Griffin Works offers Pawsitive Interactions with Service Dogs During Response Operations©, an audience-customized training that breaks down barriers by offering hands-on handling training and demonstrations with working service dogs for fire departments, EMS agencies, and public safety organizations.

Part of the National Domestic Preparedness Consortium and home to the National Emergency Response and Recovery Training Center, TEEX has been leading homeland security training since 1998. The major TEEX programs include fire and rescue, infrastructure and safety, law enforcement, economic and workforce development, and homeland security. As a member of The Texas A&M University System, TEEX is unique in its ability to access a broad range of emerging research and technical expertise. Beginning with course design and development all the way through hands-on instruction and national certification testing, TEEX delivers comprehensive training through both classroom and hands-on instruction and as online courses.

The National Child Traumatic Stress Network (NCTSN) was created by Congress in 2000 as part of the Children’s Health Act to raise the standard of care and increase access to services for children and families who experience or witness traumatic events. This unique network of child-serving professionals, caregivers and young adults, researchers, and national partners is committed to changing the course of children’s lives by improving their care and moving scientific gains quickly into practice across the U.S. The NCTSN is administered by the Substance Abuse and Mental Health Services Administration (SAMHSA) and coordinated by the UCLA-Duke University National Center for Child Traumatic Stress (NCCTS). 

The Emergency Management Institute (EMI) is part of the Department of Homeland Security’s Federal Emergency Management Agency (FEMA). The EMI provides national leadership in developing and delivering training to ensure that individuals and groups having key emergency management responsibilities possess the requisite skills to effectively perform their jobs.

The High Alert Institute maintains a list of reviewed courses provided by governments, universities and professional organizations. This list is geared towards the non-emergency management person who participates in disaster planning, preparedness, response, recovery or mitigation as part of their job responsibilities.

The High Alert Institute has partnered with Shutterstock to distribute stock images from the nature images donated by our supporters. For eligible stock images, Shutterstock will donate a portion of the royalty to the High Alert Institute. There is no cost to charitable organizations or to Shutterstock customers.

For eligible purchases through AmazonSmile, the AmazonSmile Foundation will donate 0.5% of the purchase price to the High Alert Institute. There is no cost to charitable organizations or to AmazonSmile customers. All you need to do is push the SMILE NOW button and select to support THE HIGH ALERT INSTITUTE on AmazonSmile.

Koi need forever homes, too! For pond enthusiasts, freshwater exotic and ornamental fish may not be available through pet stores or rescues in their area. The High Alert Institute Aquatic Pet Shelter Rehoming Program will be happy to assist you in stocking your new pond or adding a new finned friend to your school. Coming soon – when you adopt a Koi from the High Alert Institute Aquatic Pet Shelter Rehoming Program, we can arrange for delivery to your door anywhere in the continental United States.

Have you always wanted a Koi pond but don’t have the space one? Sponsor a Koi in our community shelter pond and we send you photos of your sponsored animal. Coming soon are live Koi Cameras above and below the water to enjoy your sponsored Koi anytime.

Dumping of freshwater non-native species and exotic aquatic pets into wild habitats is a man-made disaster that is truly preventable. The Institute’s Aquatic Pet Welfare Partnership works to raise awareness and reduce the impact on healthy ecosystems through education, as well as rescue and rehoming. Joined by champions of animal welfare and environmental stewardship, this  association of aquatic pet rescue operations and aquatic pet shelters across the United States aims to save our finned friends and preserve our waterways together.

Want to share our cause with family, friends, and colleagues? Looking for a non-traditional way to celebrate a birthday or honor someone special? Support the Institute by starting your own Peer-to-Peer fundraising challenge! Let your contacts know why our mission is important to you and what they can do to support your cause. START YOUR OWN FUNDRAISER for the High Alert Institute.

From the staffing pool to the shelter ponds, from the boardroom to the classroom, and from reading the science to writing the analyses, High Alert Institute programs and services benefit from the experience, expertise, and generosity of our volunteers. Put your talents to use for good and to good use – VOLUNTEER TODAY.

Make your donation twice as nice by rehoming aquatic pets and providing a rehabilitation companion pet to a deserving person, family, or facility. Sponsor part or all of a Joy of Koi Program pond installation – complete with rehomed koi – and give the gifts of love and recovery.

Professional photographers, amateurs, and legal copywrite holders are all welcome to participate in the High Alert Institute Nature Photo Donation Program. Sales of the images benefit the Institute and donors are eligible for tax deductions equivalent to the fair market value of their photos. Landscapes, seascapes, animals, flowers – all may be accepted – whether new or vintage  images. People may be included in the photo but only if unidentifiable (i.e., blurred figures at a distance).

Did you know that unused patents and copyrights can be donated to charity? Intellectual Property (IP) just sitting on a shelf will lose value as it becomes obsolete. The High Alert Institute IP Donation Program seeks to rescue stranded, technology-related IP with the potential for development into marketable products. Once accepted by the program, the owner/inventor is eligible for a tax deduction equivalent to the fair market value of the IP. The Institute receives the patent licensing fees or revenue from the sale of the IP to businesses, helping us to fund our mission. In turn, businesses are able to advance their markets and create jobs for less money than starting a project from scratch.

