Edited Version of November 22, 2000 Transcript
EIIP Virtual Forum Presentation

"New JCAHO Emergency Management Standards for Health Care Facilities"

Joanne McGlown
Jacksonville State University

Avagene Moore - Moderator
EIIP Coordinator

The original unedited transcript of the November 22, 2000 online Virtual Library presentation is available in the EIIP Virtual Library Archives (http://www.emforum.org/vlibrary/livechat.htm). The following version of the transcript has been edited for easier reading and comprehension. Typos were corrected, date/time/names attributed by the software to each input were deleted but the content of questions and responses are as stated by each participant. Answers to participants’ questions are grouped beneath the appropriate question to facilitate meaning.



Avagene Moore: Welcome to the EIIP Virtual Forum! Today's topic is "New JCAHO Emergency Management Standards for Health Care Facilities." If you aren't familiar with the acronym, JCAHO is the Joint Commission on Accreditation of Healthcare Organizations.

It is my pleasure to introduce Dr. Joanne McGlown today. Joanne is a friend of the EIIP with two prior speaking engagements in the EIIP Virtual Forum. She is also a frequent participant in our audiences. Dr. McGlown is an Assistant Professor in the Master's of Public Administration (M.P.A.) - Concentration in Emergency Management program at Jacksonville State University (AL) and a healthcare strategist and management consultant to hospitals and health systems. She is most competent to address today's topic. Please help me welcome Dr. Joanne McGlown. Joanne, thanks for being with us again today. I now turn the floor to you.


Joanne McGlown: Good Afternoon. It is my pleasure to join you today to discuss the new additions to the Joint Commission on Accreditation of Healthcare Organization's (JCAHO's) standards and the importance they hold for the entire Emergency Management community.

First, the assumption is being made that Emergency Managers are familiar with the basics of JCAHO and the role of hospitals in emergencies and disasters. In this presentation, I will:

a) provide an overview of the standards with emphasis on the new additions for 2001 related to emergency management (EM), and

b) identify ways the emergency manager can assist hospitals and other healthcare organizations in preparing to meet the new standards and incorporate them into their daily performance.

Second, let me stress that I am not an employee, nor do I consult for or with the JCAHO. My interpretations and suggestions are mine alone, based on many years of experience with the JCAHO survey process and assisting health care organizations in preparation for surveys and ongoing process improvement.

Your interpretation, or that of a hospital's leadership, may differ. My approach to JCAHO surveys is that it is usually best to be prepared for all contingencies - including the fact that a surveyor may interpret a standard in a manner that no one in the organization ever thought of, would never think of, and may consider implausible and ridiculous.

This is an essential part of any planning. Contingency planning requires all participants to be comfortable enough with their plans and preparations to assertively educate and defend their approach, augmented with facts, when necessary. These are new standards and will pose equal challenges for HC administrators as well as surveyors.

I do see wonderful opportunity and great need for the expertise of the emergency management community in assisting hospitals and HC facilities in their preparation to address these new standards. If the HC facilities in your community are not well integrated into community preparation and response, this is a golden opportunity to integrate these organizations. I have made comments throughout the presentation of areas where I feel you may be of specific assistance. I'm sure you will think of many more related to your city, town, or region.

I will start with a brief overview of the JCAHO and aspects of accreditation surveys and standards for healthcare (HC) organizations. I will then introduce you to each of the standard changes in the Environment of Care (EC) arena and the implications this may have for the emergency management (EM) community. (I will use these three abbreviations frequently in the rest of the presentation.)

The JCAHO accredits over 19,000 HC organizations in the U.S. and other countries. Eight types of HC organizations are accredited; however hospitals, long term care, behavioral health care, and ambulatory care are the facility types most affected by changes relevant to the EM community.

JCAHO issues their criteria in "standards" (in incredibly large volumes called "Comprehensive Accreditation Manuals") designed to "set forth maximum achievable performance expectations for activities that affect the quality of patient care and the management of HC organizations. These standards aim to improve outcomes, yet provide flexibility in how the organization meets the standards. Although revised or updated every two years, new standards are added only when they are felt to directly impact quality of care.

Surveyors physically evaluate each facility (frequency is dependent on prior accreditation status) for compliance with each of the standards. Surveyors are looking for proof of compliance with the "intent" of the standard. Much akin to scheduling an appointment for a root canal, HC organizations must "ask" for accreditation and a survey visit. It is impossible to describe to those outside a HC facility or not involved in JCAHO's ongoing process of improvement the manhours in time and effort (i.e., a cast of thousands, in some cases) expended in preparation for a survey. However, the benefits to the community, organization, and patients cannot to be understated.

