replace it.” 14 right thing to do. Also to be included The current edition of the in this section would be directives havCanadian Health Ethics ing to do with preventive health care, Guide contains an appendix addressing the social determinants of devoted to “Making Moral health, working in and with communiJudgments” with two pages ties to address health needs, collabodevoted to conscience.15 An rating with community partners to update of the current edition improve health, and addressing health of the ERDs would be prodisparities. These are all important viding an important service dimensions of the current health care to all involved in Catholic health care by affirming the role of conscience, environment. In Part Five, “Issues in Care of the what is involved in forming conscience, and the Seriously Ill and Dying,” one of the most impornecessary conditions for occasionally departing tant additions would be an affirmation of palliafrom a particular directive in the most difficult of tive care and hospice care, both of which have cases, while not giving the impression that follow- been supported by our three most recent pontiffs.

Guidance on palliative sedation also would be ing conscience means doing what one wants.

Third, the world of health care involves more helpful, as well as POLST, or Physician Orders for than providing medical treatments and proce- Life-Sustaining Treatment (medical orders that dures. There is an institutional side as well, and travel with a patient that can be helpful in end-ofthis institutional side has as much to do with Cath- life care). Finally, Part Three, “Issues in Care for olic identity as does the clinical, if not more. It the Beginning of Life,” also could use an update. would be worth considering adding a seventh section or part to the DirecThe world of health care involves tives to address some of the more important issues of an organizational more than providing medical nature, for example, the role of mintreatments and procedures. There isterial juridic persons and boards in fostering Catholic identity and is an institutional side as well, and the mission and values of the organization, formation, hiring for misthis institutional side has as much to sion fit, executive compensation in a do with Catholic identity as does the faith-based nonprofit health system, just wages for employees, respecting clinical, if not more. all forms of diversity, eliminating or reorganizing staff positions, giving employees a voice, conscientious objection, sub- There have been developments in genetics, the sidiarity and budgeting as a moral exercise. Such use of stem cells, uterine ablation, uterine ablaan addition would provide another opportunity tion with salpingectomy (the surgical removal of for bringing the Catholic social tradition to bear one or both fallopian tubes), salpingectomy for on health care and would help ensure that Catho- cancer risk reduction. There perhaps also needs to be more clarity about early induction, miscarlic identity permeates the organization.

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Throughout its 100-year history, Hospital/Health Progress has been true to its original mission of being a vehicle for communicating some of the best thought and practice to the ministry. riage and premature rupture of membranes.

Fifth, and finally, one of the most difficult issues for Catholic health care is the church’s prohibition of tubal ligations for serious medical reasons.

Such sterilizations are judged to be direct sterilizations and, hence, morally forbidden. This prohibition flies in the face of medical standards of care and common sense. There are several issues here that can only be named, but not discussed.

There is a question whether in light of the Vatican’s 2018 “Response to a Question on the Liceity of a Hysterectomy in Certain Cases,” such tubal ligations might be considered to be indirect sterilizations and, therefore, morally permissible.16 Others argue “that our rich, moral tradition possesses the pastoral wisdom to enable patients and physicians to remain true to the church’s teaching while at the same time making complex medical decisions,” decisions that take account of the complexity of some obstetrical cases, circumstances (access to care, availability of specialized obstetric services, newborn intensive care, geographic location, insurance coverage, physician-patient relationship, etc.) and the primary intention, which is to avoid potentially very serious harm to the life or health of the mother and fetus.17 Also at issue, in addition to the conscientious decision of the patient, is the conscience of the physician and the physician’s professional obligation to do no harm and to adhere to standards of care. The reality is there are very difficult cases in which alternatives are not feasible or non-existent. There must be a pastoral approach to these situations. In any case, what is needed is a thorough dialogue at the highest levels that brings together those with the needed competencies for an honest, informed, comprehensive examination.

CONCLUSION

Throughout its 100-year history, Hospital/Health

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Progress has been true to its original mission of being a vehicle for communicating some of the best thought and practice to the ministry. This is certainly true in the areas of theology and ethics.

The journal’s contribution to the development of the 1995 revision of the Ethical and Religious Directives is but one example, though a most important one. Going forward, it is critical that Health Progress continue to be a place where theologians and ethicists can exchange and probe ideas, challenge what needs to be challenged and propose new approaches. In doing so, it can influence practices in our ministries that strengthen Catholic identity, better serve our patients and communities and, quite possibly, help shape future editions of the Ethical and Religious Directives, a role it has successfully played in the past.

RON HAMEL is the former senior ethicist at the Catholic Health Association. Currently retired, he serves on SSM Health Ministries and the SSM Health Board of Directors based in St. Louis and the Irving, Texas-based CHRISTUS Health mission integration and human resources committee of the board.

NOTES 1. Rev. Lawrence E. Skelly, “Code of Ethics for Catholic Hospitals,” Hospital Progress 28, no. 1 (January 1947): 17.

2. The Catholic Hospital Association and Hospital Progress played a central role in the development of the 1949 and 1956 editions of the Directives. Rev. Gerald Kelly CHA’s consulting ethicist, was the main author of both.

In addition, for 10 years beginning in 1947, Kelly published, in virtually every issue of Hospital Progress, a column (“Medico-Moral Problems”) on some topic related to the Directives. These were eventually collected under one cover and published by CHA as Medico-Moral Problems in 1957.

3. Rev. Thomas J. O’Donnell, “The Directives: A Crisis of Faith,” Hospital Progress 53, no. 8 (August 1972): 34.

4. Commission on Ethical and Religious Directives for Catholic Hospitals, “Catholic Hospital Ethics,” Hospital Progress 54, no. 2 (February 1973): 44-56.

5. In addition to the articles listed below that were critical of the 1971 Directives, there were several published in Hospital Progress that either took a different point of view than the critics or supportive of the code. Besides the one by O’Donnell cited above, Rev. Donald J. Keefe, offered a scathing rebuttal of the Catholic Theological Society of America report (Donald J. Keefe, “A Review

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and Critique of the CTSA Report,” Hospital Progress 54, no. 2, February 1973: 57-69) and two clergy from Minnesota offered a pro and con dialogue on the Directives.

(Rev. Mark Dosh and Rev. William Hunt, “Dialogue on the Directives,” Hospital Progress 54, no. 3 (March 1973): 46-52.)

6. Rev. Kevin O’Rourke, Rev. Thomas Kopfensteiner, and Ron Hamel, “A Brief History: A Summary of the Development of the Ethical and Religious Directives for Catholic Health Care Services,” Health Progress 82, no. 6 (November-December 2001), 19.

7. Rev. Richard A. McCormick, “Not What Catholic Hospitals Ordered,” The Linacre Quarterly 39, no. 1 (February 1972): 16-20; Warren T. Reich, “Policy vs. Ethics,” The Linacre Quarterly 39, no. 1 (February 1972): 21-29.

8. Eugene Diamond, “A Physician Views the Directives,” Hospital Progress 53 (November 1972): 57-59; Warren T. Reich and Richard A. McCormick, “Theologians View the Directives,” Hospital Progress 53 (December 1972), 50-54, 68.

9. Diamond, “A Physician Views the Directives,” 70-72; Warren T. Reich and Richard A. McCormick, “Theologians View the Directives,” Hospital Progress 54 (February 1973), 73, 74, 76.

10. CTSA Commission on Ethical and Religious Directives for Catholic Hospitals, “Catholic Hospital Ethics,” The Linacre Quarterly 39, no. 4 (November 1972), 246-67. It should be noted that the themes in the CTSA Report, as well as in McCormick’s and Reich’s critiques, were con-

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cerns and perspectives that were very much “in the air” at that time in the field of moral theology/ethics.

