Future Threats

Aside from hoax attacks, where credible threats occur based on purposeful counter-intelligence efforts of terrorists, I suspect large-scale events to be the modus operandi of terrorists in the next decade. According to LaFree, Yang, and Crenshaw (2009), anti-U.S. terrorists have ample intent on attacking the U.S. on our soil; however, this would be a huge and logistically complicated undertaking. For this reason, any future organized act of terror on U.S. soil will be designed to be significant, causing extreme loss of life or toppling a significant structure or both.

Biologic weapons would be the choice for terrorists who wished to inflict harm to the greatest amount of people, though releasing biologic material lacks the sudden impact usually sought, and weaponized biologics are not easily grown or economical (Levitin, 2005). Chemical weapons are typically easier and cheaper to manufacture, though they lack effectiveness and tend to merely create a scare of equivalent magnitude of a hoax (Levitin, 2005). Aside from basic explosives, this leaves the radiologic threat, a threat that I believe, coupled with a significant target, will cause devastating effects not unlike 9/11.

A dirty bomb is a conventional explosive used to disseminate radiologic materials over an area. I foresee a coordinated attack on the financial districts of the U.S. using dirty bombs. The bombs would, first, cause physical destruction to the buildings causing immediate disruption of the financial sector of the U.S. economy, along with a large death toll. Second, the radiation dispersed over the area would cause difficulty in cleaning up the area, inhibiting recovery and further impacting the financial markets.

A law enforcement response to such an attack would certainly be large in scale. The local police department would be first to respond, along with state police, then the WMD Coordinator at the local FBI field office would be apprised of the situation. As responders start arriving on scene, personal radiation detectors would start to tone indicating the release of radiologic material. This further information would prompt the WMD Dictorate in Washington, D.C., to order a full asset response by the FBI and other federal terrorism partners (e.g. the Joint Terrorism Task Force). The response to this type of incident should be trained on in cooperative exercises involving all levels of law enforcement. Additionally, personal radiation detectors (and other detectors) should, at a minimum, be placed in police vehicles for early warning of environments immediately dangerous to life and health. Adequate training, equipment, and preparation are the only ways in which to prepare for responding to large-scale terrorist attacks.


LaFree, G., Yang, S., & Crenshaw, M. (2009). Trajectories of terrorism: Attack patterns of foreign groups that have targeted the United States, 1970-2004. Criminology & Public Policy, 8(3), 445-473. doi:10.1111/j.1745-9133.2009.00570.x

Levitin, H. W. (2005). Debunking myths: How law enforcement can help diffuse the public’s fear. On the Beat. Retrieved from http://www.adl.org/learn/columns/Levitin.asp

Fear of Terrorism

As terrorism becomes more prevalent within a society, concerns about the psychological effects are brought to the forefront. The psychological effects of terrorism, in general, should have an impact on the ability of law enforcement and the public to interface appropriately. A recent study by Bleich, Gelkopf, and Solomon (2003) of the psychological effects of terrorism on the public in Israel showed surprisingly low levels of post-traumatic stress disorder symptoms despite high incidences of direct exposure to terror events. This study demonstrated that, although up to a third of the respondents acknowledged a “limited sense of safety and substantial distress [they] reported adapting to the situation without substantial mental health symptoms and impairment, and most sought various ways of coping with terrorism and its ongoing threats [, possibly linked to] processes of adaptation and accommodation” (p. 619). The study found that the most effective and widely used coping mechanism was checking on the well-being of friends and family. As people tend to cope well with trauma, attitudes towards protective measures seem to acquiesce for the common good, and this can be assistive to law enforcement.

One of the protective measures people tend to adopt that would help law enforcement is a sense of hypervigilance (Bleich, Gelkopf, & Solomon, 2003). Hypervigilance allows the people to be more attentive to things out of the ordinary (e.g. unattended packages, suspicious loitering, anxious mannerisms of others, et al.). This promotes a line of communication with law enforcement not only regarding terrorism but for other criminal activity, also.

Another protective measure, which goes towards acquiescence, is the ability of the people, in general, to accept an increased presence of law enforcement in their daily lives. When faced with a proximal event, the bulk of the citizenship contend that it is, indeed, a function of government to protect the masses from further harm, and these citizens tend to accept limits on personal liberty for perceived increases in security (Klein, 2007). This is a double-edged sword, however. People tend to want to return to a normal state of affairs (Bleich, Gelkopf, & Solomon, 2003). Though an increased police presence is initially welcomed and embraced, the people will eventually resent the loss of liberty and require law enforcement presence to recede. How this occurs will either enhance or detract from the ongoing relationship with law enforcement. An example of this is easy to see when considering both local law enforcement and the federal effort of the Transportation Security Administration (TSA). Local law enforcement seems to have decreased their presence, at least in my area, and are respectfully viewed as helpful, whereas the TSA, an agency that continues to irrationally impede on liberty, is viewed negatively by the traveling public.