Yes, performance improvement is an ongoing process and should become a part of the daily routine of any accredited HC organization. However, in my almost 30 years in HC, I've never encountered a review process from other organizations that comes close to the effort required to gain or maintain JCAHO accreditation in HC organizations. Having said that, it is also true that difficulty or ease in the process does seem directly related to the personality and competence of the surveyors who review your facility (enough said there).

So, what does all this have to do with emergency management?

The standards related to emergency management, disaster planning and preparation have historically been found in a section titled the Environment of Care (EC) standards. In prior years, these standards focused mainly on the internal safety of the HC facility, with a statement of requirement of a disaster plan. Practically void of the facility's role or integration into a community response plan, JCAHO was woefully behind in tasking HC facilities to prepare or educate their staff for response to "all hazards" events, or integrate with the emergency management community as a viable player with a crucial role in ensuring a successful community response.

The revisions to the EC standards are a significant move on the part of the JCAHO, and very welcomed by those of us who have been concerned over the historical lack of preparation and relative disinterest in emergency planning and preparation on the part of healthcare leaders. With so many other concerns and challenges facing them, emergency and disaster preparation and planning are typically viewed as things that warrant attention only in times of need.

The majority of the new revisions related to emergency management were approved in March 1999, with revisions concerning emergency-preparedness drills in business occupancies going into effect July 1, 1999. EC standards related to Emergency Management, Hazardous Materials, and Tabletop Drills were published in October of this year (2000), becoming effective January 1, 2001 for facilities due for accreditation survey after that date. However, the JCAHO usually looks for a "track record" of performance toward these changes over the prior year (at least 4 months for facilities seeking accreditation for the first time).

Of all the EC standards, only 4 of those experienced significant revision that involve the EM community - and only two in a major way (drills and planning). I will discuss the minor ones first, then the major one.

Standard EC 2.14 is related to the testing of emergency power sources (utility systems). This one doesn't relate directly to the EM community, as these tests are performed in-house on an ongoing basis.

Standard EC 2.9 relates to Drills and exercises. This standard has existed for some time and states 'Drills are regularly conducted to test emergency preparedness'.

To meet the intent, the plan must be executed twice a year, in response to an emergency or in a planned drill. If the organization provides emergency services or serves as a disaster receiving station, they must perform at least one drill yearly that includes an influx of volunteer or simulated patients (this includes ambulatory care organizations designated as a first aid receiving site - NEW).

Drills must be documented. The details of what must be included are NEW. Records must indicate the type of emergency, staff involved and effectiveness of the response, adequacy of functioning of equipment and alarm systems, and need for training to correct identified issues. Drills must be conducted at least 4 months apart and no more than 8 months apart, and tabletop exercises are not acceptable substitutes for a drill. Bottom line is that drills must be conducted throughout the facility and involve personnel throughout the organization. Another NEW addition to this standard requires that staff in an area of the building that the organization occupies must participate in such drills.

Also NEW is clarification of the role and responsibility of community health clinics to have someone responsible to initiate, conduct, document and analyze their involvement in emergency preparedness drills, their reporting to the organization leaders and implementation of improvements. This is why the EM community may be contacted by hospitals requesting participation in their drill, or seeking to coordinate drills and exercises with other community resources.

In most larger cities or urban areas, emergency management or planning councils discuss the mutual needs of various organizations related to drills and exercises and coordinate community-wide events to meet the needs of hospitals and other HC organizations.

Cooperation of the EM community is greatly needed in rural areas, where opportunities for communication, planning and exercise may be more difficult. There are also tremendous opportunities for EM leaders and members to volunteer to assist or consult with HC organizations to assist them through their process and documentation.

Standard E.C. 2.10 relates to Fire drills, and states that they must be conducted regularly. NEW to this standard are that at least 50 % must be unannounced, they must be critiqued with identifiable opportunities for improvement, and that training is provided to all personnel according to the facility fire plan.

I have seen very few problems with the fire drills and exercises in facilities. However, more attention will be paid to conducting these on all shifts, all days, and in all areas where patient care services are provided. More frequently as well, Fire Departments are being asked to physically respond to simulated fire scenarios and drills. This activity should be encouraged to provide the staff and leadership the opportunity of interfacing with fire personnel.

