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3.5 Organization and Operation of the MRC
3.5.1 How Did the MRC Program Office Coordinate Internally with the MRC Units?
| It [the training] was appropriate for the time, but not appropriate for what happened. You leave the session in the evening and you don't have a sense that there is a deployable team that you are a member of... I think the program needs to be designed in such a way that it encourages those kinds of outcomes.
Lacking the staff to provide MRC units one-on-one guidance and oversight, the MRC Program Office overhauled the Web site to include a listserv and a message board so that information could be exchanged more easily between the program office and the units. In addition, the Web site added links to documents and technical assistance materials and a unit profile site that would serve as a repository for basic program demographics on each unit.
The establishment of the regional coordinators described previously was the next step taken to improve internal coordination. However, the number of units varied widely within any one region, from a dozen or so to over 100; thus, the level of individual communication and interaction between the regional coordinators and their units varied to a great extent as well. Initially, regional coordinators had no specific protocol to guide their interactions with the units. However, more recently, the program office has recognized the need for more consistency in technical assistance and oversight activities and is addressing these issues.
While the regional coordinator positions were formally established as part of the MRC management structure, another form of internal coordination evolved more organically. Twenty-three States have appointed a State MRC coordinator to provide a State point-of-contact for the MRC Program and the MRC units. Typically, these individuals are based in the State health department, and their role is to facilitate coordination and information-sharing between the local MRC units, the State, and the MRC Program Office. State MRC coordinators also work with other local, State, and federal agencies and partner organizations to promote the MRC concept and public health in their State. The State coordinator position is funded by the State, not the MRC Program, therefore, the MRC Program Office does not have authority over or responsibility for their activities. Having no direct oversight or authority over the State coordinators could pose management challenges to the program as it continues to grow and mature. To date, however, communication and coordination between the MRC Program Office and the State MRC coordinators is reported to be good and no specific problems were cited with this particular arrangement during the demonstration period.
The first major test of MRC's capacity and execution of internal coordination structure was the Katrina disaster. MRC had to establish a response operation to coordinate the national call-up of volunteers "on the fly" and within the protocols established by the National Incident Management System. The program office kept the units informed on the unfolding events and medical surge needs through the listserv and the regional coordinators. Overall, communications were timely and functional on a round-the-clock basis. In a report assessing MRC operations during Katrina, efforts directed at internal communication were given high marks (MRC, 2006).
3.5.2 What Internal Communication and Management Structures Were Established to Support MRC Unit Functions?
Internal coordination between MRC unit leaders and unit volunteers took two main forms: regular meetings and routine communication outside of meetings. The frequency of regularly scheduled meetings among the case study units ranged form monthly to never. Two MRC units reported monthly meetings during the demonstration period (although one of these units appears to have no regularly scheduled meetings presently); another reported bimonthly meetings. The remainder of the units reported no regularly scheduled meetings. Smaller units tended to report regularly scheduled meetings. Of those with regular meetings, participation was considered good by respondents, although unit leaders were looking for ways to increase attendance. Meeting attendance was optional for all units, with respondents reporting that approximately 30% to 50% of volunteers attended meetings and a core group of volunteers had consistent attendance. Scheduling meetings at a suitable time (one respondent mentioned that a move of meeting time from 6:00 p.m. to 7:00 p.m. was more convenient for volunteers) and lack of interest in meeting topics were cited as barriers to volunteer participation in meetings.
In lieu of regularly scheduled meetings, some units hosted optional trainings on a more irregularly scheduled basis. One MRC unit that covered a particularly large geographic area cited an unwillingness and/or inability of volunteers to travel for hours as a reason for not having meetings, but addressed the issue by moving their trainings around to different locations as a way to increase accessibility for and participation of volunteers. Over half the MRC leaders tried different means to increase participation at meetings and trainings. Besides changing the location and time of trainings, MRCs provided meals at meetings and trainings, added a training component to regular meetings, and invited outside speakers from State and local emergency response and health agencies to increase participation. All of these methods were considered effective by informants.
For routine communication between MRC unit leaders and volunteers outside of meetings, E-mail was the most commonly used tool. A few MRC unit coordinators mentioned that there were volunteers in their units without E-mail access (up to 20% of volunteers). These coordinators used telephone or traditional mail for routine communication with those volunteers. Several MRCs have regular newsletters sent to volunteers by either E-mail or traditional mail. Additionally, several MRC units have Web sites that are used for routine communication. Volunteers did not perceive that there was too much communication from MRC unit leaders; none complained that they received too many E-mails, letters, or telephone calls. One volunteer reported essentially no communication from the MRC unit. In general, traditional mail and E-mail were used for routine communication, while E-mail or phone calls were used for more urgent communication, such as information about emergency deployments or imminent community health opportunities.
