Harris County, Texas, the third largest county in the country, is located along the Gulf Coast where human health and well-being are continuously impacted by intricately intertwined man-made and natural events. Encompassing 1,777 square miles of sprawling urban and suburban landscape, Harris County is home to over 4.7 million residents, including the City of Houston which is the fourth most populous city in the U.S., and is continuing to grow at a rapid rate. With its size comes a great deal of diversity racially, ethnically, and socioeconomically – Harris County has one of the most racially and ethnically diverse populations in the country. As a result, there are a number of vulnerable groups whose needs are not fully addressed by traditional services providers, or who feel they cannot comfortably or safely use the standard resources offered during the preparedness, response, and recovery efforts.

Harris County Public Health (HCPH) sent out its first official notice to regional healthcare partners regarding SARS-CoV-2, often referred to as COVID-19, on January 9^th, 2020. The first cases of COVID-19 in Harris County were reported in late February. On March 4^th, Harris County activated the Incident Command System (ICS) and on March 11^th, a Local Disaster Declaration was issued for the County. Since the first cases in late February HCPH hit the ground running. The department quickly assembled its COVID-19 response team, ramped up staffing, tightened alliances with local government and community partners, facilitated mass testing logistics, increased surveillance of COVID-19 cases and data, and strengthened community outreach and communication.

Historically, following emergency responses, HCPH performs an After-Action Review and develops an After-Action Report (AAR). The purpose of the report is to summarize and analyze performance during the response to evaluate the achievement of the response objectives and capabilities listed in the Incident Action Plan. The development of the AAR leads to an improvement plan that identifies corrective actions to improve current and future responses. Considering the unprecedented length of the HCPH COVID-19 Response, the department began looking for ways to improve the future of response while it was still very much active. It was not until the European Centre for Disease Prevention and Control put out a technical report suggesting a novel implementation of an In-Action Review (IAR) that the department had a name for what needed to be developed. The IAR functions as a method to discover areas for improvement and mission critical issues, as well as operational strengths and best practices in order to streamline the remainder of the HCPH COVID-19 Response. The IAR aligns incident objectives with CDC Preparedness Capabilities to include the National Preparedness Goals and related frameworks and guidance. Through the development of an IAR, HCPH was able to analyze the COVID-19 response and look for areas in which corrective actions could be implemented and strengths highlighted.

With an unprecedented pandemic, such as COVID-19, innovation is not only required, but a crucial aspect of keeping our community safe and ahead of the curve. As of this submission, HCPH is leading the world in real-time identification of active-response best practices and lessons learned. The IAR is notably innovative because, to our knowledge, it has never been done by any other health department, emergency preparedness group or any other related organization. While the IAR is not a replacement for the AAR, it gives the department the ability to forecast plans and strategic options in lieu of upcoming and reoccurring spikes and phases of the pandemic.

As the department began to settle into the COVID-19 response, HCPH realized that there were areas that needed to be streamlined, maximized, and revamped in order to effectively meet the response goals and objectives. The makeup of the HCPH department is reflective of the diverse makeup of Harris County; thus, the action plan created for implementing the IAR was developed with that in mind. If HCPH could not optimize the response internally to the best of their ability, the department would be unable to fully support and serve Harris County externally. In order to achieve a wide variety of responses and corrective actions that aligned with department goals and objectives, the IAR was developed based on an anonymous IAR survey that was constructed with the help of the internal Data Team.

The Planning Section put together a web-based IAR survey of questions that was sent to anyone that had participated in the HCPH COVID-19 Response, both activated and demobilized. Anyone in a position as a Deputy, Lead or Command was invited to a virtual zoom IAR which addressed more managerial and internal conflict questions. The anonymity of the online survey was an innovation in comparison to the usual AAR, or hotwash, which tends to include members of all the parties involved in the response. Due to the nature of the COVID-19 pandemic, HCPH staff were unable to get in a room together to discuss strengths and areas for improvement; so instead, the Planning Section worked to create an open platform for free responses. The hope was that in allowing for anonymous responses without fear of judgement or command involvement, the survey would foster an environment of honesty and identify larger areas for improvement and corrective actions. On the flip side, the Planning Section had virtual meetings scheduled with those in higher positions in the organizational structure to foster an environment of collaborative problem-solving between individuals that were more involved in the inner workings and high-level decision-making areas of the response. The Planning Section took notes throughout these meetings to ensure that all information was captured.

All of the responses, both from the virtual meetings and anonymous survey, were read through in detail and recorded (all questions asked in in the survey and virtual meetings are attached to this application). The Planning Section worked through the responses to find actionable information and find comparable responses. Through this deep dive, the Planning Section was able to generate both internal department corrective actions and external response corrective actions. The documentation was separated, and a full IAR for the COVID-19 response was generated for leadership.

The IAR process was completed, from an idea to the development of the final document, in two months, ending with the submission of the final report to Command at the end of September. Since this practice has never been conducted internally, or externally to our knowledge, the evidence to support the IAR is based solely on the improvements that have been implemented through the corrective actions assigned to each goal and/or objective. A general outline of an AAR improvement plan was used to align the IAR closely to something as evidence based as the AAR has proven to be time and time again. The team aligned each goal/objective with the capabilities defined in the Public Health Emergency Preparedness and Response Capabilities: National Standards for State, Local, Tribal, and Territorial Public Health book put out by the Centers for Disease Control and Prevention.

