HHS Should Take Actions to Ensure It Has an Adequate Number of Effectively Trained Emergency Responders (GAO-20-525)
Summary
A GAO report to congressional committees, GAO-20-525, dated June 2020, on public health preparedness at the Department of Health and Human Services (HHS). It examines the National Disaster Medical System (NDMS), the main program through which HHS enrolls responders such as doctors and nurses who generally work outside the federal government and serve as intermittent federal employees. GAO notes that HHS deployed NDMS responders for COVID-19 and that NDMS had a shortage of responders during the 2017 hurricanes. It reports that in 2018 HHS developed an enrollment target of 6,290 responders but did not follow key principles in doing so.
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Full text
United States Government Accountability Office
Report to Congressional Committees
PUBLIC HEALTH
June 2020
PREPAREDNESS
HHS Should Take
Actions to Ensure It
Has an Adequate
Number of Effectively
Trained Emergency
Responders
GAO-20-525
June 2020
PUBLIC HEALTH PREPAREDNESS
HHS Should Take Actions to Ensure It Has an
Adequate Number of Effectively Trained Emergency
Highlights of GAO-20-525, a report to
Responders
congressional committees
Why GAO Did This Study What GAO Found
NDMS is the main program through Major natural disasters in the past 3 years, as well as the COVID-19 pandemic,
which HHS enrolls responders to assist have heightened attention to the nation’s ability to respond to these types of
with the federal medical and public emergencies. The Department of Health and Human Services (HHS) is
health response to public health responsible for leading the public health and medical response to emergencies.
emergencies. HHS deploys NDMS HHS responded to COVID-19, in part, by deploying responders enrolled in the
responders to provide, among other National Disaster Medical System (NDMS). These individuals, such as doctors
things, patient care and movement. and nurses, generally work outside the federal government and are federal
During the 2017 hurricanes, NDMS employees used intermittently. In 2018, HHS developed an enrollment target for
had a shortage of responders that NDMS of 6,290 responders, but GAO found HHS did not follow key principles of
resulted in HHS relying on other effective strategic workforce planning in developing this target. For example,
departments, such as the Department HHS did not identify the critical skills and competencies needed of its NDMS
of Defense, to provide medical care. workforce to meet current and future programmatic results. Specifically, HHS’s
As of December 2019, HHS had 3,667 target does not take into consideration three key areas: a workforce capable of
NDMS responders. 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.
The Pandemic and All-Hazards
Preparedness and Advancing
Consequently, HHS cannot be sure its target, if achieved, will provide an
Innovation Act of 2019 included a
adequate number of responders with the skill sets needed to effectively respond.
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.
What GAO Recommends
GAO is making five recommendations
to HHS, including to develop a HHS requires responders to take web-based training prior to deployment, such
workforce target that accounts for the as characteristics of infectious diseases, and also offers optional in-person
critical skills and competencies that are training, such as care delivery in a severe environment. However, HHS’s process
needed to meet current and future to evaluate its training does not align with key practices. As a result, HHS does
programmatic results and to develop not have assurance that it is effectively preparing responders for deployment,
processes for evaluating its training to including keeping them and others safe during an emergency, such as COVID-
ensure an effectively trained workforce. 19. For example, HHS requires a web-based course on donning and doffing
HHS concurred with our personal protective equipment to protect against infectious disease, biological,
recommendations and generally plans and chemical threats. However, HHS does not know the training’s effectiveness
to take action. until responders have deployed; at which point, if ineffective, responders could
potentially expose themselves to hazards. Further, HHS officials state their in-
View GAO-20-525. For more information, person training is most beneficial but more costly to provide, limiting its provision.
contact Mary Denigan-Macauley at (202) 512- A more effective training evaluation process would help the agency determine
7114 or deniganmacauleym@gao.gov. which in-person courses are most beneficial and should be prioritized, or even
made mandatory, for effective and safe responder deployment.
United States Government Accountability Office
Contents
Letter 1
Background 5
ASPR Is Missing Key Steps in Workforce Planning, Limiting
Assurance That It Can Adequately Respond to Public Health
Emergencies 8
ASPR Does Not Have Assurances it is Effectively Training
Responders 16
Conclusions 23
Recommendations 24
Agency Comments and Our Evaluation 24
Appendix I U.S. Public Health Service Commissioned Corps Officers and the
Ready Reserve Corps 26
Appendix II National Disaster Medical System Team Structures 30
Appendix III National Disaster Medical System Optional Training Courses for
Responders 32
Appendix IV Comments from the Department of Health and Human Services 35
Appendix V GAO Contact and Staff Acknowledgements 38
Tables
Table 1: Types of National Disaster Medical System (NDMS)
Responder Teams 6
Table 2. ASPR’s Workforce Target, by National Disaster Medical
System Team Type 8
Table 3: National Disaster Medical System (NDMS)
Preparedness-Related Mandatory Training Web-based
Courses 17
Page i GAO-20-525 HHS Emergency Responders
Table 4. Survey Questions Used To Evaluate National Disaster
Medical System In-person Training 20
Table 5: U.S. Public Health Service Commissioned Corp Officers
Available to Provide Medical Care to Humans During a
Response, by Provider Type 27
Table 6: U.S. Public Health Service Commissioned Corps Officers
Available to Provide Medical Care to Humans During a
Response, by Deployment Team 27
Table 7: Team Structures for Each National Disaster Medical
System Team 30
Table 8: Optional Training Courses for National Disaster Medical
System (NDMS) Responders 32
Page ii GAO-20-525 HHS Emergency Responders
Abbreviations
ASPR Office of the Assistant Secretary for Preparedness and
Response
HHS Department of Health and Human Services
NDMS National Disaster Medical System
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Page iii GAO-20-525 HHS Emergency Responders
Letter
441 G St. N.W.
Washington, DC 20548
June 18, 2020
The Honorable Lamar Alexander
Chairman
The Honorable Patty Murray
Ranking Member
Committee on Health, Education, Labor & Pensions
United States Senate
The Honorable Frank Pallone, Jr.
Chairman
The Honorable Greg Walden
Ranking Member
Committee on Energy & Commerce
House of Representatives
On January 31, 2020, the Secretary of Health and Human Services
declared a public health emergency for the United States to aid the
nation’s health care community to respond to Coronavirus Disease 2019
(COVID-19). 1 On March 11, 2020, the World Health Organization
characterized COVID-19 as a pandemic. Subsequently, on March 13,
2020, the President declared COVID-19 a national emergency under the
National Emergencies Act and an emergency under the Robert T.
Stafford Disaster Relief and Emergency Assistance Act. 2
To aid the response to COVID-19, as of March 27, 2020, the Office of the
Assistant Secretary for Preparedness and Response (ASPR), a division
within the Department of Health and Human Services (HHS), deployed
about 1,200 public health and medical responders through its National
Disaster Medical System (NDMS), according to ASPR officials. These
individuals, such as doctors, nurses, and paramedics, work outside the
federal government on a day-to-day basis and are federal employees
used intermittently to respond to public health emergencies. Some of
these responders deployed to help disembark American citizens who
were potentially infected with COVID-19 aboard cruise ships, including
1The declaration was retroactive to January 27, 2020.
2The President has also approved major disaster declarations under the Robert T.
Stafford Disaster Relief and Emergency Assistance Act for all 50 states, the District of
Columbia, and five territories.
Page 1 GAO-20-525 HHS Emergency Responders
the Diamond Princess in Japan and the Grand Princess in California, to
their quarantine locations in the United States.
ASPR previously deployed these responders to provide surge support as
part of the federal public health and medical response to the 2017
hurricanes affecting Texas, Puerto Rico, Florida, and the U.S. Virgin
Islands. However, we reported in 2019 that during the hurricane
response, ASPR experienced a shortage of NDMS responders and relied
on its federal partners, such as the Department of Defense, to provide
medical response personnel. 3 These events and others have raised
questions about ASPR’s public health and medical responders, including
their capacity to assist during public health emergencies, such as the
COVID-19 pandemic, as well as natural disasters, the number of which
are predicted to rise as the climate changes. 4
ASPR leads the nation’s medical and public health preparedness for,
response to, and recovery from public health emergencies. As part of this
role, ASPR aims to enhance medical surge capacity by organizing,
training, and equipping federal public health and medical responders, as
well as calling upon and deploying these personnel during responses.
The program through which ASPR enrolls responders is NDMS. ASPR
3GAO, Disaster Response: HHS Should Address Deficiencies Highlighted by Recent
Hurricanes in the U.S. Virgin Islands and Puerto Rico, GAO-19-592 (Washington, D.C.:
Sept. 20, 2019).
4According to a 2018 report from the U.S. Global Change Research Program, extreme
weather and climate-related events are expected to increase in frequency and intensity.
U.S. Global Change Research Program, Impacts, Risks, and Adaptation in the United
States: Fourth National Climate Assessment, Volume II (Washington, D.C.: 2018). We
have also reported that the number of disasters and the reliance on the federal
government for disaster assistance will likely continue to rise as the climate changes.
GAO, Climate Change: Information on Potential Economic Effects Could Help Guide
Federal Efforts to Reduce Fiscal Exposure, GAO-17-720 (Washington, D.C.: Sept. 28,
2017). Managing fiscal exposure due to climate change has been on our high-risk list
since 2013, in part, because of concerns about the increasing costs of disaster response
and recovery efforts. See GAO, High-Risk Series: Substantial Efforts Needed to Achieve
Greater Progress on High-Risk Areas, GAO-19-157SP (Washington, D.C.: March 6,
2019); also
http://www.gao.gov/highrisk/limiting_federal_government_fiscal_exposure/why_did_study.
