Organizing emergency preparedness within United States ... - CiteSeerX

ARTICLE IN PRESS Public Health (2007) 121, 241–250

www.elsevierhealth.com/journals/pubh

ORIGINAL RESEARCH

Organizing emergency preparedness within United States public health departments W.J. Duncana,, P.M. Ginterb, A.C. Rucksb, M.S. Wingateb, L.C. McCormickb a

Graduate School of Management, University of Alabama at Birmingham, 1530 3rd Avenue South, Birmingham, AL 35294-4460, USA b School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA Received 15 March 2006; received in revised form 15 September 2006; accepted 31 October 2006 Available online 19 January 2007

KEYWORDS Emergency preparedness; Organizing for disasters; Organizational configurations; State health departments

Summary Objectives: We examined the manner in which state public health agencies have organized their operations to accomplish the goals associated with emergency preparedness (EP) funds. We also examined the leadership challenges associated with the effective utilization of preparedness funds. Methods: The websites of all 50 state public health organizations in the USA were examined in order to determine the different approaches that states have used to organize for preparedness. Thirty-eight states provided sufficient information to allow for classification of their organizational approach to EP. Telephone interviews were conducted with representatives in three model states to obtain deeper insights into the organizational approach. Results: Three predominant organizational models were identified as a means to address the challenge of organizing for preparedness. The results confirmed the equifinality principle of organization (there may be more than one equally effective way to organize) and demonstrated that, contrary to the prescription of early management thought, there is no ‘one best way’ to organize. Leadership rather than formal management emerged as the primary contributor to perceived EP. Specifically, interviews with preparedness professionals indicated that they believed expert power was more important than position power and the ability to negotiate and influence through persuasion was more important than formal authority. Conclusions: All three models contained, to a greater or lesser degree, elements of matrix management with the associated leadership challenges for emergency preparedness (EP) directors. Recommendations were provided for successful leadership in the context of EP directors in state departments of public health. & 2006 The Royal Institute of Public Health. Published by Elsevier Ltd. All rights reserved.

Corresponding author. Tel.: +1 205 934 8855; fax: +1 205 934 8886.

E-mail address: [email protected] (W.J. Duncan). 0033-3506/$ - see front matter & 2006 The Royal Institute of Public Health. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.puhe.2006.10.014

ARTICLE IN PRESS 242

Introduction The Centres for Disease Control and Prevention (CDC) launched a Public Health Preparedness and Response for Bioterrorism programme in August 1999. Funds appropriated for this programme were aimed at upgrading state and local public health preparedness and particularly responses to bioterrorism, infectious disease outbreaks, and other public health threats and emergencies. Funds were allocated to the states, territories, and the District of Columbia. Centres for Public Health Preparedness were initially funded in 2000 to strengthen terrorism and emergency preparedness (EP) efforts by linking academic expertize to state and local public health agency needs. In 2004, after five years of operation, the programmes were evaluated and additional funding was provided. In the new round of funding, the CDC developed preparedness goals around the areas of prevention, detection and reporting, investigation, control, recovery, and improvement. Although the CDC established the goals for the allocation of the funds, state public health agencies were provided considerable latitude in organizing for EP in light of regional, state, and local conditions. Therefore, state health officers faced a fundamental challenge of strategic management—how best to structure or organize their operations to most effectively and efficiently accomplish the goals established by the CDC. The problem of how best to structure operations for strategy implementation has been a preoccupation of organization theorists and practitioners throughout the evolution of formal management. Early scientific management writers were convinced that there was ‘one best way’ to organize operations for goal attainment regardless of the situation facing the decision-maker.1 This view was challenged and eventually rejected as additional research was conducted and actual experiences of public and private organizations were chronicled. The historical research of Alfred Chandler utilizing case studies of American corporations2 demonstrated substantial variation in how different organizations structured their operations in pursuit of their chosen strategies. Joan Woodward at the South Essex College of Technology in the UK demonstrated that environmental contingencies, specifically the technology employed by an organization, significantly influences how best to organize for goal accomplishment.3 Her research was confirmed by Paul Lawrence and Jay Lorsch at the Harvard Business School, and the number of contingent variables that are likely to affect

W.J. Duncan et al. successful organization was expanded.4 The quest for the ‘one best way’ was replaced by ‘situational management’, which became known as the contingency theory of organization. This view argues that there is not one best way to organize and that the decision-maker must understand the environment faced by the organization and the strategy to be implemented. Only then can the decision-maker craft an appropriate organization structure.