11. See paragraph 63 for a listing of these conditions.

12. See Vatican II, The Declaration on Religious Freedom, par. 3; Constitution on the Church in the Modern World, par. 16.

13. National Conference of Catholic Bishops, “Ethical and Religious Directives for Catholic Hospitals, Introduction,” Hospital Progress 30, no. 3 (March 1949): 67.

14. The Catholic Hospital Association of Canada, Medico-Moral Guide (Ottawa: The Catholic Hospital Association of Canada, 1970).

15. Catholic Health Alliance of Canada, Health Ethics Guide (Ottawa: Catholic Health Alliance of Canada, 2012), 113-14.

16. See Peter Cataldo, “The CDF’s Response to a Question on the Liceity of a Hysterectomy in Certain Cases: A Fundamental Turn,” Health Care Ethics USA 27 (Spring 2019), 1-7.

17. See Amy Warner and Sr. Patricia Talone,“Ethics and Medical Standards of Care: Hysterectomy, Tubal Ligation, or Salpingectomy?” Health Care Ethics USA 27 (Winter 2019): 21-27. See also Rev. Francis G. Morrisey, “Restructuring Systems: A Call for Dialogue,” Health Progress 94, no. 1 (January-February 2013): 66-67. In this article, Morrisey calls for dialogue within the Catholic community regarding the need for a new approach to the matter of tubal ligations.

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MISSION AND LEADERSHIP

CLIMATE REFUGEES — THE FORGOTTEN ONES

“C

limate change is the most existential threat of our time,” announced the title character of the CBS television drama Madame Secretary in an episode that aired earlier this year called The New Normal. Secretary of State Elizabeth McCord tries to relocate the entire population of Nauru, a tiny island in Micronesia, just northeast of Australia. A super typhoon, ironically named Blessing, is on its way to the island. The prediction is made that between the already rising sea levels caused by climate change, and a 20-25 foot storm surge from the typhoon, there will be no island left. Everyone must be evacuated and there will be no place to return to when it is over.

The entire process to evacuate the Nauruan people would of course take much longer than an hour, but that’s all you have on television! No nation in the world is willing to accept these climate refugees. There are a lot of hoops to go through and people to convince to sign BRIAN SMITH off on declaring another location as a sovereign nation. The new home for the Nauruans will be an island in Fiji owned by a semi-washed up celebrity who is about to go to prison. Basically, Madame Secretary plea deals him out of his island and it becomes the new nation of Nauru. The population is evacuated right before the typhoon strikes, and the original island of Nauru is completely annihilated by the typhoon. There is nothing left but the waves.

Although this particular story is fictional, climate refugees are real. In 2018, extreme weather events such as severe drought in Afghanistan, Tropical Cyclone Gita on nations in the South Pacific, and flooding in the Philippines resulted in acute humanitarian needs. According to the Internal Displacement Monitoring Centre website, there were 18.8 million new disaster-related internal displacements recorded in 2017. Since 2008, the average number of people displaced by climate and natural disasters averages 25.3 million annually.1 The World Bank projects that within three of the most vulnerable regions — sub-Saharan Africa, South Asia and Latin America — 143 million people could be displaced by 2050.2 The United States is not immune to climate

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refugees. According to the global relief and humanitarian organization Mercy Corps, an estimated 130,000 Puerto Ricans were displaced by Hurricane Maria and have not returned.3 In addition, the coastal cities of Newtok in Alaska and Isle de Jean Charles in Louisiana have been disappearing in the rising seas for the last 20 years, and residents have been forced to leave their homes.

There will be up to 13 million climate refugees in the United States by the end of this century according to a study published in the Proceedings of the National Academy of Sciences. Even if humanity were to stop all carbon emissions today, at least 414 towns, villages, and cities across the United States would face relocation. If the West Antarctic Ice Sheet collapses, researchers predict that the number will exceed 1,000 across the country.4 While politicians continue to debate whether climate change is real and whether it is being caused by humans, the seas keep rising, the deserts keep expanding and more people are being displaced. Even the term climate refugees is controversial. Some policymakers prefer the term climate migration or internally displaced persons be used, while others argue if people are displaced by climate-related events and cannot return home, they should be

There will be up to 13 million climate refugees in the United States by the end of this century.

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called refugees. Some further point to the fact there should be a distinction made between those displaced by a one-time event like a hurricane versus those who must leave their homes because of rising seas and desertification.

CLIMATE REFUGEES

shrink and create even greater barriers to the most vulnerable in our world.

The great irony here is that nations whose pollution and waste that have contributed most to climate change are the same countries that are quickly closing their borders to the people who are most impacted by climate change. This irony is not lost to Pope Francis, who weaves the cry of the poor and of the earth together. “We are not faced with two separate crises, one environmental and the other social, but rather one complex crisis which is both social and environmental.

Strategies for a solution demand an integrated approach to combating poverty, restoring dignity to the underprivileged and at the same time protecting nature.”8 When Pope Francis wrote Laudato Sí in 2013, he recognized that there would be resistance to his message even among believers. He predicted some will deny there is a problem, be indifferent to it or put their trust in technical solutions. What

Currently, there is no international agreement on who qualifies as a climate refugee or migrant. To further complicate the issue, since the 1951 U.N. Refugee Convention, the definition for a refugee is: “someone who has been forced to flee his or her country because of persecution, war or violence. A refugee has a well-founded fear of persecution for reasons of race, religion, nationality, political opinion or membership in a particular social group.”5 Climate refugees have no legal status. “These people fall between the cracks,” according to Erol Yayboke and Aaron N. Milner, lead authors of a report for the Center for Strategic and International Studies. “It’s hard for countries to come to a consensus on something like this.”6 The great irony here is that nations So why doesn’t the international community expand the definition of whose pollution and waste that have refugees to include those displaced contributed most to climate change by climate or natural disasters? Dina Ionesco, the head of the Migration, are the same countries that are Environment and Climate Change Division at the U.N. Migration Agency, quickly closing their borders to the thinks that might have an unintended people who are most impacted by effect. “Creating a special refugee status for climate change related reasons climate change. could lead to the exclusion of categories of people who are in need of protection, especially the poorest migrants who he asked for was a conversion of heart — a univermove because of a mix of factors and would not be sal solidarity.9 But if there is to be true solidarity, able to prove the link between climate and envi- we will need to put the human family before our ronmental factors.”7 She further states that to re- self.

“The principle of subordination of private open the 1951 Refugee Convention definition because of persecution and ongoing conflicts could property to the universal destination of goods, and thus the right of everyone to their use, is a actually weaken refugees’ status.

In other words, given the rise of nationalism golden rule of social conduct and the first prinacross the world and the subsequent closing of ciple of the whole ethical and social order. The borders to refugees and migrants fleeing war and Christian tradition has never recognized the right poverty, there is little hope that expanding the to private property as absolute or inviolable and definition of refugees to include those impacted has stressed the social purpose of all forms of by climate change will do anything to help their private property.”10 This passage from Laudato cause. In fact, the definition of a refugee might Sí has resulted in Pope Francis being labeled a

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“socialist” by many conservative Catholics and politicians. Conversion of heart can be a slow process and sometimes requires the forceful voice of a prophet.

Another prophetic voice on the issue of climate change is a 16-year-old Swedish girl, Greta Thunberg. She sailed across the Atlantic Ocean to New York City for the United Nations climate talks on a boat with solar panels and energyproducing turbines producing zero carbon emissions. Thunberg also has launched a series of school strikes and climate demonstrations across Europe and the world as her generation, who will inherit the climate mess adults have created, demand immediate changes to protect their future.

