Abstract
In October 2012, Superstorm Sandy had a wide impact on the public across New York City (NYC). The NYC Department of Health and Mental Hygiene (DOHMH) activated its incident command system (ICS) and deployed a liaison officer (LNO) to the NYC Emergency Operations Center (EOC) at NYC Emergency Management (NYCEM) 24 hours a day for 6 weeks. This prolonged response period, coupled with environmental effects on NYC's coastal communities, increased public awareness of Sandy's health impacts, requiring a broad scope of interagency coordination and operational input from the liaison officer. Liaison officers involved in this response later conducted a content analysis of issues handled throughout Sandy, to better understand the skill set required to serve in this role, identify greater staff depth, integrate liaison officers into DOHMH exercises, and update just-in-time training provided before liaison officers deploy. This analysis revealed defined training topics for liaison officers to improve staff performance and effectiveness in leading interagency coordination during emergency responses. Topics include resources, staffing, data management, public messaging, and vulnerable populations, and these topics have since been used to revamp liaison officer training and guide policy changes in the liaison officer job charter. Targeted use of liaison officers to support development and implementation and to coordinate response objectives with local, state, and federal partners has only become more important. This analysis continues to influence how DOHMH defines its citywide agency response role, to inform how best to staff and train liaison officers to respond, and to pose lessons for other jurisdictions seeking to maximize the effectiveness of liaison officers deployed in emergencies.
The scale and impact of Superstorm Sandy were extraordinary for New York City.1-4 The NYC Department of Health and Mental Hygiene (DOHMH) deployed at least 1 liaison officer (LNO) continuously (24/7) at the NYC Emergency Management Emergency Operations Center for 14 days in October 2012, followed by 12-hour shifts daily for the next 31 days, to manage issues and serve as an information conduit with other city, state, and federal agencies. While the DOHMH liaison officer role, on paper, described responsibilities aligned with the Federal Emergency Management Agency's (FEMA's) definition of the role of liaison officers, 5 liaison officers soon discovered that the size and scope of Sandy required their actions to be well above prior responses, with a significantly broadened scope of requests. This article describes a content analysis of the broad issues that DOHMH liaison officers managed throughout Sandy and its post-storm response, results of which were later used to redefine the skill set, improve liaison officer training, and expand staffing depth.
DOHMH Role and Liaison Officer Function
To further understand the complexity of the position of a DOHMH liaison officer, it is essential to describe this local public health agency's role in a given NYC emergency. The NYC City Incident Management System (CIMS) protocol is the local implementation of the National Incident Management System (NIMS), 1 which has been adopted since 2005 and establishes the roles and responsibilities of NYC agencies in managing planned events, emergency responses, and recovery operations. Under CIMS, DOHMH is the lead agency for a public health emergency (eg, disease outbreaks) and part of a multi-agency unified command in response to environmental hazards. For most citywide responses, DOHMH serves as a supporting agency, but Sandy's massive impact increased awareness of the secondary impact of weather and power outages on health, 2 both for vulnerable populations and the citizenry as a whole. Thus, in every citywide event involving DOHMH, its ICS deploys liaison officers in the role of representatives to other city entities—specifically, the Emergency Operations Center (EOC) at NYC Emergency Management (NYCEM) and occasionally to other agencies.
The liaison officer is a functional position in the incident command system that serves 2 purposes: (1) to provide information to external agencies on DOHMH response activities, and (2) to serve as a formal link for leaders to obtain information from external agencies. FEMA describes the liaison officer as the go-between among personnel who leads an agency's response, primarily as the point of contact and coordinator of other response organizations. 5 Liaison officers respond to requests for resources (eg, personnel or supplies) or information, and they also monitor overall response operations and report back information for situational awareness, identify subject matter expertise needs, and facilitate resource request fulfillment.
