Reimagining Incident Management Systems for Public Health Responses

Introduction

In 2020, the COVID-19 pandemic brought a “perfect storm” to disaster response efforts in the United States: a large-scale emergency response, many uncertainties, a dearth of public health resources, uncoordinated state efforts inherent to our federalist form of government, and severe political tensions that led to unprecedented involvement by elected officials—many of whom were experiencing a public health response for the first time in their careers. Although some jurisdictions had previously responded to severe, large-scale natural disaster incidents (including widespread wildfires or devastating hurricanes), they did not have experience with response and recovery processes for infectious disease outbreaks, which are less routine. Response efforts for natural disasters are more routine because they occur more frequently, resources can be garnered from unaffected jurisdictions, lessons learned are incorporated from previous disasters, and mitigation actions are taken between each response. In contrast, SARS-CoV-2 brought a plethora of unknowns, with impacts on health, economies, educational systems, and most other foundational components of everyday life throughout most communities across the globe. No “pandemic response model” existed, and the public health system found itself stretched to a perpetual state of almost breaking.

In June 2022, the Commonwealth Fund released a report, Meeting America's Public Health Challenge: Recommendations for Building a National Public Health System That Addresses Ongoing and Future Health Crises, Advances Equity, and Earns Trust. ¹ Findings from the report included the following:

Public health efforts are not organized for success.

Expectations for health agencies are minimal.

The public health enterprise faces a crisis in trust.

These findings reflect various challenges to the public health system as revealed through the COVID-19 response. In addition, the report provides detailed recommendations for Congress, the Executive branch of the federal government, states, localities, tribes, and territories. ² Specific to this discussion is a recommendation to “build connections between the health care system and public health to strengthen day-to-day health improvement efforts and better prepare for emergencies.” With this recommendation in mind, this commentary considers the history, strengths, and weaknesses of the current response system in the context of public health, along with considerations for the future. We recognize that jurisdictions may need to customize recommendations from national-level discussions and/or directives.

History and Strengths of the Incident Command System

The Incident Command System (ICS) is a standardized, flexible structure designed to organize an emergency response. It was first created in 1970 when an interagency working group in southern California developed a system for managing wildland fires. ³ An after-action review identified field-level confusion and a lack of agency-level coordination for resource demands and prioritization, among other things. By 1974, ICS had evolved into an all-hazards system, and by 1980, it achieved nationwide adoption. The Federal Emergency Management Agency began teaching ICS in 1983 at the National Fire Academy. In the 1990s, the US Coast Guard was the first national organization to adopt ICS outside of the fire service, recognizing the benefits to their missions.

Decades later, the attacks of September 11, 2001, and subsequent anthrax attacks revealed the need for a national strategy for incident management. In 2003, President Bush issued Homeland Security Presidential Directive 5, ⁴ creating a National Incident Management System. ⁵ With the release of Public Health Preparedness and Response for Bioterrorism cooperative agreements by the US Centers for Disease Control and Prevention, ⁶ the public health sector also began to widely implement ICS. ICS has become a routine component of public health training, exercises, and response, and institutional knowledge on its use has become far more robust over the past 20 years. The implementation of ICS has allowed public health to better organize and coordinate emergency responses and to better integrate with the emergency response community by using a common language and processes. Having a common terminology and shared understanding facilitates streamlined communications and tasked assignments and lends itself to accountability, even between agencies.

ICS has almost 50 years of proven effectiveness but primarily in responses with specific characteristics, including response activities for emergencies and planned events that are smaller or localized to a region and that do not stretch over an extended timeline (although recovery actions may take years). This makes sense, as ICS was not designed for large-scale, extended responses with no defined transition to recovery. As the COVID-19 response revealed, ICS may not be the best or only structure available for organizing responses to public health emergencies.

