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Building Resilience in a Public Health Workforce: A Model Active Shooter Training and Exercise Program for Responders

State: UT Type: Promising Practice Year: 2019

LHD Description

Salt Lake County (SLCo) is the most populous county in Utah with just under 1.1 million people. SLCo comprises an area of 742 square miles and is a diverse community of 16 cities and 6 townships.  The county is considered an urban/suburban community with some small rural areas in the western and southwestern areas.

The Salt Lake County Health Department (SLCoHD) currently employs just under 375 staff, with eight locations throughout the valley.  The SLCoHD received accreditation from PHAB in 2013 and recognition for Project Public Health Ready accreditation in 2018. The mission statement of the Salt Lake County Health Department reflects the goals of the department with this simple principle: To promote and protect community and environmental health.

Public Health Issue

A tragic aspect of today's society has been demonstrated repeatedly with the increasing frequency of active shooter events (ASE's) in the United States. The law enforcement community ranks active shooter events as among the top social concerns facing communities today. These events have occurred in many public venues.  Finally, tragedy struck the public health community with the San Bernardino County Department of Public Health incident that killed 14 and injured 22 others in December 2015.

Due to this critical threat the SLCoHD developed a model training and exercise program. The SLCoHD created a four-hour classroom training that was based in part on the Salt Lake City Police Department curriculum, as well as information from other agencies and sources. A full-scale exercise was then conducted in all eight locations in the valley with jurisdictional SWAT teams.

Goals and Objectives

The overarching goal and objective of this training program was to prepare staff to make good and appropriate decisions to survive an active shooter event.

The specific goals and objectives of this training program included:

  1. Familiarize SLCoHD staff with proper Mindset and Situational awareness techniques
  2. Describe the physiology and psychology of the flight or fight response
  3. Define and discuss PTSD
  4. Explain the Jeff Cooper Mental Conditioning for Combat,” (color codes) as an awareness model
  5. Discuss the OODA (Observe, Orient, Decide, Act) Loop as it compares to the color codes
  6. Review historical ASE cases
  7. Show/discuss the Run-Hide-Fight video
  8. Discuss personal and workplace safety principles
  9. Discuss personal preparedness self-evaluation

Implementation

Twelve classroom sessions were conducted from January to June 2016. Full-scale exercises were then conducted during the last half of the year (July to December 2016). The SLCoHD partnered with law enforcement SWAT teams from six jurisdictions where department facilities are located:

  • Murray City
  • Salt Lake City (2 locations)
  • Sandy City
  • South Salt Lake
  • West Valley City
  • West Jordan City

Additionally West Jordan Fire/EMS, and Jordan Valley Hospital participated in the exercise at the West Jordan clinic location.

Results/Outcomes

Process milestones were:

  1. Secure management support for the active shooter program
  2. Develop didactic materials
  3. Conduct the classroom training with all employees from January-June 2016
  4. Partner with SWAT teams from each jurisdiction and secure their participation
  5. Conduct the full-scale exercises at each location from July-December 2016
  6. All staff participate in training by the end of 2016

Objectives attained

All goals and objectives were met through implementation of this model program. Two of the factors that led to success of this program were community partnerships with law enforcement, fire & EMS, and Health Department leadership support

Specific Factors Leading to Success

The factors which culminated in a successful program include:

  • Strong department leadership support for the program
  • Collaboration with partner agencies for creation of the didactic curriculum
  • Emergency Management staff with prior experience in law enforcement, fire service and Emergency Medical Services
  • Collaboration with partner agencies with the full-scale exercises
  • Law enforcement support of jurisdictional SWAT teams at the various SLCoHD locations in the Salt Lake Valley
  • Immediate feedback (HOTWASH) from health department staff, law enforcement and behavioral health to identify deficiencies and strengths of response
  • Post-didactic evaluations of the classroom instruction
  • After Action Reports generated after each clinic exercise and improvement plan criteria identified to improve the training

Public Health Impact

Feedback gathered from department staff was exceptionally positive.  Staff now feel that they're better prepared to deal with an active shooter event. Several indicated that while they were extremely apprehensive about the emotional and frightening nature of the exercise, they stated that this was by far the best training they've ever had. Working with public safety and other partners the SLCoHD effectively improved relationships, and provided them greater understanding about public health .