Pursuit of preparedness goals In the most recent round of funding (2004), states were faced with effectively and efficiently overseeing combined CDC (infrastructure building) and Health Resources and Services Administration (HRSA—hospital preparedness) funding, anywhere from $94.4 million in California to $7.7 million in Wyoming. The average state preparedness funding received was around $25 million. States were provided considerable latitude in how they could structure their EP operations in light of local conditions.5–8 In addition to local realities, there were several managerial and organizational questions facing state health officers in structuring their operations.9 These managerial questions were essentially the same for all states. Some of the more important were:10 1. What is the best way to organize to ensure that EP is an ‘enterprise-wide activity’ rather than a ‘silo’ activity that is not integrated throughout the organization? 2. Because numerous units in a public health agency such as laboratories, epidemiology, and health statistics must provide support to EP activities, what is the best way to ensure that all relevant units are enfranchised with regard to preparedness operations? 3. Since the EP unit will be the funnel through which EP funds are channelled throughout the agency, how does one ensure that preparedness retains its focus rather than becoming diluted in the operations of the other units? Answers to these questions had to be integrated into the thinking of decision-makers as they structured their units for accomplishing the CDCspecified goals.11 As a practical matter the actual operations of the EP units amounted to matrix management, with the EP director facing the classic problem of having substantial responsibility with little formal authority over the units he/she had to rely on to accomplish the goals of the CDC grant.12,13

ARTICLE IN PRESS Emergency preparedness within public health departments, USA

Exploring the possibilities In view of the challenges facing the various states with regard to effectively and efficiently accomplishing the goals established by the CDC, we attempted to determine what EP organizational approaches were taken. We began by examining the websites of all 50 state public health agencies in an attempt to determine each state’s approach to structuring EP. We were able to obtain useful information from 38 (76%) state websites. Although all 50 states had a link to their EP unit, the 38 selected provided relatively detailed information, which in many cases included comprehensive organization charts. A close examination of the 38 state public health websites revealed that three primary models have been employed for organizing the EP activities. The EP organization models are as follows:

Organization model 1—within an existing bureau or department reporting to the bureau director Twenty states employed an organization model whereby the director of the EP unit reported to a bureau, division, or department director who, in turn, reported to the public health officer or chief executive of a larger agency of which public health was a part. In some cases the health officer was the head of an entire agency and in some cases she/he headed a sub-agency within a larger agency such as health and human resources. In this model the director of EP most often reported to the head of epidemiology or disease control.

Organization model 2—an independent bureau or department with direct reporting to the state health officer In nine states the director of the EP unit reported to the health officer or the chief executive of a larger agency on a par with other major public health bureaux such as clinical laboratories, disease control, epidemiology, and health promotion and communications. In a very few situations, the director of the EP unit was at the same organizational level as the director of the state public health unit.

Organization model 3—staff unit reporting to the health officer In three of the states examined the director of EP operated a unit reporting directly to the chief

243

public health officer or chief executive of a larger agency but outside the direct line of authority. For example, the EP unit might appear as a staff unit reporting directly to the health officer on a par with other staff units such as the legal counsel, finance office, and human resources office but outside of line operations.

