September 11, 2001 : Attack on America
Testimony of Dr. Dennis O'Leary - A Review of Federal Bioterrorism Preparedness Programs from a Public Health Perspective. Subcommittee on Oversight and Investigations; October 10, 2001

A Review of federal Bioterrorism Preparedness Programs from a Public Health Perspective.
Subcommittee on Oversight and Investigations
October 10, 2001
10:00 AM
2322 Rayburn House Office Building


Dr. Dennis O'Leary
Joint Commission on Accredition of Healthcare Organizations


I am Dr. Dennis O’Leary, President of the Joint Commission on Accreditation of Healthcare Organizations. We very much appreciate the opportunity to testify on this critically important “Review of Federal Bioterrorism Preparedness Programs from a Public Health Perspective.” The tragic events of September 11, 2001 have served as an unwelcome catalyst for focusing on this country’s ability to deal with acts of terrorism. All aspects of our nation’s infrastructure have received renewed, and in some cases, heightened attention to their particular vulnerabilities and response capabilities. The medical care and public health systems perhaps deserve exceptional attention because they will assuredly be the centerpiece of any response to -- and therefore be severally strained by -- any terroristic event involving substantial illness or injury to multiple individuals. However, these systems also deserve close examination because our citizens can reap significant benefits from strengthening this interface even if bioterrorists do not strike. The value of a well-integrated medical and public health infrastructure transcends terrorism and expands our capacity to deal with a broad range of public health threats, such as emergent infectious diseases and epidemics.

I am here today to speak specifically about how the Joint Commission fits into the framework for bioterrorism preparedness and how we see ourselves playing a continuing, significant role in facilitating the readiness of our nation’s health care organizations to respond to untoward events. I will be raising for consideration some vulnerabilities in the current ability of the medical system to respond effectively to bioterrorism and making suggestions about solutions. It is my intent to make a strong case for the development of system-wide, integrated community approaches to preparedness that flow from federal leadership. And I want to underscore that a strong nexus between the medical and public health systems is critical to improving and maintaining our preparedness.

For those of you who are not familiar with the Joint Commission, we are the nation’s predominant health care standard-setting and accrediting body. The Joint Commission is a not-for-profit, private sector entity that was founded in 1951, and is dedicated to improving the safety and quality of care provided to the public. Our member organizations are the American College of Surgeons; the American Medical Association; the American Hospital Association; the American College of Physicians-American Society of Internal Medicine; and the American Dental Association. In addition to these organizations, the 28 member Board of Commissioners includes representation from the field of nursing, and public members whose expertise covers such diverse areas as ethics, public policy, and health insurance.

The Joint Commission accredits approximately 18,000 health care organizations, including a substantial majority of hospitals in this country. Our accreditation programs also provide quality oversight for home care agencies; ambulatory care centers and offices whose services range from primary care to outpatient surgery; behavioral health care programs; nursing homes; hospices; assisted living residencies; clinical laboratories; and managed care entities. The Joint Commission is also active internationally and, in fact, has provided consultation services on bioterrorism preparedness overseas.

The scope of our involvement in the health care delivery system places us in a unique position to both set expectations for readiness across the entire spectrum of provider services and to measure adherence to those expectations. However, leadership and resource commitments at the federal, state and local levels are also essential to any effective bioterrorism response capacity.

The Joint Commission’s Standards on Emergency Management

For many decades, the Joint Commission has required that its accredited health care organizations meet established disaster preparedness standards. Not surprisingly, these standards have focused on natural disasters such as tornadoes, floods, hurricanes and earthquakes; and on certain uncommon accidents such as power plant failures, chemical spills or fire-related disasters. Organizations have been required to develop internal response plans and conduct periodic staff drills to determine that these plans actually work. During on-site surveys, our surveyors review these plans as well as the results of the staff drills.

