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In this chapter we present the findings of our discussions with 11 key informants from the federal agencies and nonprofit private organizations that worked with the MRC Program Office during the 2002-2005 demonstration period. We also present the findings of our case studies of six local MRC units. The interviews were conducted with unit coordinators, State coordinators, MRC regional coordinators, unit volunteers, and informants from local institutional partners from the demonstration period. The comments of all key informants are mostly reflective of their experiences with MRC during that time, although some recall bias most likely is present because we were asking informants to comment on events that occurred nearly 3 years ago. We would also point out that nearly a one-third of the informants only worked with the MRC Program and units for a portion of the demonstration period, so they had less experience to draw on.
We reviewed the progress reports supplied by the MRC Program Office for each unit before we conducted the key informant interviews. While the yearly progress reports provided background information useful for the interviews, they but did not supply substantially different information from what was covered during the interviews, so the document review is not presented as a separate section in this report.
For descriptive purposes, we use terms like some, many, or few to summarize the responses. For the federal-level key informants, "most or many" generally indicates eight or more informants, "some" represents four to seven informants, and "few" reflects three or fewer informants. For the case studies, "most," "the majority," and "nearly all" indicates five of the six cases, "about half" and "over half" represent four cases, "half" reflects three cases, and "few" and "a minority" indicate two cases.
This section first provides results for issues related to MRC unit genesis, design, and purpose. Next are results for external coordination, followed by emergency deployment issues, public health engagement, and finally, the organization and operation of the MRC units. Table 3-1 shows how the goals of the MRC demonstration project map to the evaluation questions and where in this section the relevant results are presented.
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3.1 Unit Genesis, Design, and Purpose
3.1.1 What Factors Led to the Establishment of the MRC?
Most of the MRC units in the case study were formed because there was an unmet need for medical surge capacity and disaster preparedness in their communities and the potential to utilize volunteer resources to fill that need was recognized. One of the main factors that led to the establishment of some of the units in the case study is that they were in communities that had been directly affected by the events of 9/11 or were adjacent to communities that were directly affected. These communities, therefore, had a heightened awareness of the need for surge capacity in the event of a disaster.
Table 3-1. MRC Demonstration Project Goals and Evaluation Questions
|MRC Demonstration Project Goal
|Goal 1: Demonstrate whether medical response capacity can be strengthened through MRC units consisting of a broad range of medical and health professionals.
||Is the size and diversity of the MRC unit sufficient to build medical response capacity?
|Goal 2: Demonstrate whether surge capacity can be created to deal with emergency situations that have significant consequences for the health of the population.
||Have MRC unit deployments been effective in building surge capacity?
|What factors facilitate and hinder effective emergency deployments?
|How are MRC activities integrated into existing emergency preparedness and response programs?
|Goal 3: Demonstrate whether the MRC enables current and retired health professionals to obtain additional training needed to work effectively and safely during emergency situations.
||How has MRC involvement enhanced the skills and competencies of volunteers?
|Goal 4: Demonstrate whether the MRC approach provides an effective organizational framework with a command and control system within which appropriately trained and credentialed volunteers can use their skills in health and medicine.
||What factors led to the establishment of the MRC?
|Do stakeholders understand the purpose and goal of the MRC?
|How did the MRC Program Office coordinate internally with MRC units?
|What internal communication and management structures were established to support MRC unit functions?
|What were the challenges to internal coordination within the unit and how were those challenges addressed?
|Did the MRC Program design support effective functioning?
|Did the MRC leadership structure support effective functioning?
|Were systems to track and update information on volunteers effective at the local level? ||3.5.4
|How effective were MRC volunteer screening and recruitment efforts?
|How effective were efforts to retain MRC volunteers?
|What are challenges to the sustainability of MRC units?
|Goal 5: Determine whether the MRC approach facilitates coordination of local citizen volunteer services in health and medicine with other response programs of the community/county/State during an emergency.
||How has the MRC coordinated with external partners? How do MRC units complement and integrate with existing emergency preparedness and response entities?
|What are the challenges to external coordination and how have those challenges been addressed?
|Goal 6: Determine whether the MRC approach provides cadres of health professionals who contribute to the resolution of public health problems and needs throughout the year.
||How have MRC units contributed to the resolution of other public health needs in the community?