A closer look After examining the EP organization of the states, we selected a representative organization structure of each model and contacted the EP unit directly. In selecting the individual states for closer examination we referred to the assessment of EP conducted by the Trust for America’s Health (TFAH).14 The TFAH uses ten criteria (such as ‘‘Has enough laboratory scientists to test for anthrax or plague’’, ‘‘Has plans, incentives, or provisions to ensure continuity of care in the event of a major disease outbreak’’, etc.) of EP in assessing the readiness of individual states. In the TFAH assessment, 21 states received satisfactory measurements on six or more criteria and the remainder (29 states) received satisfactory scores on fewer than six criteria. No state received satisfactory scores on more than eight criteria. The process used in selecting states for further analysis involved randomly selecting a state for each model category. Only those states that received six or more satisfactory scores on the TFAH assessment were included in the sample. In each case we asked for additional materials, such as more detailed organization charts and mission statements, and interviewed either the director or her/his representative to obtain more detail concerning the operations of the EP unit.

Organization model 1: Georgia Division of Public Health The State of Georgia received seven satisfactory scores on the TFAH assessment. Only eight of the 50 states received a score of seven or above. The base funding for EP in Georgia for 2004 was $22.8 million, with $13.7 million from the HRSA giving a total of $36.5 million. The Georgia Division of Public Health is part of the Georgia Department of Human Resources, which is the largest state agency in Georgia. The Emergency Preparedness and Response (EP&R) effort is part of the Georgia Office of Emergency Medical Services (Fig. 1). The EP&R unit’s position on the Division of Public Health organization chart illustrates that the unit


W.J. Duncan et al. of cooperation among all internal and external partners. The EP&R representative stated that public health in Georgia was rather inconspicuous relative to EP until the anthrax incidents after 9/11. Since that time, public health and EP&R have been a primary focus. It was recognized that preparedness and response issues relative to bioterrorism and other weapons of mass destruction issues are very time-sensitive unlike many public health emergencies. The EP&R unit has a half-time Medical Director who is assigned the other half time to the EMS—Trauma area. This division of time works very well and the Medical Director provides many valuable services in the area of preparedness and bioterrorism. The EP&R is perceived to be the ‘pivotal player’ in the Incident Command System (ICS) in Georgia. The Division of Public Health has its own state-of-the-art ICS centre that is financed primarily by the CDC grant.

reports to the head of the Environmental Health and Injury Prevention Branch who, in turn, reports to the Division Director. The EP&R representative indicated that EP&R enjoys a great deal of autonomy on all matters relating to EP and bioterrorism. The EP&R effort is administered as part of the Georgia Office of Medical Services (Office of EMS and Trauma) as shown in Fig. 2. The EP&R unit has approximately 20.5 FTE positions although a number of positions throughout the Division of Public Health are supported by the CDC and HRSA grants. Both the CDC and HRSA grants are administered by the EP&R unit. The principal investigator for the CDC grant was formerly the Public Health Director. When the position was temporarily vacant the oversight was transferred to the EP&R unit where it has remained. There has been an ongoing effort in Georgia to build the recognition that EP is an agency-wide activity and to avoid ‘silo thinking’. The agencywide perspective has been well established in the Division and, according to the EP&R representative, there are very few turf issues. As one might expect, there are sometimes issues with other state agencies who also have roles in the more global EP efforts, but in general there is a high level

Organization model 2: Virginia Department of Health Virginia was one of only three states that scored eight on the TFAH assessment. The EP base funds

Division Director

District Public Health

Public Health IT Liaison

Maternal and Infant Health Council

Chief Financial Officer

Deputy Program Services

State Advisory Committees Newborn Hearing

Office of Health Info. & Policy

Office of Training and Workforce Dev.

Division Communications Government Relations

Chronic Disease Prevention & Health Promotion

Environmental Health & Injury Prevention

Prevention Services

Medical Director Health Promotion Cancer Control Tobacco Use Prevention

Environmental Health Emergency Medical Services Injury Prevention

Operations Refugee Health HIV STD Tuberculosis Immunization

Office of Nursing

Epidemiology

HIV/STD Epi. Tuberculosis Epi. MCH Epidemiology Chronic Disease, Injury, Env. Health Epi. Notifiable Dis. Epi.

