Intro slide (video).
Hello. My name is Mary Hoeppner and I work at the University of Minnesota, School of Public Health, Centers for Public Health Education and Outreach. If you've opened this pamphlet and disc, you're like many others who are trying to find ways to develop the abilities of public health professionals to perform the essential services, to respond in a range of emergencies and to evaluate their ability to perform those skills. Because a competent workforce is an important part of organizational capacity, the sets of competencies are a valuable tool for trainers, educators, supervisors and managers. As a HRSA Public Health Training Center and a CDC-funded Preparedness Center, we work closely with our state and local public health agency partners. One of the challenges they brought to us was to help them find a way to identify competencies in training activities. What evolved from that request is this competency mapping guide.

The tool is designed to help users identify if a training is developing skills, at what level (basic or advanced), and what competencies are embedded in training activities. Begin by reviewing the materials on this disc. What you'll find there is a presentation made for the National Laboratory Training Network. While the discussion of competencies is framed as a set for laboratory staff, you'll find that the competency discussion works across all sets of competencies for all groups of learners. If you're still interested in developing competency mapping skills, move next to the booklet. In it you'll find additional information about competencies, competency sets, competency mapping and a sample course that brings it all together and shows you how to use the guide. We hope the competency mapping guide will be useful to you in all your training endeavors.

Slide two (title).
Thanks to all of you for joining us this afternoon. I titled this program “Dissecting Training, Building Towards Competence in Emergency Preparedness” because I think that much of what we need to do is really get very good at dissecting training to determine competencies and to consider how they help us in our capacity building within our agencies.

Slide three.
When we begin this process of dissecting we always have to cut carefully and I think when we're speaking about training we need to be very cautious and clear in defining our terms. And so we're going to be talking about what is competency and what are competency sets. Sometimes we hear the phrase ‘competency models’ and so we're going to be talking about how competency sets and competency models are two different things.

Slide four.
We're also going to be talking what is the difference between capacity and competency. Frequently I hear those terms used interchangeably but they're actually two distinct concepts. We want to be clear when we talk about that. Finally, we're going to be talking about what is an indicator and what do indicators have to do with competency in the first place.

Slide five.
So what is competency? I started working in education about twenty years ago when I was working with nursing students. And even back then in the Seventies -- although I think I just dated myself -- we were talking about competencies. And one of the first persons who was writing about this was a nurse by the name of Dorothy Del Bueno. And what she said is competency is “a simultaneous integration of the knowledge, skills, attitudes required for performance in a designated role and setting”. And what's so important about this is because we're talking about simultaneous integration. We're not just looking at a single knowledge set or a single set of skills or a set of values and beliefs that we bring to a situation.

What we're really talking about is how do we bring all these things together. The other part of this definition that's really important is this notion of performance in a designated role and setting. You can be very competent in one role and be moved to another situation and expect that your competency may shift. Because that context will require from you different kinds of skills in different kinds of situations. I think about health educators who are very skilled at working with communities and public information officers who are very skilled at delivering risk communication messages. Then we put them in a classroom or in a high-school gymnasium with seven hundred frantic parents in a community who are experiencing a meningitis outbreak. That's a different context and a different setting. And so when people are working on this notion of competency, we have to be thinking about the settings that we want people to demonstrate those skills in.

Slide six.
This is a definition by Lucia and Lepsinger who wrote a book on competency models more recently in 1999. And what you can see is that definition of competency hasn't shifted very much over the last 20 years. They define it as a “cluster of related knowledge skills and attitudes that affect a major part of one's job, role, responsibility, that correlates with performance on the job”. The piece that they add is that it can be measured against well accepted standards and that can be improved by training and development. So we start to bring in this notion of how do we measure competency and how do we evaluate it. And that's what we work on frequently.

Slide seven.
In both of these definitions then you see competency is comprised of knowledge, skill and ability elements; they both talk about simultaneous integration; competency is linked to performance and it's specific to a role in a setting.