Limitations for Public Health

The COVID-19 response cast a light on unique challenges to ICS in the context of a public health response to a pandemic. Health departments, while often versed in ICS principles as required by federal guidance, may not have had the capacity necessary to employ it in practice for a large-scale, whole-government response led by the public health sector. In addition, other involved government leaders who did not regularly engage in incident response efforts may have lacked the necessary familiarity with the system. While challenges varied among health departments during the COVID-19 response, 2 main themes highlight the insufficiencies of ICS for this response: disruptions to authority and resource scarcity. In this commentary, we—public health professionals with intensive experience and knowledge of public health at the local, state, and national levels—strive to highlight our past 3 years as a lived, collective demonstration of some ways in which, given the circumstances of the pandemic, the theory of ICS may have limited effectiveness in practice.

Theme 1: Disruptions to Authority and Frameworks

During the COVID-19 pandemic, many public health jurisdictions implemented ICS with a multidisciplinary leadership team; in traditional ICS parlance, this would be created through a unified command (UC) structure. UC is often employed in incidents that are neither simple nor routine, yet it has been limited in its ability to fully support the competing priorities of differing agencies within the emergency response community. The root of this problem is twofold. First, the premise of the structure is to increase collaboration between emergency response communities and jurisdictions. However, as it stands, the original design of this framework does not completely account for the political realities of differing departmental obligations, operational norms, and community expectations—all of which would naturally lead to UC members having differing concerns and desired approaches. Second, the representatives from each response community should unanimously agree on each UC-level decision. However, this requirement for unanimous agreement on decisions is often difficult to satisfy, which exacerbates the already difficult task of making unified, rational decisions amid competing priorities.

The United States saw drawbacks to the theoretical structure of ICS played out in full force during the COVID-19 response. Aligned with theoretical ICS principles, many jurisdictions initially developed teams to manage the response, using established personnel and systems. However, as the response progressed and the teams grew by necessity, some jurisdictions also increased the number of individuals who were brought into decisionmaking roles from outside of government or from agencies within government that are not typically involved in response, such as paid consultants, community taskforces, and special appointments of COVID-19 “czars.” This approach increasingly complicated the process of making informed decisions with full UC buy-in.

Furthermore, as the scope and political nature of the COVID-19 pandemic grew, a number of elected officials and their appointees felt compelled to take a more “hands-on” approach. With that shift of control from public health to nonpublic health entities, many jurisdictions also saw a shift in their incident management frameworks. As elected leaders—who are often unfamiliar with the purpose and strengths of ICS—came into response leadership, the principles of private sector project management, including “workstream” operation organization, often superseded ICS principles. These new or layered frameworks were often difficult to integrate into the operational response framework of ICS. There seems to have been few, if any, collaborations between the private and public sectors before the pandemic about how they could complement each other. With elected officials and their appointees leading response efforts, public health departments were often forced to either integrate ICS principles into elected officials' preferred frameworks or abandon ICS structures altogether. The leadership role that was traditionally assigned to public health agencies deeply involved in the response was given to leaders who were unfamiliar with ICS or public health principles. As such, it was understandably disruptive and isolating for those trained in an ICS-based response to implement a new response structure without preemptively planning how to integrate ICS and non-ICS frameworks.

Theme 2: Extended Resource Scarcity in an Expansive Emergency

The duration and scale of the COVID-19 response revealed a weakness related to the chain of command, most apparent in jurisdictions with limited resources. In a small event like a parade or other planned event, staff may be assigned to a specific role. If other responses arise, emergent needs are handled by staff not already assigned to the planned event. The agency responsible may need to secure sufficient staff and provide overtime pay for the additional personnel required to balance normal operations and the planned event. In contrast, a large incident that requires a response lasting months or years, such as the pandemic, causes budgets to deplete and staff availability to become stretched. Jurisdictions with fixed budgets may not have had sufficient funding to absorb the prolonged costs of overtime or pay additional staff to fulfill multiple simultaneous responses, sometimes resulting in exempt employees going unpaid for extended periods of overtime worked. This challenge usually led to sharing staff on an as-needed basis, which meant that an individual might report to multiple chains of command—for the day-to-day tasks and for the planned event or emerging response. The effect of this scarcity of human resources was further heightened when the response covered a large geographic area where jurisdictions were too strained to assist each other through typical mutual aid pathways. During the pandemic, the result was the deployment of US National Guard personnel and the rapid hiring and onboarding of contractors to support the response. The public health sector relies heavily on institutional knowledge to drive its response operations and traditionally does not need to manage rapid onboarding of large cohorts of untrained staff. Unfortunately, this scenario played out many times across public health agencies throughout the COVID-19 response.