Offices State Pharmacy

Family Health Programs & Services Policy, Planning And Evaluation Data Team Operations Nutrition Oral Health

Grants Development

Legal Services & Policy Development

Laboratory

Women, Infants & Children Nutrition Program

Micro/Immun. Chemistry/ Hematology Support Services LIMS/Training Regional Labs

Policy Mgt. Vendor Mgt. Compliance Analy. Systems Info. Financial Mgt. Program Planning & Resources

Figure 1 Georgia Department of Human Resources, Division of Public Health.

Vital Records Deputy Director Data Mgt. Customer Relations Search Unit Legal Unit Customer Services Photo Unit Quality Assurance


245

EMS –Trauma Medical Director

EMS Director

Bioterrorism Coordinator

Emergency Coordinator

Bioterrorism Coordinator

Exercise Specialist

BT Training Specialist Assigned to PH/Training Workforce Development

Staff Development Training Coordinator

Program Associate

Executive Secretary

Trauma Systems Manager

EMSC Coordinator Deputy EMS Director

Regional EMS Program Directors (8)

Trauma Program Coordinator

Program Associate

License Officer

Training Coordinator

Contracts Manager

Operations Analyst

Trauma Systems Data Registrar

EMS Information Systems

SNS Coordinator

Program Assistant

Statistical Analyst

Figure 2 Georgia Office of Emergency Medical Services (Office of EMS and Trauma).

allocated to Virginia were $19.6 million from CDC and $11.9 million from HRSA for a total of $31.5 million. Virginia represents an interesting approach to organizing for EP. The Virginia Department of Health is headed by a commissioner and there are five deputy commissioners as illustrated in Fig. 3. The deputy commissioners are responsible for public health, administration, community health management, information management, and EP&R. The Deputy Commissioner of EP&R is a physician and is on the same organizational level as the Deputy Commissioner for Public Health. The Deputy Commissioner of EP&R administers both the CDC and the HRSA preparedness grants. The Virginia Department of Health representative indicated that there are 20–25 people working in the unit. Approximately 130 people are supported by the grants throughout the Department. The EP&R programme is responsible for effectively responding to any emergency impacting the public’s health. Emphasis is placed on increasing effectiveness and efficiency through partnerships with similar organizations that have concerns for bioterrorism, infectious diseases, and so on.14 All public health workers at all levels are state employees. Regional team members report to their various supervisors at the local level. The Virginia Department of Health representative indicated that a great deal of flexibility is allowed in work

assignments at the local level. It was noted that the EP unit leaders trusted the administrators of units throughout the Department to accomplish their obligations under the grants and to get their regular ‘day work’ completed. Care was taken not to micromanage individual units. There is clear accountability to ensure EP work is completed. Each area has a medical consultant who reports to the Deputy Commissioner (see Fig. 4). This approach has been successful since the Trust for America’s Health gave Virginia its highest score for state preparedness. As Virginia’s Governor noted after the State received this highest score, ‘‘Virginia has again been recognized as a national leader for its commitment to preparing for and protecting our citizens from public health emergencies.’’

Organization model 3: Washington State Department of Health Washington State received six on the TFAH assessment. Washington’s base funding for preparedness funds in 2004 was $17.1 million from the CDC and $10.1 million from the HRSA for a total of $27.2 million. The Washington State Department of Health (DOH) is known for its leadership in public health and is a stand-alone agency in state


W.J. Duncan et al.

Commissioner

Audit Director

Adjudication Officer

Chief Medical Examiner

Executive Advisor Public Relations Manager

Deputy Commissioner Public Health Health Policy And Planning Center for Primary Care & Rural Health Minority Health

Office of Epidemiology Office of Family Health Services Office of Emergency Serv. Office of Environ. Health Services Office of Drinking Water

Deputy Commissioner Administration

Deputy Comm. Community Health Serv.

