7-1-7 Digital Toolkit

Finding a place for 7-1-7 within a country or jurisdiction’s health system is largely about the leadership and core team coordinating adoption and use of 7-1-7.

1. Identify a government champion

An early priority in the adoption process is to find a 7-1-7 champion. Champions are government stakeholders who can lead change management, such as individuals with leadership responsibilities for surveillance, response and/or preparedness planning.

Although 7-1-7 adoption should not be burdensome, it may require workflow adjustments, new tools and additional responsibilities for some staff. Experience has shown that 7-1-7 adoption and use are more likely to result in improved epidemic preparedness with the buy-in of at least one government champion who can:

• advocate for 7-1-7;
• provide high-level oversight;
• initiate stakeholder mapping and engagement;
• convene stakeholders to review progress towards goals;
• elevate high-level findings and priorities emerging from routine use of 7-1-7 to leaders.

Once potential champions have been identified and introduced to the 7-1-7 target, it will be important to assess their interest, and if possible, secure a commitment to support adoption and use of the 7-1-7 target.

Government champions have included:

2. Identify the 7-1-7 coordination team

7-1-7 is most likely to be effective if a single team with a strong technical lead is clearly assigned responsibility to coordinate 7-1-7 adoption and use activities. It is helpful if the champion guides the identification of this 7-1-7 coordination team and has oversight over them.

Ideally, the 7-1-7 team should have responsibility for emergency preparedness and response, and possess both adequate staff and the convening power necessary to bring together a wide set of stakeholders for both 7-1-7 adoption and use activities. For this reason, it is especially helpful for this team to have a strong and well-respected technical leader.

During the adoption phase, this team will coordinate the key activities described in this section of the toolkit and monitor adoption progress. Once 7-1-7 is being used in the country or jurisdiction, they will coordinate the activities described in the Use 7-1-7 section of this toolkit.

Several countries/jurisdictions have found that it has worked well to situate 7-1-7 within Emergency Operations Centers or similar structures where detection, notification, and early response come together and both preparedness and response are prioritized. If 7-1-7 is situated elsewhere in the health system, the 7-1-7 team should proactively involve and build relationships with those in the other areas relevant to 7-1-7. For example, if 7-1-7 is situated on the surveillance side, then extra care may be needed to make sure that response stakeholders are integrated throughout the 7-1-7 lifecycle.

1. Mapping of stakeholders

1.1 7-1-7 functions

Early and ongoing support from a broad set of stakeholders is essential for 7-1-7 to be effective. Key 7-1-7 functions that need stakeholder support include overall coordination, capture of data, performance improvement, national planning, and communication and advocacy (see table). Which stakeholders are important for which functions depends on how roles and responsibilities are allocated within the country or jurisdiction. Some stakeholders may be relevant for only one of these functions, while others may be important for several.

1.2 Examples of relevant stakeholders

Creating a broad set of stakeholders for 7-1-7 means engaging with different sectors, levels of government (national and subnational), government departments and non-governmental partners. Specific stakeholders relevant to the above 7-1-7 functions will vary by country/jurisdiction, but should broadly include:

• Surveillance and response stakeholders across all key outbreak response pillars from the human health, animal and environmental sectors;
• Preparedness, planning or monitoring and evaluation teams that facilitate International Health Regulations (IHR) assessments and planning;
• Government stakeholders responsible for multi-sectoral coordination, policymakers, and parliamentarians;
• Financing stakeholders, including representatives from ministries of finance (for domestic financing), multilateral development banks and bilateral partners;
• Research and academic stakeholders such as universities and research institutes;
• Other relevant stakeholders, including advocacy groups, civil society and community representatives.

The above stakeholders may play different roles in supporting 7-1-7 functions as described in the table above.

1.3 Stakeholder mapping

Countries/jurisdictions should conduct a stakeholder mapping analysis to identify and document stakeholders needed for 7-1-7. In most cases, stakeholders will not be individuals but rather the relevant team, office, department, etc. This analysis should include which 7-1-7 functions (coordination, capture of data, performance improvement, national planning, and communication/advocacy) the stakeholder has influence over as well as whether the stakeholder is interested in 7-1-7. A country/jurisdiction can use its own tool for this mapping if preferred, or the available 7-1-7 Stakeholder Mapping Tool.