Law enforcement is a service-based industry where the public is the customer. Police need to understand both the rights and the fears of the people in order to maintain the appropriate level of service, which waxes and wanes.


Bleich, A., Gelkopf, M, & Solomon, Z. (2003). Exposure to terrorism, stress-related mental health symptoms, and coping behaviors among a nationally representative sample in Israel. Journal of the American Medical Association, 290(5), 612-620.

Klein, L. (2007). Civil liberties and national security in the post 9-11 era: State power and the impact of the USA Patriot Act. Conference Papers – American Sociological Association, 1-8.


Challenges in Developing  Standards

The U.S. health care industry is contemplating the implementation of pay-for-performance reimbursement schemes in order to increase quality and safety in the delivery of health care. Pay-for-performance is a business model that combines reduced compensation for those who fail to meet standards and bonus payments for those that meet or exceed the stated expectations, but the results of such programs, thus far, is mixed (Baker, 2003; Campbell, Reeves, Kontopantelis, Sibbald, & Roland, 2009; Lee & Ferris, 2009; Young et al., 2005). The introduction of pay-for-performance models is primarily to provide relief from other, more extreme, reimbursement models, such as fee-for-service (which rewards overuse) and capitation (which rewards underuse), and with rising health care costs, a diminishing economy, and the increasing number of Americans lacking adequate health insurance, its introduction to the U.S. health care system could not be more timelier (Lee & Ferris, 2009).

The impetus of contemporary pay-for-performance schemes is derived from a report from the Institute of Medicine (2001). This report argued that current reimbursement schemes fail to reward quality in health care and may possibly create a barrier to innovation (Baker, 2003; Young et al., 2005). There are many international supporters of health care pay-for-performance, especially in England where the National Health Service employs pay-for-performance to keep costs under control while attempting to provide for quality and safety in the delivery of primary health care (Baker, 2003; Campbell et al., 2009; Young et al., 2005). However, the adoption of pay-for-performance seems to face many challenges.

One challenge to pay-for-performance implementation concerns the effectiveness in the overall continuity of care. Campbell et al. (2009) conducted an analysis of the effect of pay-for-performance in England and found that, although implementation of pay-for-performance in 2004 resulted in short-term gains in the quality of care, the improvements receded to pre-2004 levels. Beyond the pay-for-performance standards, though, the quality of care in areas not associated with incentives declined. Cameron (2011) reports on a recent study of the effectiveness of pay-for-performance on hypertension – the study shows no improvement in any measure including the incidence of stroke, heart attack, renal failure, heart failure, or combined mortality among the group (Lee & Ferris, 2009). McDonald and Roland (2009) describe these effects on other aspects of care as unintended consequences detrimental to health care quality and safety as a whole.

Another significant challenge to pay-for-performance implementation is ensuring that certain patient populations continue to be able to access appropriate care (McDonald & Roland, 2009). Under some pay-for-performance schemes, practices with a sicker patient demographic (i.e. geriatrics, oncology, neonatology, etc.) will suffer economically despite providing a higher level of care than their counterparts in family medicine or other more generalized practices. Specific concerns address a physicians ability to choose not to treat patients due to their non-compliance with medical orders (McDonald & Roland, 2009). Equity and access cannot suffer under a just reimbursement model, just as physicians with a sicker demographic should not suffer.

Identifying a reliable standard of measure in health care quality proves difficult. Earlier methods, such as those developed by Campbell, Braspenning, Hutchinson, and Marshall (2002), initially appeared sound, but ineffective methods and unintended consequences were soon identified (Cameron, 2011; Lee & Ferris, 2009; McDonald & Roland, 2009). More recent work by Steyerberg et al. (2010) shows that new approaches are on the horizon and that pay-for-performance may still remain a viable scheme, providing the measures and standards are, in fact, legitimate and accurately identify improved quality without detracting from other aspects of heath care. Steyerberg et al. identifies novel approaches to prediction models that may help to standardize measures in pay-for-performance schemes to be more realistic and reliable without causing many of the unintended consequences of earlier plans.