Standard EC 1.6 is the "biggie". The standard simply states that "A plan addresses emergency management", where 'management' is used for the first time. However, the intent is more clearly specified, and new additions are discussed below. The most significant change and one where you can be of greatest service to HC organizations is in the statement "The plan should address four phases of emergency management activities: mitigation, preparedness, response, and recovery." These four terms will most likely be new to safety and risk managers, as well as hospital administrators and management staff.

I have not encountered or heard of a health administration program that provides any education on emergency management or the responsibility of the administrator in integrating HC concerns or operations with that of the community in emergency and disaster planning and preparation.

Also NEW to this standard are the following: The plan will identify procedures in response to a variety of disasters based on a hazard vulnerability analysis performed by the organization. For emergency managers, this is common sense and has been our approach to planning for a long time. However, the typical hospital emergency or disaster plan has NOT been written in an "all-hazards" approach (the disaster-specific format prevails) and plans are not based on a hazard vulnerability assessment, risk analysis, or any other qualitative or quantitative assessment of area risk. In fact, even the terms will be foreign to the vast majority of HC facilities you work with.

Also NEW are standard requirements for initiating the emergency or disaster plan (how, when, and by whom), and defining and integrating the organization's role with community-wide emergency response agencies (including the identification of who is in charge of what activities and when they are in charge) to promote inter-operability between the HC organization and the community.

Also NEW are requirements that the plan address a process to identify personnel during emergencies. I see this as another area where emergency managers should coordinate with HC organizations to ensure that identifying vests or outer clothing are not confusing to the total community response. For instance, if law enforcement elects to wear vests with a "Security" label on the front and back and the hospital places their security personnel in a similar vest, scene control, patient flow and communication could become very confusing. Also, if medical personnel respond to a mass casualty scene, vests should clearly identify personnel (front and back) by their designation: RN or Nurse, and MD; likewise for pre-hospital emergency responders.

This standard also requires addressing logistics of critical supplies, staff and family-support activities, interaction with the media and security (e.g., access, crowd and traffic control) as NEW additions. The EM community knows how crucial it is that in community-wide events, coordination with the media and security issues on the part of HC facilities must be integrated with other services to prevent confusion and misinformation.

This standard also addresses both horizontal and vertical approaches as options when the evacuation an entire HC facility may be required. This terminology and the process of safe facility evacuation will be new to HC administrators. When required, most have addressed it as best they could, without the benefit of current knowledge or training in this area.

Emergency managers and responders can assist by educating early, planning thoroughly, and exercising realistically each situation. Remember also that long-term care and behavioral care facilities will pose unique challenges in ensuring a safe evacuation. It is important that residents (of residential facilities) be given the opportunity to participate in exercises, and the EM community realistically include the challenges these facilities bring to an evacuation effort.

Also NEW are requirements to establish an alternative care site when the environment cannot support adequate patient care, including processes that address the management of patients and patient tracking to and from the alternative site; transportation of patients, staff, and equipment to and from the site, inter-facility communication between the home and alternative site, and the continuation or re-establishment of operations following a disaster.

Of note to emergency managers is this type and level of planning should be developed in conjunction with and clearly communicated to the entire emergency response community. The care of patients and other special-care populations is a recognized priority in all emergency response scenarios, will pose one of the greatest challenges to those coordinating the community response, and may pose the greatest liability, if not well planned and executed.

Also NEW to this standard is the requirement that alternate roles and responsibilities of personnel during emergencies be identified, including whom they report to within a command structure - and that this must be consistent with that used by the local community.

Now you can see why this standard is the "biggie" for the emergency management community. It imposes many challenges on hospitals and HC organizations as they face the need for education into a new way of thinking about and process for integrating their services into the community response.

The emergency manager may not know all the answers related to these new standards (for which there are a wealth of specialty consultants who do nothing but JCAHO compliance consulting), but you will be able to assist a HC organization in at least 90 percent of their needs. In fact, compliance in these areas will be dependent on integration with the emergency management community. The benefits for the entire community of working together, early and often, are significant.

The JCAHO also defines the terms "disaster", "mitigation" and "hazard vulnerability analysis" - and these are available on their web site to which Mrs. Moore and Ms. Sebring have provided links. It is noteworthy that "civil disturbance" has been added to their definition of disaster; thus, as an event that must be evident in their planning. Emergency managers should share existing response plans in this area to ensure the HC facility integrates their new planning with existing plans.