Under the DOHMH incident command system, the liaison officer is a member of the incident command system command staff reporting to the incident commander, and he or she communicates across the incident command system with section chiefs, as appropriate. Internally, liaison officers are deployable to the agency departmental operations center (DEOC) to support interagency coordination during public health emergency responses, which requires one or more liaison officers. For larger citywide responses, such as Superstorm Sandy, liaison officers can operate remotely, being deployed to external response locations such as the New York City Emergency Operations Center (EOC), other agency or incident operations centers, a formally designated incident command post, or to task forces or working groups requiring interagency coordination or formal DOHMH representation. Because of geographic limitations during Sandy, participating in key meetings and following up with key leaders and staff, largely by telephone, presented challenges for liaison officers early in the response, but these things became more routine as the response evolved. Typically, the liaison officer functions as an independent, potentially remote, and critical part of a larger agency and/or citywide response, all of which require effective and consistent communication across a number of functions. This physical location of the liaison officer, in particular, informs our analysis below.
Response Overview
By Monday, October 29, 2012, when Superstorm Sandy made landfall near Atlantic City, New Jersey, it was a post-tropical cyclone with 80 mph hurricane-force winds stretching nearly 1,000 miles in diameter. Major response operations considered and executed by government (NYC, New York State, and federal agencies) leading up to and following storm landfall included issuing evacuation orders in selected evacuation zones; opening and managing a long-term NYC mass sheltering system; conducting health facility evacuations and post-storm facility repatriations (led by the facility regulator, New York State Department of Health); and supporting vulnerable population needs in areas without power. In most instances, each of these operations was supported but not led by DOHMH, yet each required significant and unprecedented input and coordination between DOHMH and other responding agencies.
DOHMH was a major participant in the Sandy response and assisted with the evacuation of 37 healthcare facilities, the relocation and sheltering of thousands of individuals, the canvassing of over 175,000 units, and multiple information and supply distribution efforts. The NYC Medical Reserve Corps (MRC), coordinated by DOHMH, responded in large numbers as medical and mental health volunteers provided critical services in hurricane shelters, special medical needs shelters, and neighborhood-based restoration centers. DOHMH participated in response and recovery efforts until its incident command system fully deactivated on January 8, 2013, when recovery efforts integrated into routine operations.
Method: Content Analysis
To determine the skills needed for the liaison officer role during Sandy, we used content analysis to identify themes addressed by the liaison officer. Content analysis is a research method that follows a set of procedures to make valid inferences from text 7 and was an ideal process to identify liaison officer duties. We analyzed liaison officer email exchanges from Sandy and shift summary reports, which consisted of informal shift change notes that outlined issues addressed and/or outstanding from the prior operational period. This type of communication was deemed the most content-rich and descriptive in terms of the issues being handled by liaison officers, rather than formal agency situation reports. It is important to note that these shift notes were not publicly available but were shared by liaison officers with DOHMH's evaluation unit via email or hardcopy to serve this analysis and kept strictly confidential (in accordance with all response assessment records). Because these were considered response documents and not formally collected “data,” and the content was response information conveyed by the liaison officer, not personal information belonging to the liaison officer him- or herself, no information was redacted, nor did we seek IRB approval.
We acknowledge experiencing methodological limitations from the use of email as a data source. Our set of shift reports was incomplete because of a DOHMH IT policy that automatically deleted any emails not archived within 90 days, causing the loss of potentially hundreds of emails that responders were too busy to archive post-Sandy. We approximate that at least 15 missing shift reports exchanged by liaisons were lost to this policy. In addition, end-of-shift editing by liaisons about what issues to prioritize in shift reports (which were not formalized) cannot possibly be quantified. However, of the 49 emailed shift summary reports exchanged between liaison officers that were available, most were lengthy, highly detailed reports that summarized all issues addressed or in process on a given day, making them rich for content analysis.
In total, we reviewed 49 shift summary reports emailed between liaison officers between October 26 and December 6 and included a review of 526 supporting emails and NYCEM logistics records. From these emails, we initially identified 23 themes through an iterative process based on frequency. Themes were identified through a hand-coding process and were then defined, discussed, and classified by the liaison officer group, resulting in 14 themes. All themes, definitions, and examples were continuously reviewed and agreed on in a series of meetings with all liaison officers (n = 6) who worked during Sandy. These meetings, while used for verification purposes, were not formal focus groups, but allocated parts of monthly liaison officer meetings (post-response) and 3 dedicated meetings for thematic review and refinement. For themes that appeared to have overlap, liaison officers discussed them until we arrived at a clearly defined distinction; if we could not distinguish themes, they were collapsed and refined until definitions were agreed on. Transition emails were then combined into an aggregate document and reviewed and coded 3 times by 1 reviewer for consistency and vetted again with the liaison officer group to address discrepancies. Each email could contain multiple themes, depending on the issues addressed, which were typically defined by bullet points. These were then coded with the numbers 1 to 14 according to theme. Counts were placed into Excel for analysis, with total frequencies and percentages calculated for each week as well as the entire activation period. Themes were then reviewed again by all liaison officers; the final set is described below.
