Gap Analysis - A Long and Winding Process

One of the most important working tools available to any healthcare organization is a comprehensive, reasonably workable, and not overly complicated Emergency Management Program (EMP) – which itself should include an equally comprehensive “Gap Analysis” section that spells out, in considerable detail: (a) anticipated future requirements; (b) current shortages and deficiencies; and (c) the additional resources needed to ameliorate or, preferably, eliminate the deficiencies listed.

There are four major tasks involved in developing a comprehensive and usable Gap Analysis:  (1) developing a list of the most likely planning scenarios needed, along with estimates of the number of casualties anticipated for each scenario; (2) the development of requirements – i.e., the personnel and material resources needed to cope with each planning scenario if and when it becomes a reality; (3) current resources and capabilities; and (4) the gap in unmet requirements that results; in other words, the difference between the resources on hand and those still needed to cope with each planning scenario. Following is a brief discussion of how the various components of the complete Gap Analysis process are determined.

The Planning Scenarios:

The goal here is to determine: (a) the types of emergencies most likely to occur within a given jurisdiction; and (b) realistic estimates of the number of casualties (i.e., live patients) likely to be generated by each planning scenario. To make these determinations, healthcare planners should consult first with the jurisdiction’s emergency-management agency (EMA) – the director of which usually would be responsible for carrying out hazard vulnerability assessments (HVAs) for the entire community. Using the HVAs already developed, healthcare planners could compile a number of planning scenarios that the jurisdiction might reasonably be expected to face in the future.

Of course, a very large number of disaster scenarios are possible, but the Gap-Analysis probably should be based only on a few – the top three scenarios, perhaps, identified from the community HVA carried out by the EMA. For each of those scenarios, the healthcare planner should then develop estimates of the probable number of patients that would be generated. The EMA also can help here, and may already have estimated not only the number of casualties and fatalities anticipated for each planning scenario but also the various categories of injuries (e.g., burns, blunt force trauma, and blast) most likely to occur.

Those estimates usually would be based at least in part on previous disasters – e.g., the bombing of London’s Underground (subway) system, the terrorist train bombings in Madrid, and/or the 1995 Sarin nerve-agent attack on the Tokyo subway system.  The local or state public health officer usually would be the most authoritative source in estimating the number of infected patients likely to be generated by events such as a new SARS outbreak or a pandemic influenza. The U.S. Department of Health and Human Services (HHS) and other federal public-health agencies – e.g., the Centers for Disease Control and Prevention (CDC) – also can provide reasonably accurate estimates of the numbers of persons likely to be infected in such incidents – and may, in addition, offer some timely advice on the likely percentages of victims who will require hospitalization.

The Development of Requirements:

The goal in this step of the process is to fully and accurately identify all of the resources that would be needed to effectively treat the numbers and categories of patients likely to be generated by each of the disasters postulated in the community HVA. This is a daunting but not impossible task. Hospital requirements alone include but are not limited to beds, medical supplies, and equipment – e.g., ventilators, X-ray machines and other diagnostic equipment – and a broad spectrum of medicines and pharmaceuticals of all types. The requirements list also would include doctors, nurses, emergency medical services personnel, and other medical professionals. Ambulances and other transportation resources also are a permanent need; as are the continued availability of food, water, and electric power.  In short, everything it takes to equip and operate a modern hospital or other medical facility should be on the requirements list.

Here, a caveat is necessary: The requirements or “needs” developed in a Gap Analysis should not be influenced by the quantity or variety of resources the hospital already has on hand (and/or could readily purchase from its suppliers). In short, the requirements component of the analysis is not and should not be related to and/or based on the assets already available. It also should be recognized that, although completing the requirements development component of a Gap Analysis is not a difficult process, it usually is both tedious and time-consuming – which is perhaps why the development of requirements is often the most poorly defined component of the overall Gap Analysis process.

Current Resources and Capabilities: 

In this component of the process the entirety of the resources the healthcare organization has at its disposal are matched to (or measured against) the number and categories of patients it expects to treat. Many healthcare planners, it should be noted, believe that they must somehow obtain the additional resources needed to cope with a given scenario. However, that is not the case. The National Response Plan (NRP), and the proposed National Response Framework (NRF), already have anticipated that requirements will far exceed the local and state/territory resources available.

The U.S. Department of Health and Human Services is the federal organization specifically responsible for public-health and medical-services sustainment support and, as such, already has been tasked to make up the difference between the city and state/territory resources and capabilities readily available and the total requirements and capabilities needed to medically manage the large-scale events postulated in the planning scenarios. It is imperative, therefore, that local and state/territorial resources and current capabilities be expressed both fully and accurately, and in as much detail as possible.  Only then can the HHS framework (and the department’s support organizations) properly plan, program, and budget for the entire array of facilities and resources needed, including a full complement of medical staff and the non-medical as well as medical goods and services required to support state/territory and local governments during future mass-casualty disasters and other public-health emergencies.

The Gap (or Unmet Requirements):

The gap developed for each planning scenario represents the difference between the resources and capabilities available and the total requirements identified. Not incidentally, the National Response Plan requires that local healthcare organizations pass on, to the local EMA, a complete list of requirements exceeding available resources.  Those requirements that cannot be met at the local jurisdictional level must then be forwarded to the state/territory EMA.  Finally, a list of the unmet state/territory requirements for resources and capabilities should be forwarded to the federal agency, HHS, primarily responsible for implementation – with the help of its various support agencies – of U.S. public-health and medical-services plans and policies.

Thanks to the somewhat complex but fairly well defined Gap Analysis process, HHS can analyze, plan, program, budget for, procure, and pre-position the additional resources and capabilities needed by lower jurisdictions to cope with major crises. The bottom line is that cooperation, teamwork, and advance planning are needed at all levels of government to sustain and fortify U.S. public-health agencies – and the nation’s private healthcare industry – to prepare for future emergencies and disasters requiring federal support.

James M. Rush Sr.

James M. Rush Sr. has over 45 years of healthcare administration and community emergency management experience in the U.S. armed forces, the U.S. public-health community, and the nation’s civilian healthcare industry. He served as the Region III project officer for the National Bioterrorism Hospital Preparedness Program, and the CDC’s National Pharmaceutical Stockpile, always dedicated to assisting healthcare and public health organizations prepare for “all hazards” events and incidents. He is author of, among other published works, the “Disaster Preparedness Manual for Healthcare Materials Management Professionals,” and a self-published book “Unprepared.”



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