Page 2 GAO-20-525 HHS Emergency Responders
may activate NDMS to deploy medical providers, evacuate patients, and
provide veterinary services, among other supports. 5
The Pandemic and All-Hazards Preparedness and Advancing Innovation
Act of 2019 included a provision for GAO to review the federal medical
provider surge capacity in the event of a public health emergency. 6 This
report examines
1. ASPR’s workforce planning for its medical and public health
responders to assist with public health emergencies, and
2. ASPR’s evaluation of, and planning for, the training it provides to its
medical and public health responders.
To examine ASPR’s workforce planning for its medical and public health
responders to assist with public health emergencies, we reviewed ASPR
documentation and interviewed ASPR officials involved with workforce
planning for, and hiring of, NDMS responders. Specifically, we reviewed a
June 2018 staffing decision memo signed by the Assistant Secretary for
Preparedness and Response outlining ASPR’s target for NDMS
enrollment—referred to as the NDMS workforce target for the purposes of
this report. We reviewed NDMS team structures that the agency
developed in March 2018, which include position types and numbers of
responders in each position. We also reviewed direct-hire authorities HHS
received to hire NDMS responders. 7 Further, we collected and analyzed
ASPR data on the number of enrolled NDMS responders. We assessed
the reliability of these data by comparing them to data in other sources,
such as agency budget justifications, interviewing knowledgeable agency
5Under 42 U.S.C. § 300hh-11, NDMS may be activated to provide health services, health-
related social services, other appropriate human services, and appropriate auxiliary
services to respond to the needs of victims of a public health emergency. ASPR may also
activate NDMS in a location that is at-risk of an emergency.
6Pub. L. No. 116-22, § 301(e), 133 Stat. 905, 933-34.
7A direct-hire authority is generally provided to federal agencies when a critical hiring need
or severe shortage of candidates exists to expedite hiring by eliminating competitive rating
and ranking, among other competitive appointment procedures. HHS received a direct
hiring authority for NDMS that ran from February 9, 2018, to November 6, 2018, as part of
the Bipartisan Budget Act of 2018. Pub. L. No. 115-123, § 20803, 132 Stat. 64, 95. The
Bipartisan Budget Act of 2018 made supplemental appropriations to aid the response to
the 2017 hurricane season. HHS received another direct hiring authority as part of the
Pandemic and All-Hazards Preparedness and Advancing Innovation Act of 2019. Pub. L.
No. 116-22, § 301(a)(3), 133 Stat. 932 (codified at 42 U.S.C. § 300hh-11(c)(4)). This direct
hire authority began on June 24, 2019 and ends on September 30, 2021.
Page 3 GAO-20-525 HHS Emergency Responders
officials, and performing checks of the data for consistency and
completeness. Based on these steps, we found these data to be reliable
for our reporting purposes. Lastly, we interviewed ASPR officials to gather
information on the capacity factors they considered when establishing the
NDMS workforce target and the related workforce planning the agency
has conducted. We also interviewed officials from HHS’s Staffing
Recruitment and Operations Center—the office that conducts all hiring
actions on behalf of ASPR and certain other HHS divisions—to gather
information on the planning and hiring process for NDMS responders.
We assessed ASPR’s workforce planning against key principles of
strategic workforce planning that we have identified in previous work,
focusing our analysis on those principles that are related to determining
current and future workforce needs and establishing strategies to fulfill
those needs. 8 This was a general all-hazards assessment of ASPR’s
workforce planning and not specific to a single event. In addition to
NDMS, the U.S. Public Health Service—an agency within HHS—can also
deploy Commissioned Corps officers as a means to help surge during a
medical and public health response to an emergency or disaster. 9 We did
not assess the workforce planning of the Public Health Service because
the agency is in the process of reorganizing its workforce. This includes
plans for implementing a Ready Reserve Corps, which like NDMS, would
consist of intermittent employees who could be called-up as needed. For
more information on these plans, as well as the number of U.S. Public
Health Service Commissioned Corps officers available to provide medical
and public health care to humans during a response, see appendix I.
To examine ASPR’s evaluation of, and planning for, the training provided
to its responders, we reviewed ASPR’s current NDMS training catalog,
which covers fiscal years 2017-2019 and its draft NDMS training catalog,
which the agency plans to implement for fiscal years 2020-2024 but had
not yet implemented at the time of our review. These training catalogs
describe mandatory and optional NDMS training courses. We also
8GAO, Human Capital: Key Principles for Effective Strategic Workforce Planning,
GAO-04-39 (Washington, D.C.: Dec 11, 2003).
9Commissioned Corps officers may be deployed to respond to an urgent or emergency
public health care need arising from (1) a national emergency declared by the President
under the National Emergencies Act; (2) an emergency or major disaster declared by the
President under the Robert T. Stafford Disaster Relief and Emergency Assistance Act; (3)
a public health emergency declared by the Secretary of Health and Human Services
under the Public Health Service Act; or (4) any emergency that is appropriate for
deployment, as determined by the Secretary of Health and Human Services. See 42
U.S.C. §§ 204a(a)(5) and 215(e).
Page 4 GAO-20-525 HHS Emergency Responders
compared ASPR documentation on the number of optional training
courses the agency had planned to provide in fiscal year 2019 against
documentation of courses actually provided in that year. Further, we
analyzed ASPR’s efforts to evaluate its training. This included a review of
the survey questions ASPR provides to training participants to evaluate
the training they have received. Lastly, we interviewed ASPR officials who
oversee NDMS training. We assessed ASPR’s planning and evaluation of
NDMS responder training against GAO-identified key practices for
effective training programs and key principles of strategic workforce
planning. 10
We conducted this performance audit from July 2019 to June 2020 in
accordance with generally accepted government auditing standards.
Those standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our
findings and conclusions based on our audit objectives. We believe that
the evidence obtained provides a reasonable basis for our findings and
conclusions based on our audit objectives.
Background
Medical and public health As of December 9, 2019, ASPR had 3,667 enrolled NDMS responders.
responders These responders include physicians, nurses, and paramedics, among
other professions, who generally work outside of the government but may
be asked to deploy to assist with a federal public health emergency. 11
Because these individuals have regular jobs, they may not always be
available to deploy. For example, if a response occurs in a state, NDMS
responders in that state may already be assisting the response through
their civilian jobs, such as through working in hospitals, hindering their
ability to deploy.
NDMS responders are organized into five types of NDMS teams. Two of
these types—the Disaster Medical Assistance Team and the Trauma and
Critical Care Team—are primarily composed of medical providers and
focus on providing public health and medical care to individuals during a
10See GAO, Human Capital: A Guide for Assessing Strategic Training and Development
Efforts in the Federal Government (Supersedes GAO-03-893G), GAO-04-546G
(Washington, D.C.: Mar. 1, 2004) and GAO-04-39.
11According to agency officials, responders are federal employees used intermittently and
are entitled to the same liability and workforce protections offered to full-time federal
employees when deployed due to their positions as intermittent federal employees.
Page 5 GAO-20-525 HHS Emergency Responders
response. The other three types of teams are the Disaster Mortuary
Operational Response Team, the Victim Information Center Team, and
the National Veterinary Response Team. See Table 1 for a description of
each type of team and number of responders enrolled in each.
Table 1: Types of National Disaster Medical System (NDMS) Responder Teams
Number of
NDMS Team Name Team Description respondersa
Disaster Medical Provide patient care to help area health systems during a response. 2,703
Assistance Team Responders include advanced clinicians (nurse practitioners/physician
assistants), physicians, registered nurses, respiratory therapists, paramedics,
pharmacists, safety specialists, logistical specialists, information technologists,
and communication and administrative specialists.
Trauma and Critical Care Provide critical, operative, and emergency care to help people during a 212
Team response. Responders are medical professionals with expertise in trauma care.
Disaster Mortuary Identify victims and support local mortuary services. Responders include funeral 611
Operational Response directors, medical examiners, pathologists, forensic anthropologists, fingerprint
Team specialists, forensic odonatologists, dental assistants, administrative specialists,
and security specialists.
Victim Information Center Support local authorities and other NDMS teams in the aftermath of a mass 51
Team casualty event and may serve as liaison to victims’ families. Responders, who
include forensic dental officers, pathologists, and victim advocates, collect ante-
mortem data, such as pictures, fingerprints, dental X-rays, and other medical
records, to help identify the victims.
National Veterinary Provide veterinary care to working animals, such as search and rescue dogs, 90
Response Team during disasters and certain national security events. Responders include
veterinarians, animal health technicians, epidemiologists, safety specialists,
logisticians, communications specialists, and other support personnel.
Total 3,667
Source: GAO summary of data and information from the Office of the Assistant Secretary for Preparedness and Response. | GAO-20-525
Note:
a
Data as of December 9, 2019.
Workforce planning and We have previously reported that high-performing public organizations
training have found that maintaining a quality workforce requires them to
systematically assess current and future workforce needs and formulate a
long-term strategy to attract, retain, develop, and motivate employees. 12
While simple in theory, strategic workforce planning can be difficult to
carry out. Agencies must, for example, acquire accurate information on
the workforce, including assessing the workforce’s ability to assist with
mission achievement. Further, agencies must have the internal
12GAO, Veterinarian Workforce: Actions Are Needed to Ensure Sufficient Capacity of
Protecting Public and Animal Health, GAO-09-178 (Washington, D.C.: February 4, 2009).