Several years ago, in a move that now seems prescient, the Joint Commission decided to develop new standards that would broaden the ability of individual healthcare organizations to deal with rare events. At that time, we had become concerned that the medical system was inadequately prepared to deal with the rare threat of bioterrorism, and perhaps equally unprepared for the greater possibility of infectious outbreaks arising from an increasing global inventory of virulent infectious agents. Regardless of the source of the threat, readiness for managing biological events has certain common elements.

The Joint Commission’s accreditation standards were modified in three important ways, all of which infused the concept of community involvement into the preparedness process. First, we shifted the focus of the standards from simple emergency preparedness to emergency management. That modification may not sound significant, but it has far reaching implications. Now, health care organizations are expected to address four specific phases of disaster planning: mitigation, preparedness, response, and recovery. This means engaging in planning as to how an organization would lessen the impact to its services following an emergency; how organization operations might need to be altered during the heat of the crisis; and how to conduct consequency management to return the organization to normal functioning once a crisis has passed.

Further, emergency management requires that when organizations are addressing each of the four phases of disaster planning, they must broaden their preparedness and their perspectives to take into account how the community around them may be affected during a rare event. “Community” may be viewed as the population at large, the other medical institutions in the area, and/or relevant community structures and agencies. This more outward and proactive way of thinking should better position health care organizations to play an effective role in bioterrorism preparedness.

Second, the new standards, which were effective on January 2001, require accredited organizations to take an “all hazards approach” to planning. What this means, is that organizations must develop emergency management plans that contain a chain of command approach that is common to all hazards deemed to be credible threats – an approach that also can be easily integrated into their community’s emergency response structure. Hospitals must start this aspect of planning by considering a wide variety of threats that could befall their community, including terrorism. Hospitals, for example, are now required by these new standards to do a hazard vulnerability analysis that starts with an unconstrained list of extreme events, and then critically appraises their probability of occurrence, their risk to the organization and the capacity for responding to each potential threat. Inherent in this analysis is having an understanding what the community itself, rather than just the health care organization, considers to be a realistic threat.

While this vulnerability analysis is obviously important, the abilities of the individual organizations, and indeed of communities, to prepare for and respond to the full array of potential threats is seriously constrained by the major cost restraints in most health care organizations. This will obviously lead to important priority judgments about risk that will condition future response capabilities. There is also a risk of fragmented priority setting – healthcare organizations and communities may view the risk differently between and among themselves, leading to uncoordinated preparedness. To do their jobs effectively, individual health care organizations should take their lead from responsible federal and state government authorities. This is rather problematic at present because the United States has not articulated its own national threat and risk assessment. As stated in the recent GAO report on Homeland Security, “a threat and risk assessment is a decision-making tool that helps define the threats, to evaluate the associated risk, and to link requirements to program investments.” It is clearly essential that governmental agencies involved with assessing the threats from bioterrorism communicate their analyses down to the local level so that the medical system has a blueprint for appropriate action and can construct a reasonably consistent strategy of preparedness throughout the United States.

The last new requirement of the standards is the involvement in at least one annual community-wide practice drill by those health care organizations whose all hazard risk assessment identifies credible community threats. These drills must evaluate the interoperability of the response structures developed by the health care organization and the community. Responding to a bioterrorism attack will require unprecedented communication, coordination, and attention to chain of command structures. Therefore, these drills, if effectively executed, are time consuming and expensive to conduct. Moreover, thorough mock attacks must consider how the effects of bioterrorism would typically play out over a period of weeks, constantly changing the landscape of issues and decision making for health care leaders. Given the complexity and cost of these essential drills, we believe that governmental financial incentives should be considered as a means of leveraging on-going engagement in such activities.