Slide eight.
And as I said, competency measurement and evaluation can only really be measured in context. The example I give here is it's one thing to take a test in a class that's teaching me how to do CPR. It's another thing to walk down the street and see someone laying face down who is blue and unresponsive. That's when we assess competency. Can you do those things that you were taught to do in that classroom and do them at the level that you want to perform at.

Slide nine.
So if that's competency, what's a competency set? Competency sets are groups of competency statements; they’re developed by groups of professionals, usually in meetings or in consensus committees, and what they try to do are articulate and cluster specific knowledge, skills, abilities and attitudes(sometimes referred to as KSA's)into statements that are focused on a specific group of practitioners; and they become that benchmark that we measure against.

Slide ten.
So in public health what are we talking about? Well, first we're talking about core public health, always. Those are the foundational competencies. And the foundational competencies reflect the Essential Services of public health. These were developed in about 2000 or 2001 by a group called the Council on Linkages Between Academia and Practice. And they came up with these 64 competency statements plus what they called four attitudes that are basic statements of skills, knowledge and abilities. And each of those is correlated back to one of the ten Essential Services of public health.

Slide eleven.
This is a book you may have seen before. The early version was, I think, a light blue. They just did a reprint this year that's bright yellow. But this is it: these are the core competencies for public health.

Slide twelve.
If you look inside that book what you'll see is that those core public health competencies are divided into eight domains. And a domain is simply something that I think of as a book chapter or a tab in a book. It's just an organizational piece. They developed these sixty-eight statements into clusters focusing on analytic or assessment skills; policy development and planning skills; communication skills; cultural competency skills; community dimensions of practice; basic public health skills (all those EPI skills and those skills that we apply every day); financial planning and management skills and then considering that everyone is responsible for leadership, there are leadership and systems thinking skills. So those are the base. That's the foundation; and all of us in public health are working to acquire and demonstrate those core public health competencies and provide the Essential Services of public health.

Slide thirteen.
Then in 2002 another set of competencies were developed. These may be familiar to you also. Sometimes these are called the Gebbie Competencies, sometimes called the Columbia Competencies, sometimes called the CDC competencies. They're all talking about the same thing. And these are the Bioterrorism/Emergency Readiness competencies.

Slide fourteen.
These Bioterrorism/Emergency Readiness competencies are divided and organized into phases that have to do with preparedness and planning; response, recovery, mitigation and evaluation. And right away, we start to run into a little bit of language glitch because if you look at those, what you see, if you look in the book is it talks about core competencies for public health. And so whenever I look at that, the first thing I say is, “Are we talking about the Council on Linkages core competencies or are we talking about the bioterrorism competencies?” One thing that helps me sort that out is by calling these bioterrorism competencies that apply to everyone in public health cross-cutting competencies. And that's the other phrase that you'll see. And what people are trying to do is say that these are the competencies that cross all public health roles in emergency preparedness and response. The other thing they did in this book was they developed a series of role-specific competencies. So everybody has the cross-cutting (one through nine competencies). And then there are about nine other expanded sets of competencies, one of those having to do with public health laboratory staff.

Slide fifteen.
So in the public health laboratory staff competencies what you see are detailed articulation of the cross-cutting competencies as they relate to laboratory staff. And what they do is they identify additional competencies that are needed to be performed by laboratory staff in those three phases of preparedness. One of the things that Shoolah Escott did (from CDC) in preparation for this program today was forwarded me a set of laboratory competencies that you've been working on in terms of preparedness and response. The language is a little more specific because it talks about -- describing the role of hygienic laboratories, sentinel basic capacity laboratories and those kinds of things. But they're very similar and they sync very closely to the CDC Laboratory competencies, the ones that came out of Columbia in 2002. So I think we're all on the same page, really, in terms of these basic competencies for preparedness and for the specialty competencies.

