Public Health Preparedness: HHS Should Take Actions to Ensure It Has an Adequate Number of Effectively Trained Emergency Responders
Fast Facts
Medical emergency responders (e.g. doctors and nurses) enrolled in a Department of Health and Human Services program can be called up and sent to help states and localities in a public health emergency.
But HHS doesn’t know if it has enough responders available with the critical skills and competencies needed for current or future emergencies. In 2017, for example, HHS had a responder shortage and relied on the Department of Defense to provide medical care.
Also, HHS needs to evaluate its training to ensure that it effectively prepares responders for national emergencies like the COVID-19 pandemic. Our 5 recommendations address these issues.
HHS Medical Emergency Responders at a Response Preparation Briefing
Response team personnel
Highlights
What GAO Found
Major natural disasters in the past 3 years, as well as the COVID-19 pandemic, have heightened attention to the nation's ability to respond to these types of emergencies. The Department of Health and Human Services (HHS) is responsible for leading the public health and medical response to emergencies. HHS responded to COVID-19, in part, by deploying responders enrolled in the National Disaster Medical System (NDMS). These individuals, such as doctors and nurses, generally work outside the federal government and are federal employees used intermittently. In 2018, HHS developed an enrollment target for NDMS of 6,290 responders, but GAO found HHS did not follow key principles of effective strategic workforce planning in developing this target. For example, HHS did not identify the critical skills and competencies needed of its NDMS workforce to meet current and future programmatic results. Specifically, HHS's target does not take into consideration three key areas: a workforce capable of responding to (1) a nationwide event or multiple concurrent events, (2) the needs of at-risk individuals, and (3) the availability of other medical responders. Consequently, HHS cannot be sure its target, if achieved, will provide an adequate number of responders with the skill sets needed to effectively respond.
HHS requires responders to take web-based training prior to deployment, such as characteristics of infectious diseases, and also offers optional in-person training, such as care delivery in a severe environment. However, HHS's process to evaluate its training does not align with key practices. As a result, HHS does not have assurance that it is effectively preparing responders for deployment, including keeping them and others safe during an emergency, such as COVID-19. For example, HHS requires a web-based course on donning and doffing personal protective equipment to protect against infectious disease, biological, and chemical threats. However, HHS does not know the training's effectiveness until responders have deployed; at which point, if ineffective, responders could potentially expose themselves to hazards. Further, HHS officials state their in-person training is most beneficial but more costly to provide, limiting its provision. A more effective training evaluation process would help the agency determine which in-person courses are most beneficial and should be prioritized, or even made mandatory, for effective and safe responder deployment.
Why GAO Did This Study
NDMS is the main program through which HHS enrolls responders to assist with the federal medical and public health response to public health emergencies. HHS deploys NDMS responders to provide, among other things, patient care and movement. During the 2017 hurricanes, NDMS had a shortage of responders that resulted in HHS relying on other departments, such as the Department of Defense, to provide medical care. As of December 2019, HHS had 3,667 NDMS responders.
The Pandemic and All-Hazards Preparedness and Advancing Innovation Act of 2019 included a provision for GAO to review HHS's responder surge capacity. This report examines (1) the workforce planning for NDMS responders to assist with public health emergencies, and (2) training provided to these responders.
To conduct this work, GAO reviewed agency NDMS planning documentation, including NDMS staffing decisions, team structures, and training materials; compared HHS actions to key workforce planning practices; and interviewed HHS officials.
Recommendations
GAO is making five recommendations to HHS, including to develop a workforce target that accounts for the critical skills and competencies that are needed to meet current and future programmatic results and to develop processes for evaluating its training to ensure an effectively trained workforce. HHS concurred with our recommendations and generally plans to take action.
Recommendations for Executive Action
| Agency Affected | Recommendation | Status |
|---|---|---|
| Office of the Assistant Secretary for Preparedness and Response | ASPR should develop an NDMS responder workforce target that aligns with the goals and objectives in ASPR's forthcoming strategic plan. (Recommendation 1) |
HHS officials agreed with this recommendation. The Administration for Strategic Preparedness and Response's (ASPR) 2022-2026 Strategic Plan includes a goal to manage the federal response to and recovery from public health emergencies and other disasters. A key milestone under this goal is to mobilize ASPR resources to equitably distribute medical countermeasures, personnel teams, and other public health supplies to protect the nation during active responses. To meet this goal and milestone, ASPR re-evaluated its NDMS responder target. This activity was to assess and modernize NDMS team sizes to assure a more flexible and cost-effective team model to support ASPR missions during responses. The assessment was finalized in September 2023. This fulfills the intent of the recommendation.
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| Office of the Assistant Secretary for Preparedness and Response |
Priority Rec.