In most of the communities of the case study units, the effort to form an MRC unit was spearheaded by one or more individuals from within the organizations responsible for that community's emergency, medical, or public health response. One selected case study unit, however, was formed by a social services agency that, upon realizing there was no volunteer unit associated with its community's emergency management or public health agencies, took the initiative to form one.
One case study unit was formed for different motives than out of a perceived need for surge capacity. A university spearheaded the effort to create this unit in the hopes that by connecting its campus directly with the medical community, volunteers would be more responsive to enrolling in its academic programs.
3.1.2 Do Stakeholders Understand the Purpose and Goal of the MRC?
Federal MRC Program
As a new program with few dedicated resources, partnerships were critical to the program in order for it to establish itself as a credible and effective player within a complex environment of federal emergency preparedness and response. A key element to success of any collaboration or partnership is the degree to which partners share a common understanding of the purpose and goal of their respective entities (Zakocs and Edwards, 2006). Thus, it was important to assess to what degree the MRC Program had been able to convey what it was about and what it hoped to achieve.
We found that federal-level stakeholders understand some but not all of the elements of the MRC mission. When asked to describe the purpose and goal of the MRC, all federal-level stakeholders articulated the utilization of medical or allied health volunteers to respond to local emergencies and disasters. However, only about half of interviewed federal-level stakeholders indicated that MRC volunteers may include non-medical and public health professionals. Additionally, while all federal-level stakeholder responses referenced the use of MRC volunteers during disasters, few made reference to volunteer involvement in building public health capacity on an ongoing capacity throughout the year. This indicates a lack of awareness by some federal-level stakeholders that MRC has both a public health and medical care delivery focus and that the program's mission is not limited in scope to medical surge response during disasters.
The vast majority of the case study MRC unit stakeholders recognize that the MRC mission is both to build medical surge capacity during times of emergency and to build public health capacity throughout the year. Identifying and training medical volunteers to respond in the event of an emergency was a shared mission of all the unit stakeholders. Although they may not have been as quick to mention the public health component of the MRC mission, or may not have been successful in achieving that component during the demonstration project, unit stakeholders from five out the six case study units indicated building local public health capacity as a goal of their unit. These units actively worked within their communities to build relationships and identify numerous unmet public health needs they could fill.
One MRC unit, however, limited its purpose to building hospital surge capacity. Its primary goal was to create a database of potential hospital personnel and students who could support hospitals in the event of an emergency. While the unit was successful in achieving its goal, and in fact was the precursor to the Emergency System for Advanced Registration of Volunteer Health Professionals (ESAR-VHP), the unit did not fully embrace the demonstration project's priorities. It not only lacked a public health component but it did not engage the community to find other ways in which its hospital volunteer resource could be used to meet community needs.
3.1.3 Does the MRC Program Design Support Effective Functioning?
Federal MRC Program
As a demonstration program, the MRC approached unit design with a great deal of flexibility and innovation. The program office did not wish to impose a model MRC unit design because, at that early stage, it was not clear what a "model" unit should look like. Instead, the design of the MRC allowed local areas to have control over unit development, with the idea that each unit would know how best to meet its communities' needs. Units were allowed to be housed within any type of organization was interested in doing so, whether within emergency management, a health department, a hospital, a nongovernmental organization, or a police or fire department, given that the organization could provide or work toward the provision of the ability to provide liability coverage and credentialing. This permitted unit establishment in areas where units may not have been otherwise. The flexibility allowed for the rapid growth of MRC units, while the freedom to innovate resulted in the creation of multiple promising MRC unit models.