Slide sixteen.
Well, the funny thing about competency sets is that once we start writing them they just grow and grow and grow and grow. And there are well over a hundred -- and that's an old count -- I would bet there are probably up to about 130 different specialized competency sets. The American Society for Clinical Laboratory Science, if you go to their website, also talks about this notion of competency-based training, education and credentialing. So within the professional associations there are efforts and work going forward to also bring forth competencies and statements to help shape training and to look at evaluation of performance. So competency isn't something, I think, that's going to go away. I think the trick for us is to figure out, like everything else in the world, how to make it manageable and how to make it work for us.

Slide seventeen.
So if that's what competency is and that's what competency sets are, what's this notion of competency models? This is a term that started to crop up in the Nineties and I think, as I look at it, it is a meeting of human resources and really education training and theory and some management, administrative systems theory coming together. It really is a systems approach. And when people talk about competency models, what they're talking about are groupings of competency sets that you pull together, targeted to a specific role; and then these are linked to job design, the way we write our job requisitions, the way we do our tasks, our role requirements. They get used in terms of appraisal systems for performance evaluation. And when people are using a competency model approach they're also doing things like looking at the competencies, looking at the indicators, training people who interview for positions to build that into their question sets. And once you do that, then you truly have a system where you bring people in, you've looked at them in terms of what competencies they have, where some gaps might be, that can then be addressed in training. And then we're constantly giving feedback in the appraisal system and what you've got is a closed loop that helps people develop competencies.

Slide eighteen.
So building competency, and this little pyramid is a model I've used, we always start with core public health because that's foundational to what we do. We deliver the Essential Services of public health. We've established that the Bioterrorism/Emergency Readiness competencies one through nine are for everybody. So they're the next step up in that pyramid. For this particular group, the Laboratory Science competency sets would stack on top of that. And you can build your pyramid as tall as you want to build your pyramid. You just keep adding competency sets and then start to work on that in terms of role descriptions, positions and training.

Slide nineteen.
What you have here is an example of a public health laboratory staff manager. You have core public health; you have the cross-cutting competencies in emergency readiness; you have laboratory science competencies and then you have, on top of that, core competencies for supervisors, managers and executives. Things that would talk about fiscal management and human resource management.

Slide twenty.
What we're always trying to do is figure out how to thread the needle top to bottom through that pyramid. We always try to link things. And we do that because we try to answer this question about: “What is capacity and how do we build capacity inside our organizations?” So capacity is the ability of an organization to perform in a specific way which is different than an individual performing in a specific way. And there are many dimensions of capacity. If you look at the bottom of this particular slide, you see knowledge, skills and attitudes. That's competence. It's one element in capacity but it isn't the whole ball of wax. So when people start to use those words interchangeably, I'm always trying to clarify that in training we're talking about one element. And then if we're truly going to measure capacity, we have to look at many other things. We have to look at human capital, meaning do we have the right kind of people in the right kinds of positions? Do we have a lot of vacant positions and how does that impact our ability to respond? Physical capital. Here in Minnesota, we've been blessed with a brand new state laboratory. That's an example of physical capital. Very important. You have to have the right buildings and structures for people to work out of. Economic capital. You obviously have to have the money and the support to make that happen. You have to have social capital and that has to do with your networks. It's everything from the county commissioners who develop your funding base to state legislators to national networks. And you have to have cultural capital. You have to understand both the cultures and beliefs of the persons you serve; and you also have to understand the culture of the people that you partner with in terms of organizations because that's an element of culture also.

Slide twenty-one.
So capacity and competency are not the same thing. Individual competence contributes to capacity but isn't capacity. Individual performance is developed through training that reflects competencies and competencies are comprised of individual knowledge, skill and ability elements.