ASPR should develop an NDMS responder workforce target that accounts for the critical skills and competencies that are needed to meet current and future programmatic results, such as a workforce target that considers (1) a nationwide event or multiple concurrent events, (2) the needs of at-risk individuals, and (3) the availability of other medical responders. (Recommendation 2) |
HHS officials agreed with this recommendation. In February 2023, ASPR officials provided documentation demonstrating that they believe the NDMS responder workforce target of 6,290 NDMS personnel accounts for two large-scale catastrophic events, the hospital needs of at-risk individuals, and the availability of other responders. More recently, ASPR re-evaluated their NDMS responder workforce target, documented in a September 2023 decision-memo. According to the memo, the task of evaluating NDMS workforce needs was an opportunity to review where NDMS is currently and the need for revitalization beyond the COVID-19 period. Utilizing the scenario of two sequential hurricane events, ASPR completed an in-depth review of capabilities with a past and future staffing focus, according to the memo. The study also considered the last 10 years of NDMS deployments. According to the memo, the agency set realistic expectations for the path forward to be successful in the future by considering the following variables: (1) the multiple challenges hiring NDMS responders, demonstrated over the last decade, (2) funding limitations, (3) actively keeping NDMS responders engaged, and (4) the need to maintain relevancy in response. The decision memo concluded that a revised responder workforce target of 4,575 NDMS personnel across all teams was more flexible and cost-effective while maintaining response capabilities. This fulfills the intent of the recommendation.
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| Office of the Assistant Secretary for Preparedness and Response | ASPR should develop strategies to fill gaps to achieve its revised workforce target. (Recommendation 3) |
HHS officials agreed with this recommendation. ASPR undertook a strategy to re-evaluate its NDMS responder workforce. As a result, it revised its workforce target to 4,575 from a prior target of 6,290, according to a September 2023 decision memo. Variables considered in the evaluation included the multiple challenges hiring NDMS responders, demonstrated over the last decade, as well as funding limitations, among other considerations, according to the decision memo. In July 2024, ASPR indicated that it had 3,872 NDMS responders. This is approximately 700 under its revised target. ASPR has had direct hiring authority to aid hiring NDMS responders since June 2019. In July 2024, officials reiterated that they believe this direct hire authority provided the flexibility and expediency needed to hire NDMS responders. They believe Congress should codify this authority to allow ASPR to continue to maintain its NDMS responder workforce needs. In addition to direct hiring authority, ASPR stated that it had undertaken other hiring and recruitment strategies to hire more NDMS responders, such as promoting awareness of the mission and impact of NDMS through social media and networking events. According to ASPR data, these efforts have been successful in hiring more responders. However, ASPR has also experienced attrition that has closely offset the gains made in hiring. GAO will continue to monitor this area, including strategies ASPR is undertaking to address NDMS responder attrition, until ASPR is successful at addressing the gaps in its NDMS workforce. Therefore, GAO considers this recommendation open.
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| Office of the Assistant Secretary for Preparedness and Response | ASPR should develop a process to evaluate the web-based and in-person training provided to NDMS responders using GAO-identified key practices for evaluating training. (Recommendation 4) |
HHS officials agreed with this recommendation. In December 2023, ASPR officials stated that their NDMS web-based trainings now have an embedded survey and evaluation that NDMS responders are required to complete in order for them to receive credit for the training. Feedback provided through the survey and evaluation is reviewed and analyzed quarterly and findings are then funneled back into the course revision process to improve the online trainings, according to officials. ASPR also offers in-person trainings as their budget permits, according to officials. ASPR held a 2022 NDMS Training Summit and 2023 NDMS Leadership Training. For both of these in-person trainings, evaluation data were collected by a supporting contractor who produced a report that included participant data, topics covered, schedules, and evaluation/survey feedback. ASPR provided GAO the contractor's reports for the two in-person trainings held. According to officials, they review these reports and take in lessons learned to help improve future training sessions. This fulfills the intent of the recommendation.
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| Office of the Assistant Secretary for Preparedness and Response | ASPR should develop a process or approach to prioritize various in-person training needs for its NDMS responders while taking into account budget constraints. (Recommendation 5) |
HHS officials agreed with this recommendation. As of February 2023, ASPR continues to work on implementation this recommendation. In August 2022, ASPR conducted its first in-person training summit to provide hands-on training for NDMS responders, focusing on new hires to ensure basic skill sets to conduct post-disaster response operations. Over 1,400 NDMS personnel received training on new equipment, field and life support equipment, and classroom training on emerging threats, aeromedical evacuation, and disaster medicine. According to ASPR officials, the training plan developed for the Summit was focused on the needs and skills for new NDMS hires, due to funding constraints, but will be adapted for future trainings based on the needs of participating NDMS responders. Officials noted that this training plan will lay the foundation for the process and approach used to provide other training sessions when funding is available. As of December 2023, ASPR officials stated that they do not project to have any allocated training funds to support other NDMS in-person training sessions, under a continuing resolution nor within the upcoming FY 2024 appropriations bill. According to officials, this has been an ongoing issue. In the past several years, ASPR has only been able to accomplish any NDMS training using supplemental funding, officials stated. Supplemental funding usage has allowed ASPR to focus on ensuring NDMS responders complete mandatory training for them to become deployable and to be compliant with Occupational Health and Safety Administration and other federal regulations. ASPR officials provided GAO with an NDMS training priorities and strategy document for fiscal year 2024, which they stated they will implement should funding become available. This fulfills the intent of the recommendation.
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