The 7-1-7 coordination team can then use this stakeholder mapping as the foundation for their stakeholder engagement plans.

It is helpful to regularly update this stakeholder mapping, even once the adoption phase is completed, as stakeholders and/or their roles/responsibilities relevant to 7-1-7 may change over time.

2. Mapping of existing systems

Integrating 7-1-7 into a country/jurisdiction’s existing workflows is crucial for efficiency, effectiveness, and sustainability of 7-1-7. The first step is for the 7-1-7 coordination team to map out existing systems, including platforms, tools, meetings, and used for:

• Detecting outbreaks
• Notifying stakeholders when an outbreak is detected
• Collecting information on early response actions
• Convening detection, notification, response stakeholders
• National planning, financing, advocacy

Based on country experience, potential sources of 7-1-7 data on detection, notification, and early response may include initial risk assessments; epidemiologic analyses; outbreak situation reports; rapid response team (RRT) reports; Emergency Operation Center (EOC) meeting notes; event management systems; and Intra-Action Review (IAR) and After Action Review (AAR) reports.

Examples of existing meetings with relevant stakeholders may include response pillar meetings during outbreaks, regular EOC meetings, One Health meetings, annual planning/finance meetings, and other health security meetings.

It is helpful to be as complete as possible in this mapping exercise, and to include all relevant systems (e.g. both paper-based and electronic tools if both are used). A country/jurisdiction can use its own tool or the Existing Systems Mapping tool. The 7-1-7 team can then use this landscape mapping as the foundation for their workflow integration plans.

Early and consistent engagement of a broad set of stakeholders is one of the most important parts of 7-1-7 adoption and can substantially impact the effectiveness of 7-1-7. Stakeholders should be intentionally engaged based on the stakeholder mapping analysis. The more thorough the stakeholder mapping is, the more efficiently and effectively stakeholder engagement can be planned. In particular, those with influence over at least one 7-1-7 function (see previous section on stakeholder mapping) and high interest in 7-1-7 may be able to help galvanize further support amongst stakeholders. Those with influence over 7-1-7 functions but lack of interest in 7-1-7 will require additional targeted engagement.

Stakeholder engagement can be done in various ways:

• One-on-one meetings can be used to introduce the target, tailor messaging to the stakeholder’s interests, and address any questions or concerns about 7-1-7. These meetings can then also lay the groundwork for subsequent stakeholder convenings and adoption activities.
• Small technical meetings can be used to get into the details of adopting and using 7-1-7, especially with the stakeholders that will play important roles in regular use.
• Larger stakeholder convenings can be used to bring together a diverse range of stakeholders, from different government departments to non-governmental partners. This can be a powerful way to get different entities to have a shared understanding of what 7-1-7 is, how it can be rolled out and used in their country/jurisdiction, and what the roles and responsibilities are across the stakeholders.

When engaging stakeholders, it can be helpful to use targeted examples to explain why 7-1-7 is relevant for their work. For instance, examples of how 7-1-7 can be used to improve performance for nosocomial outbreaks may be helpful when speaking with a stakeholder from hospital administration, while highlighting how 7-1-7 can help build evidence for longer-term investments in lab capacity to prevent delays may be useful when speaking with lab stakeholders.

It is helpful to plan how and how often the stakeholder will be engaged based on their role in 7-1-7. Even the more distant stakeholders should be kept regularly updated on 7-1-7 findings so that they can quickly come on board when they are needed.

To most efficiently, effectively, and sustainably use the 7-1-7 target for performance improvement, 7-1-7 needs to be integrated into routine systems and workflows within a country or jurisdiction.

A few key areas that should be considered when integrating 7-1-7 into workflows include:

• Data collection
• Data verification and consolidation
• Stakeholder meetings
• Progress tracking
• Synthesis of findings
• Informing other assessments and tools
• National planning, funding and advocacy

Tip: Use your completed mapping of existing systems as a guide when determining exactly how and where to integrate 7-1-7.

When integrating 7-1-7 into each of the workflow integration areas, countries/jurisdictions should consider a few key process questions:

• What needs to be done?
• Who is the responsible officer for it?
• What support do they need to accomplish this?