Results
Top 5 Thematic Findings
The top 5 themes for all 6 weeks of liaison officer function were Resources, Staffing, Data Management, Public Messaging, and Vulnerable Populations* (Table 1). For context, we have indicated the weeks in which certain examples took place, to indicate if it occurred in the early (weeks 1-2), middle (weeks 3-4), or late (weeks 5-6) response phases. It is worth noting that certain issues, such as resources, data management, and vulnerable populations, occurred more frequently in the first 3 weeks than later in the response.
Themes October 26-December 6, 2012
Resources, defined as any issue pertaining to securing nonpersonnel, was mentioned 114 times (28% of the time over the 6-week period) with 84 instances occurring in the first 3 weeks. Examples included requests to transport special medical supplies to shelters (eg, nebulizers, insulin, valve compressors for oxygen tanks) or requests to have generators sent to healthcare centers. † We observed repeat requests from other agencies trying to discern what types and quantities of supplies were at the shelters and were not able to be filled (in week 1); in these cases, the liaison officer served as a go-between for information about special medical needs shelters (SMNS) and the citywide logistics center managed by NYCEM. Later during Sandy, DOHMH proposed distribution of N95 respirators to volunteer organizations in affected areas (in week 4) and filled multiple requests for N95 masks and Tyvek protective suits for those cleaning up homes and businesses. Agency ownership of this issue was contested throughout the response.
The staffing theme included issues pertaining to DOHMH staff, including requests of the liaison officer to obtain additional staff to help in shelters (or to manage too many staff showing up in shelters where needs were not as great). It also included staff requests for information about time sheets and shelter staffing logs, official records used to verify staff work time. Staffing issues were mentioned 59 times (17%) in weeks 1 to 3 and 6 additional times, for a total of 65 across all 6 weeks. In one example, the liaison officer provided a list of shelters with high staffing needs to DOHMH district public health office assistant commissioners for distribution to their staffs, to redirect excess DOHMH staff who had deployed to shelters near their homes. In another example, the liaison officer worked to avoid duplicate effort when 2 agencies deployed staff, specifically school nurses, to shelters.
Data management was mentioned 34 times (10%) in the first 3 weeks and ultimately comprised 10% of all issues mentioned during activation of liaison officers. Data management included requests for, collection of, or information distribution from the field, other agencies, or internal DOHMH response groups—that is, any data that could be used for operational decision making, such as addresses for naturally occurring retirement communities, geospatial data, and surveillance data. One data request sent to the DOHMH GIS group through the liaison officer indicated that a community-based organization had inquired about a geocoded map on the DOHMH website: The map could only be searched 1 location at a time, and they wanted to compare multiple locations for canvassing purposes. Also, for the first time, the liaison officer was asked to convey requests for data, which required an immediate understanding of how the data would be used for operational decision making, including how to ask the right questions to understand how it would be shared. Most liaison officers did not have this understanding at the outset of the response.
Public messaging included a wide range of issues, such as requests for guidance on warnings regarding unsafe drinking water, public rumors, obtaining DOHMH frequently asked questions, and information about mold exposure. On one occasion, a local agency requested written guidance from DOHMH stating health warnings against drinking from fire hydrants (in week 1). Another example reflected the emotional power of rumors that influenced liaison officer activity—in this case referring to “children freezing in the dark,” which urgently implored officials to address the impact of cold weather on families without electricity (in week 2). Frequently, the liaison officer received emails with rumors that turned out to be unfounded but still had to be redirected swiftly to the agencies coordinating human services response operations. It was difficult, if not impossible, to discern unfounded content from legitimate material.