Page 6 GAO-20-525 HHS Emergency Responders
capabilities to support strategic workforce planning activities. According to
our previous work, strategic workforce planning should involve certain key
principles that agencies should address, irrespective of the context of the
workforce planning. Among these principles are the need to align
workforce requirements with agency-wide goals and objectives, identify
critical skills and competencies the workforce needs to meet current and
future programmatic results, and develop strategies to fill identified gaps
in these skills. Effective strategic workforce planning enables an agency
to remain aware of, and be prepared for, its current, emerging, and future
needs as an organization. 13
We have also reported that strategic workforce planning includes the
training and development of the workforce to eliminate gaps and improve
the contribution of critical skills and competencies needed for mission
success. 14 Agencies need to ensure that training provided is strategically
targeted and not wasted on efforts that are irrelevant, duplicative, or
ineffective. Effective training and development programs are an integral
part of a learning environment that can enhance the federal government’s
ability to attract and retain employees with the skills and competencies
needed to achieve results for the benefit of the American people.
According to our previous work, key practices for effective training
programs involve evaluating training, such as using measures of (1)
training participants’ reaction to, and satisfaction with, the training
program and (2) changes in participants’ knowledge, skills, abilities, and
on-the-job behavior. Key practices also include planning for training, such
as prioritizing training around funding so that an agency can address its
most important training needs first. 15
13GAO-04-39
14GAO-04-546G
15GAO-04-546G
Page 7 GAO-20-525 HHS Emergency Responders
ASPR has not conducted key workforce planning steps for its NDMS
ASPR Is Missing Key responder workforce, and as a result, has limited assurance that it is
Steps in Workforce adequately prepared to respond to public health emergencies. While
ASPR has performed some workforce planning, the agency’s efforts do
Planning, Limiting not follow the strategic principles that we have identified in prior work as
Assurance That It essential for effective workforce planning.
Can Adequately Specifically, ASPR’s primary workforce planning efforts focused on
Respond to Public developing an NDMS workforce target of 6,290 responders. ASPR data
shows that it had reached a little more than half of this target, with 3,667
Health Emergencies responders enrolled in NDMS as of December 2019. According to ASPR
officials, this workforce target represents the number of responders the
agency estimates it needs to enroll in NDMS to position itself to effectively
respond to public health emergencies.
ASPR generated this target in June 2018 by multiplying the number of
NDMS teams it had at that time by the number of responders planned for
each of the five NDMS team types, using NDMS team structures that
ASPR developed in March 2018—which include position types and
numbers of responders in each position. (See appendix II for the NDMS
team structures for each of the five NDMS team types.) See Table 2 for
ASPR’s workforce target for each of the five NDMS team types.
Table 2. ASPR’s Workforce Target, by National Disaster Medical System Team Type
Number of Workforce target = number
Number of teams as responders ASPR of teams x number of
Team type of June 2018 would like, per team responders per team
Disaster Medical Assistance Team 57 85 4,845
Trauma and Critical Care Team 3 118 354
Disaster Mortuary Operational Response Team 10 86 860
Victim Identification Team 1 52 52
National Veterinary Response Team 1 179 179
Total 6,290
Source: GAO summary of documentation collected from the Office of the Assistance Secretary for Preparedness and Response (ASPR). | GAO-20-525
However, we found that by using this process to determine its workforce
needs, ASPR has limited assurance that reaching its NDMS workforce
target will be adequate to allow the agency to respond effectively to public
health emergencies. This is because, when setting its target, ASPR has
not followed two key principles of strategic workforce planning: aligning
workforce requirements with agency-wide goals and objectives, and
identifying critical skills and competencies the workforce needs to meet
Page 8 GAO-20-525 HHS Emergency Responders
current and future programmatic results. Further, even if ASPR’s target is
adequate, its ability to achieve this target is limited, because ASPR has
not followed a third key strategic workforce planning principle: developing
strategies to fill identified gaps in these skills. These key principles are
described below, along with an assessment of ASPR’s efforts.
Alignment between ASPR’s According to key principles of effective workforce planning, the process
NDMS workforce target and begins with an agency setting a strategic direction and aligning its
APSR’s agency-wide goals workforce requirements with agency-wide goals and objectives. However,
and objectives has been we found that the extent to which ASPR aligned its NDMS workforce
limited. target with APSR’s agency-wide goals and objectives has been limited,
because the agency has not had a strategic plan with specific objectives
since 2016. According to agency officials, the prior strategic plan expired
while the agency was under an acting Secretary, and development of a
new strategic plan led by the current Assistant Secretary for
Preparedness and Response, who began his role in August 2017, has
been delayed due to events, such as the 2017 hurricanes. Agency
officials told us that they had planned to release a strategic plan in April
2020, but at the time this report was being prepared to be published,
ASPR’s strategic plan had not yet been released.
In lieu of a strategic plan, ASPR officials told us that they aligned the
NDMS workforce target with four broad guiding priorities published on
ASPR’s website: (1) providing strong leadership, (2) building a regional
disaster health response system, (3) sustaining public health security
capacity, and (4) enhancing the medical countermeasure enterprise. 16
However, officials provided conflicting information regarding where NDMS
responders fit within ASPR’s four priorities. When we asked program
officials who oversee NDMS where the program falls within these
priorities, these officials told us that NDMS was associated with priority 1
– providing strong leadership, and indirectly related to priority 2 – building
a regional disaster health response system. ASPR officials in the Office of
Strategy, Policy, Planning and Requirements told us that NDMS falls
under priority 2. ASPR officials told us that this misalignment occurred
because leadership developing the agency-wide strategic plan had not
informed the NDMS program officials of where NDMS fell within the
priorities.
16ASPR, ASPR Mission and Priorities, accessed April 24, 2020,
https://www.phe.gov/about/aspr/Pages/About-ASPR.aspx.
Page 9 GAO-20-525 HHS Emergency Responders
In March 2020, ASPR officials provided us with a draft version of the
agency’s forthcoming strategic plan. In this draft plan, ASPR lists the
following four priority goals, which are similar to those the agency has
been operating under, albeit in a different order: (1) foster strong
leadership, (2) sustain a robust and resilient public health security
capacity, (3) advance an innovative medical countermeasure enterprise,
and (4) build a regional disaster health response system. From reviewing
this plan, it is clear that NDMS falls within priority 4 – building a regional
disaster health response system, as one of the objectives is “modernize
NDMS.” However, NDMS also falls within an objective under priority 2,
“strength response and recovery operations,” as well as an objective
under priority 1, “lead adaptive planning and emergency repatriation
efforts.” In finalizing this strategic plan, aligning the NDMS workforce
target with ASPR goals and objectives would help ensure mission clarity
and accountability. Without such an NDMS workforce target, ASPR risks
being unable to fulfill its role as the lead agency for public health
emergencies, which includes the ability to sufficiently enhance medical
surge capacity during a response.
ASPR’s NDMS workforce According to key principles of effective workforce planning, an agency
target did not adequately should identify the critical skills and competencies needed of its workforce
identify critical skills and that will position it to meet current and future programmatic results. The
competencies needed to meet NDMS team structures that ASPR developed in March 2018 broadly
current and future cover emergency response needs for medical and public health care by
programmatic results. including position types and number of responders needed in each
position.
However, ASPR’s process for calculating its responder workforce target
did not take into consideration three key workforce factors: specifically, 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, all of which would help determine
the NDMS workforce skills and competencies needed to meet current and
future programmatic results.
• Number of responders needed for a nationwide event or multiple
concurrent events. ASPR did not consider the number of responders
projected to be needed to respond to multiple or concurrent events,
such as the 2017 hurricanes, or a national event, such as an
infectious disease outbreak, when developing the NDMS workforce
target. This is notable given that during the 2017 hurricane season,
we found that ASPR experienced a shortage of NDMS responders,
which contributed to a reliance on the Department of Defense to
Page 10 GAO-20-525 HHS Emergency Responders
provide essential public health and medical service functions. 17 We
reported that during such situations, the Department of Defense may
be responding to other events and its capacity to assist ASPR’s
response to a public health emergency may be limited. Therefore, we
recommended that ASPR develop a strategy to demonstrate how the
agency can provide a public health and medical services response if
the Department of Defense’s capacity to respond is limited. ASPR
agreed with this recommendation but has not yet taken action to
implement it. Further, according to the National Response
Framework, the unprecedented scale of recent disasters highlights
the need for further progress to build resilient capabilities to respond
to disasters of increasing frequency and magnitude. 18 For example, at
the time of this report, HHS is responding to the COVID-19 pandemic
nationwide and the National Oceanic and Atmospheric Administration
has predicted that the 2020 Atlantic hurricane season will be more
active than usual. 19
• Types of responders needed to care for at-risk individuals. ASPR did
not consider the responder types needed to care for at-risk
individuals, such as children, the elderly, pregnant women, or
individuals with chronic health conditions when developing the
workforce target. 20 ASPR officials stated that this is not needed
because NDMS responders provide medical stabilization to patients
and move the patients to another facility for care, if required. 21
However, the agency’s fiscal year 2020 budget justification stated that
17GAO-19-592.
18Department of Homeland Security, National Response Framework, Fourth Edition
(Washington, D.C: Oct. 28, 2019).
19National Oceanic and Atmospheric Administration, Busy Atlantic hurricane season
predicted for 2020, accessed May 21, 2020, https://www.noaa.gov/media-release/busy-
atlantic-hurricane-season-predicted-for-2020.
20Under 42 U.S.C. § 300hh-1(b)(4)(B), “the term ‘at-risk individual’ means children,
pregnant women, senior citizens, and other individuals who have access or functional
needs in the event of a public health emergency, as determined by the Secretary [of
Health and Human Services].” The Secretary includes individuals with communication,
chronic health, and behavioral health needs, among others, in the definition of at-risk
individuals during an emergency or disaster.
21While not specific to the workforce target, ASPR officials stated that they have in the last
year given consideration to at–risk populations by, for example, working with organizations
that take care of these populations, using subject matter experts for training on Acute
Respiratory Infections in these population, and specific to children, working with the
International Pediatric Association.
