Enhancing Public Health Employee Communication With Text Messaging

State: WA Type: Model Practice Year: 2013

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Public Health — Seattle and King County (PHSKC) is the one of the largest metropolitan health departments in the United States serving the 1.9 million people of King County with personal and population-based public health services. Our community is diverse with over 100 languages spoken within our county. As a large health department with approximately 1500 employees and 40 sites, it is critical that information flows to our employees and then out to our communities in a timely and effective way. With the increased responsibilities of local public health departments to prepare for and respond to public health emergencies, it is critical that employees get public health emergency information in a timely way. Our region is vulnerable to several emergencies that may have implications for public health: earthquakes, river flooding and tsunamis, among others. Power outages resulting from any number of emergencies may pose a challenge to communicating with public health employees who may need to be contacted to respond to community needs. Despite these challenges, readily accessible communication tools such as text messaging provide opportunities to improve health departments’ ability to communicate quickly and effectively with public health staff.

The goal of this practice was to improve the ability for our health department to communicate with public health employees in emergencies. By strengthening our employee communication system, we have the opportunity to respond more effectively to our community in public health emergencies. During a severe winter storm in 2012, we implemented a text messaging pilot project where we sent text messages to employees on their personal cell phones informing them of site closures and providing instructions on reporting to work. Implementation was the culmination of a multi-step analysis. Prior to implementing the program, we conducted formative work with our employees to gauge acceptability of the program and following project implementation, we surveyed employees to evaluate the impact of the system and the messages we sent. Employee response to messages we sent during the storm were very positive: Of survey respondents, 70% received the information via text message before they heard the information another way. For those without power, who had reduced ability to check email, the text messaging system enabled the department to keep employees informed. 

The success of the project was due in part to our initial formative research where we were able to determine employee concerns about a texting program, and then address these concerns in the development of the project. Furthermore, our ability to target messages to employees based on specific work site locations enabled us to send customized messages that were relevant to individual employees. An employee testing system, with costs of approximately $5000 for the capacity to send texts messages over one year, has the potential to dramatically increase communication, particularly in the event of an emergency where other communication avenues might be compromised.

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Public Health - Seattle and King County
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Enhancing Public Health Employee Communication With Text Messaging
Public Health — Seattle and King County (PHSKC) is the one of the largest metropolitan health departments in the United States serving the 1.9 million people of King County with personal and population-based public health services. Our community is diverse with over 100 languages spoken within our county. As a large health department with approximately 1500 employees and 40 sites, it is critical that information flows to our employees and then out to our communities in a timely and effective way. With the increased responsibilities of local public health departments to prepare for and respond to public health emergencies, it is critical that employees get public health emergency information in a timely way. Our region is vulnerable to several emergencies that may have implications for public health: earthquakes, river flooding and tsunamis, among others. Power outages resulting from any number of emergencies may pose a challenge to communicating with public health employees who may need to be contacted to respond to community needs. Despite these challenges, readily accessible communication tools such as text messaging provide opportunities to improve health departments’ ability to communicate quickly and effectively with public health staff. The goal of this practice was to improve the ability for our health department to communicate with public health employees in emergencies. By strengthening our employee communication system, we have the opportunity to respond more effectively to our community in public health emergencies. During a severe winter storm in 2012, we implemented a text messaging pilot project where we sent text messages to employees on their personal cell phones informing them of site closures and providing instructions on reporting to work. Implementation was the culmination of a multi-step analysis. Prior to implementing the program, we conducted formative work with our employees to gauge acceptability of the program and following project implementation, we surveyed employees to evaluate the impact of the system and the messages we sent. Employee response to messages we sent during the storm were very positive: Of survey respondents, 70% received the information via text message before they heard the information another way. For those without power, who had reduced ability to check email, the text messaging system enabled the department to keep employees informed.  The success of the project was due in part to our initial formative research where we were able to determine employee concerns about a texting program, and then address these concerns in the development of the project. Furthermore, our ability to target messages to employees based on specific work site locations enabled us to send customized messages that were relevant to individual employees. An employee testing system, with costs of approximately $5000 for the capacity to send texts messages over one year, has the potential to dramatically increase communication, particularly in the event of an emergency where other communication avenues might be compromised.