As we become more technologically advanced and find ways, albeit expensive, to cure and treat diseases that until now were intractable, we must address the ethics surrounding the provision of this care as a system of management. By combining the whole of health care into the ethics discussion, we opt to leave no one wanting for care, but we now have to address the problem of paying for the expensive care that we have all but demanded. Pay-for-performance, though not perfect, shows much promise in keeping health care costs manageable. However, we must strive to identify those patients and practitioners that lose out under this system of reimbursement and strive to identify just and ethical means of repairing the scheme. Though, we should first answer the question: is health care a right or a privilege?


Baker, G. (2003). Pay for performance incentive programs in healthcare: market dynamics and business process. Retrieved from http://www.leapfroggroup.org/media/file/Leapfrog-Pay_for_Performance_Briefing.pdf

Cameron, D. (2011, January 27). Pay-for-Performance does not improve patient health. Harvard Medical School News. Retrieved from http://hms.harvard.edu/public/news/2011/ 012611_serumaga_soumerai/index.html

Campbell, S. M., Braspenning, J., Hutchinson, A., & Marshall, M. (2002). Research methods used in developing and applying quality indicators in primary care. Quality and Safety in Health Care, 11(4), 358–364. doi:10.1136/qhc.11.4.358

Campbell, S. M., Reeves, D., Kontopantelis, E., Sibbald, B., & Roland, M. (2009). Effects of pay for performance on the quality of primary care in England. New England Journal of Medicine, 361(4), 368-378. doi:10.1056/NEJMsa0807651

Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Retrieved from http://www.iom.edu/reports/2001/Crossing-the-Quality-Chasm-A-New-Health-System-for-the-21st-Century.aspx

Lee, T. H. & Ferris, T. G. (2009). Pay for performance: a work in progress. Circulation, 119(23), 2965-2966. doi:10.1161/CIRCULATIONAHA.109.869958

McDonald, R. & Roland, M. (2009). Pay for performance in primary care in England and California: comparison of unintended consequences. Annals of Family Medicine, 7(2), 121–127. doi:10.1370/afm.946

Steyerberg, E. W., Vickers, A. J., Cook, N. R., Gerds, T., Gonen, M., Obuchowski, N., … Kattane, M. W. (2010). Assessing the performance of prediction models: A framework for traditional and novel measures. Epidemiology, 21(1), 128–138. doi:10.1097/EDE.0b013e3181c30fb2

Young, G. J., White, B., Burgess, J. F., Berlowitz, D., Meterko, M., Guldin, M. R., & Bokhour, B. G. (2005). Conceptual issues in the design and implementation of pay-for-quality programs. American Journal of Medical Quality, 20(3), 144-50. doi:10.1177/1062860605275222

WMD Coordinator

According to the Federal Bureau of Investigation (FBI; 2007) and the U.S. Department of Justice (2009), the WMD Coordinator, a designated Special Agent within each field office, is responsible for initiating the federal response to any possible WMD event. “The Attorney General has lead authority to investigate federal crimes, which includes the use or attempted use of a WMD. 28 U.S.C. § 533 (2008) and 18 U.S.C. § 2332(a) (2008). The Attorney General has delegated much of this investigative authority to the FBI” (U.S. Department of Justice, 2009, p. 1). The WMD Coordinator helps to fulfill this mandate by being the point of contact for local and state officials when an event involving an WMD is suspected to have occurred.

In the Mattapan scenario, the initial response by the Boston Police Department and the Massachusetts Bay Transit Authority Police Department unveil a possible attempt to utilize an explosive to disseminate a chemical or biologic material in a public place. As soon as this plot is uncovered, an emergency response plan should be initiated, which involves notifying the Boston FBI field office of the suspected WMD event. The WMD Coordinator of the Boston field office would be the person receiving this notification. The Massachusetts State Police would also be notified to respond as they are able to provide their own subject matter experts and resources.

As a WMD subject matter expert, once notified of the circumstances, according to the FBI (2007), the WMD Coordinator responds to the scene and assists local and state law enforcement in determining the threat. Once it is established that an WMD is involved, whether by direct investigation at the scene or based on reports from law enforcement, the WMD Coordinator would immediately notify the WMD Directorate at FBI Headquarters. This notification would activate a team of WMD experts who would participate in a conference call with the WMD Coordinator to further identify the threat and, also, identify the additional federal resources needed to respond to the event. The additional resources could be individual experts, federal response teams from other departments or bureaus (e.g. the Joint Terrorism Task Force, the Bureau of Alcohol, Tobacco, Firearms, and Explosives), or the special teams of the FBI, including the Chemical and Biological Sciences unit (to identify the particular payload material), photo operations personnel, an explosives team (based on the dispersal mechanism being explosives), the disaster squad (to identify any potential victims), and the national level Hazardous Material Response Unit and the local Hazardous Material Response Team to collect evidence from the scene. The WMD Coordinator would, then, be responsible for leading the investigation.