As stated in the JCAHO "Frequently Asked Questions" concerning the Emergency Management standards, disasters that might be considered in an organization's emergency preparedness plan include, but are not limited to (based on definitions of Red Cross and the Disaster Relief Act of 1974) natural disasters, including: meteorological disasters, topological disasters, disasters that originate underground, biological disasters, warfare, civil disasters, criminal/terrorist actions, and accidents.

On a related point, JCAHO has clarified for HC organizations how surveyors will determine whether an organization is complying with all codes, standards, and regulations for proper handling and disposal of hazardous materials and wastes. HC organizations are encouraged to maintain a reference library of all applicable federal, state, and local laws and regulations. This will be seen as a demonstration that all various regulatory requirements have been taken into consideration during program design.

This provides an additional area in which emergency managers may assist - recommending texts, books, articles and reference materials to hospitals to ensure their plan is based on all related requirements. It is doubtful the majority of health care facilities will have an individual in-house with instant knowledge of these items; although their legal counsel will and should certainly be involved, as well, in the development of these plans.

Whew! That concludes my formal presentation. I appreciate your patience as you have read through a tome of information. I am happy to take your questions, if you have some. Back to you, Ava!

[Audience Questions & Answers]

Avagene Moore: Thank you, Joanne, for a fine presentation and overview. We now invite your questions/comments. You have given us a lot to think about, Joanne.


Amy Sebring: Joanne, can you give us a rough idea how widespread the use of the standards are, that is, per cent of hospitals vs. long term care facilities?

Joanne McGlown: Very. I don't have specific statistics. However, the importance of accreditation makes this a designation of great desire and one most HC organizations strive toward. No, I don't know that.


John Aucott: Is it true that hospitals have to adopt/use ICS?

Joanne McGlown: John, not that I know of. Back to John's question. NFPA 1600 suggests ICS but this is another education point and opportunity for emergency managers.

I'm not certain how many hospital administrators would have a clue what ICS is. We have many HC folks on board. Rick, perhaps you would be able to shed some light on this, as well.


Bill Weaver: I would recommend that hospitals adopt the Hospital Emergency Incident Command System (HEICS). It addresses almost all the requirements in the new standards.

Joanne McGlown: I agree wholeheartedly. (Welcome Bill - a great resource himself!)


Rick Bissell: Joanne: This kind of planning and exercise conduction should definitely include local EM personnel and EMS, which might be possible in areas where there is only one hospital per jurisdiction. Do you have any examples of this kind of coordination being done on a multi-institutional basis in jurisdictions that have, say, 20 hospitals?

Joanne McGlown: Yes, Rick. Birmingham, AL (my hometown) has over 20 HC facilities and does a beautiful job through the hospital emergency council approach.


Soren Beck: Hi Joanne, you said that tabletop exercises are not acceptable substitutes for a drill (standard EC). Are computer simulated exercises accepted for training emergency management? I ask because I am representing a company specialized in Emergency Management training software < http://muster.hypermart.net/>.

Joanne McGlown: Yes, Soren - I participated in part of your presentation. Very interesting. This is an excellent question, and I'm certain will baffle the JCAHO when they first encounter it. I would be glad to ask them - and would encourage hospitals to pursue this with them before survey time. This will be new technology for them. Remember, they do want to see the flow of actual patients at least once a year in a coordinated community response.


Catherine Pomerantz: FEMA's CHER-CAP program places an emphasis on inviting hospitals to participate. If any hospital is interested in participating in CHER-CAP should contact their FEMA regional office. It sounds like this program would dovetail nicely with the new requirements.

Joanne McGlown: True. It is sad, but true, that I find the majority of hospitals do not have a working knowledge of FEMA, or how to interface. As EMs, we have a strong challenge in these areas to assist and educate them - whether they think they need it or not!


Anthony Mangeri: I have done quite a bit of training and standards development in PA and NJ on this matter. Many HC that are LTC [Long Term Care] do not wish to participate because it involves substantial commitment of resources. How has JCAHO worked to address the cost of compliance and decision-making? In NJ many community HCF have worried that evacuation decisions could affect reimbursement under Part B.

Joanne McGlown: They haven't; I've received no indication that this is of concern to them. For those of you who are not familiar with the inner workings of JCAHO, this NFP organization performs extremely expensive services. It is not unusual for hospitals to spend small fortunes in fees for the right to be surveyed and accredited.