The flexibility in design is not without its disadvantages, however. Because MRC units vary in their size, structure, and sponsoring organization, they have developed different procedures, standards, and modes of technical assistance. There is no standardization across units with regard to training, credentialing, and supplying volunteers. In addition, MRC units may vary in mission focus depending on the sponsoring organization. For example, those units housed within emergency management agencies may be focused primarily on emergency response, while those housed in a public health department may be more focused on building public health capacity. Because the program is so fluid and inclusive, it is difficult to adequately describe a typical MRC unit, and therefore to establish a durable "brand identity."
In an effort to ensure that MRC units would be local in focus and developed to meet community needs, the sponsoring organizations of units were funded directly. However, as some federal-level stakeholders pointed out, the direct funding of the MRC units resulted in a number of difficulties. In many cases, the housing organizations or institutions that were funded had no direct link to the State and county government entities responsible for emergency preparedness and response systems (e.g. hospitals, universities). As a result, State and county health departments, which have critical responsibilities for public health preparedness and response, may not be aware of the existence of units within their areas. Moreover, State and county officials also may be reluctant to utilize MRC units over which they have no control. As a result, MRC units may not be integrated into State response plans and therefore not utilized to their full potential.
| I don't really think anyone had a very clear direction and, as a matter of fact, I don't think we were receiving very clear direction as to exactly what the Feds wanted out of this program.
Another result of funding units directly was that the MRC Program was initially set up with a direct federal-to-local communication structure. As the MRC has expanded to become a national resource, it is retrofitting a communication mechanism that is more in line with the National Response Plan (NRP). With the creation of regional coordinators, the MRC Program anticipates the improvement of its design and function by developing a federal-regional-local communication structure.
As mentioned previously, model MRC unit design was note promoted to grantees during the demonstration project. Grantees were allowed a great deal of flexibility to create units that would best meet their communities' needs. This did generate innovation in unit design, but more than one stakeholder expressed that they would have preferred more direction from the MRC Program Office during the development of their units: "I don't really think anyone had a very clear direction and, as a matter of fact, I don't think we were receiving very clear direction as to exactly what the Feds wanted out of this program."
| I didn't get the impression that we were given a goal of what a Medical Reserve Corps was to do. Whenever the money was handed out and the contract was put out I don't think there was a stated goal. There was a stated goal that you put together a Medical Reserve Corps unit. But it really didn't tell you how and who. I didn't get the impression we were given an explicit definition of what a Medical Reserve Corps was.
The case studies showed some evidence that the unit housing organization influenced the mission of the unit. Units housed in emergency management organizations tended to focus more on emergency response, while those housed in health departments tended to be more involved in building public health capacity. It is not surprising that a unit would initially be more focused on the area of which its housing organization specializes since those partnerships are already established; however, eventually the majority of the units worked to incorporate both public health and emergency response activities into their MRC Programs. The exception was the hospital-based unit, which did not extend its mission beyond providing hospital surge capacity during the 3 year demonstration period.
| I think it is a fabulous program. I know it is very unique in each community. And I always find a great interest in what the other units are doing... it is really very creative and I think a very valuable program that should be enhanced and expanded into the future, if possible.
More often, MRC unit activities and scope were unintentionally limited by the housing organization's role because of liability issues. For example, the two case study units housed out of emergency management agencies encountered difficulties when trying to engage in non-emergency public health activities, because their liability coverage was tied to emergency management and did not cover non-emergency activities. These units were forced to find other liability coverage options for public health activities. As one unit leader explained, "Because we were so tied to the Office of Emergency Preparedness and all of our liability coverage ran through that, we really never got to the point of actively trying to identify other ways for the members of the MRC unit to interface with the community."
| Because we were so tied to the Office of Emergency Preparedness and all of our liability coverage ran through that, we really never got to the point of actively trying to identify other ways for the members of the MRC unit to interface with the community.