Website

http://slco.org/health/

Responsiveness and Innovation

Public Health Issue

The SLCoHD Active Shooter Training and Exercise Program was established in response to the tenuous nature of workplace and public safety and security in the United States today. These events have occurred in schools, mass gatherings events, movie theaters, churches, shopping malls, hospitals, clinics, and other public venues.  Many names come to mind: Columbine, Sandy Hook, Virginia Tech, Pulse Nightclub, Fort Hood, Aurora Colorado, Las Vegas, and many more too numerous to mention.The shooting at the San Bernardino Health Department in 2015, where 14 health department employees were killed and 22 were wounded, highlighted the extant threat of terrorism/crime that could even occur in a public health agency.  Mass Casualty incident shootings occur with alarming regularity, and health department staff are vulnerable, as was seen in this incident.

This new issue for public health agencies to address should now be established as a standard component of PHEP Capability 14, Responder Safety and Health. While new employees receive emergency management and some workplace safety training at the SLCoHD, a specific and detailed active shooter training course did not exist. The Emergency Management Bureau identified this weakness and brought the issue to the attention of department leadership. The program implemented was both responsive and innovative, as a literature review and extant programs for public health agencies were not found: Responsive in that a new training and exercise program was developed to address this new threat, and innovative in that public health agencies did not consider nor address the threat as within the scope of their duties.

The Salt Lake County Health Department staff need education and practical training to know how to respond appropriately to an active shooter event. Some SLCoHD environmental health staff have been threatened with violence from angry individuals and business owners, and some clinics have experienced client or public behavior that was threatening to staff.

Target Population-Size-Participation

The target population for this threat was and continues to be the entire staff of the health department. There are approximately 375 employees in the department. While the implemented new training was not mandatory, it was strongly encouraged by the department leadership team to participate in both the didactic classroom and the full-scale exercise. Overall 88% of department staff attended the training. Salt Lake County Government has now mandated active shooter training for all employees. 

Innovative Practice-Use of Tools

With the narrow focus of the active shooter training and exercise program for health department staff, an in-depth review and utilization of the Evidence-Based Guide to Community Preventive Services, was not fully employed. However, the Emergency Management Bureau did utilize:

  • A planning team
  • Organization of content through a conceptual approach
  • Evidence search and review
  • Creation of an evaluation tool for staff feedback
  • After Action Reports and Improvement Plan

All of these elements were factors in creating a successful, innovative training and exercise program.



LHD and Community Collaboration

The Emergency Management Bureau adopted and adapted training materials from the Salt Lake City Police Department, the Salt Lake County Sheriff's Office, the Salt Lake-Summit-Tooele Healthcare Coalition, internet research, Department of Homeland Security, and other agencies in the development of the didactic curriculum. Additionally, the EMB collaborated closely with the health department Community Health Services Division and the Administrative Services Division, in coordinating assistance in program implementation and evaluation. The health department Leadership (LEAD) Committee provided logistical coordination and helped to promote the course among department staff. The LEAD Committee includes representatives from all divisions of the health department. The intention of department leadership was that all staff would participate in this training.

Goals and Objectives - Implementation Steps

The goals and objectives to implement an Active Shooter Training program included:

  • Meet with Leadership Team to have training and exercise concept approved
  • Coordinate training implementation with the health department LEAD Committee
  • Gather information and develop didactic curriculum
  • Meet with local law enforcement to develop the Full-Scale Exercises (FSE's) to include:
    • Murray Police Department
    • Salt Lake City Police Department
    • Sandy City Police Department
    • South Salt Lake Police Department
    • West Jordan Police Department
    • West Valley City Police Department
  • Schedule classroom training and exercises
  • Conduct the training classes and full-scale exercises
  • Collaborate with hospitals and Fire/EMS to invite community participation
  • Include a behavioral health specialist to attend during the full-scale exercise to assist staff having excessive fear or an adverse reaction to the stress
  • Administer a training evaluation of each class via SurveyMonkey
  • Conduct HOTWASH after each full-scale exercise (FSE)
  • Complete the AAR and Improvement Plan for each FSE

The purpose of this program was to enable and prepare staff to make good and appropriate decisions to safely survive an active shooter event. The specific goals and objectives of the didactic curriculum included:

  1. Familiarize SLCoHD staff with proper Mindset and Situational awareness techniques
  2. Describe the physiology and psychology of the flight or fight response
  3. Define and discuss Post-Traumatic Stress Disorder (PTSD)
  4. Explain the Jeff Cooper Mental Conditioning for Combat,” (color codes) as an awareness model
  5. Discuss the OODA (Observe, Orient, Decide, Act) Loop as it compares to the color codes
  6. Review and discuss historical ASE case studies
  7. Show and discuss the Run-Hide-Fight video produced by Ready Houston 
  8. Discuss personal and workplace safety principles
  9. Explain and discuss the personal preparedness self-evaluation process

TImeframe-Stakeholders

The timeframe for this program was three months for curriculum development, three months to conduct all the classroom trainings, and six months to complete the seven full-scale exercises at health department facilities in the county. Stakeholder involvement included helping to identify components of the didactic curriculum and the execution of the full-scale exercises with the respecting jurisdictional SWAT team. Without law enforcement cooperation and coordination this program would not have been as successful as it was deemed to be, with the feedback staff provided. Behavioral Health, Hospitals and Fire/EMS also participated the the planning. The SLCoHD continues to have a close, working relationship with law enforcement in the county through emergency management outreach.

There were no additional staff costs involved with the planning and implementation. Several of the police agencies did request asistance with ammunition blanks, which the SLCoHD purchased. This cost only amounted to just under $500.

Evaluation

The SLCoHD Active Shooter Training and Exercise Program was extremely successful. Even one veteran employee who is always most vocal and uncooperative stated that this was the best training the health department has ever conducted in his 25 years of employment.

A SurveyMonkey was generated after each classroom training and after each exercise, with an overall response rate of 67%. The objectives for the didactic training were:

  1. Familiarize SLCoHD staff with proper Mindset and Situational awareness techniques
  2. Describe the physiology and psychology of the flight or fight response
  3. Define and discuss Post-Traumatic Stress Disorder (PTSD)
  4. Explain the Jeff Cooper Mental Conditioning for Combat,” (color codes) as an awareness model
  5. Discuss the OODA (Observe, Orient, Decide, Act) Loop as it compares to the color codes
  6. Review and discuss historical ASE case studies
  7. Show and discuss the Run-Hide-Fight video produced by Ready Houston 
  8. Discuss personal and workplace safety principles
  9. Explain and discuss the personal preparedness self-evaluation process

Objectives for the full-scale exercise were:

  1. Assess staff's ability to be aware of their environment and any possible dangers
  2. Assess supervisor's understanding of what to do in a life-threatening situation and what lessons to take back to their staff
  3. Allow staff the opportunity to observe how local law enforcement will respond to an active shooter in their location and how they should react to their commands
  4. Assess the efficiency of interagency and interdisciplinary coordination
  5. Develop an action plan to make each location safer for staff and clients
  6. Develop a training tool to educate the staff on what their role is and how to respond in an active shooter event regardless of the location
  7. Assess the staff's ability to differentiate between the need to evacuate, hide out, or take action against the shooter

Process milestones were:

  1. Secure management support for the active shooter program
  2. Develop didactic materials
  3. Conduct the classroom training with all employees from January-June 2016
  4. Partner with SWAT teams from each jurisdiction and secure their participation
  5. Conduct the full-scale exercises at each location from July-December 2016
  6. All staff participate in training by the end of 2016

Data gathered from the evaluation demonstrated the success of the training and exercise program. A test/class evaluation  was administered after each classroom session. Staff response was overwhelmingly positive.The Emergency Management Bureau was also please with the results of the survey administered after the exercises. The data indicated that staff remembered the classroom information they'd taken months before. 

Post -Exercise Survey

  • In Cooper's Color Codes what condition is white?

81.8% answered correctly

  • Have you used Cooper Color Codes since Active Shooter and Personal Safety class?

Yes   58.2 %                        No 41%

  • Did the classroom training prepare you for the full-scale exercise?

Yes 92.1%                            No 7.9%

  • Did you notice your awareness level changing during the exercise?

Yes 95.1%                            No 4.9%

  • Did your body experience any physiological or psychological changes during the exercise?

Yes 85.7%                            No 14.3%

  • Did you better understand OODA Loop Observe, Orient, Decide and Act?

Yes 96.9%                            No 3.1%

  • Do you now feel you are better prepared for on active shooter event?

Yes 97.4%                            No 2.6%

  • What three things can you do in an active shooter event that makes a difference?