Responsiveness The public health issue that this practice addressesA 2008 IOM Report, Research Priorities in Emergency Preparedness and Response for Public Health Systems identified two key priorities: “improving timely emergency communication,” and “creating and maintaining sustainable response systems.” In order for local health departments to be able to provide timely emergency communication to their communities, they must first improve their capability to communicate with the public health workforce. For example, during a windstorm with power outages, a critical public health function is to inform vulnerable communities of the risk of carbon monoxide poisoning. If employees lose power, and aren’t able to get critical information from managers, their response capacity may be dramatically limited. In the event of a chemical spill where a public health clinic may need to close, a first step to ensuring the safety of employees and clients is to let staff know, quickly, so that they can avoid the area, help with the response, or be deployed to another location. Text messaging can enhance the timeliness and efficiency to communicate critical information with a large number of employees. By using text messaging as a communication tool, particularly when other means of communication such as email may be inaccessible, public health not only improves our ability to protect the workforce, but also enhances our ability for our workforce to respond appropriately to protect the public. The process used to determine the relevancy of the public health issue to the communityOver the past four years, Public Health – Seattle and King County received a grant from Center for Disease Control and Prevention to explore the use of text messaging for emergency communication. Through this work, our communication team conducted audience research with several communities including the Deaf and hard of hearing, Spanish speakers, those living in rural areas, Native Americans and urban young people. We also conducted a phone survey of King County residents who text to assess how the public would like health departments to use the technology. Overwhelmingly, people felt that the health department should be using text messaging to communicate with residents during public health emergencies. We decided that our employees might similarly find text message emergency alerts to be of value. Based on this information, the first step was to implement, and then evaluate the use of text messaging to communicate with the public health workforce. We needed to assess the type of information that would be most relevant for employees, because this would be a voluntary system that employees would be invited to opt into, and not a required program that they had to enroll. Our first step was to assess what types of messages would be most relevant for employees. We created an 18 item survey for employees to ask them how they currently use text messaging, whether they would be interested in signing up to receive text messages from work, what topics interested them, and what concerns, if any, they had about receiving text messages from their employer. We also asked about gender and age. Approximately 50% of all public health staff responded (n = 828 responses, including open-ended questions). Employees identified the types of text messages they would want to receive: 54% wanted to receive a text message if their worksite was closed, and 55% wanted to receive a text during an emergency. Employees also mentioned several concerns they had about receiving text messages from their employer. How the practice addresses the issueBased on feedback from the employee survey, we developed a text messaging program that would increase the ability to communicate with employees, while addressing many of the employee concerns. For example, we worked with our text messaging vendor to develop a system that would allow employees to sign up to receive test messages specific to their work locations. That allowed for greater customization of messages. Employees were also concerned about spam - defined as an unwanted message - so we emphasized in our marketing materials that messages would only be sent in emergencies or in the event of worksite closures. Employees were also concerned that they would be held responsible for messages to their cell phones. We assured employees that this was an additional way to receive critical information, but that they would not be liable for not taking action on any given message. By addressing the concerns of the employees when we marketed the program, we had much greater acceptance of the program.   Innovation Evidence based strategies used in developing this practiceOver the past several years, the evidence for using text messaging for a variety of public health purposes, including for emergency preparedness and response, has grown. From the use of text messaging in Haiti during the 2010 earthquake to help responders identify critical needs of people on the ground, to using text messages to help locate victims during the May, 2011 tornado that hit Joplin, Missouri, text messaging has gained attention from public health emergency responders and researchers. In 2010, National Academies held a workshop, Public Response to Alerts and Warnings on Mobile Devices: Current Knowledge and Research Gaps highlighted that because cell phones are ubiquitous and kept close at hand, they are “well positioned to fill gaps in message-receipt coverage by traditional systems.” This practice is new to the field of public health  Process used to determine that the practice is new to the field of public healthWe conducted a literature review on the use of text messaging for public health purposes. We identified articles about resident adoption of texting programs by the