In a 2018 speech, she accused world leaders of stealing their children’s future: “Until you start focusing on what needs to be done rather than what is politically possible, there is no hope. We cannot solve a crisis without treating it as a crisis.”11 Pope Francis and Thunberg are among those pleading with the world to face the crisis of climate change and climate refugees. We do not need more arguments over whether climate change is real. Nor does it benefit anyone to debate whether those being displaced from their homes by rising waters and growing deserts are refugees or migrants. Nor should we expect a new definition of refugees by the United Nation to include those displaced by climate change will suddenly open the borders of first world countries.

What will help is to admit that we are in a crisis and that it must be addressed now. It is not someone else’s crisis — it is the whole planet’s.

What will help move this to action lies at the heart of true conversion — to acknowledge our faults and repent. We must own how we and our country have contributed to climate change, that it has impacted our planet and it has also hurt the poor and vulnerable populations of the world.

True conversion also requires that we make amends and where necessary, restitution. This means we must help our brothers and sisters who have been harmed by our acts of pollution, waste and indifference. Helping our brothers and sisters does not equate to closing our borders and making it more difficult for migrants and refugees to enter our country. It means demanding our politicians find a just and equitable solution to the crisis. It means those countries that have led in pol-

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luting our planet should take the lead in reversing this trend and in assisting the victims of climate change.

While some might argue there is a “national emergency” on our southern border, more people are beginning to say there is an existential emergency that transcends our borders. That is what makes it the existential threat of our time.

BRIAN SMITH, MS, MA, MDiv, is vice president of sponsorship and mission services, the Catholic Health Association, St. Louis.

NOTES 1. Disasters and Climate Change, “Internal Displacement Monitoring Centre,” www.internal-displacement.org/ disasters-and-climate-change.

2. “Ground Swell: Preparing for Internal Climate Migration,” The World Bank, March 19, 2018, https://openknowledge.worldbank.org/handle/10986/29461.

3. “Quick Facts: Maria’s Effect on Puerto Rico,” Aug. 28.

2019, www.mercycorps.org/articles/united-states/ hurricane-maria-puerto-rico.

4. Benjamin H. Strauss, Scott Kulp and Anders Levermann, “Carbon Choices Determine U.S. Cities Committed to Futures Below Sea Level,” Proceedings of the National Academy of Sciences 112, no. 44 (Nov. 3, 2015): 13508-13.

5. “What Is a Refugee?,” USA for UNHCR, The U.N. Refugee Agency, www.unrefugees.org/refugee-facts/ what-is-a-refugee/.

6. Erol K. Yayboke, Aaron N. Milner, “Confronting the Global Forced Migration Crisis,” Center for Strategic and International Studies, (May 29, 2018).

7. Dina Ionesco, “Let’s Talk About Climate Migrants, Not Climate Refugees,” United Nations Sustainable Development Goals, www.un.org/sustainable development/blog/2019/06/ lets-talk-about-climate-migrants-not-climate-refugees/.

8. Francis, Laudato Sí, no. 139 (Washington, DC: United States Conference of Catholic Bishops, 2015).

9. Francis, Laudato Sí, no. 14 10. Francis, Laudato Sí, no. 93 11. Daniel P. Horan “Climate Change Is the Most Important Life Issue Today,” National Catholic Reporter, Sept. 4, 2019, www.ncronline.org/ news/environment/faith-seeking-understanding/ climate-change-most-important-life-issue-today.

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ETHICS

LISTENING WELL FOR SYMPHONIC TRUTH ALEC ARNOLD, MA, ThM

O

ne of my favorite singer/songwriters is Tom Waits, whose gravelly voice once was described as sounding like it had been “soaked in a vat of bourbon, left hanging in the smokehouse for a few months, and then taken outside and run over with a car.” Needless to say, it’s Waits’ skill as a songwriter that has gained him the most recognition. If people do know his tunes, it’s probably because a more radio-friendly crooner has put some polish on his songs.

personal presence of healing and comWaits says every good song needs at least three passion. Yet this is never an abstract, things to be “anatomically correct”: “You need shapeless program of action, for even in weather, you need the name of the town, [and] our service to others in his name he insists something to eat.” Clearly, he sees value in providwe attend oh-so-closely to persons as such, ing an audience with specific details. Withto each and every irreducible “other,” with out some concrete details to give a story their own respective contexts, their own shape—that is, without context—we find transformations, epiphanies, disappointourselves unable to relate to the characters ments and victories. Indeed, it is instructive portrayed, unable to get on the “inside” to notice that, in Christ’s story about how we of their particular transformations, can serve him in serving “the least of these” epiphanies, disappointments and vic(Matthew 25:31-46), the “righteous” are surtories. It might seem paradoxical, but prised at Christ’s retrospective revelation that we actually need these characters to they cared for him during all those basic activifully occupy their own time and place ties of feeding, housing, clothing and attending to in order for their meaning to register those in need. So much so that three times they tangibly and truly, beyond their given moment. ask, when did we see you?

An aesthetic concern for particularity and the All this may sound straightforward enough, personal has a few points in common with Chrisbut I’d say we still get confused. We are often tian faith and a Catholic approach to health care tempted to take leave of the person and the perministry. In the first place, theologically speaksonal, preferring instead to identify with more ing, the “scandal” of the Incarnation has everything to do with the way in which the Creator himself got on the “inside” of An aesthetic concern for our humanity, taking on our flesh in particularity and the personal has a a particular time and place. And yet, Christians believe, this singular life few points in common with Christian and death have somehow become efficacious for the redemption of all the faith and a Catholic approach to world. health care ministry.

Secondly, in terms of our own practice of ministry, this same Reabstract, transcendent “causes,” even ostensibly deemer invites each one of us, precisely as the good ones. For example, and to retrieve the mucharacters we are, to function as his living body sical intro above, despite being often edified by in the world today, which includes extending his

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contemporary Christian radio, I am often as not alienated by the way so many songs seem deliberately “washed out,” peddling platitudes and generic positivity, as if maximizing popular appeal required leaving the particular behind.

Within the church, too, I get the feeling sometimes that, depending on setting and conversation, there is an expectation to definitively indicate where I land in what can often feel like abstract territory, whether it be on an issue or an ethics question or theological concern. My sense is that one small disclosure will suffice to indicate just what kind of Catholicism I hope to see realized in the world today, at which point the conversation can shift decidedly.

Before concluding this thought, allow me to disclose another of my favorites, this time from the world of theology. In his book, Truth Is Symphonic, Swiss theologian Hans Urs von Balthasar extends the musical metaphor and explains how we should expect and celebrate Christian pluralism, because such pluralism is a proper expression of the church’s unity-in-diversity — as each individual heart resonates with all its particularity and uniqueness, in concert with others equally performing their own, total response to God. It is an idealistic image, to be sure, and none should feel so confident as to yet lay claim to “perfect pitch.” Our individual practice of attunement will take a lifetime. In the process, though, Balthasar says one attitude is especially characteristic of a healthy and vibrant “musician,” namely, a reticence, a willingness to give the other freedom to speak/make song and to respond in kind, to not become so absorbed with the singular part we’re playing that we become stultified and closed in on ourselves. The other here is first and foremost the living God, but it undoubtedly includes each other as well as those we are actively serving, those in whom, again, Christ says he will be found hidden.

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As a diverse church continues to perform Christ’s ministry in a complicated world, it seems only more incumbent that we practice this reticence: to listen well to the whole orchestra, and to resist collapsing persons and the personal into more generic abstractions.

In playing off this metaphor, Balthasar hardly means to suggest that truth is relative and therefore subjective. No, there is a score; there is a Conductor; we are in fact playing one song. The operative question, especially for ministries like ours, is: what does it sound like? How would listeners — for example our patients and their families, the neighbors we serve — describe our collective voice?