Slide twenty-two.
I wanted to share this model with you. This is a model that was developed by Kathy Miner at Emery University along with some of her colleagues there and with Joan Cioffi from CDC a few years back. And for me it lays out nicely this notion of how competence and capacity fit together. And it's called the MACH Model because that stands for the initials of their last names. But if you start over in the left upper corner, what you see is a little box that says ‘workforce competencies’ and following the line straight down what you have in between is really a learning needs assessment, and all the steps in that which then leads to some statement of instructional competencies. Now people use the word instructional competencies. I think that means the same thing as learning objectives, and broad learning objectives. Sometimes people call them sub competencies. That's more language. It's more verbiage. And it would be helpful if we could all get on the same page with that but we're not quite there yet. But you have this notion of how you develop training plans. You've done your assessment. You put your plan together. You organize it. You implement it. You evaluate the learning. The arrow takes off sort of, I guess, northeast, I would say, which takes you to individual performance. And there's sort of a dotted line across from that that says ‘credentialing.’ And credentials are what an individual gets. If you follow the line straight up what you see is individual performance contributes to organizational performance. And the dotted line across from that is accreditation. Agencies become accredited based on the performance of individuals. So you can see there's a difference between accreditation and credentialing and then individual performance contributing to organizational performance. And it's a circle. We keep on learning.

Slide twenty-three.
So where does that take us? Well, if we're going to really work on developing competence, it's really important for us to get very, very good at stating what it is we want people to be able to do. And that takes us to the notion of instructional objectives. And I think they are at the heart of everything that we need. They provide focus for us, they reflect learning needs assessment, they communicate both to the instructor and to the learner what the intent of the training is. They are also what we use to target our evaluation and as a set, they say, “This is what we're going to accept as evidence that somebody can do what it is we taught them to do.” So they're very important.

Slide twenty-four.
Learning objectives are really written at two different levels of specificity. If you read a paragraph that describes a conference, generally what you're talking about are general learning objectives. They're telling you what the conference is going to do. That's very different than saying what a learner is going to be able to do. And the language is different. It's much broader. It describes a purpose. And it isn't directly measurable. And we can't try to evaluate competency until we get to that level of being very clear and very specific about learning objectives.

Slide twenty-five.
The way we get very specific about learning objectives is by focusing on what we call the domains of learning. And what it says is that there are three really different dimensions or kinds of knowledge that we learn. We have the cognitive domain which is about facts. We have the affective domain which is about values and beliefs. We have the psychomotor domain which is about thinking and doing, not just about doing. And those really become the different kinds of learning that we need learners to engage in. Within these domains and a domain, again, is just a tab, a chapter in a book, each domain has different levels of learning and they're arranged from the lowest level to the highest level. They move from simple to complex. They move from concrete to abstract. And each level includes the levels that precede it.

Slide twenty-six.
So the first domain is the cognitive domain. This is sometimes referred to as Bloom's taxonomy. Bloom's was revised in 2001 and one of the things that we learn in life is that we never learn it once, we get to learn it twice. So we're all re-learning Bloom's taxonomy. It has six levels. At the very basic level, we simply ask people to remember information. One step up from that is we actually ask people to comprehend it. We want them to understand it which is different than just being able to remember it. Next up we want people to be able to use the information. That's the level of application. Level four is analysis. When people can analyze, they can differentiate and they can organize information. The fifth level is evaluation which is judgment and critique. And then level six is actually creating brand new ideas and new knowledge and new models and that's very high level learning.

Slide twenty-seven.
So here's some examples of what that looks like. If I'm asking for someone to simply “List the events that created the French Revolution”, all I'm asking for people to do is remember it. If I write a learning objective that says the learner has to be able to “State the meaning of the word ‘concentration’”, they have to be able to understand it. A learning objective like “Differentiate pre and post causes of renal failure” is about analysis. And if I were asking the learner to “Evaluate the results of current research about the correlation between obesity and type two diabetes”, that's an evaluation learning objective. And if you look at the difference between remembering and evaluating you can see that the kind of knowledge we're transmitting to the learner is very different. Much more abstract, requires much more conceptualization and work to put it together.

Slide twenty-eight.
So what I'm going to ask you to do is take about thirty seconds here and I want you to try it out. Here you see a list of five learning objectives. And I'd like you to take a shot at trying to match that learning objective to the cognitive domain taxonomy.