Page 11 GAO-20-525 HHS Emergency Responders
ASPR had identified existing shortfalls in pediatric care during
disasters, including trauma and critical care provided by NDMS. Our
prior work in this area also showed that at-risk individuals were a key
population requiring medical care during the 2017 hurricanes. 22
Further, ASPR is required to take steps to ensure that NDMS includes
an appropriate specialized and focused range of responder
capabilities, which take into account the needs of at-risk individuals
during a public health emergency. 23
• Number of U.S. Public Health Service Commissioned Corp officers
available to provide medical and public health care. ASPR did not
consider the U.S. Public Health Service Commissioned Corps officers
or their capabilities when developing the NDMS workforce target,
although these officers are available to assist with emergencies and
disasters. 24 As a result, ASPR’s NDMS workforce target may be too
high or low (or targeting the wrong positions), depending on the
number and type of officers able to provide medical and public health
care. While commenting on a draft of this report, ASPR officials stated
that Commissioned Corps officers primarily serve in administrative
roles when deployed or, at best, support basic medical care.
However, in recent years, Commissioned Corps officers have played
an important response role. For example, the U.S. Public Health
Service Commissioned Corps provided assistance during the 2017
hurricanes public health and medical services response by providing
support such as managing evacuated patients. Additionally, during the
ongoing COVID-19 pandemic, the Assistant Secretary for
Preparedness and Response stated that the U.S. Public Health
Service Commissioned Corps has been an important asset during the
response. 25 According to U.S. Public Health Service officials,
Commissioned Corps officers have assisted with the return of
American citizens from China and Japan, airport screenings to
monitor the health of travelers, and providing clinical care surge
capacity in nursing facilities and field hospitals, among other COVID-
22See GAO-19-592 and GAO, Disaster Assistance: FEMA Action Needed to Better
Support Individuals Who Are Older or Have Disabilities, GAO-19-318 (Washington, D.C.:
May 14, 2019).
23See 42 U.S.C. § 300hh-11(a)(3)(C).
24See Appendix I for more information on the U.S. Public Health Service Commissioned
Corps officers available to assist during a federal emergency or disaster.
25CQ Congressional Transcripts, House Oversight and Reform Committee Holds Hearing
on Coronavirus Preparedness and Response, Part 2, accessed March 31, 2020,
https://plus.cq.com/doc/congressionaltranscripts-5859788?2.
Page 12 GAO-20-525 HHS Emergency Responders
19 response activities. Further, ASPR officials told us they may rely
on the U.S. Public Health Service Commissioned Corps’ mental
health team for the care of individuals with behavioral and mental
health needs during a response, making it all the more important that
they consider their capabilities.
Regarding the U.S. Public Health Service Commissioned Corps and its
relationship to the NDMS workforce target, ASPR officials originally stated
that the agency does not have assurance that U.S. Public Health Service
Commissioned Corps officers will be able to deploy quickly. As we
described in the above paragraph, ASPR officials later commented that
Commissioned Corps officers mostly support administrative requirements.
With respect to the other critical workforce factors we identified, ASPR
officials acknowledged that the agency did not consider these factors
when developing the NDMS workforce target, and officials could not
provide detailed information as to why they were not considered. For
example, beyond building in redundancy to allow for responder availability
(e.g., a Disaster Medical Assistance Team deploys with 35 responders,
so each team is assigned 85 positions), officials could not tell us how they
reached the number of positions for each type of team. Officials stated
that to develop the NDMS team structures in the spring of 2018, they
used Concept of Operations for each NDMS team type, as well as the
Federal Emergency Management Agency’s pre-scripted mission
assignments, but did not provide further detail on how they used these
documents. 26 Our analysis of these documents found that the documents
do not align, so it is unclear how they were considered or used to develop
ASPR’s NDMS workforce target. For example, the pre-scripted mission
assignments referred to team names and team sizes that were not
included in the Disaster Medical Assistance Team concept of operations,
and vice versa.
Nevertheless, the draft version of the agency’s forthcoming strategic plan
we received in March 2020, identifies the aforementioned workforce
26The Concept of Operations addresses the mission and role of each NDMS team,
deployment configurations, the team structure, requirements for team employees,
operations during steady states and active states, and expectations of a deployment
environment. According to Federal Emergency Management Agency officials, pre-scripted
mission assignments are created prior to an incident to expedite the processing of a
mission assignment once it is required. These mission assignments are created for
capabilities that involve known or frequently used resources for services, such as logistics,
communications, health care, and public safety. The National Response Framework
establishes a response structure to coordinate federal resources during emergencies and
disasters. Department of Homeland Security, National Response Framework, Fourth
Edition (Washington, D.C., October 2019).
Page 13 GAO-20-525 HHS Emergency Responders
factors as important for future consideration. For example, it states that
the agency plans to review the NDMS program to identify gaps in
specialty care skills, capacity, training, and readiness to respond to
multiple, simultaneous events, and national-level public health
emergencies. The draft plan also states that medical surge capacity may
be further supported through improved alignment across multiple groups
of health care professionals, including the U.S. Public Health Service
Commissioned Corps. While the draft strategic plan does not mention the
development of a revised NDMS workforce target, ASPR’s
acknowledgement that these are important factors to consider is an
important step forward. However, ASPR still needs to finalize its strategic
plan, take specific actions to implement its plans to review these three
key factors, and then adjust its workforce target accordingly.
Without an NDMS workforce target that considers the critical skills and
competencies that are needed to meet current and future programmatic
results—such as 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—ASPR risks having
an NDMS responder workforce target that is inadequate. For example,
one that is too low, is redundant of other responders and therefore could
be too high, or has gaps, such as a workforce that is unable to effectively
care for all individuals affected by a public health emergency, as occurred
during ASPR’s response to the 2017 hurricanes.
ASPR has not developed According to key principles of effective workforce planning, once an
strategies to fill identified agency has identified the critical skills and competencies needed of its
workforce, the agency should then develop strategies to address gaps in
gaps in critical skills to
the number, skills, and competencies of its workforce. Although we
achieve an NDMS believe ASPR still needs to adequately identify the critical skills and
workforce target. competencies needed and related gaps of its NDMS workforce, the
agency is operating under a current NDMS workforce target of 6,290.
However, as of December 2019, ASPR was not close to this target—
having 3,667 responders enrolled in NDMS—and we found the agency
has not developed specific strategies to drive hiring and fill its NDMS
workforce gaps to reach its target.
ASPR officials told us that their hiring plan consisted of prioritizing NDMS
job postings by posting those of high-priority first rather than posting them
all at once. ASPR officials also stated they planned to implement a direct-
hire authority, enacted in February 2018, by hiring as many NDMS
Page 14 GAO-20-525 HHS Emergency Responders
responders as possible to meet the NDMS workforce target. 27 According
to the Office of Personnel Management’s website, the purpose of a direct-
hire authority is to expedite hiring by eliminating some of the steps
required for federal hiring. 28
We found that there have been no other strategies or specific
intermediate goals for hiring and filling gaps to achieve its current NDMS
workforce target. For example, intermediate goals could include
milestones detailing the number of responders the agency aims to hire
per month, taking into account any hiring resource constraints in order to
establish a realistic timeline for completing all hiring, as well as establish
an indicator by which they can measure progress. The lack of more
detailed strategies may have contributed to the slow hiring that ASPR is
currently facing. For example, as of March 2020, some NDMS responders
were still going through the hiring process more than 16 months after they
received offers from job postings made under the direct-hire authority.
Neither ASPR officials nor officials from HHS’s Staffing Recruitment
Operations Center (the agency within HHS that conducts all hiring actions
on behalf of ASPR) could tell us when hiring will be completed. 29 Further,
when asked about a plan or strategy to drive hiring under a second direct-
hire authority enacted in June 2019, ASPR officials stated that they had
started a draft plan. However, they put a hold on further plan development
until the hiring under the first direct-hire authority is completed. As of
March 18, 2020, 163 of the 1,447 individuals who accepted job offers
under this first direct-hire authority are still in the process of being hired,
according to ASPR officials.
Further, we found that ASPR is using a 2-year term appointment to hire
all of the 1,447 responders under the first direct-hire authority. Because of
this decision, Staffing Recruitment Operations Center officials told us that
27ASPR has received two direct-hire authorities for NDMS. The first was enacted as part
of the Bipartisan Budget Act of 2018, and ran from February 9, 2018 to November 5,
2018. Pub. L. No. 115-123, § 20803, 132 Stat. 64, 95. The second was enacted as part of
the Pandemic and All-Hazards Preparedness and Advancing Innovation Act of 2019 and
runs from June 24, 2019 to September 30, 2021. Pub. L. No. 116-22, § 301(a)(3), 133
Stat. 905, 932 (codified at 42 U.S.C. § 300hh-11(c)(4)).
28Office of Personnel Management, Hiring Information Direct Hire Authority Fact Sheet,
accessed April 3, 2020, https://www.opm.gov/policy-data-oversight/hiring-
information/direct-hire-authority/#url=Fact-Sheet.
29Staffing Recruitment Operations Center officials stated that the center is one of nine
human resource centers within HHS, which provides human resources services to HHS
agencies that do not have a human resource center, including ASPR.
Page 15 GAO-20-525 HHS Emergency Responders
these responders will further burden hiring efforts because they will need
to undergo an additional human resources action 2 years after they are
hired to renew their appointment for an additional 2-year term. According
to the job posting, the term appointment lasts for 2 years and may be
extended for another 2 years, for a total of 4 years. If ASPR still has a
need for these responders, they will have to rehire for these positions
after 4 years. If hired under an indefinite term appointment, as was
previously used to hire NDMS responders, this would have allowed these
responders to serve for an indefinite amount of time. While officials stated
that they will use an indefinite term position for hires under the second
direct-hire authority, neither Staffing Recruitment Operations Center nor
ASPR officials could tell us how they made the decision to use a 2-year
term appointment for the first direct-hire authority. Officials from both
agencies stated that the decision came from the other agency, further
exemplifying a lack of strategies.