Glenn Spradlin: I have put my hazard assessment in my management plan. Are you saying that I cannot break down hazards or events such as bomb threats, evacuations, hazmat incidents etc separately in my emergency action plan (disaster manual)?

Joanne McGlown: No, I didn't mean to imply that. JCAHO indicates and encourages an all-hazards approach. However, like the Federal Response Plan, appendices or additions that are hazards specific are certainly expected. They should also show that they are facility and region specific. There are no definitive statements as to exactly HOW the plan must look, be arranged, etc. This is your choice.


Jeff Basa: Is there a federal support incentive for each participating facility?

Joanne McGlown: Not so, per se. However, let me preface that with the incredible legal concerns over non-compliance of such a strong organization. The federal government really only interfaces with JCAHO at this time, at least, through the benefits in reimbursement through accreditation. However, with the push toward greater and more improved performance who knows what the future may bring.


Avagene Moore: Joanne, when you said it is NEW to have someone responsible to initiate, conduct, document and analyze drills, does that mean someone neutral to the HC facility? I ask because the last few years I was a local EM, our hospital did not want anyone evaluating from outside the hospital itself.

Joanne McGlown: No, the NEW requirement reads to indicate this individual must be inside the facility. They must be able to initiate the activity, etc. This should be a position, not a person and should be a position of authority that is filled in-house 24/7.


John Turley: My question is how are hospital administrators going to get an understanding on the use of the Incident Command System (ICS) and get their department heads involved? Working with the local emergency response community and understanding a unified command system when it comes to mass disaster events seems daunting to me. Your thoughts, please.

Joanne McGlown: I agree totally. JCAHO doesn't seem to be making a very strong effort to educate HC administrators about the wealth of resources and information under their noses (you, the EM community) available to assist and guide in this area. There is much work to be done, and it won't be learned overnight. I am working with other EM professionals interested and concerned over the "ostrich" approach to EM awareness of HC administrators to bring education sessions and awareness resources to the HC administrative community.


Anthony Mangeri: What efforts has JCAHO taken to work with outside organizations to reduce conflicting guidance? E.g. NFPA, NEMA, FEMA, OSHA, and trade organizations such as NANPHA, and NAHA and NANHA?

Joanne McGlown: JCAHO has input from a number of nationally recognized organizations, most are medically based and related.

Anthony Mangeri: There are substantial efforts in these groups, as well.

Joanne McGlown: The pre-hospital community is still rather foreign to them. However, I must say that a few of my colleagues were instrumental in getting these NEW changes through committee and that is something most of us never felt we would see. Progress is being made.

Anthony Mangeri: I am grateful for JCAHO's efforts. However, I am concerned that the community that you cite for guidance is not included in your standards development.

Joanne McGlown: I agree, Anthony.


Jeff Basa: Is there any participation by the JCAHO in development of the MMRS (Metropolitan Medical Response System) programs?

Joanne McGlown: Re: MMRS. Not that I know of, Jeff. Others who may know differently, please speak up.


Amy Sebring: Joanne, NFPA 1600 requires a committee for EM issues in the community, do you not think it would be a good idea to get an HC rep on such a committee, and do you know anything about the content of NFPA 99 currently with respect to nursing homes?

Joanne McGlown: Yes, Yes. No, LT care is not my area of specialty. And, my friends on the NFPA would kill me for not being that aware of 99.


Glenn Spradlin: Comment for Jeff, if your city is one of the 120 cities selected under the Nunn-Lugar-Domenici Act, federal funding is available. Hospitals in my city received PAPR's [Powered Air Purifying Respirators] etc.

Joanne McGlown: Excellent statement. I temporarily forgot about benefits through Nunn-Lugar.


Isabel McCurdy: What is the Nunn-Lugar-Domenici act ?

Joanne McGlown: "Nunn-Lugar" as it is more affectionately known was the major funding source for the implementation of preparedness and training for WMD events in the US, among other things. It started with funding for 120 cities, and has now (I believe) been expanded to around 156, with more expected to be funded in the future.


Jeff Basa: Last question along this line for me, what is your affiliation with USHHS?

Joanne McGlown: Do you mean the Dept. of HHS? Mine personally, or the JCAHO's?

Jeff Basa: With them as an organization in development of response standards.

Joanne McGlown: I have no personal affiliation with DHHS. DHHS has had representatives serve with the JCAHO providing input into their standards development. I have had no personal input into the development of standards.