Slide twenty-nine.
Okay, so let's take a look at these. If you look at the first objective which is “Describing challenges facing public health professionals planning for the year 2020”, I think that's written at the level of understand. We're asking people to comprehend. If we ask people to “Design a surveillance program for use in their agency”, we are asking them to create. That's a very high-level skill and it would take the ability to analyze and apply and comprehend to be able to do that. And that's that notion that I said things are kind of hierarchical. If you're at the highest level, you're doing all the other ones, too. Number three, “Critiquing research findings in terms of their usefulness to providing methods of maintaining low stress”, that's really about evaluation. That's critique. “Listing three causes of diseases associated with the agriculture industry” is about being able to remember what you were taught. And finally, obviously, “Analyzing the relational dynamics occurring in communities when there's a shooting in a high school” is about analysis.

Slide thirty.
The next domain is the affective domain and I personally find this one the toughest. It's about values and beliefs. And it is the toughest but the other thing to remember is that it is the domain that lights the fire and sends people out the door to create change. So it's important and when we're doing training we want to be sure that we're addressing the affective domain. So at the very basic level, all we're asking people to do is receive. We're asking people to simply be willing to listen to what someone has to say. At the next level up we're asking people to respond. We want people to react in some way. To show some interest or be willing to participate. The third level is valuing. And when people value they attach a worth to something. They begin to think it's really not only interesting but important. At the next level up, organization, people begin, and what we're trying to help them learn how to do, is resolve conflicts between two different kinds of values. I might value saving for my child's college education and I might value taking a cruise to Mexico. But somehow I'm going to have to resolve that. And that's what organization is about. And then at the very highest level in this domain is something that we call value complex or characterization by value. I sometimes call this the Gandhi level. When people are at this level, they have integrated these values into their lives to an enormous degree. And so that's the highest level in the affective domain.

Slide thirty-one.
Here are some examples of the affective domain learning objectives. “From a list of volunteer activities, select three that match personal interests and preferences”. We're asking them to respond in some way. And in these examples I've bolded certain words and that's because in learning objectives, it's the verb that creates the level. So you're very careful with your verbs. The next one, “Explain the impact of belief systems on compliance with health directives”. That's about valuing. What are people valuing? What are their beliefs? The next example is “Integrate three activities that support personal emotional health into a daily schedule”. That's that notion of integration and that's very complex. And what you have to remember when you write a high-level objective like that is your learning objectives direct your evaluation. So the only way I can measure that kind of an objective is by doing a follow up study with people. Because I really wouldn't know if they had integrated something into their life until I could go to them six months later and say, “Are you exercising thirty minutes three times a week or four times a week?” So you also have to keep in mind as you write a training, what the evaluation is going to look like and if you have the resources to do it because that's all got to sync together.

Slide thirty-two.
All right, so here's a couple of examples for you to try out. There are five of them here. Take a couple of minutes again and see if you can match them up.

Slide thirty-three.
Okay, let's take a shot at this. The first one: “Recognize accountability issues and ethical dilemmas in application of advanced life-support technology”. I'm calling responding. I'm asking people to just show some interest in that and recognize that there are accountability issues for us. The second example, “Select personal heroes from a list of famous public figures”. I'm asking people to value a little bit. Who are their heroes? And that has to do with attaching worth. Number three, “Mentoring a colleague new to the field of laboratory science”. That's value complex. Serving as a mentor is really a commitment to another person in terms of helping them develop their profession. So that's a high-level skill. “Selecting priorities for use of discretionary income” is about organizing and resolving those conflicts. And the last one, “Describing issues of personal responsibility and promoting primary and secondary prevention in order to affect social change”, I'm calling receiving.