In the draft strategic plan provided to us, ASPR states that the agency
wants to develop and launch a program to actively recruit medical
professionals into NDMS, though there are no specifics included in the
plan on how this will be achieved. It will be important for ASPR to develop
specific plans. Without strategies to fill gaps to achieve an NDMS
workforce target, ASPR continues to risk being unable to provide
adequate numbers and types of NDMS responders to effectively respond
to public health emergencies. It also risks not being able to take full
advantage of the direct-hire authority that expires in September 2021.
ASPR requires NDMS responders to take introductory web-based training
ASPR Does Not Have courses to be eligible for deployment. It also offers in-person training,
Assurances it is which ASPR officials state is most beneficial for deployment
preparedness but also more costly to provide. However, the agency does
Effectively Training not sufficiently evaluate the quality or effectiveness of its training in
Responders preparing responders. Further, ASPR does not have a process or
approach for establishing priorities among its in-person training courses.
ASPR Requires Web- ASPR requires NDMS responders to take introductory web-based training
Based Training and Also courses to be eligible for deployment. Specifically, ASPR requires
responders to complete seven web-based training courses that are
Offers In-Person Training,
Which It Considers Most
Beneficial, but Also More
Costly to Provide
Page 16 GAO-20-525 HHS Emergency Responders
specific to preparedness to be eligible for deployment. 30 Many of these
courses are required once in an NDMS responder’s career. ASPR
officials stated that these mandatory courses are intended to be a simple
introduction to the topic areas, and the web-based aspect allows them to
require these courses without incurring a large cost to the agency.
In recent years, ASPR has increased the number of mandatory courses
specific to preparedness. For example, in fiscal year 2019, ASPR added
five web-based video courses, many of which ASPR added per an
identified need for more training specific to an infectious disease
response, according to officials. In addition, based on a draft catalog of
NDMS training courses for fiscal years 2020-2024, the agency plans to
add an additional five courses, many of which are web-based courses
provided by the Federal Emergency Management Agency, but as of
March 2020, ASPR officials did not know when they would implement this
training. See Table 3 for a description of the seven preparedness-related
mandatory training courses, as well as the additional five that ASPR plans
to add, including the frequency they are required to be taken.
Table 3: National Disaster Medical System (NDMS) Preparedness-Related Mandatory Training Web-based Courses
Fiscal Frequency of
year required course
Training course added Course description completion
Psychological First Aid 2017 Introduces the concepts of Psychological First Aid and workforce Every 3 years
Training resilience and prepares personnel to provide compassionate care
and emotional support during emergencies and disasters.
Safety 101 Training 2018 Provides initial safety training generally applicable to all responders Once in a
to meet Department of Labor Occupational Safety and Health responder’s
Administration requirements and enhance deployment safety. career
Pathogens of Concern 2019 Provides NDMS responders information about the characteristics of Once in a
infectious diseases, specific pathogens and the diseases they responder’s
cause, as well as how to recognize the signs and symptoms of career
disease to determine appropriate protection measures.
Personal Protective Equipment 2019 Introduces the process of safely donning and doffing level C Once in a
Donning and Doffing personal protective equipment providing chemical and biological responder’s
protections to minimize exposure to hazards while providing care career
and support during disasters and public health emergencies.a
30In addition to these seven, NDMS responders must also take five other mandatory
courses that are general courses required by HHS: 1) Cybersecurity Training, 2) Ethics for
Special Government Employees, 3) Ethics for OGE-450 Filers, 4) HHS Travel Charge
Card, and 5) Sexual Harassment Prevention for Employees. Additionally, certain NDMS
responders involved in patient movement must take a just-in-time refresher course on
HHS’s Joint Patient Assessment and Tracking System—a patient evacuation tracking
system—as needed.
Page 17 GAO-20-525 HHS Emergency Responders
Fiscal Frequency of
year required course
Training course added Course description completion
Personal Protective Equipment 2019 Trains responders to identify and utilize different types of personal Once in a
Selection, Regulations, and protective equipment and respirators while following federal responder’s
Limitations regulations, as well as how to recognize possible limitations of use. career
Strategic National Stockpile 2019 Provides a look at available resources, supplies, and equipment for Once in a
Overview emergency logistics and planning purposes. responder’s
career
Weapons of Mass 2019 Provides an all-hazards approach to hazardous material incidents, Once in a
Destruction/Terrorism including acts of terrorism where weapons of mass destruction responder’s
Awareness for Emergency materials may have been used. career
Responders
Bloodborne Pathogens Planned Provides training on bloodborne pathogen incidents in the workplace Annually
Training consistent with Occupational Safety and Health Administration
regulation 29 C.F.R. § 1910.1030.
Federal Emergency Planned Describes the history, features, principles, and organizational Once in a
Management Agency structure of the Incident Command System and provides the responder’s
Introduction to the Incident foundation for higher level Incident Command System training.b career
Command System
Federal Emergency Planned Reviews the Incident Command System, provides the context for Once in a
Management Agency Incident Incident Command System within initial response, and supports responder’s
Command System for Single higher level Incident Command System training. career
Resources and Initial Action
Incidents
Federal Emergency Planned Provides learners with a basic understanding of the National Incident Once in a
Management Agency National Management System concepts, principles, and components.c responder’s
Incident Management System, career
An Introduction to the National
Incident Management System
Federal Emergency Planned Introduces participants to the concepts and principles of the National Once in a
Management Agency National Response Framework, and its application in actual response responder’s
Response Framework, An situations.d career
Introduction
Source: GAO summary of Office of the Assistant Secretary for Preparedness and Response’s NDMS training documentation. | GAO-20-525
Notes:
a
Level C protection is used when the type and concentration of an airborne substance is known, the
criteria for using air-purifying respirators has been met, and skin and eye exposure is unlikely.
b
The Incident Command System is the organizational management system designed to enable
effective and efficient domestic incident management by integrating a combination of facilities,
equipment, personnel, procedures, and communications operating within a common
organizational structure.
c
The National Incident Management System is the comprehensive approach guiding the whole
community—all levels of government, nongovernmental organizations, and the private sector—to
work together seamlessly to prevent, protect against, mitigate, respond to, and recover from the
effects of incidents.
d
The National Response Framework is an all-hazards response structure to coordinate federal
resources during emergencies and disasters. It divides the federal response into 15 emergency
support functional areas that are most frequently needed during a national response.
Page 18 GAO-20-525 HHS Emergency Responders
In addition to the required web-based courses, ASPR also provides in-
person training courses. ASPR officials told us that the agency’s in-
person training courses are the most beneficial, but they cannot require or
offer as many in-person training courses as they would like, due to budget
constraints and the cost of in-person courses relative to the web-based
mandatory courses. Officials stated that in-person courses are most
beneficial since they are more detailed than web-based courses and
allow responders to more fully understand topics important for
deployment. For example, ASPR brings responders together to be taught
by a live instructor, and in some courses, practice using response
equipment. Further, some of the courses are exercise-based so
responders can practice their role in a simulated real-world scenario.
However, these courses are more expensive to offer. ASPR officials
explained, for example, that for in-person training, ASPR compensates
the instructors and responders for the time they are participating in the
training, as well as pays the travel costs of the responders to the training
site, such as flights and hotel costs. See appendix III for the 22 NDMS in-
person training courses and their description, as well as those offered in
fiscal year 2019.
Our review of ASPR documentation shows that in fiscal year 2019, ASPR
provided at least one offering of 14 of the 22 in-person training courses
listed in its training catalog. For example, in fiscal year 2019, ASPR
offered six Disaster Medical Assistance Team 101 trainings, each
designed to provide up to 42 responders hands-on experience for
delivering care to a diverse group of patients in a severe environment,
including the appropriate use of equipment and supplies, among other
topics. ASPR also offered 20 Isolation, Simulation, Quarantine trainings,
each designed to teach up to 20 responders how to safely care for
patients with highly hazardous communicable diseases in both health
care and more austere environments, implement controls to curb the
spread of disease, and contain accidental exposure to contamination,
among other topics.
ASPR Does Not We found that ASPR does not sufficiently evaluate the quality or
Sufficiently Evaluate Its effectiveness of its training in preparing NDMS responders. This is
because the agency lacks a process focused on evaluating both its web-
Training’s Effectiveness in
based and in-person training. Instead, ASPR’s process is to send an
Preparing Responders email with a link to a survey to responders who participate in the in-
person training or those who deploy to real-world events, which would
include those who received the required web-based training. The survey
is optional. (See Table 4 for the four standard questions.)
Page 19 GAO-20-525 HHS Emergency Responders
Table 4. Survey Questions Used To Evaluate National Disaster Medical System In-person Training
Survey question
1. Identify an issue or observation that requires corrective action(s). This should be a simple problem statement of 1 - 2 sentences in
length.
2. Describe the issue or observation in detail. What was expected, but did or did not occur? Include the effect, positive or negative,
and the consequence that actions had on the situation. Provide specific information that can be used for follow-up (dates, times,
location, names, temporary fix, etc.).