All the case study MRC units seemed to function effectively at the local level regardless of housing organization; however, the housing organization did affect the ease and speed with which MRC units were integrated at the local level. For example, the unit that was housed out of a social services agency had to work harder to build credibility and the necessary partnerships to get buy-in at the local level than did other units housed in agencies whose mission was more in alignment with OSG/MRC goals. As one case study unit partner explained, "They had a black mark against them from the get go being the kind of organization that they were and the kind of focus.they were like a mini social services for undocumented persons. The goal and the mission of the agency didn't really fit with the MRC. It was a real big disconnect for that to be happening out of their office. I think a lot of the resistance and lack of interest was because of where it got housed."
3.1.4 Does the MRC Leadership Structure Support Effective Functioning?
Federal MRC Program
| They had a black mark against them from the get go being the kind of organization that they were and the kind of focus... they were like a mini social services for undocumented persons. The goal and the mission of the agency didn't really fit with the MRC. It was a real big disconnect for that to be happening out of their office. I think a lot of the resistance and lack of interest was because of where it got housed.
The OSG/MRC Program leadership structure initially established under the demonstration period was not sufficient to support its functions and mandates, but it moved aggressively to develop those structures to meet its needs. During the first year of the demonstration project, the MRC did not have a full-time director but was instead led by a series of project managers (who were given this role as a collateral duty). In December 2003, Commander (now Captain) Robert Tosatto of the U.S. Public Health Service (PHS) was appointed as the full-time director of the MRC Program Office. When he came on board, there was only one other full-time staff member (a junior PHS officer) and three contracted support staff. Captain Tosatto was responsible for providing technical assistance and grants management oversight to the 166 funded MRCs. His primary charge from the Surgeon General was to develop the MRC as a program and ensure its coordination with other organizations.
It was clear early on that the exponential growth of the program required more than the two full-time staff (program director and program officer) and a small contract support to maintain good communication with external partners, provide oversight and guidance to the units, and provide the outreach that would be necessary to grow the program. In 2004, Tosatto hired an additional junior PHS officer and amended the technical assistance contract to provide 10 MRC regional coordinators to be located within the HHS regional offices. These regional coordinators would have no direct supervisory authority over MRC units but instead were to be responsible for day-to-day communications, addressing technical assistance needs and serving as channels for communication with the program office. They also were tasked with developing relationships and partnerships with regional, State, and local health officials; emergency management officials; and other partners relevant to the MRC mission as a means of promoting and developing the MRC Program in their regions. Later still, a number of State MRC coordinator positions emerged outside of the formal MRC leadership structure to facilitate coordination between MRC units, State officials, and the regional coordinators.
The leadership structure now in place at the MRC Program Office allows for a communication structure that is more in line with the NRP, and has resulted in more effective functioning. However, overall, the resources provided to the program have not been commensurate with the demands of the MRC Program Office. While all the federal-level stakeholders were very complimentary of the MRC Program Office staff and their dedication, a number of them voiced concerns about the staffing levels at the Program Office and questioned whether MRC had the resources to meet the demands placed on it. Therefore, continued attention to staffing capacity is warranted as the program continues to evolve in size and complexity.
The leadership of case study units varied with regard to background and experience. Of the unit coordinators, two had a background in emergency management services, one in public health, one in sociology, one in social work, and four in volunteer coordination. Many of the interviewed case study unit stakeholders felt that the most important components of unit leadership were experience in emergency medical services (EMS) and volunteer coordination. Some unit leaders did not possess both of these skills, but were teamed up with others who did. The leadership of all the units except one received praise from interviewed stakeholders. The unit that did not was one in which the leadership did not possess EMS or volunteer management skills.
In addition to a background in EMS and volunteer coordination, many interviewed stakeholders felt that units benefited from leaders who were highly regarded members in their community and who already had many established relationships with numerous partnering entities. Those types of individuals were quickly able to bring all the necessary players to the table and get their involvement and input in the unit's advisory board. In addition, these individuals' high standing in the community automatically brought credibility to the MRC unit. As one volunteer explained, "The [invitation] letter came from [name of unit coordinator]. I had had workings with him through Boy Scouts when my son was younger. So his name had credibility to me. Anything from [name of unit coordinator] made sense to me—that it was real."
| The [invitation] letter came from [name of unit coordinator]. I had had workings with him through Boy Scouts when my son was younger. So his name had credibility to me. Anything from [name of unit coordinator] made sense to me—that it was real.
