1000-Year Flood (2015)

Though an established practice during normal operations, the first deployment of the DCI by the MUSC Health HEOC came during 1 of the most extreme rain events ever documented in the state of South Carolina. In October 2015, the churning Charleston harbor broke over the sea wall and water gushed from storm drains throughout the city as nearly 2 feet of water inundated the area over the course of 4 days. Flooding is typical around MUSC Health’s downtown campus, with nuisance flooding occurring at an average of 23.3 days per year (2007–2013). ^{Reference Sweet, Park and Marra6} However, the severity of “1000-year flood” – so called because it statistically had a 1 in 1000 chance of happening in any given year – was so great that a new approach to coordinated emergency communication was necessary to maintain sensitivity to operations.

As an HRO, MUSC Health must perform “flawless communication and coordination to maintain the situation awareness (SA) required to manage these rapidly changing and complex events.” ^{Reference Autrey and Moss7} To provide group SA to all leadership levels in preparation for the 1000-year flood, the HEOC was initialized using DCI as the primary means of operational communication for the first time. The DCI during this emergency event represented a conscious effort to continue high-reliability practices regardless of circumstances. Despite the impact to the organization, the continuation of an already reliable practice allowed staff to operate with the enhanced awareness and communication required by high-reliability teams. As the 1000-year flood unfolded, groups within MUSC Health, such as the Pediatrics Emergency Department, began to place the DCI on speaker phone for staff, deploying the meeting as a unit huddle. Rather than matriculate information through leadership to staff, all levels of the organization could receive unfiltered situational awareness concerning operations and contingencies in real-time, resulting in time saved and increased transparency. Though high-level direction must follow a chain of command in the form of top-down resolutions, organizational awareness among all levels of staff provides greater understanding of why and how decisions are made, and the DCI provides every care team member the same message.

The DCI is not intended to be directive, and rather provides the tools and information sharing necessary for unit and department-level leadership to make decisions and take action. As frontline staff, they are most in tune to issues that directly impact their teams and are therefore better equipped to share information and direct resources under their control. Optimal accountability, like meta-leadership, relies on connectivity for individuals to communicate freely, ^{Reference Farra, Miller and Gneuhs8} and frontline staff are better positioned to respond to and understand issues when information is more readily available. Though a minor change to the way the DCI had been used, nurse leaders facilitating the call for the entire unit were able to connect frontline staff directly with leaders and other groups within the organization allowing the entire staff to be aware of the same information at the same time, breaking down the restrictive aspects of strictly hierarchical information dissemination and improving accountability and efficiency.

Frequency of communication and familiarity with emergency management processes can have enormous impacts on organizational operations during an emergency. ^{Reference Carley and Mackway-Jones9} While preparedness through training and exercises focuses staff on response readiness, the coordination and management of resources in an emergency can be seamlessly performed by the DCI. The reporting staff are familiar with the format and the pertinent information that must be provided, normalizing the transition from an everyday process into an emergency process. Using the same basic reporting template as a daily operations DCI, the HEOC can appropriate the DCI during an emergency without requiring rehearsal or training of staff. The DCI is modified to suit the unique conditions of every event, but the basic function and process change little during an emergency. In all instances, the reporting template includes different functional areas of the health system and their responsible parties, a look back into events since the last DCI, a look forward at potential issues, and a follow-up of action items and issues identified previously. All reporting at the DCI is documented and posted for enterprise-wide review on MUSC Health intranet sites. During an emergency, information from each DCI is reviewed by the AOCs and operational leadership for relevance to all care team members. Essential information is parsed into official messaging via e-mail, websites, and other forms of internal communication. Serving as a source of information that matriculates throughout the organization, an emergency DCI occurs every 4 hours or more frequently as conditions warrant. Further summarizing the conference call in follow-up messages maintains communication control while still providing transparency. Increased frequency ensures that the most current reports and immediate issues are reviewed as soon as they occur and maximizes operational sensitivity.