Run, Hide, Fight                Yes 100%


Evaluation Responses

This is just a quick sample of feedback the SLCoHD requested from participants:

What was the most important thing you learned from the full-scale exercise?

             There is no perfect scenario.

             The reality of sound and emotional outcome of seeing the reaction as if this was a real. Having to put the mind into alert mode and think fast but cautiously. Because of the drill and the police force interacting with us employees, it was one the greatest ideas. It helps in a roundabout way. Instead of being told of what to be prepared for we are all acting it out. Thank to everyone that takes great pride for people and employees of the Government.

             As to being better prepared; Yes this class has help in more ways than we tend to realize. I feel these types of demonstrations is a great idea. Instead everyone standing around and wondering? Now we are in full action force to make a better decision with every caution needing to take. As if we can never stop learning; other than to be on the alert of caution and reaction. Thanks to everyone that worked so hard to prepare us as employees of the government. Terry Begay you are amazing!:-)

             What I had planned to do changed during the scenario.

             This was a great training. Thank you for providing this exercise and training for us. I feel more prepared.

             To keep calm, it helped me to think better.

             It has made me better understand why we have to prepare ourselves to what might happen and what we need to do to protect ourselves by either running, hiding or fighting. We have been able to observe and be oriented about the situation and then to decide and act are the greatest challenge that is put on anyone that is in this situation. It is very hard to decide and act on the decision that you make is the right one especially if there is no other choice to be made.

             The first exercise I completely froze, so I felt like doing multiple exercises helped me to realize what I would need to do to calm down and think clearly if a situation like this every actually happened.

             To always be aware of your surroundings and be prepared for anything to happen at any given time anywhere you may be.

             Most times running away is the best choice to save your life.

             I learned to be more aware of my surrounding and look for exit signs. I also learned to level my train of thought in order to make life saving decisions.

             To me everything was very important, I really love this drill, was amassing learning opportunity I will love to thanks to everybody!

             during the third and final exercise , I felt more empowered , the officers that debriefed us brought up points that help me realize the incredible power of survival we all possess along with a brain that can be activated with know how to rise to the occasion , thank you again for your time and all you do to keep our communities safe , your life's and safety it's important to us . stay safe please.

             There is not the perfect scenario, we have to expect the unexpected and try to be ready as best as possible, and always think before acting. Escape if you can, be ready to fight if you cannot escape.

             To be more aware of my surroundings and to mentally review and/or have an escape plan. Thanks to each and every one that made this training possible. It was an eye-opening experience!

             you are never really prepared

             Keep a Clear head

             It helped identify how to respond in a high stress scenario as the one we practiced.

  • I feel that the entire exercise was very important. I have always told myself this is what I would do in this situation. Although I knew it was a exercise I did not think I would get emotional like I did and feel the anxiety. I feel like all companies should offer this to employees. Was a fantastic drill and well worth it. Good job to everyone.

Modifications were made to the classroom training to develop further in-depth certain concepts as feedback was received. There were three evolutions of exercise play at each location. Staff was debriefed after each evolution and input given to the SWAT teams. The SWAT teams provided many lessons learned for staff as they reviewed the exercise. Many staff tried different approaches during the evolutions, most of them being a better choice. 

With both the verbal and written feedback responses being so positive, the Emergency Management Bureau deemed this a most successful training and exercise program.

Sustainability

The plan is for the Active Shooter Training to continue with new employees completing the classroom section of the course. Exercises will only be conducted every three years due to the additional heavy workload placed on emergency management staff and partner agencies. Salt Lake County Government has now created their own curriculum and has mandated that all county employees complete the training as a part of the probationary period. There are some questions leadership has about which training to pursue; the SLCoHD classroom section is four hours, while the county's course is only two hours. Law enforcement partners have stated their support to conduct future full-scale exercises at each health department location. The Emergency Management Bureau is committed to continuing this close partnership and training program.

Lessons learned were myriad and overwhelmingly positive from the staff. They were very supportive to continue the exercises in the future, even when they had expressed fears about the emotional response to experience live gunfire (blanks) in the workplace. The six different police departments were enthusiastic about training with the health department and getting to know the layout and design of the clinics in their jurisdictions. They were quick to help staff understand law enforcements role and what employees could do to make their job easier.

At a NACCHO conference