Discussion of Lessons Learned

Our interviews with stakeholders of the federal MRC Program Office and case studies of six MRC units of diverse size and organization homes revealed numerous insights about the challenges and complexity of implementing a new program in a highly dynamic environment. In this section, we summarize briefly the lessons learned from the MRC demonstration project and their implications for future program development.

4.1 External Coordination

The resources devoted to the MRC Program during the demonstration period were relatively modest and, as a small player operating within a complex system for emergency preparedness and response, the viability of the program depended heavily on its ability to (1) establish collaborations with government and private partners and (2) demonstrate its utility and value to those partners. Our findings suggest that the MRC project has been successful on both fronts at the federal and local levels.

• Lesson Learned 1. Developing partnerships and collaborations is critical during a demonstration period. At the federal level, the MRC developed strategic alliances with ESAR-VHP, MMRS, and NACCHO and worked closely with the American Red Cross. At the local levels, units developed partnerships with local emergency agencies, public health agencies, and the American Red Cross.

Regardless of an MRC unit's organizational home, they will likely have to counter perceptions that volunteers are unreliable and unskilled, that their organization has no role in disaster relief or in public health, and/or jurisdictional turf battles.

• Lesson Learned 2. MRC units have to demonstrate their value to their partners and can do so by engaging with them in regular and frequent trainings and drills, participating actively in meetings, and establishing a spirit of quid pro quo so that the partners feel they are gaining as much as giving through the collaboration.
• Lesson Learned 3. MRC units need champions, not only the individuals who are committed to giving time and energy, but also the individuals who are highly respected and have the connections to key stakeholder groups (e.g., physicians, hospital administrators, emergency management officials) that may be inaccessible to the unit coordinator.
• Lesson Learned 4. A strong Citizen Corps presence in a State or community can help an MRC unit establish itself more quickly within the emergency preparedness community.

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4.2 Emergency Deployment

The MRC Program was profoundly affected and shaped by the response to Hurricanes Katrina and Rita. As a demonstration project focused on local development and activity at the community level, the MRC Program did not have an established mechanism for a national-level deployment. To its credit, the program office quickly established a communication protocol and ultimately was successful in helping deploy members from 105 units to the affected regions. The demonstration of effectiveness was all the more remarkable given that communication and activation protocols were being developed "on the fly" and that the response required was of an unprecedented scale and complexity.

• Lesson Leaned 5. The MRC response to Katrina and Rita demonstrated convincingly that it had a core capacity to create surge capacity (Goal 2) through local operations and out-of-State deployments.
• Lesson Learned 6. Listing MRC as a medical asset within the ESF 8 of the NRP may give it greater visibility and utility for future national deployments.
• Lesson Learned 7. Communication tools such as E-mail and cell phones are a critical necessity during an emergency deployment. Communication during emergency deployments was largely unproblematic because unit coordinators could use these technologies to contact volunteers quickly and at all hours. Communication with volunteers who are less comfortable with E-mail and mobile telephones (i.e., some retired volunteers who do not use or check E-mail frequently and prefer to use a landline phone) could be a potential problem to address.
• Lesson Learned 8. Flexibility is critical when there are no protocols or procedures to guide the situation or when protocols are simply breaking down. A disaster by its very nature brings a host of unforeseen problems and no emergency plan can account for all of them. An effective response requires not only an orderly attention to the established protocol, but also the ability to rapidly assess the limitations and gaps of those protocols and develop alternative strategies and approaches.
• Lesson Learned 9. Shared volunteers could be a problem in a large deployment. Volunteers with multiple commitments to Red Cross or CERT, and other volunteer organizations that could be called to support an emergency, raise serious issues of reliability. The problem of shared volunteers is not unique to the MRC; the problem is felt by other federal volunteer efforts, such as DMAT and MMRS.
• Lesson Learned 10. Integrating medical personnel into Red Cross can be problematic because Red Cross is only able to provide first aid. Some physicians are reluctant to do only first aid if their advanced skills could be used elsewhere.
• Lesson Learned 11. The MRC unit must operate as part of established emergency preparedness and response structures. At the local level, all but one unit was named as a medical asset in its their local emergency plans by the end of the demonstration period. Integration and communication at the State level were not as well developed. Only one case study unit had been incorporated into the State's emergency preparedness plans.
• Lesson Learned 12. The lack of formal integration and/or routine interaction between local MRC units and State entities undermines a command and control structure that is based on a hierarchy of local-State-federal communication. Most local deployments will not require the assistance or intervention of a State authority. However, in States where public health or emergency management authority are centralized at the State level, some level of formalized integration would be imperative; otherwise, the MRC would be seen as operating as a "lone-wolf" entity. Even in more decentralized systems, some preestablished line of communication would be helpful in a multijurisdictional deployment that requires the activation of multiple MRC units within the State. Such integration and interaction may also help MRC units take advantage of State resources (e.g., databases, credentialing) and planning.
• Lesson Learned 13. Naming an MRC unit as a deployable asset within a local or State emergency preparedness plan is an important precursor to functional integration but not sufficient to ensure it. If key stakeholders such as emergency management officials and hospitals do not trust the competencies and skills of the volunteers, these volunteers will not be utilized no matter how dire the situation.