For example, for data collection, it is crucial to think through how the various data for 7-1-7 are collected and brought together. Who is coordinating this work, and what support, resources, and tools do they need to accomplish this work? For data verification and consolidation, who will be taking the information across outbreaks and putting it into one place? What process will be used for data verification? Will they use the data consolidation spreadsheet tool or something else already in place? For stakeholder meetings, who will be tasked with getting Early Action Reviews and 7-1-7 onto the agenda of relevant meetings? Will they need the backing of the champion or other high-level stakeholders? And so on.

Then across the workflow integration areas, it is useful to think through:

• How and where do the processes overlap?
• What handoff is needed between steps?

Asking and answering the questions above within and across the different workflow integration areas can help the 7-1-7 coordination team avoid gaps in their 7-1-7 workflow plans.

In the following sections, we have included tips that countries have found useful for the key workflow integration areas.

1. Data collection

Integrating 7-1-7 data collection into existing outbreak data collection first involves determining which system(s) are most appropriate for 7-1-7 data, who is best placed to collect the data, whether definitions of existing variables are aligned with 7-1-7 definitions, and which variables may need to be added for a complete 7-1-7 analysis.

The 7-1-7 Assessment Tool (Word / PDF) includes the key data needed for a 7-1-7 analysis. The fields from this tool can be incorporated into existing templates for risk assessments, rapid response team reports, or event management systems. If no suitable data collection form already exists, the 7-1-7 Assessment Tool can be used as is. Note that this 7-1-7 data tool includes the timeliness metrics and narratives, as well as fields for identified bottlenecks/enablers across the three 7-1-7 intervals and proposed corrective actions to address the bottlenecks.

It is most effective for 7-1-7 data – from timeliness metrics to bottlenecks/enablers and proposed corrective actions – to be collected and recorded during an outbreak by those best positioned to do so, namely public health professionals directly involved in the initial investigation and response. Several countries have found rapid response teams to be very useful for real-time 7-1-7 data collection as those teams are often on the ground investigating the outbreak and coordinating at least parts of the response. Some have integrated 7-1-7 variables into their existing rapid response team templates.

Of the core 7-1-7 data, countries have found that the emergence, detection, and notification milestone dates are often already being collected in their existing systems, though definitions should be compared and aligned. The milestone dates for the early response actions, the milestone date narrative fields, and the text fields for bottlenecks, enablers, and proposed actions are less commonly already included and thus typically need to be added. These are critical for 7-1-7 to be effective for performance improvement. See the 7-1-7 Assessment Tool (Word / PDF) or the Data Consolidation Spreadsheet for examples of key variables to include for 7-1-7.

2. Data verification and consolidation

The 7-1-7 coordination team is typically tasked with ensuring data quality and consolidating 7-1-7 data across outbreaks into a common database.

Ideally, data verification processes already used in a country/jurisdiction to ensure quality (e.g. completeness, accuracy, etc.) can be adapted to include verification of 7-1-7 data. In some places, data verification will be done by the 7-1-7 coordination team. In others, verification may be done at a lower level, but the 7-1-7 coordination team may conduct final checks. Since milestone date narratives and bottlenecks/enablers are crucial for 7-1-7 analyses but may be new data fields, monitoring these fields for completeness and quality may be especially important.

A platform to consolidate 7-1-7 data across outbreaks is needed to facilitate performance analysis across events. Ideally, these data should be captured in event or project management systems used to track other activities and collect other surveillance and/or response data. If no system already exists, the 7-1-7 Data Consolidation Spreadsheet is available. This spreadsheet is a Microsoft Excel database containing four different tabs:

1. Input timeliness data: this tab allows recording of timeliness metrics, bottlenecks and enablers for each outbreak event reviewed against the 7-1-7 target;
2. Assess 7-1-7 results: this tab automatically calculates the three 7-1-7 timeliness metrics for each outbreak event and generates tables and graphs that summarize performance across all events entered in the spreadsheet;
3. Track corrective actions: this tab allows countries to record all corrective actions identified as well as the responsible authority and implementation status;
4. Bottleneck analysis: this tab can be used to consolidate the identified bottlenecks identified and categorize them, facilitating identification of the most common bottleneck types. This analysis has been found useful in helping countries/jurisdictions prioritize longer-term actions for funding.