The COVID-19 pandemic response was constrained by multiple factors of scalability, the need for an effective UC, as described above, that was often impeded by implementation difficulties and a strained and scarce workforce. An event of this size, scope, and duration was far beyond what ICS was designed for and, thus, presents a prime opportunity to evaluate areas for improvement. As the public health preparedness field discusses how to improve responses moving forward, we recommend pursuing changes that are flexible, adaptable, and take all issues into full consideration.

Comparison of Response Frameworks

Understanding how ICS and “workstream” project management models differ may offer insight into the best course of action for future responses to public health emergencies. While ICS is steered by tasks and response management is driven by objectives, the workstream model—a hallmark of private consulting firms hired by states across the nation to lead COVID-19 responses—approached the response as a discrete and immediate project. Just as with operational branches in ICS, each workstream (eg, testing, treatment, vaccination) brings together subject matter experts and necessary supports to execute its sole operational directive. In contrast, in ICS, staff in branches within a section (eg, operations section) perform discrete tasks that are coordinated with other branches through an incident action plan; all staff have access to this plan. ICS reporting and communication are uniform and streamlined, with linear flows of information shared both horizontally and vertically during structured briefings. This ensures all branches and incident command simultaneously have access to the same situational awareness. The workstream model fosters a collaborative environment within each “workstream,” or work group, but it may not include cross-workstream information sharing or a centralized document to support ongoing situational awareness for all responders. This lack of information sharing leads to a duplication of efforts and other inefficiencies. Operations during an ICS-led event are focused on the use of existing plans (and institutional knowledge) and event-specific incident action plans to drive the completion of tasks and continuous quality improvement in operational implementation. The workstream model, while still driving operations forward, focuses more on the ongoing collection and calculation of metrics that are primarily for policymakers and less for operational purposes. A foundational principle of ICS is that instituting a common language with uniform principles supports organizational efficiency. The workstream model, however, came with language unfamiliar to public health leaders and others who spent decades building a common language through ICS, forcing them to suddenly learn a new language for thinking, meeting, and speaking, with little operational gain.

Recommendations for Public Health Response Frameworks

Many public health practitioners involved in the COVID-19 response have shared the sentiment that non-ICS structures, such as the workstream model, may be here to stay. With this in mind, we recommend that professionals in public health, emergency management, and others who may lead future complex responses consider the strengths and weaknesses of both frameworks and resolve to establish standard guiding principles for national application.

Public Health Incident Command System

Customizing the structure of ICS specifically for public health response efforts may enable the public health sector to address some of the challenges highlighted during the COVID-19 pandemic. This customization would require a complex assessment of after-action reviews, interviews with a wide variety of emergency response practitioners, federal guidance and support, revised training programs, and public health official adoption. In order to incorporate the lessons from the COVID-19 pandemic and other past responses, developers of an improved ICS would need to clearly define the leadership role of public health in emergency response structures.

Hybrid Approach to Public Health Response

An alternative recommendation is a hybrid approach to managing public health response efforts. This approach combines components of ICS and “workstream” or other project management-focused models that cater to wider groups of stakeholders (eg, emergency management, National Guard, elected officials), regardless of their familiarity with ICS. Because training needs and priorities for each of these sectors vary, it is imperative to agree upon core principles, such as standardized language and clear chain of command, that would need to be implemented to effectively manage a large-scale emergency response from each system and then provide cross-training to each involved sector. A hybrid strategy may necessitate a mechanism (eg, federal requirement, Presidential directive, or doctrine) to ensure its adoption and implementation. This strategy could involve using multiple approaches, including integrating ICS structures and workstreams upon incident activation to explore how the models could best work together; determining the triggers to activate for workstream components as a public health response engages elected officials as response leadership; or predetermining a hybrid response structure in the jurisdiction's emergency response plan. The COVID-19 response revealed challenges related to operating under 2 frameworks that were not calibrated for compatibility. A hybrid approach will need to be collaboratively designed by and require buy-in from jurisdictions' responders (public health and emergency management), elected officials, and any other impacted stakeholders, with reinforcement from the larger national response infrastructure. In addition, professional and educational communities in the project management framework space should be integrated.