The vulnerable populations theme involved situations in which an individual, organization, or community reported a concern affecting the health of one or more vulnerable populations. Examples from Sandy included how to best serve seniors in shelters or appropriately address the needs of methadone patients seeking open facilities for maintenance treatment. Like other themes, these issues occurred more frequently in the first 3 weeks than later in the response. One example stated: “for several days we have been receiving various requests that don't fit in the HEC [Healthcare Evacuation Center] and also are not a Mass Care issue. They tend to need some investigation regarding the facility or an individual's issue. Some … issues relate to health, [and] emerging health issues, due to the prolonged effects of the disaster … [being able to track these issues] will help us see trends and … inform future planning … for vulnerable populations issues within DOHMH ICS. … ” (in week 1).
Additional Thematic Findings
Additional themes included:
volunteer management (eg, organizations or individuals offering to help with relief efforts); environmental issues (eg, pertaining to sanitation, restaurant inspection, and medical waste pick-up); utility issues (eg, related to power and electricity, such as requests about DOHMH buildings being prioritized for power restoration); evacuee/patient tracking (eg, DOHMH implemented a new tracking system for evacuees from long-term care facilities to shelters); transportation issues (eg, transport of evacuees, volunteers, and staff); door-to-door canvassing operations (eg, logistics and protocols for a canvassing operation to homebound individuals who had not evacuated); prescriptions and access to medications (eg, for those in shelters without prescriptions); mental health (eg, services for staff, volunteers, or people in shelters); and animal needs (eg, issues related to sheltering and feeding pets).
While many of these themes were not mentioned frequently, they illustrate the breadth of issues that crossed the liaison officer's desk during Sandy; these have been increasingly integrated into planning protocols since then. For other jurisdictions seeking to incorporate these findings into their liaison officer charters, these themes may be relevant irrespective of the counts we experienced.
Discussion and Recommendations
During Sandy, DOHMH liaison officers handled numerous issues likely to recur in future storms and other incidents. This analysis sought to describe how staff assigned to a liaison officer role could be trained and used more effectively across all types of emergencies. Our experience during the Sandy response showed that the liaison officer position, and related support for the liaison officer function, was important to this and subsequent responses. The data presented here outline core issues likely to be repeated and highlight how essential it is for staff to be pre-identified with specific skillsets. Our discussion centers on the combined knowledge and abilities we believe should be required for liaison officers to be successful in responses.
Knowledge
In addition to the content of identified themes, it makes sense for liaison officers to have a basic understanding of how local emergency logistics, supply tracking systems, and related citywide processes work. In Sandy, liaison officers were well positioned to obtain information (especially “early information”) on requests for critical supplies that arose in both the shelter and healthcare systems (eg, cleaning supplies for infection control in shelters, portable generators). These requests had to be prioritized due to supply shortages, requiring elevation to formal citywide and statewide resource request processes consistent with coastal storm and logistics response plans—all of which were aided immensely by the physical presence, advocacy, and timely documentation by the liaison officer in the emergency operations center.
Having an awareness of other agencies' resources can also expedite liaison officers' prioritization of requests. Knowledge of NYC agencies helps liaison officers direct questions appropriately and provides context when addressing questions from agency incident command system leadership, in turn allowing them to be highly receptive to other agency needs. Our own agency's evolving role in operations, as well as in managing outside requests for staff, were prevalent and should be anticipated. Thus, liaison officers would do well to understand staffing structures of shelters and evacuation centers, including the responsibility, function, and capacity of our own agency to mobilize and deploy its staff. In one example during Sandy, the liaison officer helped coordinate environmental health and other staffing resources to support targeted community outreach operations, based on priorities set by emergency operations center leaders under the ESF-6 Human Services and ESF-8 Health/Medical functions. When environmental issues arose in buildings that required additional follow-up, the liaison officer served as an important communications mechanism to refine and target public health and volunteer outreach staffing complements.