The WMD Coordinator would most likely fulfill his role within the unified incident command structure as Law Enforcement Command. This position would allow him or her to delegate the responsibilities of the response, including the need to provide information to the public. Public Information Officers provide a critical role in major response efforts. They provide enough information to the public to allay any unfounded fears, provide direction and instructions when needed, and filter sensitive information so that it does not become public knowledge. It is important for the public to be apprised of the situation in a calm and authoritative manner to assure them that everything necessary is being done. It is also important for the public to understand the risks of the situation in a realistic manner to prevent a mass overreaction.

The WMD Coordinator position is a valuable tool of the FBI and the federal government. Though the value of this position has been criticized for the lack of readiness and training, preparations are being undertaken to ensure a quality approach to responding to WMD events in the future (McDonald, 2009; U.S. Department of Justice, 2009).


Federal Bureau of Investigation. (2007, March 5). WMD threats: How we respond. Retrieved from http://www2.fbi.gov/page2/march07/wmd030507.htm

McDonald, J. (2009, October 8). FBI WMD Coordinator program needs improvement [Web log]. The OC Sheriff Blog. Retrieved from http://blog.ocsd.org/post/2009/10/08/Audit-of-FBI-Weapons-of-Mass-Destruction-Coordinator-Program-Recommends-Improvements.aspx

U.S. Department of Justice. (2009, September). The Federal Bureau of Investigation’s Weapons Of Mass Destruction Coordinator program (Audit Report #09-36). Retrieved from http://www.justice.gov/oig/reports/FBI/a0936.pdf

Electronic medical records:

The Push and the Pull

Increasing safety and efficiency in medicine can only lead to an increase in health care quality, right? Some might not agree, especially when it comes to the implementation of electronic medical records (EMRs). There is a federal effort to ensure all medical records are in digital format by 2014, and supporters of EMR technology laud their effectiveness at minimizing medical errors, keeping records safe, facilitating information portability, and increasing cost-efficiency overall (The HWN Team, 2009; Preidt, 2009). Unfortunately, many are skeptical of the cost, security, and utility of such systems (Brown, 2008; The HWN Team, 2009; Preidt, 2009; Terry, 2009). These concerns (and others) are dramatically slowing the pace of EMR adoption, especially in smaller private practices where cost is a significant issue (Ford, Menachemi, Peterson, & Huerta, 2009).

Does EMR adoption actually increase safety? As Edmund, Ramaiah, and Gulla (2009) point out, a working computer terminal is required in order to read the EMR. If the computer system fails, there is no longer access to the medical record. This could be detrimental in a number of cases, especially when considering emergency medicine. Edmund, Ramaiah, and Gulla also describe how difficult it can be to maintain such a system. With this in mind, it is plain that as the system ages there will be more frequent outages and, therefore, more opportunity for untoward effects. Further, recent research shows how EMRs enforce pay-for-performance schemes that many U.S. physicians resent. McDonald and Roland (2009) demonstrate that physicians in California would rather disenroll patients who are noncompliant when reimbursed under pay-for-performance models enforced by the EMR software. Declining to treat patients who express their personal responsibility and choice in their own medical treatment cannot improve the effectiveness of safety in the care that they receive.

There needs to be a middle ground. Baldwin (2009) offers some great real world examples of how some hospitals and practices use hybrid systems to ensure effectiveness and quality while enjoying the benefits of digital records. According to Baldwin, there are many concerns to account for when considering a move from an all paper charting system to an all digital system. Many times, these concerns cannot be allayed and concessions between the two systems must be made. Brown (2008) suggests providing a solid education to the front-line staff regarding EMR implementation, and hence, obtaining their ‘buy in’ to the process to create a smoother transition to implementation. However, this does not address the safety concerns. Baldwin’s advice to analyze which processes should be computerized allows a solid business approach to EMR implementation, allowing some processes to remain paper-based if it makes sense to do so.


Baldwin, G. (2009). Straddling two worlds. Health Data Management, 17(8), 17-22.

Brown, H. (2008, April). View from the frontline: Does IT make patient care worse? He@lth Information on the Internet, 62(1), 9.

Edmund, L. C. S., Ramaiah, C. K., & Gulla, S. P. (2009, November). Electronic medical records management systems: an overview. Journal of Library & Information Technology, 29(6), 3-12.