As a diverse church continues to perform Christ’s ministry in a complicated world, it seems only more incumbent that we practice this reticence: to listen well to the whole orchestra, and to resist collapsing persons and the personal into more generic abstractions. Otherwise, symphonic truth runs a two-fold risk: of either being washed out into business as usual, or of devolving into an all-too-familiar version of a more polarized cacophony.

ALEC ARNOLD is a doctoral candidate in health care ethics and theology at Saint Louis University.

He is currently the graduate intern in ethics at the Catholic Health Association, St. Louis.

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T H I N K I N G G L O B A L LY

WORK TOGETHER TO IMPROVE DISASTER RESPONSE “There is a saying in Tibetan, ‘Tragedy should be utilized as a source of strength.’

No matter what sort of difficulties, how painful experience is, if we lose our hope, that’s our real disaster.”

— The Dalai Lama

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ardly a week goes by without news of a natural or man-made disaster somewhere in the world.

In fact, as I pen this column, our neighbors in the Bahamas are being besieged by Hurricane Dorian with Floridians and those on the East Coast preparing for her arrival.

The human suffering associated with these events garners the attention of the international community. Through social media and news sources, we first see the struggles of victims to even survive, much less recover, and the commitment of aid BRUCE workers also stirs us to action.

COMPTON For Catholic health ministry, our Shared Statement of Identity for the Catholic Health Ministry sums up how it is that we respond to such need, how we see these disasters and are moved with compassion. We answer God’s call to foster healing, act with compassion, and promote wellness for all persons and communities, with special attention to our neighbors who are poor, underserved and most vulnerable. By our service, we strive to transform hurt into hope.

That’s a big statement—especially saying we strive to transform hurt into hope—and an evergreater call to action in times of disaster. But as we all know, our first aim is to do no harm. And in our action, is there, too, a call to recognize the true need and desires of victims over our own preferred ways to help?

CHA typically receives requests as disasters occur: member organizations inquire about the possibility of a coordinated response; individuals hoping to assist the health facilities and communities impacted; and we hear from organizations or persons affected who seek aid. Although CHA is not a disaster response organization, in the past we have responded by sharing timely information,

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providing links to trusted resources and making introductions to appropriate relief agencies. We also share precautions that should be taken into consideration at these critically important times.

But what might we need to do to serve our members in future disasters? CHA held a meeting at the CHRISTUS Health headquarters in 2018 to gather our members, partner organizations and disaster experts to share insights and lessons learned from disasters occurring primarily in 2017 and 2018. While it was an opportunity for our members to collectively discuss response challenges, protocols and policies, and even what went wrong or right, it also provided feedback to the Catholic health ministry about the need for more robust disaster response initiatives.

The meeting in Dallas highlighted several opportunities and since that time we have been working to detail potential opportunities. CHA does not intend to be a disaster response team or coordinate direct response activities, but we can serve as a facilitator. Here are some opportunities currently under consideration. I value your insights and hope that you will share any additions or questions by emailing me at bcompton@ chausa.org.

ADVOCACY

Support mission leaders and facility/system leadership advocating for additional attention to and investment in disaster preparedness, as a means to uphold their organizations’ missions.

Create a disaster preparedness and response focus area within CHA.

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GUIDANCE FOR ASSISTING IN DOMESTIC AND INTERNATIONAL DISASTERS:

Share normative and operational guidance for responding to disasters that directly affect our ministries.

Create/share guidance for responding to disasters that are outside of our ministry/community borders.

Create a decision matrix to assist in determining responses.

Identify/develop and share templates for disaster communications.

CONVENING

CHA has an opportunity to convene and facilitate a coordinated networking approach of its members with other federal, regional, state and local authorities, community actors and other members of the Catholic network, such as Catholic Charities USA, Catholic Relief Services and others.

We can host regional disaster meetings and conferences to facilitate networking and determine member coordination needs, starting with highly disaster-prone regions.

BECOME AN ADVISOR IN DISASTER PREPAREDNESS

Identify resources for members that help facilitate investments of time and resources in

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hose who work in Catholic health care are compassionate people often compelled to provide help and hope to victims of disasters around the world. Below are a few reminders from CHA’s online resources that are available to everyone.

Monetary contributions to established relief agencies are almost always the best way to help. Our financial contributions enable relief agencies to purchase exactly what they need when they need it, and they avoid the expense and environmental impact of transporting and storing donated goods. In addition, financial contributions can help revive the local economy by allowing the relief agencies to buy from local merchants.

Every disaster is unique and should be carefully tailored to population needs by relief professionals on the ground. These personnel

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disaster preparedness and infrastructure for disaster management.

Identify appropriate participation in Catholic Charities USA’s disaster preparedness and response training.

This work to further develop resources in disaster response also will identify existing guidelines and best practices, identify opportunities to convene members to share lessons learned and allow for networking. As necessary, we can develop and share tools and resources for member utilization.

CHA is exploring how it can best provide guidance to our members in the area of domestic disasters and also welcomes input on the disaster resources we currently provide on our webpages, webinars and meetings.

Our shared experiences in responding to disasters and discerning proposed response activities in light of ethical implications and their actual outcomes enables us to do what the Dalai Lama says: utilize tragedy as a “source of strength” and truly become agents who turn hurt unto hope for those impacted by disaster.

BRUCE COMPTON is senior director, international outreach, the Catholic Health Assocation, St. Louis.

coordinate with each other, with government entities and with local groups to make accurate assessments of the needs and appropriate response.

Unsolicited, unneeded commodities are never required in early stages of response.

These donations often compete with priority relief items and create unnecessary expenses related to transportation and storage. In addition, the needs evolve daily and therefore an unsolicited donation may not be useful when it arrives.

Many unofficial “relief campaigns and agencies” appear during disasters. Donations made to unregulated or disreputable agencies can be misallocated and/or fail to reach those in need because of the lack of expertise, relationships and cultural competence.

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COMMUNITY BENEFIT

CAREGIVERS CAN REACH OUT TO IMPROVE HEALTH BARRY ROSS, RN, MPH, MBA

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atholic health care employs more than 750,000 people in the United States.1 Each of these people, whether directly or indirectly, touches the lives of those in need of care and makes a difference. Imagine the impact we can have if each of us working in Catholic health care uses our collective talents and voice to improve and better coordinate health care in our communities.

Key comparative indicators show that the schools supporting the policy? Help the schools United States health care system is not performing transition from parties and rewards with sugaras well as health care systems in other developed laden foods and drinks to healthier alternatives. nations. The United States ranks 10th in life expectancy among world naKey comparative indicators show tions, yet spends between 20% to 50% that the United States health care more than most developed nations on health care. Significantly, when total system is not performing as well health and social service expenditures among developed nations are as health care systems in other considered, the U.S. spends the same developed nations. as most nations, but in the U.S. twothirds of expenses go for health care and one-third for social services, whereas in many Participate in or lead healthy fundraisers. Do the schools address the social-emotional needs of developed nations we see the reverse.2 What are some simple actions each of us can students? If not, find out if there are ways to link take to make a difference in our community and, the school with community resources. Offer to together, in our nation? The places where we form a club where students can reach out to peers learn, pray, work and live are where we can make so they know it is OK to talk about the things in their lives that are troubling them. (As part of this a difference. work, make sure peer educators are well-versed on what to do if someone needs immediate help IN OUR SCHOOLS Schools are a great place where we can impact from an adult.) If you have a child, grandchild or the health of our community for a better future. friend at a school, this is a great connection to imFind out if the school district or districts in your prove that health status of children in our nation. communities have a wellness committee. These committees are required by all school districts IN OUR CHURCHES, SYNAGOGUES AND MOSQUES that participate in the free and reduced meal pro- Faith-based organizations are another place grams and usually consist of school food service, where we as caregivers in Catholic health care management, parents and interested community can impact the health of our community. Start members. If the district does not have a wellness with a simple survey of your congregation about committee, become an advocate to start one. If its health needs. You can approach the leader of the district does have one, ask if you can join the a faith community and ask volunteers to conduct committee. Read the district’s wellness commit- face to face surveys, or develop an electronic surtee plan and provide input. Does the policy sup- vey using online tools. Find out if there are other port healthy eating and physical activity? Are the members who are health professionals and share

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the survey information to see how they might help form a wellness committee. Whether it is encouraging healthier snacks after services, incorporating healthy lifestyle education, arranging for screenings or health education classes, or identifying options for advocacy, there are many opportunities for us to improve the health of our congregations.

