Moving Forward from COVID-19: Organizational Dimensions of Effective Hospital Emergency Management

Abstract

Federal investment in emergency preparedness has increased notably since the 9/11 attacks, yet it is unclear if and how US hospital readiness has changed in the 20 years since then. In particular, understanding effective aspects of hospital emergency management programs is essential to improve healthcare systems' readiness for future disasters. The authors of this article examined the state of US hospital emergency management, focusing on the following question: During the COVID-19 pandemic, what aspects of hospital emergency management, including program components and organizational characteristics, were most effective in supporting and improving emergency preparedness and response? We conducted semistructured interviews of emergency managers and leaders at 12 urban and rural hospitals across the country. Through qualitative analysis of content derived from examination of transcripts from our interviews, we identified 7 dimensions of effective healthcare emergency management: (1) identify capable leaders; (2) assure robust institutional support; (3) design effective, tiered communications systems; (4) embrace the hospital incident command system to delineate roles and responsibilities; (5) actively promote collaboration and team building; (6) appreciate the necessity of training and exercises; and (7) balance structure and flexibility. These dimensions represent the unique and critical intersection of organizational factors and emergency management program characteristics at the core of hospital emergency preparedness and response. Extending these findings, we provide several recommendations for hospitals to better develop and sustain what we call a response culture in supporting effective emergency management.

Introduction

Emergency management (EM) programs in US hospitals were reborn after the 9/11 attacks, as the government invested billions of dollars and issued ever-more specific guidance to public health and healthcare systems to improve their preparedness for large-scale emergencies.¹ However, despite investments and efforts undertaken to date, the US healthcare system's level of emergency preparedness remains unclear. A decade after the 2001 attacks, the Research and Development (RAND) Corporation published a report assessing the country's preparedness, noting that many components of the public health system remained fragmented, particularly the healthcare systems' capacity to absorb a large surge of patients.² Additionally, communities across the country demonstrated wide variability in their capacity to detect, respond to, and recover from a potential crisis, revealing an uneven environment.

Now, 20 years after 9/11, the United States is beginning to emerge from the worst of a well-anticipated pandemic and must once again confront its fragmented and limited capacity to respond to disasters.³ Considering the persistently valid conclusions of the 2011 RAND report, it is unclear whether the United States requires a new set of preparedness critiques, or novel solutions to better address obvious problems. Improving its healthcare systems' preparedness is essential to rebuilding public confidence in the country's ability to save lives during a crisis. However, hospital leaders' assessments of their own institution's level of preparedness are often unrealistic and overestimate clinical, operational, and financial readiness.^4,5 A systematic study of leaders' perceptions of preparedness in the face of a crisis is needed to develop a more accurate assessment of the country's hospitals.

Misperceptions about emergency preparedness likely persist in part because of a lack of clarity, validity, and reliability of measures^6,7 and an inability to assess overall preparedness because plans and capabilities are not put to a true test.⁸ To help hospitals move past these challenges and identify new solutions, we posed the following research question: During the COVID-19 pandemic, what aspects of hospital EM, including components of EM programs and organizational characteristics, were most effective in supporting and improving emergency preparedness and response? In this article, we describe the main aspects of effective EM in 12 urban and rural US hospitals in order to identify key organizational and operational contributors to hospitals' facilitating response during the COVID-19 pandemic.

Methods

We conducted interviews with 26 key informants at 12 urban and rural hospitals throughout the country.

Study Hospitals

Before recruiting interviewees, we used maximum variation purposive sampling to select a heterogenous group of urban and rural hospitals with established EM programs demonstrating differences in emergency preparedness approaches, resource availability, performance levels, and other characteristics.⁹ We began by compiling a list of approximately 40 hospitals throughout the country that had established EM programs and a notable response during the pandemic. The hospitals were identified based on conversations with our expert panel members, media coverage, and discussions with state-specific hospital association contacts. We further narrowed the sample to 12 hospitals that reflected geographic diversity and variability across other domains including size, ownership, health risk (eg, increased risk due to the prevalence of certain chronic conditions, based on US Centers for Disease Control and Prevention county designations), performance measures (eg, financial, quality), patient mix (eg, proportion of Medicaid patients), and other characteristics (for these details, see Supplemental Table 1, www.liebertpub.com/doi/suppl/10.1089/hs.2021.0115).