Ford, E. W., Menachemi, N., Peterson, L. T., & Huerta, T. R. (2009). Resistance is futile: But it is slowing the pace of EHR adoption nonetheless. Journal of the American Medical Informatics Association, 16, 274-281. doi:10.1197/jamia.M3042

The HWN Team. (2009, March). Electronic medical records: the pros and cons. Health Worldnet. Retrieved from http://healthworldnet.com/HeadsOrTails/electronic-medical-records-the-pros-and-cons/?C=6238

McDonald, R. & Roland, M. (2009, March). Pay for performance in primary care in England and California: Comparison of unintended consequences. Annals of Family Medicine, 7(2), 121-127. doi:10.1370/afm.946

Preidt, R. (2009, December 16). Pros and cons of electronic medical records weighed. Business Week. Retrieved from http://www.businessweek.com/lifestyle/content/healthday/634091.html

Terry, N. P. (2009). Personal health records: Directing more costs and risks to consumers? Drexel Law Review, 1(2), 216-260.

The Role of Federal Law Enforcement

The role of federal law enforcement has changed with the inception of the National Response Framework (NRF; U.S. Department of Homeland Security, 2008). In the past, according to the obsolete National Response Plan (NRP; U.S. Department of Homeland Security, 2004), the effort of the federal government was to support local efforts and only take charge if necessary or requested to do so by the responsible jurisdiction. The NRF furthers this goal. However, according to a recent U.S. Department of Justice (2010) report, federal law enforcement is ill-prepared to provide a robust and organized response to an act of terrorism on U.S. soil, save for the Federal Bureau of Investigation (FBI).

For instance, assume that a small group of terrorists detonate a bomb, otherwise known as a ‘suitcase bomb’, designed to shower radiologic material over an area approximately 9 city blocks in downtown Los Angeles. What chain reaction, in regards to a law enforcement response, would this event trigger?

First, calls to 9-1-1 reporting a large explosion would trigger a local response by both the Los Angeles Police Department and the Los Angeles County Sheriff’s Office, along with other emergency services. As local assets begin arriving, hopefully they determine the large and possibly catastrophic nature of the event and advise their communications center to make the appropriate notifications. These notifications would be contingent on the preplanned incident action plans of each agency, which would, hopefully, open emergency operations centers (EOCs) for the City of Los Angeles, Los Angeles County, and the State of California. These EOCs would be responsible for making further notifications and coordinating the response with mutual aid agencies as well as state and federal assets. Common to most all preplans in the event of a suspected terrorist attack is the notification to the FBI’s Joint Terrorism Task Force, which is responsible, according to the Department of Justice (2010) report and the NRF, for coordinating all law enforcement and investigative activities of federal agencies (U.S. Department of Homeland Security, 2008).

A suitcase bomb is significant as it involves the spread of radiological materials that are harmful to humans. According to the Department of Justice (2010) report, the only federal law enforcement agency prepared to deal with such an event is the FBI. Thus, the FBI would be expected to offer expertise and specialized teams to the Los Angeles Police Department in a cooperative effort to begin law enforcement and investigative procedures as soon as possible.


U.S. Department of Homeland Security. (2004). National response plan. Retrieved from http://www.au.af.mil/au/awc/awcgate/nrp/nrp.pdf

U.S. Department of Homeland Security. (2008). National response framework. Retrieved from http://www.fema.gov/pdf/emergency/nrf/nrf-core.pdf

U.S. Department of Justice. (2010, May). Review of the department’s preparation to respond to a WMD incident (OIG Report# I-2010-004). Retrieved from http://www.justice.gov/oig/reports/plus/e1004.pdf

The Need for Multi-Agency Coordination

Terrorists, whether foreign or domestic, typically choose targets that have value in societies or philosophies that they oppose (LaFree, Yang, & Crenshaw, 2009). For instance, according to the Federal Bureau of Investigation (n.d.), al Qaeda, under the leadership of Usama bin Laden, had their sights on the World Trade Center, a symbol of global capitalism, for many years. Another example, involving domestic terrorism, is the bombing of the Alfred P. Murrah Federal Building in Oklahoma City by Timothy McVeigh, Terry Nichols, and Michael Fortier. This target was chosen as a representation of the federal government, which McVeigh and Nichols despised, citing the incident involving federal agents in Waco, Texas, two years earlier.

Considering local community events that might be of significant interest to terrorists as potential targets, the Bristol Fourth of July Parade comes to mind. The parade is a major component of the oldest celebration of our nation’s independence and is attended by over 200,000 people each year (Fox Providence, 2011). The parade is symbolic and casualties could number in the thousands, depending on the tactics and strategies used.