Advocating for healthier food in the cafeteria and vending machines or organizing fun physical activities are important ways we can impact our workplaces.

IN OUR WORKPLACES

As caregivers in Catholic health care, we can be advocates to improve the health of our community through our workplace. We can start a wellness committee to evaluate the policies and practices in our workplace that impact health. Advocating for healthier food in the cafeteria and vending machines or organizing fun physical activities are important ways we can impact our workplaces.

Serving as an advocate for employee assistance programs and ensuring that there is no stigma in accessing services is another important role we can play. As caregivers in health care we can serve as role models to patients and visitors in how we adopt healthy lifestyle choices. Similarly, our health care workplaces should demonstrate healthy living for the rest of the community, such as being a smoke-free campus or offering fruitinfused water instead of soda in the cafeteria.

IN GOVERNMENT

As health care workers, we are credible professionals who can influence change in the cities where we live. Walking around our neighborhood and seeing if there is easy access to parks, healthy grocery stores and bike/pedestrian paths can provide an opportunity to raise concerns to local council members. We can provide testimony at local government meetings when issues impacting the community’s health are being discussed. Serving on neighborhood boards or municipal commissions or running for council are other ways we can have a profound effect on the health of our community.

For caregivers who have little time to spare, a quick way to impact community health is through legislative advocacy. Critical issues that influence community health are being decided every day

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by city boards, county commissions, state legislatures and in U.S. Congress. Join online discussion groups or sign up for the electronic advocacy option of organizations that are addressing public health issues. Then, with a few clicks on the computer, you can let your representatives know what is important to your community’s health. As guardians of health, we can make our voices heard to ensure that policies promoting community health are passed. If policies are not being proposed that we wish to see in place, we can seek out and communicate with a legislator who might introduce a bill to make this policy a reality.

A CALL TO ACTION

The current health status of our nation is like a patient who is on life support. How powerful it would be if every caregiver in Catholic health care took one action today to improve their community’s health! What action will you take?

BARRY ROSS is the regional director – community health investment for Providence St. Joseph Health in Southern California. He is based out of Orange County.

NOTES 1. Catholic Health Association’s U.S. Catholic Health Care 2019 infographic, using data from the 2017 American Hospital Association Annual Survey, www.chausa. org/docs/default-source/default-document-library/ cha_2019_miniprofile.pdf?sfvrsn=0.

2. Ano Lobb, “Health Care and Social Spending in OECD Nations,” American Journal of Public Health 99, no. 9 (September 2009): 1542-44.

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POLICY

MODELS CHANGING TO BETTER MEET SOCIAL NEEDS INDU SPUGNARDI

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ecades of research have shown that improving the social determinants of health — economic stability, physical environment, education, food and social context — has the greatest potential to improve health for the greatest number of people.1 While recent health policy innovations tend to focus on meeting the health-related social needs of individual patients, it is important for health care organizations to advocate for policies that improve the adverse social conditions of their communities. Policies that address issues such as poverty, early childhood education and violence do not directly impact the operations of the health care delivery system, but they have a significant impact on health outcomes. Only by addressing both individual and community-level social needs can there by a transformational impact on health care costs and quality and community well-being.

POLICIES ADDRESSING SOCIAL NEEDS THROUGH THE HEALTH CARE DELIVERY SYSTEM

Tax Exemption Policy — The Affordable Care

Act requires tax-exempt hospitals to conduct community health needs assessments (CHNAs) and develop implementation strategies based on assessment findings.2 When hospitals analyze the needs identified in their CHNAs they should understand their causal factors. For example, if the community has higher rates of obesity than neighboring communities, the hospital should examine potential causal factors such as the availability and safety of places to exercise, the availability of healthy foods and income levels. While the hospital cannot address these factors on its own, it can join like-minded community partners to work for policy changes.

Federal Health Policy — Addressing the social determinants of health is seen as a key piece in moving the health care delivery system toward value-based care, care with payment models based on meeting certain performance measures.

In a November 2018 speech U.S. Health and Human Services Secretary Alex Azar noted “social determinants are closely integrated into the priority I’ve laid out to move toward a value-based health care system – one that delivers better outcomes at a lower cost.” This recognition has resulted in changes to Medicare and Medicaid that

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incentivize health care organizations to meet the unmet social needs of beneficiaries, including: Medicare Advantage—Starting in 2020, Medicare Advantage plans will be allowed, but not required, to offer chronically ill beneficiaries services that can help meet their health-related social needs. Examples of these services include: home delivered meals, minor home modifications to support mobility and transportation for nonmedical needs.3 Centers for Medicare and Medicaid Innovation (CMMI) — Starting in 2016 the CMMI has been running the “Accountable Health Communities” model demonstration.4 The model tests whether systematically identifying and addressing health-related social needs of Medicare and Medicaid beneficiaries through screening, referral and community navigation services will affect health care costs and reduce health care utilization.

Medicaid — Much of the policy innovation around addressing the health-related social needs of patients is happening in the Medicaid program.

Reforms such as alternative payment models, waivers and health plan care management can enable states to incentivize or require managed care organizations and other health care organizations to develop systems and processes to address social needs as well as open up new funding streams to advance this work.5

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POLICIES ADDRESSING THE ROOT CAUSES OF POOR HEALTH OUTCOMES

While policy to address the health-related social needs of patients is critical to improving health care quality and costs, it is only part of the solution. To achieve sustainable results, the underlying social and economic conditions that impact the health of all people need to be improved. In a recent Health Affairs blog post, Brian Castrucci of the de Beaumont Foundation and John Auerbach of the Trust for America’s Health discuss the importance of recognizing these two related policy goals and distinguishing between efforts to address a patient’s or beneficiary’s social needs and the social determinants of health of a population: “Redefining the meaning of “social determinants” to be mostly or only about the immediate social needs of expensive patients makes it harder to focus on the systemic changes necessary to address root causes of poor health.”6 The good news is that there are national initiatives and organizations that have started to identify and implement evidence-based policies to address the root causes of poor health in communities, including: The Centers for Disease Control and Prevention has developed the Health Impact in 5 Years (or HI-5) initiative that highlights 14 well-known, already proven community-wide interventions that have seen results in five years or less.7 Organizations such as PolicyLink and ChangeLab Solutions offer research, model policies and technical assistance aimed at advancing racial and economic equity.

Cityhealth, an initiative of the de Beaumont Foundation and Kaiser Permanante promotes a set of evidence-based policy solutions to improve community health and regularly assesses the country’s 40 largest cities in terms of their progress on nine specific policies.

The Health Anchor Network brings together more than 40 leading health care systems to share ways their hospitals can use their economic power — hiring, purchasing, investing — to strengthen their local economies. The group also is starting to look at federal policies they can support, such as housing and community investment policy, which will make their local efforts more effective.