3.5.3 What Were the Challenges to Internal Coordination Within the Unit and MRC Program and How Were Those Challenges Addressed?
Few challenges to internal coordination within the unit were reported; no challenges were reported by units regarding communication with the MRC Program Office. Although most respondents did not mention coordination at that level, one regional coordinator was especially pleased with the responsiveness of the Program Office. The biggest challenge to internal coordination was lack of staffing to complete routine tasks. Some tasks fell through the cracks—for one MRC it was writing an official unit plan of action. For others a challenge was keeping track of volunteers over time. Organizing different types of volunteers was also a challenge that has been addressed previously. A minority of MRC units used volunteers as team leaders for people with the same types of skills to help with organization, recruitment, and retention. In general, MRC units seemed to be quite successful and resourceful and did not mention specific challenges.
3.5.4 Were Systems to Track and Update Information on Volunteers Effective at the Local Level?
Systems to keep track of volunteers and their contact and training information were similar for all of the case study units. In addition to an initial application for membership, data on volunteers were kept in an electronic database for all units. Over half of the units used either a Microsoft Excel spreadsheet or Access database to keep information on volunteers. One unit used a software program called disasterhelp.net, which is designed for emergency response. A few units are changing their databases to more sophisticated systems that they have purchased from other groups. The cost of upgrading to a Web-based system was prohibitive for one MRC unit, which wanted to make the change so that the database would be more portable and easy to access by partner agencies. Although the level of sophistication of the systems used for tracking volunteers varied, a common theme was that once a volunteer was in the database, the volunteer stayed there. Unit coordinators updated databases if they were notified by a volunteer that the volunteer was leaving the unit or if routine lines of communication failed (i.e., E-mails or items mailed through the U.S. Postal Service were undeliverable). An MRC unit with a large cadre of student volunteers used student team leaders to keep information on their ever-changing list of volunteers current. One MRC unit sent out membership renewal postcards to volunteers in order to keep contact information current. For the most part, though, there was either no procedure for keeping in touch with volunteers and reassessing their interest on a regular basis or no time to do so. This lack of updated information has not been problematic for the MRC units to date, but it does suggest that the numbers of reported volunteers may be inflated.
3.5.5 How Effective Were MRC Volunteer Screening and Recruitment Efforts?
An important duty of MRC units is to ensure that their medical volunteers have the appropriate credentials. Checking credentials was accomplished through a variety of means—State licensing boards and their Web sites were the most commonly described method. Online credentialing was most successful for physicians, nurses, physician assistants, and pharmacists. For other health professionals such as dentists and veterinarians, MRC unit coordinators either called licensing boards via telephone or had volunteers fax copies of their licenses directly to the MRC unit. Credentialing programs are constantly being updated and improved, and the ESAR-VHP program will probably positively affect how the MRCs do credentialing in the future.
In addition to credentialing, a few MRC units discussed the completion of background checks of volunteers. One unit coordinator wanted to obtain background checks on all volunteers, but was unable to find a way to meet the required costs. Another coordinator was able to get background checks through the State for $10 per volunteer, but discovered that those checks only included criminal history in their State. For volunteers participating in activities in elementary schools, for example, the coordinator used other (not described in detail) means to obtain more complete background checks. One coordinator recognized that some background information could be gleaned through the credentialing boards, in that medical licenses would not be granted to persons convicted of felonies. Another asked volunteers to give permission for a background check on the MRC application, hoping that just informing volunteers that the unit had the ability to perform background checks (in the absence of having the resources to truly obtain checks on all volunteers) would influence potential volunteers to self-select.
Methods of recruiting volunteers did not vary much by unit size or housing institution. Common means of recruiting volunteers included newspaper ads and articles, press releases, mailings to physicians' offices, and presentations at professional meetings. MRC units also had recruiting materials available at community health fairs and other activities. Word of mouth, or volunteers recruiting their colleagues, was described as a very important recruiting tool by half of the units. One MRC volunteer said she kept MRC applications at home so she would have them available for interested persons. Although half of the units mailed recruiting materials to the members of professional organizations, only one MRC reported actually purchasing State lists of licensed professionals. Overall, most MRC units felt that their recruiting efforts have been successful.