3. What action(s) would you recommend to correct/resolve the issue or observation?
4. Submit positive feedback here.
Source: Office of the Assistant Secretary for Preparedness and Response National Disaster Medical System Responder Survey. | GAO-20-525
However, the survey does not directly ask about the quality or
effectiveness of the training. This approach is inconsistent with GAO-
identified key practices for evaluating training, which include using
measures of (1) training participants’ reaction to, and satisfaction with, the
training program and (2) changes in participants’ knowledge, skills,
abilities, and on-the-job behavior. 31
According to ASPR officials, although the survey is not specific to training,
ASPR still receives feedback about the training courses through that
survey, so they do not feel that they are missing any information from
using this format to evaluate training. However, reliance on this process
does not allow ASPR to understand training participants’ reaction to, and
satisfaction with, the training, or whether responders’ knowledge, skills,
and abilities or on-the-job behavior are affected if they deploy having
received training. For example, it does not allow ASPR to understand
whether the Disaster Medical Assistance Team 101 training course has
an effect on responders’ ability to effectively provide care during a
response. According to the NDMS training catalog, objectives of the
Disaster Medical Assistance Team 101 course include that students have
learned to use equipment and supplies in accordance with manufacturer
instructions, and that those in clinical care positions have learned how to
provide medical care to a diverse group of patients, including individuals
with special health care needs, in a disaster setting. Effective evaluation
questions could include those that specifically ask participants about
these objectives and if they felt the objectives were met. For example,
• Did training participants feel that they sufficiently learned how to use
the equipment and supplies in preparation for a real event?
31GAO-04-546G
Page 20 GAO-20-525 HHS Emergency Responders
• To what extent do training participants feel confident that they can
apply the information they learned regarding use of equipment and
supplies in a disaster setting, or teach it to others?
Additionally, by relying on survey feedback once deployed to receive any
information on the effectiveness of required web-based courses, ASPR
does not know if they are effective until after the fact, which can
potentially put responders and others as risk. For example, ASPR does
not know if its required web-based course on donning and doffing
personal protective equipment is effective until responders have
deployed. At that point, if the training was not effective, the responder
could have potentially exposed themselves and others to hazards,
especially during a response to an infectious disease, chemical, or
biological threat.
Our prior work has shown that a balanced, multilevel approach to
evaluating training and development efforts is most appropriate, and that
not all training and development programs require, or are suitable for,
higher levels of evaluation. 32 We acknowledge that higher levels of
evaluation can be challenging to conduct because of the difficulty and
costs associated with data collection and the complexity in directly linking
training and development programs to improved individual and
organizational performance. We have reported that factors to consider
when deciding the appropriate level of evaluation include estimated costs
of the training effort, size of the training audience, management interest,
program visibility, and the anticipated “life span” of the effort. ASPR
should consider these factors in developing a process that specifically
evaluates the web-based and in-person training provided to NDMS
responders. Using GAO-identified key practices for evaluating training
could help ASPR know the extent to which its training is effective in
preparing responders for deployment, including keeping them and others
safe during a public health emergency. A process that specifically
evaluates the training can also help determine whether the web-based or
32See GAO-04-546G. We reported that one commonly recognized four-level model for
evaluating training and development efforts is a model conceived by Donald L. Kirkpatrick
(author of Evaluating Training Programs: The Four Levels). In this model, the first level
measures the training participants’ reaction to, and satisfaction with, the training program
or planned actions to use new or enhanced competencies. The second level measures
the extent to which learning has occurred because of the training effort. The third level
measures the application of this learning to the work environment through changes in
behavior that trainees exhibit on the job because of the training or development program.
The fourth level measures the effect of the training program on the agency’s program or
organizational results. The fourth level is sometimes split into two levels with the fifth level
representing a comparison of costs and benefits quantified in dollars.
Page 21 GAO-20-525 HHS Emergency Responders
in-person training courses need to be improved, or whether any of the in-
person training courses are so effective that they should be required.
Similarly, this information will allow ASPR to assess the relative
effectiveness of in-person training courses, which is important when
planning which of these training courses to offer each year.
ASPR Does Not We also found that ASPR does not sufficiently prioritize its in-person
Sufficiently Identify training. Specifically, ASPR has not sufficiently identified priorities among
its in-person training courses that take into account its aforementioned
Priorities Among Its In-
resource constraints to provide this training, because the agency lacks a
Person Training Courses process or approach for prioritizing its training.
GAO-identified key practices for planning training state that an agency
should prioritize training around funding so that the agency can address
its most important training needs first. 33 Further, effective strategic
workforce planning means that agency officials should develop training
that they can implement with the resources that can be reasonably
expected to be available, and be aligned to eliminate gaps and improve
the contribution of critical skills and competencies needed for mission
success. 34
Because ASPR officials have no process or approach for prioritizing the
in-person training, we found that ASPR officials could not provide
information on how they chose the 14 in-person training courses the
agency offered in fiscal year 2019, such as whether they prioritized any
identified skill or competency gaps when selecting these courses. Further,
ASPR officials could not provide documentation to support changes the
agency made to training originally scheduled for fiscal year 2019. For
example, ASPR documentation indicated that ASPR initially planned to
offer an exercise-based Disaster Medical Assistance Team 201 course
several times in fiscal year 2019 but did not end up offering the course at
all. When asked about this change, ASPR officials attributed to its NDMS
training budget. However, officials could not provide documentation
showing that (1) their plans for the NDMS training the agency would offer
in fiscal year 2019 had taken into account budget constraints, or (2) that
the budget had changed subsequent to their plan development. As a
33A key tool to aid this prioritization is an annual training plan that targets developmental
areas of greatest need and that outlines the most cost-effective training approaches to
address those needs. We have also reported that if training is identified as a solution to
improve performance, agencies should compare various training strategies by weighing
their estimated costs and anticipated benefits. GAO-04-546G.
34GAO-04-39
Page 22 GAO-20-525 HHS Emergency Responders
result, it is difficult to know if the decision to drop the exercise-based
Disaster Medical Assistance Team 201 course was due to budget
constraints or due to poor planning, such as the agency not accounting
for those constraints when originally determining which courses to offer.
A process or approach for identifying priorities among its in-person
training courses while taking into account budget constraints, will help
ASPR ensure that it is maximizing its available training resources, by
providing the training responders need the most for effective deployment
during a public health emergency.
The seriousness of recent natural disasters and the COVID-19 pandemic
Conclusions illustrate the importance of having a skilled workforce to respond to public
health crises. However, our past work and current review of ASPR’s
workforce planning and training raise concerns about its efforts to prepare
NDMS responders to assist during public health emergencies.
Specifically, ASPR experienced a shortage of NDMS responders to assist
with the federal public health and medical response to the 2017
hurricanes. Since that time, the agency has not followed key strategic
workforce planning principles to effectively address this response shortfall
and prepare for future responses, including natural disasters of increased
frequency and magnitude, which are predicted to occur. Until ASPR
develops an NDMS workforce target that aligns with agency-wide goals
and objectives, it risks being unable to fulfill its role as the lead agency for
public health emergencies, which includes the ability to sufficiently
enhance medical surge capacity during a response. In addition, until
ASPR develops an NDMS workforce target that considers the critical
skills and competencies needed to meet current and future programmatic
results—such as 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—ASPR risks having
an NDMS responder workforce target that is inadequate.
Furthermore, ASPR has faced slow hiring and has not developed specific
strategies to help drive hiring and address workforce gaps. Until ASPR
develops strategies to fill gaps to achieve a workforce target, the agency
continues to risk being unable to provide adequate numbers and types of
NDMS responders to effectively respond to public health emergencies. It
also risks not being able to take full advantage of the direct-hire authority
that expires in September 2021 that is specifically designed to facilitate
hiring.
Page 23 GAO-20-525 HHS Emergency Responders
Finally, ASPR does not have a process to collect information that would
allow it to evaluate the effectiveness of the individual courses it offers in
its training program nor a process to identify priorities among its in-person
training courses. Such processes will help ASPR ensure that it is
maximizing its available training resources to provide training most
beneficial for effective deployment, including training to keep responders
and others safe during a public health emergency.
We are making the following five recommendations to the Assistant
Recommendations Secretary for Preparedness and Response:
1. ASPR should develop an NDMS responder workforce target that
aligns with the goals and objectives in ASPR’s forthcoming strategic
plan. (Recommendation 1)
2. 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)
3. ASPR should develop strategies to fill gaps to achieve its revised
workforce target. (Recommendation 3)
4. 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)
5. 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)
We provided a draft of this report for advance review and comment to
Agency Comments HHS. HHS provided written comments, which we have reprinted in
and Our Evaluation appendix IV. HHS concurred with our five recommendations and
generally plans to take action.
Although HHS concurred with our five recommendations, the agency
expressed concern about our references to the COVID-19 response in
the draft report. Specifically, HHS noted that a pandemic response is
outside the primary scope of NDMS—as its responders should be
assisting the response through their civilian jobs, such as through working
in hospitals—and for that reason COVID-19 pandemic planning did not
include NDMS. While HHS states that it did not include NDMS in its
Page 24 GAO-20-525 HHS Emergency Responders
COVID-19 planning, as we also state in our report, the agency has
deployed more than 1,200 NDMS responders to assist in the COVID-19
response. Also in its comments, HHS stated that any assessment of
NDMS in the ongoing response would be premature. Our review did not
assess NDMS’s response to COVID-19, rather we assessed ASPR’s
workforce planning more generally for all-hazards events. We clarified
this in the report.
HHS also commented on our concerns with HHS’s evaluation of the
training provided to NDMS responders. Specifically, the agency stated
that we did not ground, in context or examples, our assertion that
responders may be at risk since ASPR does not receive feedback on
training until after deployment. We stand by our statement that there is
the potential for this risk to occur given that HHS does not collect specific
feedback on its trainings’ quality or effectiveness and does not collect any
feedback on mandatory training until after a responder has been
deployed. As discussed in the report, an example is the mandatory web-
based training on donning and doffing personal protective equipment.