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The good news is that there are national initiatives and organizations that have started to identify and implement evidence-based policies to address the root causes of poor health in communities.

CATHOLIC HEALTH CARE’S COMMITMENT TO ADDRESSING THE SOCIAL DETERMINANTS OF HEALTH

Driven by its mission to serve the poor and vulnerable and the need to prepare for value-based care, Catholic health care is embracing this work.

Examples include: Catholic health systems AMITA Health, CHRISTUS Health, Trinity Health and Dignity Health have hospitals participating in the CMMI Accountable Health Communities demonstration.8 Mercy Care, a nonprofit health plan owned

by Dignity Health and Ascension, provides Medicaid and Medicare managed care coverage in Maricopa County, Ariz., and has improved and expanded housing options for its members enrolled in Medicaid.9 (Dignity Health combined with Catholic Health Initiatives in February to create CommonSpirit Health.)

Providence Health and Services in Oregon, part of Providence St. Joseph Health, has set up community resource desks at five facilities where anyone in the community can receive help enrolling in health insurance and obtaining food, employment and housing assistance. This aligns with the state’s recent direction to Medicaid managed care plans to address social determinants of health and health equity.10 Catholic health care’s experience with early policy reforms to address patient social needs positions the ministry to inform and guide future policy development. It will be important to emphasize the need to make it easier for vulner-

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able patients to access these social services and to point out any unintended consequences that might impact policy goals. It is also necessary to advocate for and build the will for broader policy changes that will fundamentally change the way people live in our communities. As health care providers we see firsthand the failure of our society to enact policies and programs that support all people. This work will not be easy, but these words of Pope Francis should inspire and guide our efforts, “Jesus tells us what the ‘protocol’ is, on which we will be judged. It is the one we read in Chapter 25 of Matthew’s Gospel; I was hungry, I was thirsty, I was in prison, I was sick, I was naked and you helped me, clothed me, visited me, took care of me. Whenever we do this to one of our brothers, we do this to Jesus. Caring for our neighbor; for those who are poor, who suffer in body and in soul, for those who are in need.”

INDU SPUGNARDI is director, advocacy and resource development, the Catholic Health Assocation, Washington, D.C. CHA RESOURCES Community Benefit: www.chausa.org/community benefit/community-benefit.

Policy Briefs: www.chausa.org/advocacy/policy-briefs/ social-determinants-of-health and www.chausa.org/ advocacy/policy-briefs/commitment-to-communitybenefit.

NOTES 1. Thomas R. Frieden, “A Framework for Public Health Action: The Health Impact Pyramid,” American Journal of Public Health 100, no. 4 (April 2010): 590-95, https:// www.ncbi.nlm.nih.gov/pmc/articles/PMC2836340/.

2. “Additional Requirements for Charitable Hospitals; Community Health Needs Assessments for Charitable Hospitals; Requirement of a Section 4959 Excise Tax Return and Time for Filing the Return,” 79 FR 78953, Federal Register (December 29, 2014).

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3. Melinda K. Abrams and Shawn M. Bishop, “New Medicare Advantage Benefits Offer Social Services to People with Chronic Illness,” To The Point (blog), The Commonwealth Fund, April 8, 2019, https://doi.org/10.26099/ pm2a-gt42.

4. Centers for Medicare and Medicaid Services, “Accountable Health Communities Model,” https://innovation.cms.gov/initiatives/ahcm.

5. Samantha Artiga and Elizabeth Hinton, “Beyond HealthCare: The Role of Social Determinants in Promoting Health and Health Equity,” The Henry J. Kaiser Family Foundation, May 2018. https://www.kff.org/disparitiespolicy/issue-brief/beyond-health-care-the-role-ofsocial-determinants-in-promoting-health-and-healthequity/.

6. Brian Castrucci and John Auerbach, “Meeting Individual Social Needs Falls Short of Addressing Social Determinants of Health,” Health Affairs Blog, January 16, 2019, doi: 10.1377/hblog20190115.234942.

7. Centers for Disease Control and Prevention, “The HI-5 Interventions,” Office of the Associate Director for Policy and Strategy webpage, https://www.cdc.gov/policy/ hst/hi5/interventions/index.html.

8. Centers for Medicare and Medicaid Services, “Accountable Health Communities,” Data.CMS.gov, https://data.cms.gov/SpecialPrograms-Initiatives-Speed-Adoption-of-Bes/ Accountable-Health-Communities-Filtered-View/ xjfx-cdeh.

9. Ken Leiser, “Arizona Medicaid Insurers Combat Homelessness,” Catholic Health World, March 15, 2019, www.chausa.org/publications/catholichealth-world/archives/issues/march-15-2019/ arizona-medicaid-insurers-combat-homelessness.

10. David Tuller, “To Improve Outcomes, Health Systems Invest in Affordable Housing,” Health Affairs 38, no. 7 (July 2019), https://www.healthaffairs. org/doi/full/10.1377/hlthaff.2019.00676?utm_ source=Newsletter&utm_medium=email&utm_ content=All-Payer+Claims+Databases%3B+ Health+Systems+Invest+In+Affordable+Housing &utm_campaign=HAT+7-12-19.

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EXECUTIVE SUMMARIES Wipe Every Tear from Their Eyes

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NATHANIEL BLANTON HIBNER — Disasters, whether from natural or human causes, seem incomprehensible to our rational minds. When we mix the circumstances with a God that has the power to prevent them and chooses not to, our faith stumbles.

Yet, if instead of a God existing outside the violence and destruction, we understand that our God is one who witnesses our difficulties and even suffers with us, perhaps we can begin to see the irrationality of an event for what it is, a symptom of our fallen and incomplete world. Christians are a people yearning for the coming Kingdom of God.

David Bentley Hart, an American theologian and philosopher, concludes his book, The Doors of the Sea, with a passage that responds to our collective yearning for answers to our questions about suffering. Hart recognizes that through Christ’s death on the cross, God created a connection to human suffering: “… rather than showing us how the tears of a small girl suffering in the dark were necessary for the building of the Kingdom, he will instead raise her up and wipe away all tears from her eyes — and there shall be no more death, nor sorrow, nor crying, nor any more pain, for the former things will have passed away, and he that sits upon the throne will say, “Behold, I make all things new.”

Guns, Germs and Health Care: Lessons Observed and Learned

He has served as a paramedic, an emergency physician, a soldier deployed in conflict, a government executive at the U.S. Department of Homeland Security, a public health faculty member, and now as an executive in a large Catholic health care ministry. In these roles, the environments were different, but the underlying principles the same. Guns, violence and germs are formidable threats to be understood and countered.

Understanding environment, risk and response are important for any population, government or health care system in order to deal with these different yet similar threats.

While we have become very good at treating the injured on the battlefield, just as we have become very advanced in treating victims of gun violence, victory in a war zone occurs when an improvised explosive device (IED) is never placed to begin with. The same is true of gun violence: Victory is when we can prevent it in the first place.

ALEXANDER GARZA — Although civilization has progressed on many fronts, particularly in the treatment of trauma and infectious diseases, the negative effects of guns, violence and germs continue to plague our communities. Harm inflicted on individuals from guns or germs can be random, but in both cases there are unequal burdens on populations, and they are heavily influenced by social determinants of health. Health care must continue to plan its responses to both small outbreaks of violence and disease, as well as largescale disasters caused by them. In addition, we must mitigate the issues that place vulnerable and marginalized people at increased risk of suffering from guns and germs in the first place.

The author, Dr. Garza, has seen firsthand the effects of guns, violence and germs throughout his career in medicine.