Office of Human Resources

35 Health Districts

Office of Budget Services

Director of Public H. Nursing

Office of Purchasing & General Services

Policy and Planning Manager

Office of Information Management

Deputy Comm. Em. Prepared. and Response

Division of Vital Records

Education and Training Director

Center for Health Statistics

State Planning Director

Information Systems

Regional MD Consultants

Office of Accounting Center for Quality HC Services & Consumer Protection

Figure 3 Virginia Department of Health.

government. The Chief Executive Officer of the DOH is the Secretary who leads the agency comprised of four divisions and administrative services. The divisions are Community and Family Health, Environmental Health, Epidemiology, Health Statistics and Public Health Laboratory, and Health Systems and Quality Assurance. The State Health Officer reports directly to the Secretary and is the chief spokesperson on medical issues. As illustrated in Fig. 5, Public Health Preparedness and Response (PHP&R) reports to the Secretary along with Public Health System Planning and Development, Policy, Legislative and Constituent Relations, and the Office of Communications. The Special Assistant for PHP&R plays a major policymaking role in the state. This unit is responsible for preparing public health and other health care systems in the state to effectively respond to incidents of bioterrorism, outbreaks of infectious disease, and other public health emergencies. The Washington Department of Health representative indicated that Washington has made considerable progress in making EP an ‘agency-wide

enterprise’. As with most states, this was a problem in the early years of the CDC funding. The DOH experienced many of the same problems as other states with individual divisions experiencing difficulty visualizing exactly how they fit into the EP effort. However, pandemic influenza has become the ‘handle’ by which all elements in the DOH understand the importance of their involvement in EP. The PHP&R unit developed a well-grounded approach to leadership with regard to the use of grant funds. EP clearly communicated the expectations for the use of preparedness funds, developed a system for ensuring accountability, and stepped aside and allowed the individual divisions to run their operations. Accountability is high and trust is exercised as a philosophy throughout the agency. A similar leadership philosophy was expressed by representatives in other state health agencies such as Kansas. Although Kansas is organized differently from Washington State, the accountability/trust approach has done much to ensure that EP is viewed as an agency-wide enterprise and line and staff units are ‘enfranchised’ into the preparedness theme.


247

Deputy Commissioner for Emergency Preparedness and Response Administrative Staff Assistant

Executive Advisor Volunteer Coordinator Business Manager

Financial Technician

Administrative Coordinator Human Resource Analyst

Education and Training Director Distance Learning Coordinator Instructional Designer Program Support Technician

State Planning Director

Regional MD Consultants

Hospital Planner

Central Region Eastern Region

Regional Planners

HD/NW Region

Exercise & SNS Coordinator

Northern Virginia Southwest Virginia

Training Coordinator Regional Trainers

Executive Secretary

Industrial Hygienist (2)

Figure 4 Virginia Department of Health, Emergency Preparedness and Response.

Discussion Equifinality is a well-established principle of organizational design. This principle, contrary to the prescription of early scientific management, asserts that there is no one best way to organize for strategy accomplishment. Or, stated another way, there may be more than one equally effective way to obtain desirable organizational goals.15 Each of the predominant organizational models demonstrated aspects of matrix management. The administrator of the EP unit was expected to engage and involve individuals and leaders in units over which she/he had no formal authority. Those

who have insisted on employing formal management tools such as chain of command, hierarchy, and authority have, by and large, been less successful than those directors of EP units who have adapted new ways of getting things done in the absence of formal authority.16 Specifically, the more successful directors have relied on leadership rather than formal management by emphasizing the following: 1. Exert power rather than position power. Respect for the EP director, and ultimately cooperation, is more a function of proven experience than position in the organization. It is true that those