Slide thirty-four.
So let's take a look at the last domain which is psychomotor. This one is probably the easiest for all of us because we focus on skills a lot. At the lowest level, perception, we're simply asking people to use their senses to gather cues. At the level we call ‘set’ we want people to be ready to act. At the third level, guided response, people can follow some directions to perform a skill. It's about imitation and trial and error. I think about when I was a student nurse and I was learning how to take blood pressures and I'd go into the skills lab and there'd be a little card here that would say, “Pick up the blood pressure cuff and hold so the Velcro is facing you.” And I'd pick it up and I'd hold it so the Velcro…, you know, it's that notion of it's very sort of step by step by step by step. It's early. Mechanism. When people are at the level of mechanism and they've been taught to that level, what they can do is perform a skill with some confidence. It's consistent. It's smooth. They know what they're doing. They're not following the check list anymore. At the level of complex overt response, they're very proficient. They're skillful. They're accurate. They move through it. In adaptation they can modify the skill to respond to a situation that they're in. And then origination is about creating whole new patterns of movement and whole new ways of doing things.

Slide thirty-five.
So examples of psychomotor domain learning objectives. If I'm asking a learner to “Identify the correct meter for a waltz”, I'm talking about perception. That's about cues. If I ask them to “Display the correct position of feet for addressing the tee”; we did a lot of this in my golf lessons; that's guided response. That's a very beginning level skill and you're looking at your feet and you're looking at the tee. And it's step-by-step. If we're asking our learners to “Modify the strength at which a volleyball is hit based on location of opponents”, that's adaptation. People have to put it together and make some judgments and perform in a different way. And if we're asking people to “Compose” something totally new like a sonata, that's about origination.

Slide thirty-six.
And here, again, are a few examples for you to take a look at and see if you can match up the psychomotor domain to these learning objectives. Take a couple minutes.

Slide thirty-seven.
Okay, so let's take a look at this. If I were asking a learner to “Demonstrate the ability to make chocolate-chip cookies without a recipe” I'd be asking, really, for mechanism; some confidence in that because they don't get to use that recipe. They just have to know how to do it and be able to do it. If I were asking someone to “Gather materials needed to weed a garden”, that's about readiness to act. That's set. If I asked people to “Alter their responses to requests for information based on the assessed stress level of a client”, that's about adaptation. Number four, “Creating an arrangement of common folk music for performance by a string quartet” is about origination. It's creation. Number five, “Distinguishing among the needs of cats based on their meow” is about perception. Again, it's listening to cues. Number six, “Using a template provided by conference organizers, write a letter to the editor to inform the community of an upcoming event”, I'm calling that guided response because they're using a template. It's not an original letter. And I'm going to let the learner have that template. Number seven, “Demonstrate the ability to perform a square dance as part of a group of performers” is complex overt response. That's a skilled level of movement.

Slide thirty-eight.
So let's examine the specimen a little bit. If we had a class with a set of learning objectives how could we use them in a way that's useful to us beyond simply structuring the training and figuring out the evaluation? One of the ways that it becomes useful is by trying to identify the level of skill development targeted by a training.

Slide thirty-nine.
The group that wrote the core public health competencies, that Council on Linkages, defined some levels of learning. And these have become fairly commonly used. At the Awareness level, we're asking people to develop basic levels of mastery. Learners at this level can identify a concept or skill and they have limited ability to perform it.

Slide forty.
The Council on Linkages Knowledgeable level defines a Knowledgeable level of learning as an intermediate level of mastery of a competency. People can apply a skill as well as simply describe it.

Slide forty-one.
And the Council on Linkages has defined Proficiency or an Advanced level as an advanced level of mastery and the ability to synthesize, critique or teach the skill to other people.

Slide forty-two.
One of the things that I think about, then, is that definition of competency that we looked at the beginning; both of them, by del Bueno and by Lucia and Lepsinger. Competency requires the ability to apply knowledge, skills and abilities. And if you look at the Awareness level description that we just talked about, people developed at the awareness level have a very limited ability to perform a skill. And when we think about the ability of people to respond in crisis situations, where they're not going to have a check list and they're going to have to have some ability to perform quickly in a stressful situation, I think we're looking at something else.