Using the best resources available, the HCPH Office of Public Health Preparedness and Response (OPHPR) was able to create the first known IAR. The department has since implemented multiple corrective actions listed in the IAR and is thereby working to improve the COVID-19 response while it is still happening. The IAR has allowed HCPH to show resilience and ensure the department is serving the Harris County community and employees to the best of its ability. As HCPH continues to work this response, transition employees in the response back to their regular roles, and gear up for mass vaccination, the team will lean on this review to remember how far the department has come and how far the response has to go. HCPH will be able to use the IAR as a stepping-stone for the end-of-response AAR to draw from the best practices and mission critical issues mentioned back in September as a gauge of the department’s ability to apply in-action improvements.

The goal of an IAR is to discover areas for improvement and mission critical issues, as well as operational strengths and best practices in order to streamline the remainder of the HCPH COVID-19 Response. While this report focused on both internal and external relationships, the surveys and meetings were conducted internally to help fix those issues from the inside and begin the improvement process. At the beginning of the practice development, the Planning Section was solely involved in the creation of the IAR questions. The questions were kept between a very small group of people to ensure the survey questions were generic enough to maintain anonymity and the virtual meeting questions were free of personal agendas or altered. Overall, this tactic helped to keep IAR responses valid.

After clearing the questions with Command, the Planning Section reached out to the Data Team to determine what steps would be needed to get the survey up and running. After multiple calls to ensure the survey was what was needed and compatible with the code the Data Team was running, the Planning Section sent the survey out to all individuals who had been, or currently were, working in the HCPH COVID-19 Response. An important part of the survey included the selection of their employment status and section within the organizational chart, so the team was able to effectively determine the goal/objective to apply the corrective action when reviewing the responses. With over 1,500 individuals involved in the response at that time, the information that was asked for was not enough to identify an individual. The Data Team worked tirelessly with the Planning Section throughout the first few days the survey was live to correct some unforeseen reporting complications and the teams were updated on issues for the two weeks that survey was live.

Due to the variety of individuals in COVID-19 response positions being asked to fill out the survey, the team kept the survey live for two weeks to give those who did not have constant access to a computer time to respond. The IAR would not have been successful without everyone’s responses and willingness to be honest and forthcoming with their suggestions and thoughts on how the department was handling this novel pandemic. With almost 5 million residents to serve, the responsibility of a response this size can seem incomprehensible. The IAR allowed for employees and contractors who work for the community and have friends and family that live within it to give their feedback on improving how the department can best serve that community. As a result, this review provided important and unique perspectives that could greatly benefit the community as a whole.

At the conclusion of two weeks, the survey was closed, and the virtual meetings were completed. The Planning Section began going through responses to highlight the areas for improvement and mission critical issues, as well as operational strengths and best practices to develop into the IAR. When the Planning Section began developing the document, strengths, areas for improvement, and analysis were included for each goal/objective and assigned an internal organization point-of-contact responsible for implementation of the corrective action associated with their area for improvement. As with AARs, this  process allowed for increased partnership and collaboration to solve COVID-19 response issues across the department.

HCPH’s innovation practice, the IAR, was developed to help improve internal goal/objective completion in order to ensure the community’s health during the remainder of the pandemic. This novel practice was generated to meet the needs of the community on all fronts of the HCPH response by implementing corrective actions in all areas, including Operations, Finance, Planning, Logistics and Command. HCPH continues to work on applying the outcomes of the IAR, but huge strides in implementation have already been made over the last three months.

HCPH began strengthening communication within the department immediately following the IAR, as it was the most frequently mentioned mission critical issue across the board. The department addressed and streamlined communication horizontally and vertically across the response. This has resulted in improved document dissemination, condensed meetings, and stronger interdisciplinary communication, both internally and externally. Another way HCPH achieved one of the corrective actions is through the automation of ICS-214 Activity Logs with the county timesheet system. Employees are now able to keep record of notable activities within the COVID-19 Response through their timesheet instead of a separate document. The automation has greatly improved the compliance rate and will help strengthen the FEMA reimbursement package plus quantity and quality of reference documents available for any after-action report conducted. 

Contact tracing has been a large part of the HCPH COVID-19 Response due to the size and diversity of the Harris County community. The IAR allowed us to identify concerns from those working in the contact tracing area, whether they were a Contact Tracer, Epidemiologist, or Supervisor. Many individuals expressed difficulties they were facing that made their work more difficult and those that caused concern for the community members. HCPH now have a contact tracing force that speaks over five languages and are well-trained in providing the resources available to the community during this pandemic. The department now has a text message campaign that sends a message to any case that did not receive an epidemiological interview that day to contact HCPH. When these cases call, the reference code from the text messaged can be provided to the call center agent to be transferred live to a case investigator. This has greatly improved community trust of the contact tracing process.

While all we can do is hope that there is not another novel pandemic in our lifetime, HCPH now has a practice that will help make a future pandemic easier. By creating and implementing an In-Action Review of best practices and mission critical issues, HCPH has set the stage for the department, other local public health departments, and emergency management organizations nationwide to improve their responses to all kinds of emergencies in real-time. This process will allow for employees and contractors to feel heard in their response roles as they see their Command staff using their actionable responses to streamline the rest of the COVID-19 response. Instead of having the Command staff faced with a large hotwash with hundreds of staff and many months of information gathering, the IAR created a method to review opinions, suggestions, and actionable responses during the response, helping to improve current processes and anticipate corrective actions moving forward.