After selecting our hospital sample, we invited emergency managers and leaders at each hospital to participate in interviews. Before their scheduled interviews, we invited all interviewees to complete a survey to quantify certain aspects of their hospital's EM program before and during the pandemic. The survey included questions building on previous research that examined emergency preparedness capabilities to assess the degree to which these capabilities were used at each study hospital.⁷ Thus, we used the survey responses to get a sense of how each hospital varied in different aspects of their EM program (eg, activities, capabilities) so that we could ensure differentiation in our study sample.

Table 1 presents a summary of organizational characteristics of study hospitals including several aspects of their EM programs. Table 2 shows the characteristics of interviewees including their roles, number of years in their current roles, and responsibilities related to EM. These tables depict variation across study hospitals and interviewees, which was important when considering the smaller sample size.

Table 1.

Characteristics of Study Hospitals and Their Emergency Management Programs

Hospital	Urban/ Rural	Full-Time Staff Dedicated to Program	Where Program Fits in Organizational Structure	Program Includes Full-Time Emergency Manager (or Equivalent)	Program Includes Emergency Management Medical Director (or Equivalent)	Program Includes Emergency Operations Center	Before Pandemic, Perception of Adequate Funding for Program to Meet Its Goals	Before Pandemic, Level of Confidence in Hospital's Emergency Readiness Related to Hospital's Plans, Training, and Capabilities
1	Urban	15	Under Operations Division in Protective Services, reporting to chief security officer	Yes	No	Yes	Yes	High confidence
2	Urban	Unsure	Emergency manager reports to the patient care director of emergency services	Yes	Yes	No	Unsure	Mostly confident
3	Urban	2	Under Center for Disaster Medicine in the Department of Emergency Medicine	Yes	Yes	Yes	No	High confidence
4	Urban	7	Under Risk Management in Emergency Management/Business Continuity	Yes	Yes	Yes	Yes	High confidence
5	Urban	3	Under the Environmental Health and Safety Department, emergency management has its own division, reporting to the chief operations officer	Yes	Yes	Yes	Yes	Mostly confident
6	Urban	9	Part of administrative hierarchy	Yes	Yes	Yes	No	Mostly confident
7	Rural	1	The program has a system emergency management director and emergency management coordinator assigned to each hospital in system	Yes	No	No	No	Some areas of concern
8	Rural	1	Reports to the chief executive officer, a level below the C-suite	Yes	Yes	Yes	Yes	Mostly confident
9	Rural	1	Under Facilities Management Department reporting to the senior vice president of operations	Yes	No	No	Yes	High confidence
10	Rural	1	Under Operations Division, with the emergency management coordinator reporting to the manager of protective services, within the Patient Support Services Department	Yes	No	Yes	Yes	Some areas of concern
11	Rural	0	Under the Quality and Safety program	Yes	No	No	Yes	Mostly confident
12	Rural	1	Part of administrative hierarchy, with a designated workgroup reporting to the chief operating officer	Yes	No	No	No	Some areas of concern

Table 2.

