Chapter 26 Sandy Bogucki and Kevin J. Schulz The operational effectiveness as well as the safety, or even survival, of all components of the local, regional, and state medical infrastructure confronted with a large-magnitude natural, manmade, or terrorism-related disaster will largely depend on the quality of the overall incident management. Public safety, public health, emergency management, and health care system officials should be familiar with the rudiments of emergency incident management theory and practice. Nowhere is this more important than in EMS, where the system must interface seamlessly with public safety entities that use the incident command system (ICS) for daily operations, and hospitals, where the administration typically alters its organizational management scheme to an ICS during major emergencies. It is easy to understand why it is necessary to organize the management of emergency incidents differently than normal business or public administration plans. For example, a bureaucracy is, by definition, the wrong structure through which to manage a low-frequency, high-hazard incident. According to Webster’s Dictionary [1], a bureaucracy is a “government marked by diffusion of authority among numerous offices and adherence to inflexible rules of operation … [or] an administrative system in which the need to follow complex procedures impedes effective action.” In organizational theory, the core features of bureaucratic management include formalization (i.e. enforcement of rigid rules and procedures), specialization, and hierarchy [2]. This form of administration is most effective at handling large-volume, variably complex but routine tasks, in stable environments [3]. Management of unstable situations with potentially catastrophic outcomes requires establishment of high-reliability organizations [4]. Roberts et al. [5] observed that reliability is directly related to flexibility of the organizational structure. Temporary organizations assembled in response to specific challenges may provide such flexibility, and offer an attractive alternative to conventional structures that have not performed well in high-risk, high-hazard environments. Virtual organization represents an increasingly common temporary administrative architecture for corporate and public safety entities operating in crisis mode. One distinguishing characteristic of virtual organizations is the time-limited assembly of diverse agencies, corporations, or other specialized teams into a task-determined architecture for the purpose of accomplishing an immediate goal. Linkage within the virtual organization is through information pathways. When constituent units are not colocated, they are electronically networked [6]. The relationships among the units can be evanescent, as structural changes are dictated by the demands of the mission. Virtual organizations make good high-reliability organizations, as units having diverse expertise or resources can share previously inculcated health and safety priorities as well as the joint vision of the mission at hand [6]. Their innate adaptability to rapidly changing conditions as well as some intrinsic redundancy also favor the use of virtual organizations for management of complex, high-hazard, or high-consequence incidents. Several investigators have studied the ICS employed by local emergency responders as a model high-reliability, virtual organization [6,7]. As required by presidential directive [8], state and federal agencies have nominally incorporated ICS into their emergency response plans because of its simple design, and to facilitate integration of their assets into local emergency operations. The National Incident Management System (NIMS) [9] was designed to coordinate multiagency, multijurisdictional responses to large-scale emergencies. For ICS and NIMS to function effectively, the basic premises of ICS must be understood by those implementing it. These principles cannot be compromised without losing the effectiveness and performance for which ICS and NIMS have become so highly regarded. Incident command systems were first designed for use by civilian emergency responders in the United States in the mid-1970s. An interagency representative group, Firefighting Resources of California Organized for Potential Emergencies (FIRESCOPE), developed the best-known prototype ICS in response to critical management deficiencies associated with the state’s wildland firefighting [10]. Foremost among the problems encountered were ineffective communications, unclear jurisdictional and tactical command authority, inability to account for the geographic location or task assignments of personnel, and difficulty responding effectively and expeditiously to challenges of the dynamic, high-hazard environment. Although FIRESCOPE was originally conceived for wildland settings, the Phoenix Fire Department and others recognized similar deficiencies in structural firefighting and formulated the Fireground Command System (FCS), for use in all fire department emergency incidents involving more than a single-company response [11]. The US Fire Administration and its National Fire Academy endorsed the FIRESCOPE ICS as the preferred management model for application throughout the fire service, and widely disseminated it through published documents and curricular offerings. Throughout the last two decades, a consortium of fire and emergency services representatives has collaborated on a single incident management system (IMS) incorporating the best features of ICS and the FCS [12]. In the following discussion, the terms ICS and IMS will be used interchangeably, as they are in the emergency response communities. The use of ICS by civilian emergency responders became standardized through its incorporation into a number of consensus standards issued by government and non-government agencies, including the federal Occupational Safety and Health Administration (OSHA) and the National Fire Protection Association (NFPA) [13]. Both required incident management through an ICS during emergency operations that are considered dangerous to response personnel, including hazardous materials incidents, confined space rescues, and structural fires [14,15]. Full implementation of ICS is also a cornerstone of the integrated emergency management system, which is taught to emergency managers by the Federal Emergency Management Agency (FEMA). Health care systems, including EMS [16,17] and hospitals [18,19], have adopted customized versions of ICS for use during mass casualty incidents and other threat- or hazard-associated operations. It can be argued that public health emergencies also represent incidents that require multiagency, multijurisdictional responses in that they pose substantial threats to both the population and the response community. The same management deficiencies that launched ICS in the fire service have been cited in after-action analyses of responses to public health emergency incidents [20–22]. Health and medical emergency incidents are similar to those encountered in the fire service, as they share the elements of operating in a hazardous environment and the urgency with which tasks must be accomplished. The need to accomplish a complex mission in the face of proximate threat or hazard distinguishes the ICS management methodology from other business or public administration practice. The tasks integral to mission completion require authority, reporting relationships, and personnel that are not intrinsic to the public health and emergency management structures maintained in local, state, and federal jurisdictions. The essential characteristics of ICS must be understood in order to adapt it for use in the all-hazards environment. ICS is a modular management system that can be expanded or contracted to match the size and complexity of an incident and the availability of resources to manage it. The overall priorities of an incident commander (IC) are predetermined, regardless of whether the incident is a structure fire, wildland fire, passenger train derailment, or toxic hazard release. In order of priority, they are life safety, incident stabilization, and property conservation. Strategies and tactics employed by the IC, as well as intermediate goals and objectives, are designed to address those priorities. This facet of the ICS is an important determinant of its success as a high-reliability organization. The basic design and staff assignments that typically comprise an ICS also reflect these priorities, and help distinguish ICS from other military command structures, business administration methodologies, and standing bureaucracies. All responsibility for every aspect of response to the incident belongs to the IC until it is specifically delegated. Tasks that are delegated may be assigned to an individual or an individual heading a group (Figure 26.1). The organization of personnel into assignments and the designation of reporting relationships are guided by certain constraints. One of the most important is referred to as “unity of command.” This ensures that each member of the response team, regardless of assigned position in the organizational chart, is responsible to, or reports to, only one person. Similarly, “span of control” dictates that no leader anywhere in the organizational structure is directly responsible for more than 3–7 (optimally five) personnel or functions. These two features should override the complex reporting relationships characteristic of the mix of elected, appointed, hired, and voluntary personnel that participate in large-scale emergency responses. Those appointed to command role should be trained for that role, and when active, wear easily seen garb (e.g. colored vests) identifying the positions they hold. A job action sheet should be available for each command role to be used as a decision-making reference guide and documentation tool. Figure 26.1 Small structure ICS. ICS for small structure fire requiring only four working crews.
Incident command system and National Incident Management System
Introduction
ICS standardization
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