Knowledge of interagency functions also allows the liaison officer to anticipate requests other city agencies will make of DOHMH—for example, regarding data exchange. Being familiar with or pre-identifying types of data that external agencies collect, then initiating relationships to facilitate that exchange, can contribute to rapid problem solving. Similarly, since other agencies make frequent requests of the DOHMH for health-related guidance, a strong relationship between the liaison officer and the public information officer is necessary. Liaison officers should maintain awareness and, if possible, have quick access to preapproved public-facing information, to promulgate messages to inquiring agencies and convey messages from external agencies directly to the public information officer. Finally, liaison officers should have a strong understanding of health equity and, specifically, how vulnerable populations are adversely affected in emergencies. Liaison officers should develop relationships to fully understand the capacities and functions of human services agencies that will be key supports in response and recovery phases.
Abilities
The ability of liaison officers to build relationships, be flexible, and document effectively, in addition to understanding interagency functions and resources, is paramount. Liaison officer knowledge, coupled with strong communication skills, can convey a positive face of their agency, resulting in relationships that can expedite response requests. Liaison officer relationships and physical presence during chaotic, large-scale responses also serve as a critically important back-up to electronic or radio communications to ensure tasks are completed quickly.
In Sandy, being able to convey urgency at the point of decision making was critical to operationalizing response decisions, for staff deployment, prioritizing scarce resources, and linking decisions made by other agencies to response decisions with potential public health implications. While technological solutions to communicate needs continue to improve, our Sandy experience supports that the human element of decision making will always require direct contact and follow-up to maximize timeliness and efficiency.
Recommendations
We found clearly defined topics on which the liaison officer should be trained that have since been used to improve staff performance. We surmised the utility of being able to qualitatively anticipate functions most important to the success of a response, given the unexpected size and scope of Sandy and its volume of new, evolving issues. We found the ability to build relationships, be receptive, and convey urgency, combined with this thematic knowledge, can potentially facilitate responses to coastal storm and all-hazards incidents.
We recommend liaison officers be pretrained on how functions that do not fall under the realm of public health are structured, including how DOHMH intersects with and supports these functions. To address observed needs from Sandy, we developed comprehensive liaison officer training to provide skill building and content knowledge across the 5 most frequently mentioned content areas: resources, staffing, data management, public messaging, and vulnerable populations. Additionally, DOHMH liaison officers strengthened communication protocols to increase appropriate knowledge of city, state, and federal emergency response procedures and agency engagement in health/medical emergency support function response processes, as follows:
Agency response roles: DOHMH response roles are largely an extension of day-to-day activities, so educating liaison officers on the core functions of public health response is fundamentally important, for communicable disease outbreak investigations, environmental health investigations, public health laboratory testing and surge response, disaster mental health, healthcare emergency preparedness, postdisaster emergency canvassing operations, community resilience planning, and public information and messaging.
Coastal storm response roles: After Sandy, certain DOHMH coastal storm response roles and support functions needed to be made distinct; likewise, liaison officer support for these operations needed expansion and greater support. To this end, agency roles in coastal storm response are now more formally defined, such as in the assignment of DOHMH as agency lead in postemergency canvassing operations. Other examples include support to long-term resiliency and recovery roles to restore primary care services, monitor disease spread, and bolster mental health and other recovery functions. Now, the liaison officer role in the DOHMH incident command system is better recognized to support interagency requests for these operations and has improved formal linkages to agency leadership and command staff in DOHMH's incident command system. These enhanced reporting procedures vastly improve how agency requests are captured, coordinated, and resolved across numerous coastal storm response operations.
Citywide, statewide, and federal emergency response procedures: Formal knowledge of NYC, New York State, and federal emergency response procedures is key to enable liaison officers to both speak the same languageas their city, state, and federal response counterparts and also understand naturally occurring, predefined, or shared responsibility.