Characteristics of Interviewees from Participating Study Hospitals

Hospital	Interviewee	Role	Approx. Length in Role (Years)	Responsibilities Related to Emergency Managementa
1	1	Emergency manager	11	Supervises emergency managers across all health system hospitals as the senior manager of EM
	2	Hospital/operations leader	9	Executive responsible for investigations, protection, duty of care, due diligence needed to enforce hospital security
2	1	Emergency manager	2	Oversees the hospital preparedness program
3	1	Emergency manager	3	Senior administrator responsible for the function of the EM program
	2	Hospital/operations leader	41	Executive responsible for EM program; senior administrator reports to them; can take on role of incident commander
4	1	Hospital/operations leader	12	Provides high-level leadership and physician input to the EM program as the hospital's medical director
	2	Hospital/operations leader	11	Executive who ensures resources are provided to the EM program
5	1	Emergency manager	2	Runs hospital drills and exercises related to emergency preparedness
	2	Hospital/operations leader	4	Director responsible for all inpatient operation, including patient safety and patient placement; member of hospital on EM program team
	3	Hospital/operations leader	6	Director of EM for hospital system; ensures there is a uniform EM program across the system
6	1	Hospital/operations leader	6	Oversees an infectious disease program within the department of emergency management; helps the system respond to any infectious disease event
	2	Hospital/operations leader	20	Chief medical officer who helps with the EM planning process
7	1	Hospital/operations leader	6	Executive who lends their support to build the system's EM program; can take on role of incident commander
	2	Emergency manager	1	Runs all drills and training related to EM
	3	Hospital/operations leader	4	Executive who works with hospital leadership to ensure resources are available for hospital resiliency planning; can take on role of incident commander
8	1	Hospital/operations leader	29	Director responsible for emergency preparedness and response; develops and updates the emergency operations plan, runs drills and exercises, serves as liaison with local EM coalitions
	2	Hospital/operations leader	2	Executive who assists with pandemic preparedness planning
9	1	Hospital/operations leader	2	Executive who ensures that the hospital has an accredited EM program; can take on role of incident commander
	2	Hospital/operations leader	8	Executive with direct oversight of the EM program; can take on role of incident commander
10	1	Hospital/operations leader	<1	Manager of hospital protective services, which includes security and emergency preparedness
	2	Hospital/operations leader	<1	Director of patient support services; oversees manager of hospital protective services
	3	Hospital/operations leader	<1	Executive who oversees the EM program and provides senior-level support and helps to rewrite emergency operations plans; can take on role of incident commander
11	1	Hospital/operations leader	4	Executive who took role of incident commander during disaster
	2	Hospital/operations leader	<1	Director who oversees quality and ensures that the EM program meets all regulatory requirements
12	1	Emergency manager	2	Primary emergency director and half-time emergency manager responsible for running EM program
	2	Hospital/operations leader	5	Executive who oversees EM manager and program; can take on role of incident commander

^a Responsibilities related to EM may not be comprehensive

Abbreviation: EM, emergency management.

Data Collection

We collected data through interviews with emergency managers and hospital operational leaders who were intimately involved in their organization's COVID-19 pandemic response. We first developed an interview guide, which was reviewed for clarity and relevance by a panel of 3 EM experts. The interview guide contained 17 questions, each with follow-up questions to help us delve deeper into the topic discussed (interview guide available in Supplemental Material, www.liebertpub.com/doi/suppl/10.1089/hs.2021.0115). Four members of the research team conducted in-depth, semistructured interviews with 2 to 3 individuals at each site who had intimate knowledge of EM at their hospital and the overall COVID-19 emergency response. Interviewees included emergency managers and/or executive-level leaders in each hospital, including clinical and nonclinical personnel. After conducting initial interviews, we sought additional interviewees at the study hospitals to provide further information through a process of snowball sampling.¹⁰ Interviews primarily emphasized the structure of EM programs in the respective hospital, related organizational characteristics, and elements of the hospital's response during the pandemic. We conducted interviews via videoconference through Zoom from February through April 2021. Interviews lasted 90 to 120 minutes and were transcribed from audio recordings.

Analysis

We first analyzed survey responses to assess and compare overall perceptions of aspects of emergency preparedness before and during the pandemic. To guide our analysis, we focused on the broad question: What have we learned about hospital emergency preparedness and response during the pandemic? We then examined transcripts of the audio-recorded interviews using qualitative methods and identified common themes, based on inductive and deductive methods, to code the interview data.¹¹ We began with initial coding to categorize the data and assign meaning to actions and perceptions communicated by interviewees. After the initial analysis, we deepened our central research question: How do organizational characteristics and EM program features intersect to support an effective emergency response for hospitals across urban and rural settings? We then developed a codebook, using focused coding and further grouping codes into larger overarching themes.¹² Applying the codebook to the interview transcripts, we observed patterns in the codes and identified those that best represented common responses across interviewees, while simultaneously reviewing prior literature to build on existing EM concepts (for our coding structure, see Supplemental Table 2, www.liebertpub.com/doi/suppl/10.1089/hs.2021.0115). We conducted qualitative analysis using NVivo software version 1.4.1 (QSR International, Melbourne, Australia).

This study was approved as exempt by the Harvard T.H. Chan School of Public Health, Massachusetts General Brigham, and Stanford University institutional review boards.

Results

Figure 1 summarizes survey responses and highlights how often the study hospitals implemented various aspects of EM (eg, training, exercises) before the pandemic. The findings demonstrate notable variation in the structure of EM programs across the study hospitals. Figure 2 shows the percentage of study hospitals requesting external support and the degree to which the support they received met their needs.