public, (e.g. Susanto, T. D., and Goodwin, R. (2010). Factors influencing citizen adoption of SMS-based e-government services. Electronic Journal of E-Government 8(1), pp. 55-71.; however, we are unaware of any published literature on the use of text messaging to improve public health employee communication. By implementing this pilot project, we were able to gauge the feasibility of implementing such as system. Our current practice is to use telephone trees, a recorded hotline, and an employee-only internet site to provide emergency alerts to our 1500 employees. Text messaging has some advantages over these systems for several reasons. Text messaging occurs over a packet switching network, which is less encumbered than voice calls on mobile phones during periods of peak cell phone activity. Unlike a voice call, once a text message is sent, the message will remain in the gateway until there is network availability to deliver the message. This means that text messages may reach employees when a voice call may not. A recorded hotline is another way we currently reach employees, however, it is a “one-size fits all” approach for all 1500 employees, and cannot be customized by worksite. In addition, employees have to think to call the hotline. We also post emergency messages on the internet; electricity is typically necessary to power computers (though many staff may have mobile or pad-based access); and again, employees need to think to check. Text messaging is a powerful approach to reach employees with critical information because the technology provides instant access, is more active than passive in that information is provided directly to the user’s phone, texting allows for two-way exchange of information and may be more effective when other communication channels, such as voice-to-voice calls are down or the system is overloaded. There is a model practice for using text messaging for STD program purposes, but there is no model that uses text messaging to improve public health employee communication within a local health department.
Primary StakeholdersThe primary stakeholders for this project were the 1500 employees at Public Health – Seattle and King County and their family members who might be informed in the event of an emergency. We consulted with department administration and managers, labor unions, and staff. LHD role This proposed model practice is responsible for the development of the practice and its employees directly benefit from the practice. Within our LHD, communications unit staff sends text messages using a web-based interface to employees who opted in to receive emergency text messages on their personal cell phones. Communications within our LHD was responsible for crafting the messages, sending them out in a timely manner, and collecting evaluation data following project implementation. In the gathering of information and best practices about using text message for alerting, we talked to a variety of stakeholders and vendors. We attended multiple Mobile Health Conferences and convened a group of other local and state health departments and research institutions who were interested in the use of text messaging within public health, and facilitated conference calls to share best practices and gather input on implementing texting programs. Specifically, we discussed lessons learned about working with text messaging vendors and ways to get the target audience, in our case, public health employees, to opt-in for a program. We consulted with U.S. Department of Health and Human Services public information staff on the creation of emergency messages. We talked to dozens of vendors about the services they provided. There is a significant interest by our public health partners to learn how to use text messaging to communicate with their audiences. We recently received funding from Washington State Department of Health to be able to disseminate best practices on using text messaging to communicate with a variety of audiences. Lessons learnedGiven the relatively new use of this technology within a local health department context, it has been extremely valuable to network with other health department and leaders in mobile health around the country to share knowledge and strategies. For example, it has been helpful to learn about how to avoid some of the pitfalls of working with vendors who may have not have a focus in either emergency communication or public health. The specific tasks for improving communication with employees was to develop a text messaging system, pilot the project in the event of work site closures or other public health emergency, and evaluate how well the system functioned and how much employees valued the service. Throughout 2010 we conducted audience research with our employees. In 2011 we worked with a vendor to develop the system, and marketed the program to employees. In January of 2012, we piloted the program during an ice storm that left several public health sites without power. We evaluated the program in February, 2012. Outline of steps taken to implement practice1.) Conducted audience research with employees to assess what employees wanted in a text messaging program 2.) Utilized findings to work with a text messaging vendor to develop a system where we could text employees at specific worksite locations. 3.) Marketed program to employees by sending emails to employees asking them to sign up for the emergency texting program. 4.) In January, 2012 piloted texting program in an ice storm. We sent 15 messages over five days with work site closure information and other safety information. 