Flexibility, Staff Generosity Key to Weathering Storm LANCE MENDIOLA — Everyone knows that in times of disaster, preparation is key. But at CHRISTUS Health, we have learned from past storms that these preparations requires a much broader approach than many might realize. We prepare our resources, from food and water to fuel for our generators, to ensure our potentially affected facilities will have enough to weather a storm. We plan as far ahead as possible, spending the last 10 years focused on strengthening our buildings to withstand Category 5 storms.

But we also know we’ll have to decide quickly if we will cease non-essential medical procedures or move patients. We learned during Hurricane Rita in 2005 that when the federal government makes an emergency declaration, all patient transportation options are then directed by the government.

We now plan the potential need to move patients as soon as a storm appears imminent.

Preparations for Hurricane Harvey in 2017 began when the

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storm was still out in the Gulf of Mexico and forecast to make landfall near six CHRISTUS Spohn facilities in Corpus Christi, Alice, Beeville and Kingsville, Texas. CHRISTUS activated its emergency operations and opened command centers in each of these hospitals and in our system office in Irving.

Local facility management, security, operations, supply chain and clinical teams committed to working around the clock. They secured our campuses, inventoried supplies, transported patients and leveraged resources, including additional staff, to serve those expected to be in harm’s way. They closed clinics and urgent care centers, canceled non-urgent surgical procedures, and transferred patients who would be the most difficult to care for if the storm persisted.

When the hurricane hit farther north than originally forecast, the health care system supplied water in areas without it, and many facilities were able to remain open even when flooding affected roads. Employees struggled with damage to their own homes, and staff from other areas stepped up to help.

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Spiritual Care When Disasters Strike

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DAVID LEWELLEN — Chaplains who ministered to those affected by the Pulse nightclub shooting in Florida in 2016 and to California wildfires and a hurricane in Texas in 2017 recount the ways they provided spiritual care in a time of crisis.

People who are injured, uprooted or suffer losses during a hurricane, a fire, a plane crash, or any other catastrophe will have spiritual needs as well as material concerns. Along with every other health care department, spiritual care staff both plan in advance and then improvise in the moment, using therapeutic skills to minister to those in need of support.

Those who work in spiritual care often attend to those still trying to get information about the health status or location of a loved one in the midst of an emergency. In a prolonged crisis,

plans may call for them to be on site, sometimes for a few days at a time, with nearby sleeping accommodations. Chaplains and others who work in spiritual care may be asked to provide many more prayers than usual, or to respond to larger numbers of people than they routinely would. Taking some time to check in with staff as they perform this work is an important step.

This article also details that when the Red Cross mobilizes for major disasters, its response includes spiritual care. As of 2015, the organization recognizes spiritual care as an integral part of its disaster response, on par with relief supplies and mental health. This recognition is the culmination of decades of working with certified chaplains’ groups to assist people in the aftermath of disasters.

Disaster Landscapes in Health Care: Learning Experiences from Florida to Peru KAREN REICH and CAMILLE GRIPPON — During 2017, Bon Secours Health System had to face disasters that hit at the heart of its ministry. One disaster, Hurricane Irma, caused the evacuation of two facilities in St. Petersburg, Fla.: Bon Secours Maria Manor and Bon Secours Place. The response posed significant challenges to patients and staff. The other disaster was more than 2,600 miles away from Florida. The floods in Peru that year directly impacted over one million people in a South American country where the Sisters of Bon Secours live, minister and provide health care to vulnerable communities. These very different disasters provided valuable organizational lessons about resilience and action. Health care’s complex systems for providing care can be fragile in

times of disasters, and we must continue to thoughtfully develop disaster preparedness plans to secure ongoing operations while at the same time increasing mitigation practices to prevent greater warming of our common home.

Curtailing the human impact on the Earth’s climate requires moral choices and bold action from every sector of society, including the health care sector. The challenge before society is not only to be resolute in the conviction that climate change is real but also to ensure that appropriate personal, organizational and societal action takes place in an accelerated manner. As a global family, we can no longer ignore the need for updated environmental regulation of industry and the need to end water and air pollution and improve energy practices. The victims hit hardest are already among the most vulnerable in the world.

Creating a Culture of Emergency Preparedness JEFF MOSELY — On the morning of July 10, 2019, the command center opened at Our Lady of the Lake Regional Medical Center in Baton Rouge, La. This article describes preparations as Tropical Storm Barry strengthened into a hurricane, and the author details many of the ways the system prepared for emergencies. At Our Lady of the Lake this is referred to as a “culture of preparedness.” The facilities operations department is at the center of this preparedness. Events that could affect safety come in many forms other than weather. They can include mass casualties, an active shooter or loss of critical utilities such as information systems or electronic medical record systems. Preparedness comes from well thought-out policies and intense training and drills.

Among the steps the system takes: A hazard vulnerability

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plan is completed annually to identify and prioritize potential natural, technological and/or human emergency events that could affect demand for or the hospital’s ability to respond to needs for services. The hospital uses an incident command structure that is compliant with FEMA’s National Incident Management System structure.

Training for team members about incident command begins in general orientation and is included in annual education that can include classes, webinars and drills. Hospital leaders—including managers, directors, division directors and senior leaders—are assigned incident command training. Leaders with assigned roles in the command structure also complete two courses, one on the National Incident Management System and another on the National Response Framework.

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Building ‘Muscle Memory’ in Public Information Officers BRIAN REARDON — CHA surveyed a number of public information officers working in Catholic health systems and hospitals to gauge their level of participation and training within their incident command system and/or emergency operations plan.

Of the 31 respondents, less than half indicated they had done FEMA training. Both the independent study courses and the courses conducted in Emmitsburg, Md., are free, with many of the related costs picked up as well.

Those working for systems say that frequent drills help im-

Compassion in Disasters

mensely, because the practice prepares everyone for when an emergency arises.

Several systems have found it helpful to have public information officers attend meetings about an organization’s command center and emergency operations plan. In times of disaster, being able to get the message right and get it out quickly is not enough. Public information officers need to understand not only the “who, what, and where” but also the “how and when.”

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DAVID G. ADDISS — Compassion is never more important — or more difficult — than in disaster situations. The magnitude and intensity of suffering in disasters can lead to empathetic overload and personal distress. In the presence of intense suffering, emotional regulation is essential for compassion. In disaster settings, the tools of compassion vary. In the search for survivors amidst the rubble of an earthquake the most effective tool of compassion — the means through which compassion is enacted — may be a bulldozer.

Whether a specific act is compassionate depends both on the act itself and how it is performed.

The opposite of compassion is cruelty. Pity may masquerade

The Health Care Leader’s Role in Safety

Reducing the Risk of a Cyber Crisis

board and hospital leaders have gotten better about asking questions and thinking about care and quality in new ways.

Significant effort has been put into thinking about each process or system and how to improve each one to include safe supervisory practices for high reliability. The author encourages executive-level boards to call for increased public accountability, transparency and more rigorous external oversight.

Patients, he says, are suffering harm at unacceptable rates, and health care systems need to pick up the pace for improvement.

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JARRETT KOLTHOFF — The boards of directors and executive teams of every health care operation in the United States need to place cybersecurity on par with patient care in terms of importance. Without proper cybersecurity in place, patient care and safety are at serious risk, perhaps even mortal risk.

Once cyber criminals have accessed a health care organization’s networks, operat-

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as compassion, but it is in fact its “near enemy.”

Those responding to disasters need to recover the compassionate impulse and commit to nurturing it at the individual, organization and systems levels. But they also need to awaken to and appreciate the myriad ways in which they already are participating in the work of compassion. The need for this awakening, and for setting ourselves on a pathway toward mature compassion, has never been greater. We live in a world that paradoxically is more globalized and more polarized than ever before. For the foreseeable future, the frequency of disasters will continue to accelerate. Being able to respond to those disasters with compassion, wisdom and skill makes all the difference.