Emergency support functions (ESF-8 and ESF-6) communication processes: Nationally and in NYC, ESF-8 (Health/Medical) and ESF-6 (Mass Care, Emergency Assistance, Housing, and Human Services) response functions reflect widely varied response capabilities and expectations. After Sandy, NYC formalized ESF-8 information and reporting procedures and developed tools and templates useful to liaison officers. These model how ESF-8 or ESF-6 interagency task forces can achieve citywide operational objectives and communicate during a response. For example, the “Health/Medical ESF-8 Operational Summary,” codified in 2017 by NYC Emergency Management in consultation with DOHMH and other ESF-8 agency partners, reflects an informed “snapshot summary” of key data points representing the status of public health and health system response indicators. This report is designed so that ESF-8 health/medical system objectives and response priorities are addressed with support from the liaison officer and interagency task force partners. Use of this summary to inform ESF-8 response partners is a promising approach that has been undertaken in several storm responses since Sandy. Also, planned operational task forces have been formalized by developing interagency task forces linked to homebound individual outreach, transportation, and related logistics issues, which were problematic areas for Sandy liaison officers. Establishment of an interagency vulnerable populations task force (likely staffed by liaison officers) is anticipated during coastal storm responses, which informs interagency decision making and coordination of available agency and community-based organization data on vulnerable populations and prioritizes operational objectives during citywide public health responses. In short, these tools guide response communication of liaison officers reporting to the DOHMH incident command system, as well as incident command system communications to liaison officers.
We recommend a joint liaison officer/agency leadership training program be developed to formalize response and communication expectations between liaison officers and incident command system agency leaders and, in particular, the incident commander. This would explain key liaison officer functions and best practices for how incident commanders can use liaison officers to inform rapid decision making and to effectively send key messages outside the agency.
Because any agency's role in developing, leading, and supporting citywide health and medical policy efforts continues to evolve, so will the liaison officer role. Liaison officers themselves are valuable contributors in this process, building on their expanded role in Sandy and other responses, and applying lessons learned from all large activations. In NYC, any large-scale incident response is inherently an interagency response, as there are many stakeholder and regulatory agencies with overlapping client services, responsibilities, and mission interests at stake. With multiple agencies formally taking the lead in managing pre-identified operations, DOHMH must reinforce the liaison officer as an essential component of its preparedness and response framework. Active public health concerns can and do emerge across many types of incident response—not just in narrowly defined formal public health emergencies. Thus, accurate and appropriate representation and communication in the interagency response space remains critical to effective, efficient response operations.
Limitations
As mentioned, limitations of this study are based foremost in the number of emails we were able to include. This analysis should not be regarded as a comprehensive review of all matters that arose via liaison officer communications during Sandy, but as an archival sampling of salient issues. We are limited in generalizing these findings to other jurisdictions, in part because Sandy had broad impact, and because of how local response operations are structured. We are aware of reviewer bias because only one researcher was able to conduct the comprehensive review of emails, although we did seek to address this by holding multiple meetings with the 6 liaisons mobilized. Finally, while supplemental documents such as non–shift change emails and formal situation reports from NYCEM and DOHMH were examined, they were not ultimately analyzed as part of this dataset. These documents were merely used as background information to refine and finalize the key themes.
Conclusion
In recent years, technological advances (eg, social media, direct messaging applications, web-based response portals) have advanced response communications tremendously, but they cannot replace the physical presence of a liaison officer in a response. Emergencies as complex as Sandy and geographically small as a steam-pipe explosion have shown that in-person representation at multiple locations yielded richer levels of interaction and enhanced opportunities to rapidly address emergent issues. A solid and sustainable working relationship between incident response leadership and incident command system leadership requires face-to-face discussion, complex negotiation, and layers of explanation, all of which extend beyond electronic communication. An informed and empowered liaison officer in the incident command system structure is a critical tool.
In NYC's complex, multiagency response environment, coordinated reporting processes and communication with health system partners are essential to future complex responses. Emergencies can be used to test and learn how a role was actually used and then reviewed to inform training for improved performance and response coordination. In more than 5 years following Sandy, DOHMH agency and citywide reporting processes have been streamlined, improved, and codified into NYC coastal storm planning assumptions and reporting documents. Here, a role-specific training module was developed, and targeted meetings were held with response partner agencies to gain partners' operational knowledge for improved training led by these agencies. DOHMH's incident command system structure is being refined to test and support notification and general response communication protocols with NYCEM, the New York Police Department, and the New York Fire Department, with liaison officers as a critical link between external agencies and incident command system leadership.
While applying specific lessons learned from NYC's position during Sandy may not be generalizable, we find great value in using retrospective content analysis to examine lessons from real-time response documentation. The challenges liaison officers faced and solutions we have begun to implement since Sandy can serve as a starting point for other jurisdictions to define the liaison officer role in their local landscapes, placing liaison officers in the best position to succeed in similar large-scale responses.