Rick Bissell: Still on the multi-hospital jurisdiction. Doesn't this kind of requirement that local authorities participate soon lead to burnout/budgetout on the part of EM/EMS personnel? I can imagine coordinating the exercises of all facilities into 2 or 3 big events per year per jurisdiction, but doesn't JCAHO require that the practice be institution-specific?

Joanne McGlown: Rick, I believe only that each institution should make their response institution specific. For instance, a Children's hospital must demonstrate a response quite different from other hospitals in an adjacent medical center responding to the same drill or exercise. I hope that clarifies, a bit. I agree on the burnout and budget-out aspects, and cities have certainly seen some refusal to participate. Thus the need for scheduling and timing these events for the greater benefit of the area.


Jeff Basa: In your studies of hospital evacuation, what concerns have you encountered on liability issues?

Joanne McGlown: Many and varied. In any situation decisions made are made with great care and fear. I feel it is most important for the EM community to sit with hospital managers and administrators to discuss, plan, etc. evacuation scenarios - especially questioning resource availability. I'm sure you are aware that hospitals truly believe all the evacuation means (school buses, transit authority, etc.) will be available to them - just in time! These decisions should be made in concert with others on the scene who have the authority to call for a facility evacuation.


Anthony Mangeri: I would suggest JCAHO add a section on external coordination and communications as well as a recovery section. The latter would go far to prepare Facilities with securing both federal and non-federal disaster assistance. State and County OEMs could prepare materials for this. Last, FEMA does hold free training sessions in each State, through the State Emergency Management Agencies on a variety of topics such as emergency management planning, domestic preparedness and disaster recovery operations.

Joanne McGlown: True - excellent suggestions and statements. Our challenge is to ensure HC administrators know of the resources available to them, how to access the EM system, and become a viable partner.

Anthony Mangeri: I would be happy to assist as appropriate. I have been consulting on this issue for quite some time


John Turley: I find it interesting that JCAHO is now getting on the bandwagon with having emergency response plans and for conducting exercises. Up till now these things have only been on paper with no tests. What is the projected timeline for the training and conducting the exercises?

Joanne McGlown: This will vary according to the dates of next accreditation survey for each facility.

Final Comment:

Jerry Mothershead: Right now, the JCAHO standards, limited as they may be, are about the only hammer to get the hospitals on board. With tight funding, spending for these low probability, high severity events is just not a priority. Until such time that the community recognizes that, at least the disaster piece of hospital operations should receive additional funding, I sincerely believe the CEO's will only do as much as necessary to get JACHO off their backs.

Joanne McGlown: Although they should all be "hopping to" - the sooner the better -- procrastination is actually a reality in this area of hospital preparedness (sad to say).

Anthony, interesting point and true statement Jerry. Most hospital executives don't even want to talk about it. It is not their passion, as it is certainly ours.


Avagene Moore: Joanne, thank you very much the presentation today. Your time and effort is much appreciated on behalf of the EIIP. Please stand by a moment if you can while we take care of some announcements.

Joanne McGlown: Thanks to everyone for attending and hanging on for the entire session. If I can be of assistance to anyone, Ava knows how to reach me. My email is <[email protected]>.

Avagene Moore: Great audience today as well. Thank you! Amy, will you please bring us up to date on any new EIIP Pledgers, next week's midweek topic and speaker, etc?

Amy Sebring: Thanks Ava. Thanks to Joanne for an excellent presentation and we are delighted with the interest in this topic today, so thanks to all our participants.

We do have a new pledger this week -- Rick Bissell, Ph.D. with the UMBC Dept of Emergency Health Services. <//bell http://www.emforum.org/pledge.wav> Thanks Rick and welcome!

Next week in the Library we are very pleased to present Dr. Kathleen Tierney, Professor of Sociology and Director of the Disaster Research Center at the University of Delaware. She will be presenting the results of studies and focus groups on FEMA's Project Impact initiative. We are very excited and honored to have her with us, and we encourage you to come, and to invite others for this session. Back to you, Ava.

Avagene Moore: Thank you, Amy. We will have a transcript of today's session posted later on this afternoon. You can access it via the Transcripts link on the EIIP Virtual Forum home page. Look for the reformatted versions by either Friday or Monday.

Thanks to all our participants today. You are very important to the success of the Virtual Forum. We will formally adjourn the EIIP Virtual Forum for now. You no longer need to use question marks. Please join us in expressing our thanks to Joanne for today's presentation.