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4.3 Community Health Engagement

The original mission and intent of the MRC was to support both the public health and preparedness/response needs of the community, in recognition of the fact that disasters and emergencies would be few and far between and maintaining volunteer interest would involve creating other opportunities for engagement. However, it was clear from the findings of this case study that the community health activities were not given the same priority as those related to emergency preparedness and response during the demonstration period. In the units in which the most community health activities were performed, the organizational home was either a social service or public health agency.

• Lesson Learned 14. Community health engagement is a worthy goal of the MRC design, but achieving it will require additional emphasis at all levels of MRC leadership. Helping units develop their community health mission could be an area for technical assistance, as well as recognizing the community health contributions of units more widely.
• Lesson Learned 15. Organizational homes other than those with direct ties to public health can support the public health mandate of the MRC. MRC units in agencies such as emergency management were eager to find opportunities to engage their volunteers in public health activities and had some success in doing so.

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4.4 Organization and Operation

At the federal level, the systems and resources devoted to management and oversight evolved rapidly over the demonstration period. While communication and oversight were decentralized though contracts with 10 regional coordinators and additional program office staff devoted to outreach, a number of the informants voiced concerns about the staffing levels at the MRC Program Office and questioned whether MRC had the resources to meet the demands placed on it.

• Lesson Learned 16. Systems to track and update MRC unit size, composition, and capacity for deployment are in need of continued attention. Unit reporting is still largely voluntary because most MRC units are not funded and the MRC Program Office currently lacks the contractual authority to mandate more rigorous reporting of current grantees.
• Lesson Learned 17. The resources of the program have not been commensurate with the demands placed on it. The program has evolved to a size and complexity that warrants continued attention to staffing capacity and funding.

  As the goals and mission of the MRC Program have now expanded to include national deployment, federal-State-local communication protocols will need continued attention.

• Lesson Learned 18. The organizational structure of the MRC at the federal and local levels needs to be closely aligned to the NRP model of local-State-region-federal communication and command structure. Although the majority of MRC unit activities and deployments will never involve any form of federal intervention, in those rare situations in which it is necessary, following a command structure that is in line with the NRP will facilitate a smooth and effective use of MRC volunteer resources.

  As part of the demonstration project, MRC units were permitted to be housed in a variety of organizational homes, such as universities, hospitals, emergency management agencies, State and local public health agencies, and nongovernmental organizations. In choosing to select case studies by organizational home, this evaluation was able to assess whether this factor had any bearing on performance. Among the six case study units in this evaluation, the organizational home was in no way related to performance in any way we could systematically detect.

• Lesson Learned 19. MRC units can operate effectively in a range of organizational homes, but all will have a set of different challenges to address. All will have a set of skeptical stakeholders they will need to engage and commit to their mission and a new set of technical competencies and skills to master.
• Lesson Learned 20. The organizational home may influence the focus of the unit activities. To ensure that the unit meets both its mandates to support the emergency and public health needs of the community, the unit should be prepared to engage disciplines different from those of its organizational home.
• Lesson Learned 21. The lack of standardization among units and State governmental authority is a significant barrier to external coordination. The fact that units are "unique" and housed in a variety of organizations does not sit well with stakeholders, who need to be assured that all MRC volunteers have some basic core competencies and that they can be readily integrated into existing State and local plans. Working with stakeholders on training and drilling activities and supporting their efforts with MRC resources, as appropriate, can largely ameliorate these concerns.

  Leadership of a fledgling program requires vision, energy, and persistence. By and large, most informants felt their unit coordinators were adequate in this regard. However, some were not as aware or skillful in managing volunteer relations.

• Lesson Learned 22. It is advantageous for unit leadership to have volunteer management experience. In particular, understanding how to engage volunteers through activities and creating opportunities to meet and build relationships with volunteers were the defining characteristics of the unit coordinators that were most active and viable by the end of the demonstration period.