Drills also can be extremely instructive. Large-scale ones such as TOP-OFF have elucidated unanticipated planning gaps and have exposed the need for unconventional thinking in times of emergency. To elaborate, we rightly consider our hospitals the first place to go when people are severely ill. In fact, in this country we go to great lengths to ensure that everyone has access to hospital emergency care. Yet in the throes of a biological disaster, we may not want to admit everyone who arrives at the hospital door. First, if individuals are infected with a virulent pathogen, they will then infect physicians, nurses and other staff, and thus limit the availability of critical medical personnel. Under such circumstances, it may be prudent to keep the hospital free from contamination by setting up off-campus isolation units and treatment modalities outside of the hospital that are overseen by properly protected staff. This would permit the hospital itself to remain a safe haven for management of other injuries and illnesses.

Further, if -- in the face of a biological threat -- everyone were accepted into the hospital for evaluation, there is a real risk of overwhelming facility capabilities. Experience with drills has shown us that even the largest hospitals would be unable to handle the onslaught of people who are concerned that they may have the dreaded agent. This raises the real potential need for off-site evaluation and triage of individuals in a fashion different from the usual conduct of emergency services.

The new Joint Commission accreditation standards for emergency management represent a significant step toward improving the nation’s readiness for a biological emergency, but national leadership in the area of risk analysis will be necessary to convince many organizations that bioterrorism threats are worthy of their serious attention. The Joint Commission is participating in an Agency for Healthcare Research and Quality funded project with Science Applications International Corporation to investigate the linkages among key entities in response to a bioterrorism event. This project will not be completed until next year, so I am unable to share any final results with you. However, as part of our contribution to the project, we conducted a survey of a sample of hospitals to assess their community linkages for purposes of mounting a bioterrorism response. Among the obstacles identified by those hospitals which did not have effective community linkages were the lack of community awareness of the issue and therefore, interest in planning; and inadequate funding for bioterrorism planning, training and resources at both the community and organizational levels.

Vulnerabilities in the Medical and Public Health Care Readiness

Much additional progress needs to be made. Given the outstanding training we provide to our medical and public health personnel in this country, and given our scientific know-how, state-of-the-art technology, and high level of health care spending, it is reasonable for the American public to expect that this country is ready to respond to the worst of disasters that terrorists could bring to our doors. This perception has been reinforced by the admiral way in which New York City medical and public health personnel handled themselves in the face of the massive disaster last month. But is should be pointed out that the medical care and public health systems were not tested for the level of stress that would result from a bioterrorist event, because sadly there were many more deaths from the World Trade Center calamity than there were persons needing medical attention.

Some people believe that the health care delivery system – if faced with a bioterroism event – will somehow be able to accommodate the thousands of ill, injured and worried well who will seek health care in that situation. The unfortunate truth is that we have much to do before such a belief can be fulfilled. This is not intended as an alarmist statement, but there are some stark realities that must be faced about the current capacity and integration of our public health and medical care systems and the readiness of governmental agencies to assume authoritative leadership roles.

To that end, I would like to offer a series of recommendations for upgrading our system capabilities and for weaving together a tighter response fabric among responsible parties. This fabric should be pattern recognizable to all those who comprise the cloth, because its essential elements will be comprised of effective coordination, communication, cooperation, chain of command, and capacity building.

  • More medical care workers must be trained to become familiar with pathogens that may be used in bioterrorism, aware of the symptoms they produce, and alert to the possibility of their use. Medical personnel must also become knowledgeable about routes of transmission, the transmission vectors for various biologic agents and the effective therapeutic approaches to these agents. The reality is that most physicians would not recognize a case of anthrax, tularemia, or smallpox that presented to them in the emergency room or in their office. Nor would they know what kinds of specimens to collect for testing, how to handle such specimens or which clinical laboratories possess the expertise to detect some of the rare agents that could be used by terrorists. Such education is essential to a prompt response to any bioterrorism attack.