Figure 1.

Survey responses capturing the implementation of emergency management program elements at the study hospitals before the pandemic.

Figure 2.

Survey responses capturing hospitals' request for external support and the degree to which that support met the hospital's needs.

Analysis of the interview transcripts revealed that responses from across the study hospitals were clustered around 7 dimensions of effective EM (Figure 3): (1) identify capable leaders; (2) assure robust institutional support; (3) design effective, tiered communications systems; (4) embrace the hospital incident command system to delineate roles and responsibilities; (5) actively promote collaboration and team building; (6) appreciate the necessity of training and exercises; and (7) balance structure and flexibility. These dimensions include key organizational attributes of culture and structure, as well as operational elements of the hospital's EM program.

Figure 3.

Seven organizational dimensions of effective emergency management.

Seven Dimensions of Effective Hospital Emergency Management

1. Identify Capable Leaders

Organizational leaders and EM personnel who had prior experience with planning and directing emergency response efforts were crucial in a crisis. However, when identifying “battle-tested” staff was not possible due to inexperience with emergencies, budgetary constraints, or other limitations, interviewees emphasized the need to identify the “most talented” leaders in their organization for response efforts, even if it required selecting leaders to fill positions outside of their typical job descriptions. Interviewees noted that prepandemic preparation activities (eg, drills, exercises) helped identify potentially capable leaders, especially if such leaders were not identified based on their prior emergency experience.

The actual implementation of all of it that we had—and still have—in play for dealing with the pandemic, I would say has been the ability to let really talented people play [leadership] roles, and the balance between centralized oversight and decisionmaking with certain levels of autonomy in each one of the sections to get [things done]. (Senior vice president, urban hospital)

The availability of a full-time manager or director dedicated to EM to help lead preparedness and planning efforts was also important. Interviewees noted that individuals in this role had the experience and expertise necessary to keep the institution on track with its planning and testing goals, while frequently adapting the program's goals and efforts in response to new knowledge and experience and changes in the environment.

2. Assure Robust Institutional Support

Financial and operational support from hospital leaders for EM programs was repeatedly highlighted as an essential element of effective hospital emergency preparedness, especially as leaders encouraged participation in trainings and exercises and provided financial support for their implementation.

Disaster exercises aren't cheap. It's an investment of time, energy, and resources. It's time away from the clinic for some of our physicians who participate, it's time away from the pile of emails that are on all of our plates and driving other projects forward. […] it's leadership's investment and then the staff willingness to engage in exercises to become better and more confident in incident management, and to uncover processes that we needed to improve. […] that's another foundational item that really set us up to be more successful than we would have been during the pandemic. (Deputy chief security officer, urban hospital)

In addition to financial support, having institutional and EM program leaders with the foresight, vision, and demonstrated commitment to planning for an emergency was a recurring theme. This included both planning for supply and equipment needs as well as linking planning, training, exercise, and evaluation needs into a cohesive, prospective, multiyear process.

The institution's investment into a multiyear strategy to maintain a strategic reserve of PPE [personal protective equipment] was critical to providing a safe work environment for our staff. Our supply chain folks: top notch. They did a great job acquiring what we needed. We would not have been successful without that, nor would we have been successful in providing a safe environment with PPE without leadership's decisions to make that investment years ago. (Deputy chief security officer, urban hospital)

3. Design Effective, Tiered Communications Systems

Participants from the study hospitals uniformly agreed on key informational challenges during the COVID-19 pandemic, including an inability to access information in a timely way and having to cope with constantly changing information from a variety of sources. Collecting and sharing information became a central activity for the hospitals. Interviewees described the importance of assuring that essential information routinely flowed from regular multidisciplinary meetings that occurred during the response (eg, incident command briefings, assembling task forces) to appropriate staff throughout the organization. The ability to do this was foundational for an effective response during the pandemic. Predictable and transparent briefings to and from both leadership and working group meetings were thought to have served an important role in reducing silos and barriers between groups, in addition to helping incident command staff make critical decisions with the right information.