3.5.6 How Effective Were Efforts to Retain MRC Volunteers?
Retention of MRC volunteers fell into two categories for the case study units: either volunteer turnover was very low or the unit coordinators did not have a clear knowledge of turnover rates because lists of volunteers were not updated.
Units of all sizes and from all types of housing institutions reported very low rates of separation from the unit. Reasons volunteers actually left MRCs tended to be because they moved away from the area. Sometimes scheduling was a problem because volunteers realized they did not have time available to make a commitment. Occasionally, a volunteer's skills and interests were not a good match for the MRC mission. Although this problem was rarely described, one MRC unit coordinator made an effort to help those individuals find a more suitable group with which to volunteer.
MRCs that tended to have good relationships with their volunteers also tended to be smaller units (although this was not always the case), and have a mission that included public health. Larger MRCs had less contact with volunteers individually, including making an effort to recognize or retain their MRC volunteers. It was unclear if MRCs with more individual contact with volunteers or units with less contact with volunteers really had a better idea of what level of volunteer participation to expect in an emergency, but all units generally assumed response would be good. One MRC coordinator did point out that a significant proportion of their volunteers would have a first priority to make sure their families were safe before they volunteered for an emergency.
| We've had very little turnover. I was incredulous. I am still E-mailing most of the people that came 3 years ago and they still come to trainings and I still see them. So I'm surprised that there has been a very small turnover. I'd say about 10%. Of the ones who dropped out I know it was for health reasons—aging population, death, and moving out of the community.
Besides personal relationships and communication, volunteers in units that included a public health focus reported that they felt very appreciated and valued by the MRC. Some of the ways in which MRCs recognized their volunteers were through means as simple as personal thanks for participation in activities. Other gestures included publishing volunteers' names in the unit newsletter, hosting awards dinners and recognizing volunteers individually, and providing certificates for participation in activities. Volunteers who participated in one unit's response to Hurricane Katrina were hosted by the State House of Representatives for a day in the State capitol and given a standing ovation from the House members. Less grand gestures may be just as important to retention of volunteers. Some tangible items that MRC units give their volunteers were MRC and Citizen Corps lapel pins, bags, T shirts, mouse pads, and even MRC license plates. Volunteer responses were clear that any kind of recognition was appreciated, and it is reasonable to conclude that such gestures increase retention.
3.5.7 Are MRC Units Sustainable for the Long-term?
| I thoroughly believe that a relationship with a volunteer is how to retain a volunteer. I don't think you can just keep their names on a list. I try to call them as often as I can, let them know who I am.have a relationship with them.
| I think having the ability to process the Katrina incident and the stress debriefing and taking care of the volunteers was helpful. And then there is a winter awards banquet and people gain recognition. I think that was helpful with retention. And we have our MRC and our Citizen Corps pins. People like having their pins.... You feel appreciated.
The long-term sustainability of MRC units was mentioned by multiple respondents, although there was little consensus on the most important factors for sustainability. Because interviews with unit key informants were completed more than a year after the demonstration period ended, it is clear that they have succeeded in sustaining themselves in the short-term. It was observed that challenges identified by units during the demonstration period are being addressed now, if they had not been overcome during the demonstration period. Some units have changed leadership, and others have changed their institutional home. One unit has broken into several smaller units to increase its focus on local communities. Most units have managed to obtain funding from some source, with State/county agencies the most commonly reported sources. In only one case is funding a problem, and that unit still has a few more months until the funding for the unit coordinator's salary runs out.
| There are a lot of things I would like to start over and do differently, but I don't think the MRC is one of them.
| I think that the potential of the local MRC has finally been realized.
A key indicator of the likely sustainability of an MRC unit is its perceived success in the past. The case study respondents were overwhelmingly supportive of the achievements of their units. Respondents recognized that the demonstration period was one in which the local units were finding their direction and were on a steep learning curve. For one respondent, the ability to change perceptions of the MRC was a success: "The MRC is nice but it wasn't perceived as something vitally necessary. I think over the course of the 4 [sic] years... I think we began to change that. In fact, my understanding now is I think the MRC is actually included in some first response initiatives." For others, the things the MRC units did to overcome challenges and accomplish their goals were signs of success. As one respondent from a partnering organization stated, "From my point of view, I think they have done an excellent job. I guess I'm giving high marks for sticking to it and working hard and looking for ways to improve and making these improvements quickly. I think they have done a really great job locally." In general, the perceived success of the MRC units by persons involved with the units would suggest that future challenges to the MRC can and will be met.
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