There is limited egress from the Town of Bristol (see figure 1). Hope Street and Metacom Avenue are the only two roads that provide a route in and out of the town. Both lead to the Town of Warren to the north, and Hope Street converges with Metacom Avenue just before exiting the town by way of the two-lane Mount Hope Bridge to the south. Both roads are heavily trafficked during the parade inhibiting both evacuation and emergency response.

In the event that a significant terrorist act was to occur at this parade, the initial law enforcement response would be limited to those officers already on site. These officers, operating under the auspices of the Bristol Police Department would be primarily Bristol police officers with a small contingent of off-duty officers from neighboring jurisdictions. There is usually a small contingent of Rhode Island State Police troopers present. These officers would be on their own for a length of time, some of them probably affected by the attack.

Secondary responders would include both Rhode Island and Massachusetts State Police, along with mutual aid officers from approximately 10 to 15 neighboring communities; however, as people flee the initial attack, a secondary attack could create further confusion and increase the likelihood of severe traffic jams at all three evacuation points further inhibiting a timely response. Once the degree and scope of the incident is ascertained and the access difficulties are identified, it would make sense for a contingent of law enforcement to board helicopters and boats out of Providence and cross Narragansett Bay. Once on land, these officers (most likely consisting of U.S. Coast Guard, Providence Police, U.S. Border Patrol, and other federal law enforcement entities housed in Providence, RI) would rely on alternative means (walking, bicycles, ATVs, et al.) to reach the scene.

Colt State Park, to the southwest, would make a viable forward area command, allowing access for all types of vehicles, including single-engine fixed-wing aircraft. There is also an added benefit of a strong sea breeze to help direct any plume away from this forward area command post.

I have to consider that the law enforcement entities, along with the local emergency management authorities, have a working disaster plan in place for the Bristol Fourth of July parade; however, the plan must detail the fact that all resources would be overcome due to the scope and severity of such an incident; therefore, contingencies, such as stand-by assets, must be established and ready to respond by alternative means in the event that a catastrophic event were to occur, whether criminal or accidental in nature.


Federal Bureau of Investigation. (n.d.). Famous cases & criminals. Retrieved from http://www.fbi.gov/about-us/history/famous-cases/

Fox Providence. (2011, July 5). Inbox: Fourth of July festivities. Retrieved from http://www.foxprovidence.com/dpp/rhode_show/inbox-fourth-of-july-festivities

LaFree, G., Yang, S., & Crenshaw, M. (2009). Trajectories of terrorism: Attack patterns of foreign groups that have targeted the United States, 1970-2004. Criminology & Public Policy, 8(3), 445-473. doi:10.1111/j.1745-9133.2009.00570.x

Rhode Island Emergency Management Agency. (2008). State of Rhode Island hurricane evacuation routes: Town of Bristol [Map]. Retrieved from http://www.riema.ri.gov/preparedness/evacuation/Hevac_Bristol.pdf

Figure 1.

Bristol RI Evacuation Route
“State of Rhode Island hurricane evacuation routes: Town of Bristol” (Rhode Island Emergency Management Agency, 2008).

Challenges Developing Measurement Tools

Common sense would dictate that a person should want to purchase quality when choosing any product or service, and as health care costs soar in the United States, we also want to ensure that we, as consumers of health care and taxpayers who subsidize health care, are reaping maximum quality for that cost (Buck, Godfrey, & Morgan, 1996). According to McGlynn (1997), the costs for health care in the U.S. have been rising dramatically causing disruption in the manner of which professionals provide care and patients seek it out. It is important to realize the impact that these increasing costs and other changes have on the delivery of care, and, as McGlynn points out, assessment of quality measures are the means of evaluation. Unfortunately, McGlynn and others at the time have found quality measures to be lacking the requisite data needed to make an accurate evaluation of the delivery of health care (Brook, McGlynn, & Shekelle, 2000; Grimshaw & Russell, 1993; McGlynn, 1997).

Over the past decade, many efforts have been made to develop quality measures in order to direct quality improvement; however, these efforts, though effective, have been disjointed and ad hoc at best. McGlynn and Asch (1998) cautions that careful attention to methodology is essential when developing these measures. Accurate methodologies can be reproduced and used to effectively compare efforts between institutions. This leads to a best practices continuum of health care provision.