Slide forty-three.
I think what we're looking at is an intermediate or an advanced level. The Knowledgeable level, people can apply and describe what they're doing. I'm not sure that we need everybody at the Proficient level. But I do think we need people at the Knowledgeable level.

Slide forty-four.
So how can we use what we've just talked about? Well, we can classify things. As I was starting to try to work on this probably about four or five years ago, thinking about what I know about learning objectives, I know that the domains of learning are arranged from simple to complex. It's a higher level of learning to be able to evaluate than remember. And I look at these definitions of the Council on Linkages and they're also written in a sequence. Training at the Awareness level is less skilled than at the Proficient or Advanced level.

Slide forty-five.
So I put those two things together and it seemed to me that we could characterize our training activities by analyzing learning objectives and the language of learning objectives. And know that if we're developing a training in which we're asking people to remember or comprehend information or to be willing to listen to us or to be able to perform a skill in a very, very basic way, we're talking about Awareness level training. On the other hand, if we want people to be able to apply and analyze and to understand what they're doing and why it's important and to place a value on that, and we want them to be able to perform smoothly, then we're talking about developing training at the Knowledgeable level. Again, over here on this table, Proficient and Advanced has to do with evaluation; creation; origination. I'm not sure that we need everybody to be teachers or to be able to create new systems. So I think what we can do is look at our training plans, figure out where they fall and if we're doing a lot of Awareness level training we may want to be thinking about how do we kick that up a notch? And if we're spending a lot of time trying to develop everyone at the Proficient level, we may be able to use our resources in another way. And that's what we've been thinking about here at our Centers. How to get it to the right level and use our resources well.

Slide forty-six.
So what do we know? We know that BT/ER competencies are built on the core public health competencies, cross-cutting bioterrorism competencies are for everyone who's a public health responder. And we know that the language of learning objectives can be correlated to the level of skill that we want and need to develop.

Slide forty-seven.
I've talked a little bit about evaluating competency as we've gone through this presentation. But I think it's important to think that within a learning objective, there are specific knowledge, skill and ability elements. And sometimes we refer to these as indicators. And sets of indicators are developed through research and written in behavioral terms and we use them to evaluate progress. If you think, for example, when someone has had a heart attack, one of the indicators that hospitals will use of their ability to treat that patient is: How fast did someone get an aspirin? Did they get it at home? Did they get it in the ambulance? Did they get it as they were rolling through the door? That's an indicator of quality, an indicator of performance. So what we've tried to do here at our Center is develop indicators. And we've used these for our assessments that we've done with our states. We've developed twenty-nine indicators that reflect the cross-cutting indicators and then ninety that are role specific.

Slide forty-eight.
For example, some of the core or cross-cutting bioterrorism indicators that we've developed are “Identifying the modes of transmission for all biological agents of concern”, “Demonstrate the ability to correctly use PPE”, “Communicate directions in a clear and concise manner”, and “Recognize signs of post-traumatic stress in the behavior of yourself or colleagues following an event”. Those are things we want everyone in public health to be able to do.

Slide forty-nine.
As I said, we also developed some role-specific indicators and here are a couple of the ones that we developed for laboratory science and pathology. “Describe how to arrange for transport of a specimen”. “Correlate the type of specimen to the appropriate level of laboratory required for receipt and analysis”. “Describe procedures used to rapidly analyze suspected biological chemical agents” or “Identify precautions to be taken for autopsy when bioterrorism is suspected”. Those indicators represent and are linked to each one of the bioterrorism competencies.

Slide fifty.
As I said, we also developed some role-specific indicators and here are a couple of the ones that we developed for laboratory science and pathology. “Describe how to arrange for transport of a specimen”. “Correlate the type of specimen to the appropriate level of laboratory required for receipt and analysis”. “Describe procedures used to rapidly analyze suspected biological chemical agents” or “Identify precautions to be taken for autopsy when bioterrorism is suspected”. Those indicators represent and are linked to each one of the bioterrorism competencies.