ASPR does not know if this training course is effective until responders
have deployed. At that point, if the training was not effective, responders
could have potentially exposed themselves and others to hazards,
especially during a response to an infectious disease, chemical, or
biological threat.
HHS also provided technical comments, which we incorporated as
appropriate.
We are sending copies of this report to the appropriate congressional
committees and the Secretary of the Health and Human Services. In
addition, the report is available at no charge on the GAO website
at https://www.gao.gov.
If you or your staff have any questions about this report, please contact
me at (202) 512-7114 or DeniganMacauleyM@gao.gov. Contact points
for our Offices of Congressional Relations and Public Affairs may be
found on the last page of this report. GAO staff who made key
contributions to this report are listed in appendix V.
Mary Denigan-Macauley
Director, Health Care
Page 25 GAO-20-525 HHS Emergency Responders
Appendix I: U.S. Public Health Service
Appendix I: U.S. Public Health Service
Commissioned Corps Officers and the Ready
Commissioned Corps Officers and the
Reserve Corps
Ready Reserve Corps
The U.S. Public Health Service, an agency under the Department of
Health and Human Services (HHS), comprises Commissioned Corps
officers who are available to assist with emergencies and disasters. 1
Commissioned Corps officers’ duty stations are typically within the federal
government, including agencies within HHS such as the Centers for
Disease Control and Prevention, Food and Drug Administration, and
National Institutes of Health, but these officers can be temporarily
assigned to HHS’s Office of the Assistant Secretary for Preparedness and
Response to assist with a federal response.
There are a number of types of Commissioned Corps officers, including
Current Number of those who are deployed to provide medical care to humans during a
Officers Who Provide response and fall within four professional categories—dental officer,
health services officer, medical officer, and nurse officer. 2 As of October
Medical Care to 4, 2019, the U.S. Public Health Service had 2,127 of these types of
Humans During a officers available to assist with emergencies and disasters. (See Table 5.)
Response
1Commissioned Corps officers may be deployed to respond to an urgent or emergency
public health care need arising from (1) a national emergency declared by the President
under the National Emergencies Act; (2) an emergency or major disaster declared by the
President under the Robert T. Stafford Disaster Relief and Emergency Assistance Act; (3)
a public health emergency declared by the Secretary of Health and Human Services
under the Public Health Service Act; or (4) any emergency that is appropriate for
deployment, as determined by the Secretary of Health and Human Services. See 42
U.S.C. §§ 204a(a)(5) and 215(e).
2There are 11 professional categories for Commissioned Corps officers: physicians,
dentists, clinical and rehabilitation therapists, dieticians, engineers, environmental health,
health service, nurses, pharmacists, science and research health professions, and
veterinary medicine. As of September 9, 2019, these officers totaled to approximately
6,200 Commissioned Corps. According to Public Health Service officials, as of March
2020, ASPR had only requested four of these 11 professional categories to help provide
medical care to humans during a response to a disaster or emergency—dental, health
services, medical, and nurse officers. Medical officers are physicians. Health services
officers include allied clinical care providers, such as physician assistants and
optometrists, and those that serve in other roles, such as health information managers
and public health educators and administrators.
Page 26 GAO-20-525 HHS Emergency Responders
Appendix I: U.S. Public Health Service
Commissioned Corps Officers and the Ready
Reserve Corps
Table 5: U.S. Public Health Service Commissioned Corp Officers Available to
Provide Medical Care to Humans During a Response, by Provider Type
Percent of total number of
Professional category Number of responders responders
Dental officer 141 6.6
Health Services officer 156 7.3
Medical officer 460 21.6
Nurse officer 1,370 64.4
Total 2,127 99.9a
Source: GAO analysis of U.S. Public Health Service data as of Oct. 4, 2019. | GAO-20-525
Note:
a
The total percentage does not sum to 100 due to rounding.
These officers are assigned to deployment teams that provide both direct
and indirect health care services to humans. The deployment teams
provide support ranging from providing medical services to connecting
affected individuals with community services, such as home health care.
See Table 6 for the number of U.S. Public Health Service Commission
Corps officers available to provide medical care to humans during a
response, by deployment team.
Table 6: U.S. Public Health Service Commissioned Corps Officers Available to Provide Medical Care to Humans During a
Response, by Deployment Team
Number of officers
available to provide
medical care to
Team name Team description humans
Rapid Deployment Force Health and medical services to support a Federal Medical Station.a 300
Capital Area Provider Health and medical services to support national special security 96
events in the national capital region.
Mental Health Behavioral health services for impacted citizens and deployment 29
teams.
Applied Public Health Public health services to augment state and local public health 39
departments.
Regional Incident Support Incident support services focused on liaison and information 45
management.
National Incident Support Incident support services focused on assisting command and control. 16
Services Access Assist impacted citizens and federal partners with access to follow-on 63
services.b
Tier 3 Augment any of the above teams once deployed. 1,539
Total 2,127
Source: GAO analysis of U.S. Public Health Service data as of Oct. 4, 2019. | GAO-20-525
Page 27 GAO-20-525 HHS Emergency Responders
Appendix I: U.S. Public Health Service
Commissioned Corps Officers and the Ready
Reserve Corps
Notes:
a
A Federal Medical Station is a Health and Human Services deployable health care facility that has a
3-day supply of medical and pharmaceutical resources to sustain from 50 to 250 patients who require
medical services.
b
Follow-on services can range from providing support to health care institutions on the discharge
planning process to connecting individuals affected by a disaster or emergency to services such as
housing or home health care.
To augment capacity, the U.S. Public Health Service is in the process of
Plans for a Ready implementing a Ready Reserve Corps, but plans are still in development. 3
Reserve Corps The Ready Reserve Corps would consist of intermittent employees who
could be called up as needed. Implementing a Ready Reserve is part of a
broader plan to modernize the U.S. Public Health Service Commissioned
Corps announced by the Assistant Secretary for Health in March 2018. A
contractor hired to assist with the modernization effort assessed the
agency and concluded in April 2019 that, among other things,
establishing a Ready Reserve Corps will give the U.S. Public Health
Service Commissioned Corps the needed bandwidth to meet demand for
its services. The contractor stated that the demand for services is likely to
increase in the future based on multiple demand signals (e.g., natural
disasters, biological pathogens, the opioid epidemic and suicide clusters,
and international and immigrant-related situations).
In September 2019, the U.S. Public Health Service tasked the contractor
with developing a plan by June 10, 2020, to establish the Ready Reserve
Corps, including an organization infrastructure design plan and
recruitment strategy. It also included the development of a training plan
applicable to Commissioned Corps Officers.
U.S. Public Health Service officials we spoke with agreed that the
introduction of a Ready Reserve Corps would dramatically help their
ability and capacity to respond to emergencies and disasters, especially
given the rise in demand on the agency. According to these officials, the
number of U.S. Public Health Service Commissioned Corps deployments
has increased 44 percent over 6 years—from calendar year 2013-2018—
and officials expect demand to continue to grow. Ready Reserve Corps
3The Ready Reserve Corps was established in 2010 by the Patient Protection and
Affordable Care Act to have additional personnel available to assist the U.S. Public Health
Service Commissioned Corps with routine and emergency missions. Pub. L. No. 111-148,
§ 5210, 124 Stat. 119, 614-15 (2010) (codified as amended at 42 U.S.C. § 204). The
CARES Act amends federal law to allow members of the Ready Reserve Corps to receive
certain compensation and benefits for their service. See Pub. L. No. 116-136, § 3214(d)
134 Stat. 281, 373 (2020) (to be codified at 42 U.S.C. § 213a).
Page 28 GAO-20-525 HHS Emergency Responders
Appendix I: U.S. Public Health Service
Commissioned Corps Officers and the Ready
Reserve Corps
officers would be deployed or backfill positions of deployed U.S. Public
Health Service Commissioned Corps officers.
U.S. Public Health Service officials stated that there is a target of
commissioning 100 Ready Reserve Corps officers in fiscal year 2021,
which was set based upon fiscal constraints and force management
planning factors. According to officials, since the vast majority of the work
in the first year of establishing a Ready Reserves Corps will be dedicated
to establishing the policies, procedures, information technology, and
management infrastructure necessary to recruit, organize, train, and
manage a ready reserve component, a conservative target was deemed
most prudent. Officials stated that 50 percent of their goal of 100 Ready
Reserve Corps officers will be targeted toward retaining already trained
officers with significant clinical experience who otherwise would separate
completely from the service.
Page 29 GAO-20-525 HHS Emergency Responders
Appendix II: National Disaster Medical Appendix II: National Disaster Medical System
Team Structures
System Team Structures
The Office of the Assistant Secretary for Preparedness and Response
(ASPR) enrolls responders into its National Disaster Medical System
(NDMS). Once enrolled, ASPR can deploy these responders to assist
with the federal public health and medical response during a public health
emergency. There are five types of NDMS responder teams. Two of
these types, the Disaster Medical Assistance Team and the Trauma and
Critical Care Team, focus on providing public health and medical care to
humans during a response. The National Veterinary Response Team
provides veterinary care, while the Victim Identification Team and
Disaster Mortuary Operational Response Team collect information on
victims and support local mortuary services during a response,
respectively. In March 2018, ASPR developed team structures for each
NDMS team type, which include position types and numbers of
responders in each position. See Table 7 for the team structures of each
of the five types of NDMS teams.