It is useful to develop a workflow where outbreak data is added to the data consolidation database soon after the outbreak occurs, which allows for the team to obtain corrected information, if necessary, from ground-level staff while the event is still current or recent.

The information in this database should be updated if any new or updated data becomes available.

3. Presentation of 7-1-7 findings to stakeholders

An essential component of 7-1-7 implementation is deciding on an approach for convening key stakeholders to review performance against the 7-1-7 target and discuss actions for future improvement. The 7-1-7 coordination team should select the best fitting meetings to review 7-1-7 findings based on participants, frequency, and meeting purpose. The most effective way to integrate 7-1-7 is to add it as an agenda item to regular meetings. Different approaches can be used to convene stakeholders, as described below:

In addition, the coordination team should determine how and when 7-1-7 findings can be added to other meetings relevant to health security and planning, such as Intra Action and After Action Review meetings, other health security and/or assessment meetings, and meetings where attendance by a member of the 7-1-7 technical team for awareness and engagement may be useful (e.g. One Health coordination meetings).

During the review meetings, 7-1-7 findings for individual disease outbreak events should be presented to stakeholders, with information shared about the outbreak event, the timeliness metrics, bottlenecks/enablers, and proposed actions. The 7-1-7 Event Review Slide template is available for this, or a designated alternative can be developed.

4. Progress tracking

To ensure performance improvement is achieved, the progress of immediate- and longer-term actions selected through the 7-1-7 process needs to be monitored, ideally using a tracker. For example, the 7-1-7 Data Consolidation Spreadsheet includes a tab for tracking actions. As described in the previous section, this progress should ideally be regularly reviewed during a designated stakeholder meeting. Thus, the relevant workflows, tools, and meetings should be identified to enable this progress tracking.

5. Synthesis of findings

7-1-7 data across public health events should be routinely synthesized to assess performance against the 7-1-7 target. A brief report summarizing this analysis would ideally be disseminated regularly to stakeholders and policy makers. A 7-1-7 Synthesis Report Template is available for this.

The ideal frequency of Synthesis Report dissemination will vary based on the number of public health events, available human resources, and the periodicity of planning activities and funding opportunities that can support completion of corrective actions. At a minimum, a report should be developed and disseminated shortly before each planning cycle. Planning for how and when this type of synthesis and reporting should be done is an important part of 7-1-7 workflow integration.

6. Inform other assessments / tools

7-1-7 findings and recommendations can be useful alongside other tools and assessments for health security. It is useful to identify which other tools/assessments are used and when, and how 7-1-7 findings may be systematically added to the relevant meetings/discussions for these. For example, 7-1-7 bottlenecks and enablers have been mapped to JEE indicators, and guidance is available for how 7-1-7 findings map onto After Action Review discussions.

7. National planning, funding and advocacy

The 7-1-7 target helps identify bottlenecks and corrective actions that can feed into the development of operational (annual) or strategic (multi-year) planning cycles, including National Action Plans for Health Security (NAPHS). Integrating the 7-1-7 target into the NAPHS process and focusing on areas identified for performance improvement help define a more feasible number of priorities per IHR technical area for financing and implementation.

Integrating 7-1-7 into relevant workflows for national planning includes ensuring that:

1. Critical stakeholders are involved in event reviews, so that they understand the 7-1-7 target and rationale for the identification of bottlenecks and corresponding actions;
2. Corrective actions are assigned to relevant IHR technical areas since, commonly, technical area priorities are defined before consolidation into national plans;
3. The 7-1-7 Synthesis Report is disseminated to stakeholders before national planning meetings
4. 7-1-7 findings are included in relevant stakeholder meetings for planning and funding (see section 3 on stakeholder meetings above).

Those who will be supporting 7-1-7 functions, whether data collection on the ground or high-level national planning, need to be trained on what the 7-1-7 target is and how to use it. The level of training will depend on their role. For example, most high-level stakeholders will need to be made broadly aware of how to use 7-1-7, while technical staff will require more in-depth training on specific tools and workflows. For this reason, it is important to train technical staff once most of the workflow integration is completed. Some of the technical staff will also need to be trained on how to train others (i.e., training of trainers). This is important so that staff can be trained when there is turnover, but also for when there is expansion into other levels such as to subnational teams.