W.J. Duncan et al. Board of Health

Secretary

State Health Officer

Central Administration

Financial Services

Public Health System Planning & Development

Policy, Legislative & Constituent Relations

Office of Communications

Public Health Preparedness & Response

Human Resources

Information Resource Management

Risk Management

Community and Family Health

Environmental Health

Infectious Disease & Reproductive Health Maternal and Child Health

Adjudicative Services

Community Wellness & Prevention

Drinking Water

Epidemiology

Radiation Protection

Center for Health Statistics

Food Safety & Shellfish Programs Environmental Health & Safety Environmental Health Assessments

Figure 5

Epidemiology, Health Statistics & Laboratories

Public Health Laboratories Washington Emergency Disease Surveillance System

Health Systems Quality Assurance Facilities and Services Licensing Health Professions Quality Assurance Emergency Medical & Trauma Prevention Community and Rural Health

Washington State Department of Health.

public health agencies that have provided EP directors direct access to the health officer and structural visibility have gone a long way in setting the stage for success. However, representatives indicate that ultimately it has been the director’s ability to demonstrate to leaders in functional units that they understand both EP and the realities faced by affected leaders that has been the difference between effectiveness and ineffectiveness. 2. Ability to influence and persuade. Effective EP directors are those who are able to influence functional leaders and their staff by emphasizing the importance of preparedness as a superordinate goal of the organization and a legitimate concern of public health. This has been an important challenge because very few public health professionals have substantial experience, particularly with emergency response. Planning and prevention have been the cornerstones of public health whereas EP is significantly involved with response. 3. Negotiation and diplomatic skills. The most successful EP directors have a mindset that is

different from the typical managerial mindset. Successful managers perform roles as planner, organizer and controller and rely on authority and position to get things done. Within the matrix, however, neither authority nor position is an available tool. The most effective EP directors rely on negotiation and diplomacy. Neither of these tools can be found in the list of management functions. When one does not have authority or position she/he must be good at negotiation and diplomatic in dealing with others. 4. Reciprocal favours. Finally, effective EP directors are skilled at achieving quid pro quo. Fortunately, EP directors have at their discretion financial resources with which they can purchase the desired time and effort. When used improperly the funds can breed resentment and envy. In public settings where funds are always scarce the resources available to the EP unit are often the source of conflict. When used properly these same funds can be the means to involving and enfranchising leaders and staff throughout the organization.

ARTICLE IN PRESS Emergency preparedness within public health departments, USA This article examined the approaches various states have taken to organizing for EP and in the process confirmed the existence of equifinality. Of the 38 state public health agencies that provided sufficient information on their websites to assess their approach, there were three predominant organizational models. There were also a few variations that were not easily classified under any of the three standard models. Each model or approach had its strengths and weaknesses but each appeared to work reasonably well in view of local realities. In examining each of the models we interviewed individuals in one state that employed each approach to organization. In the interviews we were particularly interested in probing the questions that seem to challenge every state with regard to the effective use of EP funds. The challenges included how to ensure that preparedness was viewed as an agency-wide enterprise rather than being limited to the ‘emergency preparedness silo’, how leaders and staff in critical units such as epidemiology and disease control can be enfranchised with regard to preparedness while accomplishing their primary tasks, and how accountability for preparedness funds disseminated to functional units can be achieved without excessively micromanaging the affected units? These challenges had been considered by all representatives contacted and, to a greater or lesser extent, continued to occupy a great deal of their attention. In the end the success or failure of preparedness funds to prepare public health for natural and human-initiated disasters will be determined by how successfully state and local health agencies are able to organize human and non-human resources to plan for, prepare for, prevent, and respond to emergencies when they occur.17 All disasters cannot be prevented but plans can and should be developed and capabilities for response, damage control, and recovery should be in place. The challenges are great and it is likely that answers do not lie in conventional management and organizational wisdom. High impact low probability events require leadership, risk-taking, innovation, and even a spirit of entrepreneurship. Bureaucracy simply will not suffice for confronting the new realities of our increasingly dangerous future. Studies of this nature inherently possess certain limitations. This study is no exception. The more important limitations are briefly discussed. First, every country and geographical region has its own unique approach to organizing and funding EP. The approach chosen in the USA is highly decentralized. Each state has a high degree of autonomy relative