Just the ability to sit down with the right people in the room, making the right decisions in a systematic way […] responding from the hip when you have to … But making good sound decisions and backing it up and continuing to review to make sure it's the right decision. So that's the biggest strength I saw was how we made our decisions and how we communicated, and how we leaned on each other. (Chief executive officer, rural hospital)

Essential outcomes of these meetings include making sound decisions based on data, prioritizing action, and communicating next steps to the frontlines in a timely way. Some interviewees emphasized the importance of being selective about who could attend certain meetings—such as those designated for the command and general leadership staff. Others noted that it is possible to keep the number of “active participants” in leadership meetings small while also including managers and others as “listeners-only,” thereby improving information flow and inclusivity in decisionmaking and response efforts. Interviewees emphasized the importance of keeping people throughout the organization well-informed of current happenings and preparations for future challenges.

During the pandemic, such communications were never perfect, but leaders found that it was most important to have consistent messaging and reliable flows of information between leaders and staff. Tiered meetings, or meetings layered across operational objectives and organizational levels, and briefings tailored to the appropriate audiences served to assure that all levels of the organization had access to consistent information that reached staff through multiple modes of communication (eg, town halls, daily emails).

I loved our daily leadership email: “Here are the questions that came in today, and here are the answers.” They put this in an email so people, if they are thinking by themselves about the same question, they will see it right there and the answer. In the beginning, we were delivering an essay answer […] then they told them a long answer will not help, just go to the facts and that helped a lot […] our communication evolved during the pandemic but I think the [EM] team evolved. (Director of patient flow, urban hospital)

Information exchange was so important to an effective response that it warranted reassessment of the plans and systems used by the group responsible for communications, especially for healthcare entities and systems that spanned multiple states or had a wide variety of practice types and settings. Because of the breadth, length, and complexity of the pandemic response, interviewees noted that broad communications can be difficult to tailor accurately to reflect the unique needs of ambulatory, inpatient, and specialty care areas within and across different jurisdictional boundaries. Some participants noted that experience with prior disaster events was particularly helpful in effective communications.

[G]etting the information and pulling together a core group was very important early on. […] that was something that the fire [prior disaster] prepared this hospital for. […] Even though I said earlier that it was kind of a pitfall at first, it was really neat to see how many people wanted to help and wanted to be part of a solution. And I think that it was inspiring. (Risk management officer, rural hospital)

Honest and up-to-date communications including status reports on known challenges were generally well-received, particularly those reports that described supply availability and helped staff know what resources were available.

[B]eing ready and being transparent about our readiness, meaning we were very, very careful of saying our supply is okay for the next 30 days, our shipment is coming in 30 days, our N95 again we need to use the same one all day because our supply will not last for another 18 days—communication and transparency was number 1. (Director of patient flow, urban hospital)

4. Embrace the Hospital Incident Command System to Delineate Roles and Responsibilities

Clarity among hospitals leaders around roles and responsibilities was a vital element of a successful response during the COVID-19 pandemic, especially when emergency response systems and structures potentially conflicted with usual hospital management roles. While some interviewees described an early and existing comfort with the use of the hospital incident command system (HICS) to define leaders' responsibilities throughout the pandemic, others described a more gradual evolution of their ability to use HICS effectively. In both cases, however, interviewees agreed that HICS structures provided the best mechanisms for avoiding duplication of efforts and gaps in response.

Our organizational structure and sticking with that [was critical]. We knew who the shots were being called by and who to go for, for information, so that was especially beneficial. […] And knowing that this is my role, this is what the expectation is, was a real benefit. (Director of emergency management, urban hospital)

Reinforcing the authorities of the section chiefs (eg, in operations, planning, logistics, finance/administration) to act within their areas of responsibility helped to streamline decisionmaking and identify appropriate leaders.

[J]ust being able to get the [incident command] group together and people understanding, “Hey, this is what we need to do,” and understanding that structure was important because that really helps get everybody in line in terms of, “Okay, this is who's responsible for this,” and really help with effective communication through the appropriate channel. So instead of everybody going to the incident commander and asking questions, the appropriate section chiefs were able to help steer and guide those discussions and then the [incident command] meetings were to discuss some of those events. (Senior vice president of operations, rural hospital)

More generally, HICS provided a structure for roles and responsibilities that ultimately reinforced teamwork across the study hospitals.