One recommendation based on country experiences is to consider adding 7-1-7 training to existing training opportunities on related topics. This can help reduce travel and other costs while further linking 7-1-7 to existing activities.

The 7-1-7 Alliance has a variety of training packages for countries/jurisdictions and institutional partners. These include an orientation package, an implementer’s package, and training-of-trainers materials. The packages are built from adaptable modules and are highly interactive, with short presentations, hands-on activities, and discussions.

Learn more about training packages.

Applying the 7-1-7 target to a few outbreaks during the adoption phase is helpful for several reasons. It helps test workflow integration and allows for iteration as needed. For example, some countries/jurisdictions have discovered gaps in data collection or information flow after piloting 7-1-7. It also provides excellent hands-on training, especially for the 7-1-7 coordination team that will lead many of the 7-1-7-related activities.

Piloting the 7-1-7 target during adoption also provides an additional approach to introducing stakeholders to its benefits. By presenting findings from the pilot to stakeholders, teams have been able to quickly show the power and potential of 7-1-7 to leadership, which has helped to both galvanize support for further use and build momentum to address initial corrective actions.

7-1-7 can be piloted both in real-time through an Early Action Review or retrospectively. When piloting 7-1-7, the coordination team applies the target to recent or current outbreak events and presents their findings to stakeholders, thereby directly demonstrating how the approach can be used to assess system performance and identify required corrective actions. The outcomes of these stakeholder engagements may then be used by the champion and 7-1-7 team to revise their stakeholder mapping to reflect perceived levels of interest, conduct additional stakeholder engagement, inform consensus building and refine roles and responsibilities.

Several countries/jurisdictions that have adopted 7-1-7 have piloted it on 5-10 recent outbreaks. Some have started with retrospective reviews for the first few and then shifted to real-time use of the target.  This has helped them move quickly into real-time application of 7-1-7 for new outbreaks soon after the adoption phase.

More details on using 7-1-7 in real-time through Early Action Reviews or retrospectively can be found here in the Use 7-1-7 section of this toolkit.

Ideally, 7-1-7 data are captured in real-time or near real-time for each disease outbreak event as part of Early Action Reviews. This maximizes the benefit of using early 7-1-7 findings to inform the ongoing response. However, the capture of real-time data may not always be possible, and it may be necessary to retrospectively collect data after the event response has concluded.

Retrospective data collection can provide value, but can also be time intensive; locating historical data can be challenging, especially for all response actions; and bottlenecks and their corrective actions could potentially be outdated. For these reasons, we recommend using the 7-1-7 target retrospectively only for recent outbreaks where relatively complete 7-1-7 information is feasible to obtain.

Learn more about conducting retrospective reviews.

1.1 Collect 7-1-7 data for a disease outbreak event

During the adoption phase, the country or jurisdiction should have selected a 7-1-7 data collection tool by integrating the fields from the 7-1-7 Assessment Tool (Word / PDF) into existing systems or by using this Assessment Tool directly. Ground-level staff designated to use the data collection tool should also have been trained on its use.

This section provides detailed definitions of the milestone dates in the Assessment Tool, as well as instructions and examples of how to complete the Assessment Tool.

One of the earliest steps of using the 7-1-7 target is to determine the milestone dates and explain why those dates were selected. This information should be recorded in the designated 7-1-7 data tool. In the 7-1-7 Assessment Tool, these milestone dates and narrative fields are included in Step 1.

Definitions of the key milestone dates are included here.

Collecting the narratives alongside the milestone dates is essential to drive the performance improvement cycle forward because they are crucial for identifying useful bottlenecks and enablers.

Date of emergence

The date of emergence varies by how the disease type is classified in the country/jurisdiction:

• Endemic diseases: the date when a predetermined increase in case incidence over baseline rates occurred (e.g., IDSR alert thresholds).
• Non-endemic diseases: the date when the index case or first epidemiologically-linked case experienced symptoms.
• Other health threats: the date the threat first met criteria as a reportable event, based on existing reporting standards.

Note that the date of emergence is often unknown when a health event is first detected. Epidemiologic information gathered during the outbreak investigation should be used to determine the date, based on whatever information is available. The date may then change as more is learned and earlier cases are identified.