249

to organization and resource utilization. In other countries such as the UK (four countries) the variety of operation would likely be less. Second, sample selection is frequently a problem as it was in this case. Since not all states placed sufficient information on their websites regarding EP organization, we limited our analysis to 38 states that did provide enough public information. However, since the sample represented 76% of the total states and the variations in primary models were limited, we believe the sample was representative of the states as a whole. Finally, EP is difficult to assess without concrete data relative to a state’s ability to plan for, respond to, and recover from natural and human-made disasters. In the absence of such concrete data, we were fortunate to access the Trust Fund for America’s Health assessment of the EP of individual states.

Acknowledgements The authors wish to thank the following people who were interviewed and assisted greatly in putting together the details for this paper. Kim Allen, Executive Advisor, Emergency Preparedness and Response, Virginia Department of Health; R. David Bean, EMS Director, Georgia Office of Emergency Medical Services, Bioterrorism and Emergency Response; John Erickson, Special Assistant to the Secretary for Public Health Preparedness and Response, Washington State Department of Health; and Sandy Johnson, Operations Director, Centre of Public Health Preparedness, Kansas Division of Health.

References 1. Gilbreth LM. The quest for the one best way: a sketch of the life of Frank Bunker Gilbreth. Easton, PA: Hive Publishing Company; 1973 [reprinted from original version]. 2. Chandler C. Strategy and structure. Cambridge, MA: MIT Press; 1962. 3. Woodward J. Industrial organization: theory and practice. London: Oxford University Press; 1965. 4. Lawrence P, Lorsch J. Organization and environment. Boston: Graduate School of Business Administration, Harvard University Press; 1967. 5. Lindell MK, Perry RW. Preparedness for emergency response: guidelines for the emergency planning process. Disasters 2003;27:336–50. 6. Perkins BA, Popovic T, Yeskey K. Public health in the time of bioterrorism. Emerg Infect Dis 2002;8:1015–7. 7. Cohen S, Eimicke W, Horan J. Catastrophe and public service: a case study of the government response to destruction of the World Trade Center. Public Adm Rev 2002;62:24–32. 8. Ja ´ros GG, Dostal E. A teleonic management framework for organizations. Syst Pract Act Res 1999;12:195–217.

ARTICLE IN PRESS 250 9. Ramanujam R, Goodman PS. Latent errors and adverse organizational consequences: a conceptualization. J Organ Behav 2003;2:815–36. 10. de Laat PB. Matrix management of projects and power struggles: a case study of an R&D laboratory. Hum Relat 1994;47:1089–120. 11. Burns LR, Wholey DR. Adoption and abandonment of matrix management programs: effects of organizational characteristics and interorganizational networks. Acad Manage J 1993;36:106–38. 12. Turoff M, Chumer M, Hiltz SR, Klashner R, Alles M, Vasarhelyi M, et al. Assuring homeland security: continuous monitoring, control and assurance of emergency preparedness. J Inf Technol Theory Appl 2004;6:1–24.

W.J. Duncan et al. 13. Nolan S. Though better prepared after 9/11, America still vulnerable to bioterrorism. J Am Vet Med Assoc 2003;222: 163–4. 14. Individual reports on states of Georgia, Virginia, and Washington. Trust for America’s Health Report. Washington, DC: Trust Fund for America; 2005. Available at: /http:// healthyamericans.org/reportsS. 15. Reeves TC, Duncan WJ, Ginter PM. Strategic configurations in health services organizations. J Bus Res 2003;56:31–43. 16. Hodgetts RM. Leadership techniques in the project organization. Acad Manage J 1968;11:211–9. 17. Beatty ME, Phelps S, Rohner C, Weisfuse I. Blackout of 2003: public health effects and emergency response. Public Health Rep 2006;121:36–44.