  If the experience of the six case units we studied is any indication, MRC leadership can be expected to change about every 3 years. Over half of the unit coordinators with whom we spoke had been out of the position for at least 2 years. Therefore, there is a need to ensure that a small cadre of individuals are ready to assume the leadership of the unit and carry it forward is critical for sustainability. Furthermore, volunteers who put a lot of time and energy into the unit may eventually need to reduce their involvement.

• Lesson Learned 23. Given the commonly short duration of MRC unit leadership, ample attention should be given to transition and succession planning to minimize any disruptions in unit activities and progress and share the burden of the work with those who have been less actively involved.

  The training and preparation of volunteers is varied and could be improved with regard to content, frequency, and structure. Half of the units held regular meetings and trainings (including orientations for new volunteers); the others were only regularly engaged through E-mails and newsletters. Only a few units held a deployment drill more than once during the demonstration period.

• Lesson Learned 24. Volunteers need regular and sustained opportunities to personally engage with each other and the unit coordinator so that their commitment and enthusiasm is developed and sustained over time. The MRC unit should not be a collection of individuals in a database who have taken a few online courses or attended a few meetings.
• Lesson Learned 25. Units of larger size (more than 50 volunteers) will need to make greater efforts to create a personal relationships with and among the volunteers (e.g., by assigning volunteers with similar interests and skills to teams) and to recognizing their efforts.
• Lesson Learned 26. The lack of activation drills is a major weakness of the MRC volunteer experience. Drills can be expensive and time consuming, but it is difficult to measure the readiness of the volunteers to respond without any opportunity to apply and practice their newly acquired skills. This is an area of training that deserves additional consideration and resources.
• Lesson Learned 27. Ensuring volunteers have a common set of core competencies and skills can help address concerns stakeholders have about training, preparation, and utility. A cooperative agreement for capacity-building support in 2006 through NACCHO was an effort to address this lack of uniformity in knowledge and training.

  It was difficult for unit coordinators of the larger units to assess volunteers' level of retention because interaction with the volunteers was limited and databases were not up to date. The smaller units had more frequent interaction with their volunteers and coincidentally also made greater efforts to recognize volunteers' efforts.

• Lesson Learned 28. Volunteers appreciate efforts to recognize their participation, even in small ways (e.g., pins, T-shirts). Recognition of volunteer efforts should constitute an important task of unit leadership.

  The MRC units had little difficulty developing tracking systems for their volunteers, but keeping them current was a challenge. The task might be made both easier and more complex with the establishment of State-based credentialing systems supported by the ESAR-VHP program. Synchronizing the individual unit and State databases may be beyond the resources of the unit, and there may be a reluctance to share and exchange volunteer information.

• Lesson Learned 29. More attention needs to be given to resources and protocols for updating volunteer tracking information. The MRC Program Office could encourage units to share and exchange information regarding various software applications and tools they have developed or found useful.

Validating the credentials of the volunteers was a major concern during the demonstration period and a task that potentially could be addressed through closer integration with ESAR-VHP systems. However, not all States have an ESAR-VHP—funded database and those that do may only enroll medical personnel.

• Lesson Learned 30. As ESAR-VHP programs are established, units may need additional support, guidance, and incentives at the State level to ensure optimal coordination.

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4.5 Sustainability

All but one unit had secured funding beyond the demonstration period. These units had demonstrated their value to the community and been either absorbed into the housing organization or moved to another organization that would provide a stable source of funding. Ironically, the one unit that was described as having terrific "buy-in" from the "higher-up" from the beginning, was the one that had failed to secure its long-term viability. Undoubtedly, the fact that MRC inputs are relatively modest and unit staff time is usually shared with other similar duties facilitated the institutionalization of the program.

• Lesson Learned 31. Building a track record of success and demonstrating effectiveness is critical to long-term sustainability. Planning for postdemonstration funding should be addressed early in the implementation process.

In summary, overall the MRC Program has been highly successful in meeting the goals of the demonstration project. The success of the MRC Program at the national and local levels has been proven by the constant addition of new local units and new volunteers. (At current count, there more than 675 local MRC units and more than 121,000 volunteers.) The characteristics that make the MRC Program unique and attractive—the organization and utilization of a ready cadre of medical professionals, the fact that it is a volunteer corps, and the flexibility that local communities have in the structure and functioning of their MRC units—are precisely the characteristics that are most challenging. Many of the challenges and lessons learned from the assessment are not surprises for persons familiar with the MRC Program. In fact, many of those challenges are already being addressed by individual MRC units, the national MRC Program Office, and stakeholders of the program. Although many of the findings of this assessment signal action needed from the national program office, it is recommended that the lessons learned be shared with the local MRC units, their partners, their volunteers, and other stakeholders. Many individuals and groups will have an interest in contributing to the ongoing improvement and long-term success of the MRC Program.

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