Three of the case study units incorporated a leadership substructure under the unit coordinator. One of these units divided its volunteers into teams based on skill sets and assigned leaders to each team whose expertise was in that skill area. Another unit, in an effort to successfully manage its very large group of volunteers, divided its volunteers into platoons and units, each with a leader who was responsible for maintaining communications with those volunteers. A third unit, which covered a large region of its State, subdivided its volunteer base by location so that each group could more closely tailor its activities to the needs of its assigned community. In addition to providing more guidance to volunteers, these subleadership structures also ensure the sustainability of the units. As one unit coordinator stated, "This is the one thing that I think is most important: you can't do this with one person being responsible. Where is the business continuity in that? So I really think leadership is only as good as your ability to delegate and to make sure there is somebody else who can do what you do on any given day or you are disserving the project." In contrast, at least one case study unit had no leadership other than the unit coordinator.
3.1.5 Is the Size and Diversity of the MRC Unit Sufficient to Build Medical Response Capacity?
The MRC units recruited volunteers from a wide range of professions. Nurses tended to make up the largest group in the six case study units. Physicians also were represented in all units but in smaller numbers. Other professions represented were pharmacists, veterinarians, physician assistants, paramedics, emergency medical technicians (EMTs), dentists, public health workers, and clergy, to name a few. Most units also recruited mental health professionals as volunteers. Two units did not, but worked closely with a mental health association. One unit targeted medical and nursing students as volunteers. Two other units located in areas of large Hispanic populations had a sizable number of interpreters as volunteers. Some units actively recruited retired medical professionals as volunteers, with much success. As one unit coordinator described, "One of the things that we didn't expect, particularly in the first year and a half with the retired people, was the revitalization of them personally and professionally. And the feedback we got of that, that they felt they were throwaways and that now there was something important for them to do." Overall the units were very diverse with regard to the skills of their volunteers.
| One of the things that we didn't expect, particularly in the first year and a half with the retired people, was the revitalization of them personally and professionally. And the feedback we got of that, that they felt they were throwaways and that now there was something important for them to do.
For a number of reasons, it is more difficult to determine whether the size of each MRC unit is sufficient to build medical response capacity. One reason is that the volunteer counts of the units may be unreliable and inflated. A common theme repeated in case study interviews is that once a volunteer is put in the unit's database, they stay there. Rarely are volunteers removed from the database. In addition, many individuals are also active in other agencies such as the Community Emergency Response Teams (CERT) and the Red Cross, as well as the MRC. In the event of an emergency response, these volunteers may not be available to the MRC unit because they have been deployed through other response agencies. As one regional coordinator explained, "If I called that unit tomorrow and said I have an incident in the State and I need your volunteers, I would probably get 100, even though they have a database with 20,000 people in it. It probably covers the majority of the health care providers in the State. It's not real. It's sort of too big because I can't count on that number." Although the numbers stated are an exaggeration, the underlying message may be true for many MRC units—that the number of volunteers in a database is significantly larger than the number likely to respond to an emergency. To an extent, it is expected that only a portion of volunteers will respond, and there is no way to force 100% participation.
The units selected as case studies ranged in size from 68 to 3,400 volunteers, and each unit expressed the desire to increase its volunteer numbers. However, there is a volunteer size balance that units should strive to achieve. As the previous quote suggested, there is such a thing as too many volunteers. If units become too large, the unit leadership will not be able to manage them effectively and the volunteers will feel as though they are just a name on a list. As one unit coordinator explained, "It [my unit] needs to be bigger, but not to the point where I don't have an opportunity to create a relationship with the individual volunteer at some point and they know that this is a viable and sustainable program. We are not looking for a list."
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