Recently, researchers have studied teamwork behaviors and their influence on patient and staff-related outcomes, but many of the discussions were institution-centric and may not have applied in the macro environment of U.S. health care. Reader, Flin, Mearns, and Cuthbertson (2009) recently attempted to organize these studies and develop a portable and robust framework which would lead to the development of effective team performance and provide means of further testing and improvement of team dynamics. Their findings suggest that effective teamwork is crucial to providing patient care in critical settings. Reader et al. shows one of the shortcomings of recent quality measure development but also illustrates a manner in which to overcome the limitations.

Developing methods for measuring and evaluating performance in health care have been challenging, overall. Campbell, Braspenning, Hutchinson, and Marshall (2002) identify three component issues to addressing these challenges: “(1) which stakeholder perspective(s) are the indicators intended to reflect; (2) what aspects of health care are being measured; and (3) what evidence is available?” (p. 358). This addresses the qualitative concerns of capturing indicators, while efforts like those of Steyerberg et al. (2010) concern themselves with quantitative abstraction and portability, as well as predictive value. Steyerberg et al. promotes the use of reclassification, discrimination, and calibration when using statistical models to develop valid prediction models and novel performance measures.

Performance indicators that are an accurate reflection of health care provision can lead to development of best practices, lower overall health care costs, and improve the delivery of care which will decrease mortality and morbidity. When considering these performance indicators, especially during development, researchers and administrators need to ensure the validity of the measurements. Approaches to developing quality improvement measures are constantly evolving, and new and novel methods are being designed to standardize the instruments, the application, and the reporting. Quality improvement is still, however, a challenge to many health care providers.


Brook, R. H., McGlynn, E. A., & Shekelle, P. G. (2000). Defining and measuring quality of care: a perspective from US researchers. International Journal of Quality in Health Care, 12(4), 281–95. doi:10.1093/intqhc/12.4.281

Buck, D., Godfrey, C., & Morgan, A. (1996). Performance indicators and health promotion targets (Discussion paper No. 150). York, UK: Centre for Health Economics, University of York. Retrieved from http://www.york.ac.uk/che/pdf/DP150.pdf

Campbell, S. M., Braspenning, J., Hutchinson, A., & Marshall, M. (2002). Research methods used in developing and applying quality indicators in primary care. Quality and Safety in Health Care, 11(4), 358–364. doi:10.1136/qhc.11.4.358

Grimshaw, J. M. & Russell, I. T. (1993). Effect of clinical guidelines on medical practice: A systematic review of rigorous evaluations. Lancet, 342(8883), 1317-1322. doi:10.1016/0140-6736(93)92244-N

McGlynn, E. A. (1997). Six challenges in measuring the quality of health care.Health Affairs, 16(3), 7-21. doi:10.1377/hlthaff.16.3.7

McGlynn, E. A. & Asch, S. M. (1998). Developing a clinical performance measure. American Journal of Preventive Medicine, 14(3), Supp. 1, 14–21. doi:10.1016/S0749-3797(97)00032-9

Reader, T. W., Flin, R., Mearns, K., & Cuthbertson, B. H. (2009). Developing a team performance framework for the intensive care unit. Critical Care Medicine, 37(5), 1787-1793. doi:10.1097/CCM.0b013e31819f0451

Steyerberg, E. W., Vickers, A. J., Cook, N. R., Gerds, T., Gonen, M., Obuchowski, N., … Kattane, M. W. (2010). Assessing the performance of prediction models: A framework for traditional and novel measures. Epidemiology, 21(1), 128–138. doi:10.1097/EDE.0b013e3181c30fb2

Expansion of Law Enforcement Post-9/11

Prior to 1993, federal law enforcement agencies, specifically the Federal Bureau of Investigation (FBI), felt more than adequate in investigating and preventing terrorism on U.S. soil (Smith & Hung, 2010). On September 11, 2001, as has been done on numerous emergent occassions, the U.S. government all but suspended Article III, Sec. 2 and Amendments II, IV, V, VI, IX, X, XIII, XIV of the U.S. Constitution in the name of protecting liberty; a premise I find sadly ironic.

According to an article by Abramson and Godoy (2006), the passage of the USA PATRIOT Act (2001) promotes intelligence sharing among the intelligence community, utilization of technological tools to combat tech-savvy terrorists, allows easier access to the business records of suspected terror supporters, allows search warrants to be affected without undermining other concomitant investigations, and allows wiretaps to be dynamic in order to follow the target suspect more easily. Detractors of the USA PATRIOT Act, however, argue that these measures undermine certain liberties that Americans are right to enjoy. These detractors warn of information cataloging that could lead to massive data stores of private information of regular citizens, unwarranted investigations, searches, and seizures of casual contacts of someone under investigation, and general use of “sneak and peek” warrants for the investigation of petty crimes.