Role designation, I would say, [was essential]. […] everybody knew what they were supposed to do, and what role they played in it. And that was helpful … everybody took a piece of something and perfected it. […] And that's what made everything [work together]: “You go ahead and do that. I'll get that part done and I'll get that sent out.” (Emergency response director, rural hospital)

5. Actively Promote Collaboration and Team Building

Several organizational characteristics fostered teamwork throughout the study hospitals during the COVID-19 pandemic. Interviewees commented on the positive impact that a culture of collaboration and resilience already present in the organization had on their ability to respond to the crisis. This culture often emerged from prior disaster experience in the hospital's history or from leaders across ranks who made efforts to create an atmosphere of collaboration throughout the organization.

One interviewee characterized organizational members as having a mindset of “strong community coming together,” which served many other purposes including the ability to congregate with the right people in the room to make inclusive decisions. Sometimes teamwork came down to having strong team players wanting to rise to the occasion.

And just really the entire community coming together, when we had to stand up a mobile field hospital in like a week. That can't be done just by the [emergency management] or the facilities department. It took so many different departments of people who are working through Thanksgiving, working through the Christmas holiday. (Emergency manager, urban hospital)

6. Appreciate the Necessity of Training and Exercises

On the surface, conducting emergency preparedness training and exercises seems like an obvious essential element of hospital emergency preparedness. However, interviewees repeatedly described that what mattered most was not just the conduct of trainings and exercises, but also staff engagement and robust participation in those activities. Hospitals with strong engagement in training and exercise programs before the pandemic often invested heavily in additional training and testing activities even as the pandemic itself progressed because they valued the effort.

The training and exercise, I'm a huge advocate of that. It doesn't really matter to me so much what the event is, because those are all different, and the responses are going to be different, but training for those, doing hazards assessments every year, making sure you're looking critically … Well, the only way you can do it without actually having an outbreak […] you have to exercise, you have to go through your plan, making sure your plan is realistic, and if it's not, don't be afraid to change it, and push your exercises to the point of failure. If you don't fail in your exercise, you didn't push it far enough because you're going to fail in a real response. (Safety and security officer, rural hospital)

Solely having plans in place was not enough—the exercises and drills created important learning opportunities that would also serve to refine the plans before they needed to be implemented.

So just because we create a surge plan and put it on paper does not mean that when you implement that surge plan, it's going to work right. And so we're still to this day doing tabletop exercises, and we just did one a week or so ago … we just kind of work through a surge and realized a lot of things. So it's still constant learning. (Chief operating officer, rural hospital)

Emergency managers frequently commented on the importance of creating opportunities for staff to think about hypothetical emergency scenarios that would otherwise be overlooked in daily work. Exercises provided opportunities for staff to gain familiarity with different elements of emergency response, including the HICS structure. Additionally, during the pandemic, emergency managers thought it was important to share both previously and newly developed educational resources with hospital staff, such as EM webinars and training classes offered by external organizations, reinforcing the importance of emergency preparedness among hospital staff.

I would say a very well-thought-out plan with this very important tool of the [incident command] structure, coupled with a significant amount of training that's done on an annual basis [are most essential to emergency management]. Those are the fundamentals that we depended upon. (Senior vice president, urban hospital)

7. Balance Structure and Flexibility

Effective emergency response requires both strong structure and adaptability—and effectively balancing them. A centralized, clear, and predictable structure, primarily visible through the use of HICS and preexisting emergency operations plans, was important to develop and sustain necessary routines, meetings, planning activities, and designating roles of staff throughout an emergency. Having a structure also promotes clarity in regard to which leader is responsible for making which decisions and who is the right source for incident information. Using these response structures to adapt plans to meet the evolving needs of the pandemic was also essential.

Our team was inexperienced and hadn't practiced, didn't know what right looked like. A week in after watching people struggle a little bit, I changed the configuration of our [incident command] room and set it up like a command post that I had experienced in the past, implemented the situation briefings, and designed it as a shift change or a battle update, so you could hand off operations to the next group of folks. (Chief operating officer, rural hospital)

Hospitals needed strong feedback mechanisms to monitor the emergent situation and to know when adaptation or realignment was necessary. For example, flexibility in plans and systems was essential to make changes swiftly as regulations and governmental directives changed. Interviewees explained how the incident command structure enabled staff to have regular discussions that would facilitate timely adaptation.