  • It is essential that a single, integrated system of response be created that will be effective in addressing a full range of diseases and rare events whether of terrorist or natural origins. Because it will serve multiple purposes, a single system is less likely to wither from inattention or nonuse. This system should be a blueprint for action that is also scalable to the extent of the emergency and to the settings that are involved. The framework should be community-wide and utilize common concepts so that it is transportable. For example, we should be reliance upon a consensus-based “chain of command” construct that has interoperability common to all states. This would make emergency management plans quickly and easily understood by all who are engaged in emergency activities. The system should be periodically tested and evaluated for its currency and feasibility.

  • Community or state-wide capacity analyses of preparedness that include available medical facilities and delivery sites must be carried out. We are pleased that the CDC is working to identify the core capacities that state and local health departments must have in order to be adequately prepared for a biological attack. However, this evaluation needs to be expanded to include the core capacities of the medical infrastructure within each geographic area. This should lead to a gap analysis that addresses issues of supplies at hand, which additional personnel may be needed, transfer agreements during times of system overload, and other identified medical system vulnerabilities. Such assessments should be integrated into any other assessments being undertaken by state and local authorities.

  • A medical/public health surveillance system should be established to promptly detect naturally occurring epidemics as well as terroristic activity. The rapidity with which a rare disease or terrorist weapon is recognized at the provider level and communicated to public health experts will largely determine the extent of its spread and the overall mortality rate. With today’s technology, the reporting system should not rely upon an astute clinician to pick up the telephone and know whom to call about an unusual case, or number of cases. Rather, a surveillance system should be designed for the routine collection of automated data on presenting symptoms at points of delivery system entry and of health care utilization and laboratory data. Such information should be provided to public health officials for ongoing surveillance. Public health epidemiologists might then be able to detect “spikes” in the data and take investigatory action if warranted. A system of this nature could also communicate electronically with CDC and could be used in time of bona fide bioterrorism to inform decision-makers about disease spread.

  • Issues of national supplies and their disbursement need to be evaluated and resolved. Determinations as to how much vaccine, pharmaceuticals, medical equipment and other supplies are needed for stockpiling should be made at the national level after a credible threat and vulnerability analysis. Equally important is how supplies are prioritized for distribution and how fast they can be deployed. It may be that there is no effective way to expeditiously distribute to localities the massive amount of supplies that may be needed if there is as large-scale bioterrorist attack, especially if the transportation infrastructure is also affected. The practicalities of needing to act quickly require considerations as to when regionalized supplies are preferable, who will have the authority to disburse them, and what criteria will be used to make dispersal decisions.

  • It is essential that the national funding policies which have progressively reduced the elasticity of the medical system to ramp up to a peak demand be re-evaluated. For more than two decades, public policy makers have taken clear steps to reduce excess delivery system capacity (e.g., hospital beds). During this time many emergency departments and satellite clinics have closed. But we are entering a new era that requires a reexamination of fiscal public policy on emergency preparedness. We are not advocating an unfettered build-up of delivery system capacity, but rather a strategic reassessment of the resources needed to assure necessary system elasticity in the face of national or local crises.

  • The Joint Commission stands ready to work with many others on the aforementioned recommendations, because we believe that our organization has a key role in the strategic planning for medical and public health systems’ response to terrorism.


    It is said that all health care is local. That maxim ultimately applies to emergency management. Indeed, local readiness planning will need to be scaled and tailored to the characteristics and capabilities of individual communities. However, it is equally important that there be strong leadership at the federal and state levels that directs particular attention to the issues raised in our testimony. The resources needed to support effective emergency management at the local level are not simply vaccines, antibiotics, and medical technology. There are definitive needs for government investment in the conduct of risk analyses, in the development of community infrastructures, in the training of key health care personnel, and in information gathering and dissemination. And in the end, government must set national priorities for resource deployment and assure that emergency management efforts are carried out at the local level.

    We as a nation are not unprepared to deal with bioterrorism and natural disaster and epidemics, but our nation’s public health and medical systems could be better prepared than they are today. We therefore need to start addressing the identified needs with all due haste. In this regard, the joint Commission standards ready to commit its own resources to work alone and with others to meet our collective national readiness goals.

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