One particular part of the USA PATRIOT Act, the usage of letters of national security that demand secrecy of government involvement from the recipient, was struck down by a federal judge based on Constitutional freedom of speech issues (Liptak, 2007). This is no surprise. Passing 357 to 66 in the House of Representatives and 98 to 1 in the Senate just six weeks after 9/11 and with little debate, this knee-jerk legislation was destined for failure, at least where public relations is concerned (Weigel, 2005).

The USA PATRIOT Act (2001) grants immeasurable power to law enforcement to investigate and prevent terrorism, this is a good thing; however, most of the provisions seem to fail whenever exercised against a U.S. citizen or lawful resident (Weigel, 2005). We need to rethink our approach to terrorism and ask the question of ourselves: is our safety worth every ounce of our liberty?


Abramson, L. & Godoy, M. (2006, February). The Patriot Act: Key controversies. Retrieved from http://www.npr.org/news/specials/patriotact/patriotactprovisions.html

Liptak, A. (2007, September 7). Judge voids F.B.I. tool granted by Patriot Act. The New York Times, pp. A18. Retrieved from http://www.nytimes.com

Smith, C. S. & Hung, L. (2010). The Patriot Act: issues and controversies. Springfield, IL: Thomas Books.

USA PATRIOT Act. P. L. 107-56 Stat. 115 Stat. 272. (2001).

Weigel, D. (2005, November). When patriots dissent. Reason, 37(6). Retrieved from http://www.reason.com/news/show/33167.html

Quality and Safety Measurement

In regards to the incident surrounding the death of Josie King (Josie King Foundation, 2002), there have been many great improvements in the delivery of care at Johns Hopkins (Niedowski, 2003; Zimmerman, 2004). Those aside, and if I was faced with having to develop performance measures of quality and safety in the context of such a tragedy, I would strive to ensure that my measures were accurate and valid to identify areas of grave concern where Johns Hopkins would do good to improve.

First, I would consider measuring the structure of the care delivered. In Josie’s case, a medical response team responded when it was identified that she was in the midst of a medical crisis. The first measurement would serve to identify the availability of such teams and the adequacy of the team’s staffing. The measure would indicate the response time of the team and the licensing and certification level of each team member.

Second, I would consider measuring processes that might have contributed to the death of Josie King. In this instance, Josie was administered a narcotic while suffering acute dehydration. The administration of this medication was contrary to the physician’s orders regarding pain medication for this patient. This measure would indicate the appropriate use of narcotic analgesia in patients faced with contraindications, such as acute dehydration or shock. This measure would be a cross tabulation of recent vital signs and laboratory results.

Third, I would consider measuring outcomes. In cases where pediatric patients are downgraded from the pediatric intensive care unit (PICU) to a general ward, any adverse condition should prompt an upgrade back to the PICU. This measure would identify the number of cases in each reporting period that any recently downgraded patient was upgraded back to the PICU. This measure should account for the time between a crisis and upgrade along with a statement indicating the cause of the crisis and resultant upgrade. This measure should be augmented by a mortality and morbidity subset involving any patients who were downgraded from PICU.

My considerations for these processes are to determine if general ward nurses should be administering any medications on standing order or if there should be a requirement to ensure that any medication administered to a general ward patient is explicitly written in the patient’s chart at the time of administration. Also, nurses should be acutely aware of the contraindications of any medications that they are administering. The process measure will, hopefully, identify misuse of narcotic analgesia and any failure to assess the patient for other possible causes of distress before assuming the distress is in response to pain. Ultimately, a more timely and efficient use of medical response teams should result, which would avail physicians and more experienced nurses to the original patient care team. This should lead to an open discussion of how to better manage the patient post crisis. Also, a greater understanding of medication administration concepts should result, benefiting all patients.


Josie King Foundation. (2002). About: What happened. Retrieved from http://www.josieking.org/page.cfm?pageID=10

Niedowski, E. (2003, December 15). From tragedy, a quest for safer care; Cause: After medical mistakes led to her little girl’s death, Sorrel King joined with Johns Hopkins in a campaign to spare other families such anguish. The Sun, pp. 1A. Retrieved from http://teacherweb.com/NY/StBarnabas/Quality/JohnsHopkinsErrors.pdf

Zimmerman, R. (2004, May 18). Doctors’ new tool to fight lawsuits: Saying ‘I’m sorry’. Wall Street Journal, pp. A1. Retrieved from http://www.theoma.org/files/wsj%20-%20medical%20error%20-%2005-18-2004.pdf