Disasters are defined as situations in which needs exceed or overwhelm available resources. Some disasters affect an entire community, while other disasters impact individuals and families. Crises of physical or psychological health can be very personal disasters.
The therapeutic value of pets during illness, trauma, and recovery is well established. And Koi fish may be well suited for people who are not able to provide verbal pet commands or physically care for pets like dogs and cats. Koi ponds are also a source of beauty and peace, providing an ideal setting for quiet reflection or meditation.
We are working to partner with pond installers and aquatic pet rescues/shelters to offer free or reduced-cost ponds with rehomed Koi fish to people seeking this type of pet therapy.

Disasters disrupt life and impact our sense of personal, family, and community safety. Survivors and responders alike often are not aware of the emotional, psychological or spiritual challenges that they may face from disaster onset through recovery. With two decades of experience training responders and communities to prepare for the behavioral health aspects of disasters, we will continue to provide education and a curated list of resources to groups or individuals.

Non-medical factors that impact overall health are termed Social Determinants of Health or SDoH. Noise pollution, poor air quality, and poor water quality are three environmental factors known to have a strong link to overall health. And the same environmental factors that impact humans impact their pets and other animals in their care. We continue to assist in advocacy, education, and technology development to mitigate the impact of SDoH on humans and animals alike.

Our efforts in shelter and rescue are the main focus of our environmental stewardship, reducing the environmental impact of non-native aquatic animals being dumped into public waterways. The High Alert Institute also assists innovators with the design, development, and evaluation of green and renewable energy technologies. Reducing the carbon footprint associated with disaster preparedness, response, and recovery furthers our continued mission to mitigate risk and improve resilience.

We partner with public and private organizations, sharing resources and fostering partnerships to improve disaster preparedness, response, and recovery, and mitigation.

The High Alert Institute team has over a century of combined research experience in medical, nursing, behavioral health, and disaster sciences. Our team provides support to researchers and technology developers through comprehensive literature searches and reviews, as well as failure mode database searches and adjudicated reviews.

When disaster strikes, most aquatic pet owners have limited options to secure the safety of their pets. Sheltering in place may not be possible if there is no power to provide aeration and “pet-friendly” shelters do not include ponds or aquariums. Our goal is to provide an option for aquatic pet owners in need of rescue and shelter for their finned friends.

Our goal is to share our two decades of disaster readiness experience with animal welfare organizations, shelters, caretakers, and pet owners, as they implement contingency  plans for natural and manmade disasters.

High Alert Institute



Did We Ever REALLY Ask?

by | Feb 20, 2008

Hospitals and their corporate officers live and die by customer satisfaction scores such as the Press/Ganey Survey and Harris Poll. The problem is that these “surveys” & “polls” are little more than “opt-in” commentaries. Scientific data shows that, regardless of industry, a dissatisfied customer is three times more likely to express their opinion than a satisfied customer. Given this fact, the healthcare industry standard “opt-in” model, by its very nature, should yield a 3 to 1 dissatisfaction bias. Given that this bias is not seen indicates that other, unaccounted for factors, are skewing the data.


Survey Construction

To obtain meaningful data from a survey or poll, specific criteria for data collection must be met. The first and most important is that the demographic make-up of the study group must be determined before the data is collected. Demographics includes more than gender, age and ethnicity. In the healthcare setting, treatment area specific identifiers such as time of year, triage level on presentation (ESI 1-5), initial evaluation and management level (E/M 1-5), waiting room wait time, length of stay, etc. allow for further differentiation of individual factors influencing patient sentiment and satisfaction.


These demographic groups must be strictly adhered to and once the number of a particular group is obtained for a given survey, no further survey responses are accepted in that demographic group. Further, if a particular demographic group is not fully enrolled with respondents, additional individuals are recruited in that demographic group only until the required number of responses are obtained. This is currently not done in healthcare, yet it is the key to obtaining interpretable data.


Questions Are Key

In healthcare, the rule is to ask open ended questions to obtain global information and then ask close ended questions to obtain specificity. In survey construction, specific questions must be asked before the survey is constructed. Like a scientific investigation (and all valid surveys are scientific investigations) the first question is to ask what specific and narrow question we seek to answer. Commonly, the response from corporate leaders is that they want to know if customers are satisfied, but this is not sufficiently specific. Which customers? Under what circumstances? Such a customer satisfaction question would be, 


“Are customers with an ER lobby wait of greater than 4 hours (all other demographic factors being equal) more satisfied customers than those with a lobby wait greater than 4 hours?”


Once the question is narrowed to a specific single area, a null question (null hypothesis) must be formed. This is a testable question such as,


“Is there a difference between customers with an ER lobby wait of greater than 4 hours (all other demographic factors being equal) and those with a lobby wait greater than 4 hours?”


This latter question can be answered easily by having a demographically specific and identical group score their satisfaction then dividing them based on their lobby wait time. A simple comparison of the satisfaction scores between the two groups will then indicate the influence of lobby wait on satisfaction. Obviously, those with different demographic factors will respond to wait times differently and thus narrow demographic groups with large numbers must be studied to determine if lobby wait is in fact a factor at all.