Table 7: Team Structures for Each National Disaster Medical System Team
Position description Disaster Disaster National
Medical Mortuary Veterinary Trauma and Victim
Assistance Operational Response Critical Care Identification
Team Response Team Team Team Team
Administrative Specialist 2 2 3 2 2
Animal Health Technician - - 100 - -
Behavioral Health Specialist 2 - - 2 2
Chaplain - 2 - - -
Dental Assistant (Forensic) - 3 - - -
Dental Officer (Forensic) - 11 - - 2
Deputy Team Commander 3 2 3 3 2
Diagnostic Radiologic Technologist - 4 - 3 -
Fingerprint Specialist - 2 - - -
Forensic Anthropologist - 4 - - -
Health Technician (Autopsy Assistant) - 2 - - -
Health Technician (Paramedic) 15 - - 8 -
Information Technology Specialist 2 - - 3 -
Logistics Management Specialist 5 2 3 6 2
Medical Investigator - 21 - - -
Mortuary Specialist - 18 - - -
Nurse Anesthetist - - - 8 -
Nurse Practitioner 6 - - 5 -
Nurse Specialist (Registered Nurse) 21 - - 33 -
Page 30 GAO-20-525 HHS Emergency Responders
Appendix II: National Disaster Medical System
Team Structures
Position description Disaster Disaster National
Medical Mortuary Veterinary Trauma and Victim
Assistance Operational Response Critical Care Identification
Team Response Team Team Team Team
Pharmacist 6 - 3 4 -
Physician 10 - - 23 -
Physician (Pathology) - 6 - - 2
Physician Assistant 6 - - 5 -
Respiratory Therapist 2 - - 5 -
Safety and Occupational Health Specialist 2 2 3 2 2
Security Specialist - 2 - - -
Surgical Technologist - - - 2 -
Team Commander 1 1 1 1 1
Telecommunications Specialist 2 2 3 3 2
Veterinary Medical Officer - - 60 - -
Victim Advocate - - - - 35
Total 85 86 179 118 52
Legend: — = not applicable
Source: GAO summary of documentation collected from the Office of the Assistant Secretary for Preparedness and Response. | GAO-20-525
Page 31 GAO-20-525 HHS Emergency Responders
Appendix III: National Disaster Medical Appendix III: National Disaster Medical System
Optional Training Courses for Responders
System Optional Training Courses for
Responders
The Office of the Assistant Secretary for Preparedness and Response
(ASPR) enrolls responders into the National Disaster Medical System
(NDMS). Once enrolled, ASPR can deploy these responders to provide
medical care, evacuate patients, and provide veterinary services, among
other supports. 1 To prepare these responders for deployment, ASPR
offers optional, in-person training throughout the year. This training may
be applicable to all responders, or specific to responders on certain of the
five types of NDMS teams. Table 8 summarizes the 22 optional training
courses that may be available to NDMS responders, though not all
courses are available each year.
Table 8: Optional Training Courses for National Disaster Medical System (NDMS) Responders
Course Number of
capacity (max course
participants offerings in
per course fiscal year
Course name Course description offering) 2019
Aeromedical Evacuation Develop the skills required of NDMS responders as members of an 25 10
Team aeromedical evacuation team expected to deliver care inflight.
Aeromedical Evacuation Develop the skills required of NDMS responders on an aeromedical 18 5
Team Critical Care evacuation critical care team who are expected to deliver critical
care in flight.
Critical Care Air Transport Develop skills related to the clinical care of the critically ill and 18 1
Team Advanced injured patients in flight.
Critical Care Air Transport Teach and test operational concepts, flight and altitude physiology, 18 7
Team Initial and critical care knowledge as it applies to air and ground transport
of a critically ill or injured patient.
Disaster Medical Assistance Develop and improve upon the skills required of NDMS Disaster 42 6
Team 101 Medical Assistance Team responders to deliver care in a severe
environment and familiarize new or not recently deployed personnel
on general principles of NDMS deployments.
Disaster Medical Assistance Prepare NDMS Disaster Medical Assistance Teams for short-notice No course 0
Team 201 Exercise disaster relief deployments. The training involves the reporting, capacity
mobilization, and demobilization activities that would occur during an maximum
actual deployment. indicated
Disaster Mortuary Allow mortuary specialists—one of the positions on the NDMS 100 0
Operational Response Disaster Mortuary Operational Response Teams who identify victims
Teams 101 and support local mortuary services—to prepare, train, and enhance
the processes, procedures, and practices used during Disaster
Mortuary Operational Response Team missions.
1Under 42 U.S.C. § 300hh-11, NDMS may be activated to provide health services, health-
related social services, other appropriate human services, and appropriate auxiliary
services to respond to the needs of victims of a public health emergency. ASPR may also
activate NDMS in a location that is at-risk of an emergency.
Page 32 GAO-20-525 HHS Emergency Responders
Appendix III: National Disaster Medical System
Optional Training Courses for Responders
Course Number of
capacity (max course
participants offerings in
per course fiscal year
Course name Course description offering) 2019
Disaster Mortuary Prepare NDMS Disaster Mortuary Operational Response Teams for 80 0
Operational Response short-notice disaster relief deployments. The training involves the
Teams 201 reporting, mobilization, and demobilization activities that would occur
during an actual deployment.
Electronic Medical Records Update the knowledge, skills, and response capabilities of 36 9
emergency medical records users in the revised deployment and
utilization of the new emergency medical records software.
Highly Infectious Disease Address the transportation of highly infectious patients to No course 0
Patient Transport appropriate facilities such as assessment or isolation centers. capacity
maximum
indicated
Isolation, Simulation, Provide the knowledge, skills, and abilities to ensure that 20 20
Quarantine competencies in the areas of situational awareness, preparedness
and planning, infection prevention and control, and crisis and risk
communication are met.
Joint Patient Assessment Improve the knowledge, skills, and response capabilities of 36 7
and Tracking System responders in the deployment and utilization of the Joint Patient
Assessment and Tracking System (a patient evacuation tracking
system) software.
Joint Patient Assessment Support Federal Coordinating Center exercises conducted by the 2 0
and Tracking System Departments of Defense and Veterans Affairs with a two-person
Exercise: Supporting Joint Patient Assessment and Tracking System Team.a These
Department of Defense and exercises are controlled and scenario-driven trainings for federal
Veterans Affairs Federal responders.
Coordinating Center
Regional Equipment Prepare responders enrolled in NDMS Disaster Medical Assistance 40 20
Familiarization Teams for the challenges of disaster care by supporting
familiarization with field equipment.
Logistics Specialist 101 Utilize a combination of classroom and hands-on training to 50 2
familiarize logistical personnel with equipment used during actual
deployments.
NDMS/Department of Prepare responders to support operations that may involve 12 0
Defense Outbreak infectious diseases with high infectivity, morbidity, and mortality.
Response Course
National Veterinary Prepare NDMS National Veterinary Response Team responders to 55 0
Response Team Working properly handle and provide medical support to working animals
Animal used in post-disaster environment, public health emergency, or
planned national security event.
Trauma Critical Care Team Allow responders enrolled in NDMS Trauma and Critical Care 48 1
101 Teams to deliver the highest level of trauma and critical care to
victims of disasters in accordance with current clinical standards and
NDMS guidelines.
Team Leadership Improve the knowledge, skills, and response capabilities of NDMS 142 1
Team Commanders and Deputy Team Commanders to enhance
their leadership capabilities.b
Page 33 GAO-20-525 HHS Emergency Responders
Appendix III: National Disaster Medical System
Optional Training Courses for Responders
Course Number of
capacity (max course
participants offerings in
per course fiscal year
Course name Course description offering) 2019
Safety Specialist 101 Qualify Safety and Occupational Health Specialists—a responder 14 4
position on all of the NDMS teams except the Victim Identification
Team—to perform pre-deployment health and safety activities.
Victim Identification Center Allow the Victim Identification Response team and all 10 NDMS 35 1
101 Disaster Mortuary Operational Response Teams to train and
prepare for the practice of ante mortem (before death) data
collection used during disaster missions.c
Trauma and Critical Care Prepare NDMS Trauma and Critical Care Teams for short-notice 48 0
Team 201 Exercise disaster relief deployments.
Source: GAO summary of Office of the Assistant Secretary for Preparedness and Response NDMS training documentation. | GAO-20-525
Notes:
a
Federal Coordinating Centers are activated to receive, triage, stage, track, and transport patients
affected by a disaster or national emergency to a participating NDMS medical facility capable of
providing the required care to manage the patient’s condition.
Each NDMS team is led by a Team Leader and a Deputy Team Leader that constitute a team’s
b
Command Staff during steady state or day-to-day operations.
c
The Victim Information Center is a location for local authorities and Disaster Mortuary Operational
Response Team members to collect ante-mortem data, such as pictures, fingerprints, dental X-rays,
and other medical records, to help identify the victim.
Page 34 GAO-20-525 HHS Emergency Responders
Appendix IV: Comments from the
Appendix IV: Comments from the Department
of Health and Human Services
Department of Health and Human Services
Page 35 GAO-20-525 HHS Emergency Responders
Appendix IV: Comments from the Department
of Health and Human Services
Page 36 GAO-20-525 HHS Emergency Responders
Appendix IV: Comments from the Department
of Health and Human Services
Page 37 GAO-20-525 HHS Emergency Responders
Appendix V: GAO Contact and Staff
Appendix V: GAO Contact and Staff
Acknowledgements
Acknowledgements
Mary Denigan-Macauley, (202) 512-7114 or
GAO Contact DeniganMacauleyM@gao.gov.
In addition to the contact named above, Kelly DeMots (Assistant
Staff Director), Deirdre Gleeson Brown (Analyst-in-Charge), Kenisha Cantrell,
Acknowledgements Aidan Larsen, Catherine Parylo, and Janet Wilson made key contributions
to this report. Also contributing were Sam Amrhein, Shae Bader, Kaitlin
Farquharson, Dan Lee, Janet McKelvey, Meghan Perez, and Vikki Porter.
(103673)
Page 38 GAO-20-525 HHS Emergency Responders
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