I just attribute that to the quality of people that we have in our organization, but with that structure that's already established through [incident command], it really gave everyone that platform to come together, being able to quickly adapt. Regulations would change on the fly, or waivers were pulled, or new requirements were put in place, and just having the flexibility of everyone to make those changes to make sure we were compliant, was a really big thing. (Emergency manager, urban hospital)

With frequent changes in plans, policies, and procedures necessary for ensuring an effective response, emergency leaders had to think of new and better ways to manage staff expectations and help staff anticipate the recurring need to adapt.

The other strength was our ability to be flexible and innovative and use our intuition to make adjustments quickly and on the fly, and people's willingness to change fast. If they didn't learn how to change and get used to it, if people didn't learn how to figure that out, I don't know, they didn't learn very well, because we were constantly changing. So change management went really well. Managing expectations was a key component of this too. (President and chief executive officer, rural hospital)

Interviewees commented on the importance of encouraging an institution-wide mindset of flexibility and an understanding that emergency plans and even the command structure itself may need to change if something was not working.

[H]aving an effective emergency operations plan [was used] as a guide and for people to understand that, “Yes, this is what we had planned, this is what we thought but things didn't quite unfold the way that we had thought they would.” […] it's not just, “Hey, once a year, we'll check the box and meet this,” but every other month, those are things that we're talking about. We are reviewing our plans and our goals as it relates to [emergency management]. (Senior vice president of operations, rural hospital)

Discussion

Our findings revealed 7 dimensions of effective EM supporting emergency preparedness and response during the COVID-19 pandemic and beyond. These dimensions include both key organizational attributes and operational characteristics of a hospital's EM program, highlighting aspects of an organization's structure and culture in supporting effective emergency preparedness and response. Other studies have described the importance of organizational characteristics in providing the essential structures for a coordinated response. For example, an organizational culture of collaboration, capabilities to adapt operations, and mechanisms for allocating scarce resources can facilitate effective emergency response and planning activities.^13,14 However, specific consideration of key organizational characteristics that pertain to effective EM programs is important for updating emergency plans, training, and education, as these structures can change over time, and can help or hinder preparedness efforts.^13,15 Findings from our research emphasize the crucial interplay between organizational characteristics and components of a hospital's EM program in fostering effective emergency preparedness and response. Of note, despite many important differences between the resources and sizes of hospitals in urban and rural settings, interviewees across all study hospitals described these dimensions as common to their experience during the COVID-19 pandemic.

While an effective response does not depend on rigid requirements, each of the dimensions represent elements of commitment on the part of hospitals to adequately invest in EM and incident management preparedness activities and then avidly support them during a response. Beyond having the resources to support an effective response, however, our recommendations build on prior ones, such as those found in the 2011 RAND report,² emphasizing the value of creating and sustaining what we call a response culture in hospitals, in which the value and importance of emergency preparedness is widely embraced by those within the organization and in the surrounding community. According to the interviewees in our study, the value of developing a response culture reaches beyond the traditional regulatory and textbook recommendations for assessing EM programs in hospitals but appears to be a key factor in determining the overall quality of emergency response. We did not focus on approaches to adequately invest in EM program resources in this study, but our analysis revealed common themes across the study hospitals that attest to other critical elements of EM programs and emergency response. The need to involve and engage nursing staff, supply chain personnel, and physician leaders—among others—in creating a response culture involves important tradeoffs, such as demanding their time and attention apart from their usual duties. However, acknowledging that it is the job of hospital leaders to address emergency preparedness should be a normalized organizational concept that is part of the response culture.

Based on our findings in this study, we recommend several ways in which organizations can create and maintain a response culture:

• Senior leaders and managers need to appreciate that exercises and events are opportunities to both nurture the desired response behaviors and enthusiasm for collaborative response and to identify promising leaders who are effective in emergency situations. Executives who prioritize EM activities and encourage a flexible, adaptive approach during preparedness are much more likely to succeed during a response.

• Hospitals should invest in the appropriate resources for EM and assure direct reporting of EM issues to appropriate executives.

• Hospitals must cultivate relationships with state and local partners to be more cooperative and supportive during their response, as well as share valuable information between public and private entities. Supportive partners will share best practices and resources. They may also drive executive support for commitment to preparedness through peer influence.