As the COVID-19 and mpox (monkeypox) responses have demonstrated, future responses cannot be managed effectively or efficiently by siloed departments or program areas. Preparedness and response practitioners will need to work closely with partners from multiple sectors, including vendors, consulting firms, other public health branches, and nonpublic health agencies within their jurisdictions. However, there may inevitably be competing frameworks and potential resistance to the recommendations we propose in this commentary. For example, emergency responders and emergency management, for whom ICS has historically been extremely effective as is, may resist changes to the traditional framework. Contractors from the private sector may also resist frameworks that are not in line with the business workstream model. To set up the country for success, a national standard must be established by an authority that can marshal the necessary resources to support such a change in practice or to equip the public health workforce.

Determining Nontraditional Incidents

Our recommendations for updating the National Incident Management System to alter the use of ICS should allow for individual agencies to have appropriate jurisdiction and autonomy in a nontraditional incident, or one that does not fit the acute and limited scope or scale incident for which ICS is traditionally designed. The following are some suggested criteria that can help determine whether an incident or event is nontraditional and requires a multifaceted response:

• The incident is expected to last more than 60 days in a response phase

• Agencies from more than 5 different sectors are involved ⁵

• No single jurisdiction has the authority to manage the entire event or incident

Final Thoughts

There are many possibilities for the trajectory of response structures and the future of ICS in preparedness. The following general considerations can help guide strategic planning for future events:

• Model practices and lessons learned are not always translatable. Although a concerted effort to review insights from after-action reviews of the COVID-19 pandemic is vital for future responses, partners involved in emergency response should recognize that some of the model practices or lessons learned from the COVID-19 response may not be applicable to the entirety of preparedness. Just as response structures for natural disasters or mass casualty events may not be fully translatable to infectious disease outbreaks, the reverse applies as well.

• Incremental action, through assigned process change champions, is needed to balance rapid and immediate improvements with the slow pace of bureaucratic federal improvement initiatives. Timely process change is needed to support local flexibility because the pace, scope, and inclusivity (ie, applicability and appropriateness) of federal process improvements will never fully meet the needs of local, state, and territorial jurisdictions.

• Altering strict adherence to traditional ICS to meet the needs of public health may face resistance and perhaps require a presidential directive like Homeland Security Presidential Directive 5. Short of a new HSPD, however, wider acceptance could occur if a unified decision is made by public health officials and supported by federal leadership and the emergency response community. An approach to pivot away from ICS or to incorporate traditional ICS structures would need to clearly articulate the benefits and how they would alleviate challenges experienced during previous disasters beyond the COVID-19 pandemic. The public health sector should consider changing standardized ICS structures to meet its needs, similar to how the hospital incident command system was customized to support hospitals.

• Staffing needs to adequately respond to a public health emergency must be addressed. Although ICS is intended to be a scalable approach that adapts to the response, the COVID-19 response grew to a size, scope, and duration beyond what most public health agencies could adapt to or accommodate, especially as it extended beyond public health authority. As discussed earlier, the staffing demands of the temporal expansion of the response increased demands on agency incident command staff by either requiring agencies to cycle more personnel through incident command roles or requiring longer durations in these roles, contributing to prevalent burnout and departures across health departments. ⁷ This impact on the public health workforce must be addressed as we prepare for future responses.

Conclusion

The vast scope, size, and complexity of the COVID-19 pandemic response has reaccentuated the need to revisit longstanding ICS principles as an essential quality improvement area for the future. Careful attention and incremental action are needed now to ensure improvement to the emergency management structure that supports public health response. Integration of collaborative administrative preparedness best practices into the ICS nomenclature is critical to ensure governmental response can scale and grow its workforce to meet the needs of a response. Ongoing dialogue is needed to ensure a revised ICS framework receives buy-in from the emergency response community—including public health, emergency management, elected officials, and other impacted stakeholders—with reinforcement from the larger national response infrastructure. Improved and more flexible structures will allow public health to respond more efficiently and effectively, thus better serving the American people and our communities.