Acknowledge Framing Bias

The construction of a survey or poll must also include a consideration of the bias held by those asking the questions. Failure to acknowledge even seemingly unrelated bias will inevitably skew the results due to the framing of the question. Referring back to the ER lobby wait example above, most in healthcare leadership hold the belief, based only on unscientific “opt-in” commentaries, that ER lobby wait is a key factor in customer satisfaction for all ER patients (regardless of other demographics). This bias results in customer satisfaction studies that are skewed to elicit comments congruent with that bias such as, 


“Was your ER wait time short, adequate, long, excessive?”


This question primes the reader to view a long ER wait (even for a non-emergency) as excessive if it is longer than they wanted. The unbiased approach would be to determine ER wait time as a demographic factor based on the time from sign-in (arrival) to the time place in a room (door to room time). Having this information, the question would then be,


“Please rate your overall satisfaction on a scale of 1 through 5 (1 = very dissatisfied & 5 = very satisfied)”


The statistical comparison of overall satisfaction between those with an ER lobby wait under 4 hours and those with a wait over 4 hours within otherwise matched demographic groups yields an accurate reflection of the impact of ER lobby wait on overall satisfaction.


Bad Questions Yield – Bad Conclusions

Just in case there is any doubt of the influence of bias, an “opt-in” commentary invitation was placed on the internet for seven days and circulated using a professional networking service. An analysis for power determined that 53 respondents were required for statistical significance.1 Like all healthcare customer satisfaction surveys currently employed, any person having been an ER patient was included in the final analysis.1 Over 28,900 individuals viewed the question, but only 59 “opted-in” with responses.1 A heuristic analysis for bias was preformed to generate a question that minimized bias based influence on responses.1 The resultant question asked,


“Given that your wait in the lobby and your total time in the ER would be unchanged, would you rather have your ER doctor come into the room 10 minutes after you are brought from the lobby to introduce themselves but do nothing else, or would you rather have your ER doctor come into the room 25 minutes after you are brought from the lobby and complete the entire interview, exam and ordering of tests/treatment?” 1


The 10 minute option and the 25 minute option represent the current ER incarnations of LEAN and Six Sigma respectively. Pre-study review of the ER management literature found that the majority of the responses would prefer one of the other, but there was no consensus on which option would be preferred.1


Surprisingly, out of 59 responses, 1% offered no preference, 53% preferred the 25 minute wait and 46% preferred the 10 minute wait.1 Of greater interest, one in twenty of those who preferred the 10 minute wait stated that they only preferred it because they could “bully” the doctor into staying and completing the entire patient encounter rather than leaving after the introduction.1 Despite respondent reframing of the options, there was still no statistically different difference between the options.1 


While each of these approaches have ardent supporters who insist that their approach is the solution to low patient satisfaction, this data suggests that the right question has not yet been asked and thus the true answer has not yet been found.


Asking a Better Question – Getting Better Answers

Asking better questions often yields surprising and useful information. Markoul, Zick and Green published a survey based study looking at how patients prefer to be addressed when they first meet their healthcare provider. In most healthcare encounters, physicians greet patients by either first name or title with last name while introducing themselves with their title and last name. Conversely, nurses are taught to great patients by first name and introduce themselves by first name only. Across the board, all healthcare providers are counseled to offer a handshake at every encounter.


Answering closed-ended, narrowly constructed questions, a survey of 415 patients found that 50% the patients wanted their first name to be used when physicians greet them.2 Similarly, 16% of patients preferred to be greeted by their title and last name, and 24% wanted their first and last names to be used.2 As to how healthcare providers should introduce themselves to the patient, 56% wanted to hear both names; 33% wanted the provider to use just their title and last name, and only 7% wanted first names to be used.2 Approximately 78% of respondents expected to receive a handshake, with older patients less likely than younger patients to want a handshake (74% vs. 87%; P < .005).2  


This data shows that the broadest group of patients would be satisfied if their provider greeted them using first and last name names (satisfying all three groups). Further, providers should introduce themselves using title with both first and last name while offering a handshake (again satisfying all groups).


Getting to the Answers Needed

Patient and customer satisfaction surveys are a fact of life in the business of healthcare. Improving these critical business benchmarks is too often linked to hastily contrived and implemented process changes. If the key to making the best decisions is having the best information and the key to having the best information is asking the best questions to the right groups of people, then before the next survey is sent out, healthcare must create better surveys.


  • Determine the distinct demographic groups to be surveyed
  • Determine the exact number from each group to be surveyed
  • Survey exactly that number from each group (no more and no less)
  • Determine the question to be answered and the null question to ask
  • Acknowledge framing bias and frame the null question without that bias
  • Limit conclusions to the answer for the null question
  • Use inconclusive results as a guide to identifying factors without influence on customer satisfaction
  • Use conclusive results as a guide to identifying actions that will improve customer satisfaction


When healthcare really asks patients for the answers it seeks, customer satisfaction scores will become irrelevant because patients will automatically get what they need and deserve.


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