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KIM HOLLON — As the author learned more about high reliability and human error models, he realized that his previous thought that a hospital could be error proof and checklist its way to zero harm was fundamentally flawed. As president and chief executive officer of Massachusetts-based Signature Healthcare, he works to create a culture of safety.

He began interacting differently with the health care system’s board quality committee, encouraging its members to serve as coaches for executives and physician leaders. The

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ing systems and controls, the opportunity for harm escalates on an alarming scale. Medications and dosages can be altered, scans and X-rays manipulated and life support systems compromised.

Boards and executive teams must determine the amount of risk exposure they are willing to accept in relation to cost of protection, prevention and the potential for loss across a number of categories. This article details a number of tips to help prevent a cyber breach.

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U.S. Postal Service

STATEMENT OF OWNERSHIP, MANAGEMENT, AND CIRCULATION (Required by 39 U.S.C. 3685)

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Title of publication: Health Progress Publication number: 0882-1577 Date of filing: October 1, 2019 Issue Frequency: Bi-monthly No. of issues published annually: 6 Annual subscription price: free to members, $75 for nonmembers and foreign subscriptions Location of known office of publication: 4455 Woodson Rd., St. Louis, MO 63134-3797 Location of headquarters of general business offices of the publisher: 4455 Woodson Rd., St. Louis, MO 63134-3797 Names and complete addresses of publisher, editor, and managing editor: Catholic Health Association, Publisher; Mary Ann Steiner, Editor; Betsy Taylor, Managing Editor; 4455 Woodson Rd., St. Louis, MO 63134-3797 Owner: The Catholic Health Association of the United States, 4455 Woodson Rd., St. Louis, MO 63134-3797 Known Bondholders, Mortgagees, and Other Security Holders: None The purpose, function, and nonprofit status of this organization and the exempt status for federal income tax purposes has not changed during the preceding 12 months.

13. Publication name: Health Progress 14. Issue date for circulation data below: November - December 2019 Average No. Copies Each Issue During Preceding 12 Months

15. Extent and nature of circulation: a. Total no. copies (net press run) b. Paid and/or requested circulation (1) Paid/requested outside-county mail subscriptions stated on Form 3541 (2) Paid in-county subscriptions (3) Sales through dealers and carriers, street vendors, counter sales, and other USPS paid distribution (4) Other classes mailed through the USPS c. Total paid and/or requested circulation [sum of 15b (1), (2), (3), and (4)] d. Free distribution by mail (Samples, complimentary, and other free) (1) Outside-county as stated on Form 3541 (2) In-county as stated on Form 3541 (3) Other classes mailed through the USPS (4) Free distribution outside the mail (Carriers or other means) e. Total free distribution (sum of 15d (1), (2), (3), (4) ) f. Total distribution (Sum of 15c and 15e) g. Copies not distributed h. Total (sum of 15f and g) i. Percent paid and/or requested circulation (15c divided by 15f times 100) 16. This statement of ownership will be printed in the November-December 2019 issue of this publication.

Actual No. Copies of Single Issue Published Nearest to Filing Date

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14,454 366 14,820 87.85%

CHA Chief Operations and Finance Officer CHA is seeking a strategic executive aligned with the association’s mission to serve as its chief operations and finance officer. A member of the CHA president’s advisory council, this individual will be accountable for leading key financial and operational functions during a pivotal time for the association, with a recently appointed president and chief executive officer and a new strategic plan under development that will be in effect beginning July 1, 2020.

Based in St. Louis and reporting directly to the president/CEO, the chief operations and finance officer will be responsible for the financial and operational vision, and alignment of operations to advance CHA’s strategic priorities and ensure the financial, technology, production and business intelligence functions remain efficient, effective and service-oriented. Strong financial acumen and demonstrated fiscal stewardship are top priorities as this person will be the key staff liaison in support of the association’s finance committee, co-staff for the organization’s audit and compliance committee, and its corporate treasurer. In addition, this person must have a proven ability to build relationships and collaborate effectively with other leaders. Excellent verbal and written communication skills are imperative as well as the ability to maintain integrity, establish credibility, and earn trust and respect.

Requests for additional information or nominations should be directed to the consultants supporting this search: Donna Padilla, Jim King, and Wendy Brower c/o WittKieffer 7733 Forsyth, Suite 725 St. Louis, MO 63105 Phone: 314-754-6072 Email: wbrower@wittkieffer.com CHA is an equal opportunity employer.

I certify that the statements made by me above are correct and complete.

Mary Ann Steiner, Editor

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P R AY E R

SERVICE

Unless the Lord Builds the House KARLA KEPPEL, MA, MA MISSION PROJECT COORDINATOR, THE CATHOLIC HEALTH ASSOCIATION, ST. LOUIS

OPENING PRAYER AND INTRODUCTION Leader: Gracious and merciful God, still our minds and our hearts, that we might be attentive to your stirrings within us.

Grant that we may listen to your word with humility. (Pause) A reading from the first Letter of St. Paul to the Corinthians: Therefore, neither the one who plants nor the one who waters is anything, but only God, who causes the growth.

The one who plants and the one who waters are equal, and each will receive wages in proportion to his labor. For we are God’s co-workers; you are God’s field, God’s building.

According to the grace of God given to me, like a wise master builder I laid a foundation, and another is building upon it.

But each one must be careful how he builds upon it, for no one can lay a foundation other than the one that is there, namely, Jesus Christ. (1 Corinthians 3: 7-11) The Word of the Lord.

All: Thanks be to God. INTERCESSION Reader: Inspired by the rich heritage of our community and challenged by our call to collaborate with God continually toward the building of the Kingdom, please respond: Unless the Lord builds the house, those who build it labor in vain.

All: Unless the Lord builds the house, those who build it labor in vain. (Psalm 127:1) Reader: As we strive to reverence the dignity of the whole person and nurture the giftedness, self-worth and potential of each member of our community, let us remember: All: Unless the Lord builds the house, those who build it labor in vain.

Reader: As we strive to embody active faith journeys rooted in prayer and connection with the Divine and invite others to similar rootedness, let us remember:

Reader: As we live out your call to model servant leadership dedicated to the spirit of the Gospel and following in the example of Jesus, let us remember: All: Unless the Lord builds the house, those who build it labor in vain.

Reader: As we live out our commitment to the poor, marginalized and vulnerable, let us always see your face in them such that we remember: All: Unless the Lord builds the house, those who build it labor in vain.

Reader: As we recognize with humility your grace and generosity, grant that we might offer similar grace and generosity to those with whom we work. In so doing, guide us closer to you, and let us remember: All: Unless the Lord builds the house, those who build it labor in vain.

Reader: As we pause now for a moment to give to God our own needs, one another’s needs, the needs of our families, communities and world, we entrust these personal prayer intentions to God using the words that Jesus gave us: (Pause) Our Father …

CLOSING PRAYER Leader: Sustainer God, you have called us as witnesses to the teaching of the Gospel through the healing ministry of Jesus. Grant that we may never cease to appreciate the marvelous deeds you continue to accomplish in our lives and through our works. May the Good News always be made visible in our labors, and may we be ever present to your stirrings in our hearts. We make this prayer through Jesus, your Son. All: Amen.

All: Unless the Lord builds the house, those who build it labor in vain.

“Prayer Service,” a regular department in Health Progress, may be copied without prior permission.

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FAITHFULLY UNITED AGAINST HUMAN TRAFFICKING

We the people of Catholic health care can: • Raise awareness about human trafficking • Care for those who are victims • Advocate public policies that bring solutions Learn more about human trafficking and available resources for Catholic health care at www.chausa.org/humantrafficking

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