5.) Evaluated the program following pilot project implementation. It is critical to understand the needs of your target audiences in order to tailor a texting program effectively. Had we not surveyed our employees prior to implementation, we might not have realized some of their concerns such as being “spammed,” or receiving too many texts. We were also able to assure them that they were not required to act on any text in any particular way. We were able to define for them that the messages we’d send would be about actual emergencies. Another key lesson learned was the importance of establishing clear procedures and protocols prior to implementing a system. During an emergency, there isn’t time to determine who is responsible for crafting the messages and who needs to approve the messages. In addition, it is helpful to have some draft messages ready to go for various scenarios, because writing clear and extremely concise – 160 character – text messages in the middle of an emergency is challenging. In the case of the ice storm, while we were waiting to receive word from management about whether a particular public health site would be closed or not, we drafted several different 160 character messages so that they were ready for sending once we received the final decision from management. Finally, by establishing a texting program, you may set up expectations by staff for immediate communication. The technology can facilitate delivery of the message, but that doesn’t mean that the decisions are made any faster, and this point was a challenge to communicate. It may be that because employees’ personal experience with text messaging is something that is rapid, they had the same expectations of our employee texting program. In reality, our text messages were only as good – and rapid – as the policy decisions were that guided the messaging It is also important to set up expectations about whether the system is only for pushing out information, or if employees may text back in with questions. A two-way texting program requires a much larger investment in human resources to be able to monitor and respond to messages. Cost of implementationThe primary cost of the program covered the vendor- hosted text messaging system. The system enabled us to send text messages to employees during any emergency that might take place over a year-long period. The system included the capability to send text messages to specific groups of employees based on their worksite location. The system, with start-up and customization, was approximately $5000 for the year. In addition, there were personnel costs associated with conducting the formative research with employees, developing the employee opt-in marketing, writing and sending the messages during the snow storm, and evaluating the system. The project costs were supported through a CDC grant.
Objective 1:Increase capacity to reach public health employees quickly with critical information. The performance measures we used to evaluate the practice included: - Implementation of a web-based system to send text messages to large numbers of people at once. - Functionality of the system. This focuses on the ability for the Communications Team to use the web-based system from off-site in case of emergency. - Ability to reach employees through text faster than other means of communication Data: We distributed a web-based survey of employees to evaluate the texting system. Results: We successfully met the objective to increase capacity to reach public health employees quickly with critical information. During the severe snow storm, we were able to use the web-based system to target messages to workers at specific locations. The system was accessible and functional from outside of our Public Health offices. Key survey findings include: • 83% of employees surveyed said the messages were fairly or very relevant and helpful. • On at least one occasion, 70% of respondents received a text message alert before they heard about the information another way. • 83% reported that the number of messages we sent was about right, while 15% thought it was too few, and 2% said it was too many. • For 17% of employees surveyed, it is important or very important that the employee messaging service be two-way so that they could text back, while 73% thought texting back was not important or very unimportant. Feedback: Survey respondents also provided comments to help us text more effectively in the future. We heard from many employees that messages about site closures would be more effective if they were sent earlier in order to help them plan your commute. As one employee explained, “Texts need to come by 6 am so train commuters and others can make travel plans.” Another employee commented, “Since I had no power and was unable to access my email or the internet, I really appreciated the text messages.” In a larger scale power outage, a texting system may be even more critical.
Stakeholder CommitmentThe Emergency Preparedness Unit and the Public Health Department Leadership witnessed first- hand the value of communicating via text message with employees. They have identified local health jurisdiction funds to sustain the program for the upcoming year. Clearly, as a large local health department with multiple sites, using technology to improve communication systems is a worthwhile investment. SustainabilityGiven the costs of implementing a text messaging system, it is important to leverage resources to fund these systems. Currently, our Communications Team is working across other King County Departments outside of Public Health to gain support for a county-wide employee text messaging system as well as a county-wide public facing text messaging system. We have met with several departments to gather information on the various ways they would use a text messaging system. We have received buy-in from County leadership to sponsor a county-wide text messaging system.
 
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