Following every major emergency event since Hurricane Matthew in October 2016, a voluntary, online, after-action survey has been used to collect data on employee perceptions of the organization’s handling of events. The survey asks respondents to assess the effectiveness of the organization and its processes and tools during an emergency. After-action surveys for emergency incidents that have occurred since the institution of DCI in such situations indicate communication as a recurring positive element of operations. The surveys offer leaders the opportunity to collect feedback from staff using 3 simple response criteria: what worked well, what did not work well, and what could be done to improve the organizational response to future events.

Each threat since its initial use has offered an opportunity for refinement and testing of the operations and safety briefing model, as lessons learned and after-action feedback have indicated new and better ways of deploying the DCI. The HEOC DCI and its use as a unit huddle during emergencies were noted in the after-action report as best practices, and subsequent events saw the HEOC DCI adopted more widely for unit huddles. The positive after-action reports from the 1000-year flood led to adjustments in the Emergency Management Plan and the incorporation of the DCI in future events. As significant natural disasters continued to threaten MUSC Health in coming years, the use of DCI would continue to evolve.

Winter Storm (2018)

Commonly occurring events, like nuisance flooding, allow emergency management procedures to become refined and well-rehearsed, but a winter storm in 2018 brought some unique and unanticipated challenges to MUSC Health. Until that time, all of the major incident responses using DCI had been for water-related events (flooding, hurricanes, etc.). In January 2018, a truly unusual occurrence impacted the region and threatened operations at MUSC Health. The winter storm of 2018 brought 5 to 7 inches of snow accumulation to an ill-equipped area with annual accumulation averages of zero. Snowfall immobilized the surrounding areas, causing travel and logistical problems for thousands of people. Secondary and tertiary roads were unplowed and remained so for days. With little to no salting of local roads, the snow soon turned to thick sheets of ice, causing a lasting hazard to commuters and emergency vehicles. Weather alerts for the area were incorporated into DCI’s leading up to the event and allowed for assessing the preparedness of the organization and facilities, staff planning, and requesting emergency supplies. As a wintry mix began to fall, the HEOC was formally established and the DCI was used to coordinate efforts to test generators, locate and secure areas with poor heating, and relay parking information.

As part of the emergency management protocol, a designated primary response team is expected and prepared to remain at MUSC Health for the duration of an anticipated event (Team A), with relief staff offsite until conditions permit their return (Team B). Hurricanes approaching the Charleston area sometimes prompt evacuation orders from the state government, and, in those instances, the relief team may evacuate, ensuring the safety of non-essential personnel and limiting the number of participants in the DCI to the essential staff remaining in the area. Unanticipated impact levels from events like snow and ice storms mobilize a modified primary response team of staff who are already onsite. When an event affects transportation routes to and from MUSC Health, the relief team stands by until conditions improve. Official direction is cascaded to teams from direct supervisors and other means, but the reliance on the DCI as a real-time source of information had become common throughout the organization at the time of the winter storm. With relief staff confined to their homes and seeking greater situational awareness, the demand on the telephone trunk line carrying the DCI quickly exceeded its capacity of 200 external callers. Though the HEOC DCI helped MUSC Health maintain uninterrupted clinical care through identifying issues and coordinating resources, the inadequate trunk line prevented some staff from joining the call to listen or report statuses, presenting a potential failure in maintaining high reliability. As part of the greater HRO effort of MUSC Health, the DCI served the clinical staff of the hospital as a communication tool that facilitated greater awareness among staff.

Limitations of the technology used for the DCI in the 2018 winter storm led to an analysis of its vulnerabilities, which determined that, during a phone outage, the DCI call line would not function and was not a reliable means of communication. To overcome this deficiency, MUSC Health reviewed alternative systems that could provide reliably accessible communication for high-volume calls. Cisco Webex, already in use at MUSC Health for online collaboration, was selected as an alternative system on which to conduct the DCI. Webex is a cloud-based collaboration service that includes capabilities for voice over Internet protocol (VOIP), online, and video conferencing. The Webex Audio service allows MUSC Health to include 1000 participants, internal or external callers, in the DCI, thus greatly reducing the likelihood of a responsible leader being unable to report their status. As an existing asset, additional training and costs of using Webex were not required, and the system has worked without issue since being implemented for DCI calls. Though MUSC Health uses Webex, similar products could be used in any organization, including GoToMeeting, Skype, Zoom, among others.