• Hospitals must make practical assessments of space and staffing requirements, identifying possible alternatives and assuring that the appropriate training and knowledge is in place to execute these contingencies. Assessments should engage representatives from a broad cross-section of facilities, nursing and physician leadership, and supply chain personnel to develop a graded surge response that is understood by line employees and leaders alike.

• Hospitals may need to consider restructuring leadership in a way that could better clarify roles and responsibilities during times of crisis, particularly during longer-duration emergencies.

• Data and analytics should be harnessed to provide better day-to-day awareness of resources. The ability to leverage that information at the facility, system, and regional levels can contribute to improved response priorities.

• Hospitals can bolster a response culture by integrating HICS and incident management principles into daily processes and routine operations more effectively. Integrating HICS may include using incident management for planning tests of change, special events, and other activities where interdisciplinary engagement shift personnel away from their usual roles.

While having adequate resources to fund and support an EM program is a necessary aspect of creating a response culture, resources alone are not sufficient. Our recommendations highlight other essential factors in creating and sustaining a response culture, including operational (eg, integrating external partnerships), behavioral (eg, motivating staff), and structural (eg, restructuring leadership to better define roles during crisis) elements.

Our study was limited in scope to characteristics of hospital response; thus interagency, governmental, supply chain, and other issues were not addressed by design. While our study focused on what hospitals learned about effective response and preparedness during the COVID-19 pandemic, interviewees also commented on several shortcomings. For example, they mentioned the lack of staff experienced in EM; poor situational awareness related to managing space, supplies, and other assets; limited capabilities to integrate HICS into daily operations and routines; and deficiencies in tools for rapid, appropriate communication. These issues underscore some of the detrimental effects of inadequate leadership on the ability of hospitals to appropriately respond to the demands of the COVID-19 pandemic. Future research could investigate the challenges that arise during a crisis and how the 7 dimensions of effective EM may assist in successfully managing the challenges.

We did not prescribe a particular definition of success or effectiveness when asking interviewees to describe their hospital's level of preparedness. Although allowing interviewees to self-define effectiveness could be viewed as a potential limitation of the study, we viewed this approach as an opportunity to elicit the range of responses describing EM during a highly uncertain pandemic. However, in our analysis of interview responses, most participants seemed to identify similar elements of effectiveness (eg, adjusting capacity to care for patients with or without COVID-19, being able to act on decisions quickly, continuing clinical operations), which was evident in the common themes consistently described across interviewees.

By focusing on hospital leaders and experts versed in EM in their organizations, our study was limited to their perspectives and did not capture views of frontline clinical and nonclinical staff. However, we intentionally limited the interviews to such individuals to achieve the goal of our study, which was to capture the overarching elements that support EM programs. Future research can examine how clinical and nonclinical staff perspectives resonate with the views of our study participants.

In discussions with EM leaders and experts, our findings emphasize the importance of identifying and nurturing leaders and managers who are experienced in EM or who are identified through trainings and exercises to be talented in EM. Our study suggests that although active engagement in emergency education and training was necessary for leaders to develop the skills (eg, operating an incident command system) needed for preparedness in their organizations, other considerations and capabilities are also important. Specifically, interviewees described leadership qualities required for managing an incident, including leaders' seniority or experience (eg, experience and ability to prioritize action) and the temperament to lead effectively under pressure during a crisis (eg, calm in times of stress, ability to resolve conflict). We also underscore that a response culture requires senior leaders and executives to be familiar with and actively use tenets of crisis leadership, understanding the need to pivot from daily management structures and operations to embracing HICS and special disaster systems. Ultimately, we believe that hospital EM programs can and should influence senior leaders' beliefs about preparedness and response and vice versa.

Conclusion

In dealing with future disasters, healthcare leaders must understand the organizational characteristics supporting emergency management programs that are instrumental for an effective response. This study highlights 7 dimensions that represent organizational attributes and operational characteristics of hospital EM programs that emergency managers and leaders described as essential to their response. Although it is critical that hospitals adequately resource EM programs, our findings extend beyond textbook definitions of financial and capital investment to other key organizational attributers such as leadership characteristics, culture, staff attitudes, communication systems, and the capability of balancing structure with flexibility. From these findings, we recommend that hospitals create and sustain a response culture in which the value and importance of emergency preparedness is widely embraced by those within the organization, especially leaders and the surrounding community. We argue that the adoption of a response culture will provide necessary support for organizations preparing for and responding to future disasters.