For examples of date of emergence for different event types, see the 7-1-7 Milestone Dates Reference Guide.

Date of detection

The date of detection is the date the public health event was first recorded by any source or in any system.

This may happen at the community or health facility level, through a lab, through the surveillance system, or elsewhere.

For indicator-based surveillance, the date of detection would be when case or incidence data were recorded (e.g., in a log book, case investigation form, laboratory requisition form). For event-based surveillance (EBS), the date of detection would be when the event information was first recorded (e.g., detected by a media scanning system, recorded by a community health worker, recorded by a hotline operator).

Note that detection for the 7-1-7 target is not based on lab confirmation; rather, lab confirmation is an early response action. The date of detection includes suspicion of the event (e.g. entry in a log book, laboratory requisition form, record by community health worker).

For examples of date of detection for different detection types, see the 7-1-7 Milestone Dates Reference Guide.

Date of notification

The date of notification is the date the event is first reported to a public health authority responsible for action.

Oftentimes, the most immediate public health jurisdiction (city, district) will be the public health authority responsible for action and the first public health authority to be notified. Notification of responsible health authorities could be from a clinical setting to a district surveillance officer. In the case of event-based surveillance or when outbreaks are detected centrally, notification to a responsible authority might be from the central level to the subnational level.

For countries that require notification of reportable events to multiple levels of government that are tasked with different actions, the earliest date that any of these public health authorities were notified would be the date of notification. In some guidance, this step may be referred to as ‘reporting’ to a public health authority or district health team.

This step should not be confused with notification to WHO as defined by the International Health Regulations (2005), which is typically only done after local or national public health authorities have become aware of an event.

For examples of date of notification for different scenarios, see the 7-1-7 Milestone Dates Reference Guide.

Date of early response action completion

The date of early response action completion is the latest date on which any of these seven 7-1-7 early response actions are completed:

1. Initiate investigation or deploy investigation/response team;
2. Conduct epidemiologic analysis of burden, severity and risk factors, and perform initial risk assessment;
3. Obtain laboratory confirmation of the outbreak etiology;
4. Initiate appropriate case management and infection prevention and control (IPC) measures in health facilities;
5. Initiate appropriate public health countermeasures in affected communities;
6. Initiate appropriate risk communication or community engagement activities;
7. Establish a coordination mechanism.

As shown in the Assessment Tool, the dates for each of these separate early response actions should be recorded, and the date of early response action completion recorded as the last of these dates.

All seven early response actions may not be applicable for some public health events. For example, an event that is determined to be low risk may not require public health countermeasures or risk communication. For events where some early response actions are not applicable, the latest date among the applicable actions should be used as the date of early response completion. “N/A” should be recorded in the data collection platform for these in order to differentiate them from early response actions with missing data.

For examples of dates for each of these 7-1-7 early response actions, see the 7-1-7 Milestone Dates Reference Guide.

1.2 Calculate the three timeliness metrics and determine if the 7-1-7 target was met

The value of determining the dates of emergence, detection, notification, and early response action completion is to calculate intervals between these key events, referred to as timeliness metrics. Public health officials and other stakeholders can use these timeliness metrics to identify whether the processes for detection, notification, and early response were timely for an outbreak event, and whether the event met the 7-1-7 target.

Calculation of the 7-1-7 timeliness metrics

Time to detect = Date of detection – Date of emergence [Target: 7 days]

Time to notify = Date of notification – Date of detection [Target: 1 day]

Time to complete early response actions = Date of early response action completion – Date of notification [Target: 7 days]

The calculated 7-1-7 metrics should be recorded in the designated 7-1-7 data collection tool. In the 7-1-7 Assessment Tool, these are recorded in Step 3.

While the 7-1-7 timeliness metrics provide a quantitative measure of the performance of systems for surveillance, notification, and early response, on their own they do not provide information about why systems did or did not perform well. Documenting the bottlenecks and enablers of system performance is critical for identifying best practices and the specific systems or processes that require strengthening.

• Bottlenecks are barriers, challenges, or other obstacles that delay detection, notification, or early response activities.

• Enablers are processes, systems, relationships, or other factors that facilitate prompt detection, notification, or early response activities.

Bottlenecks and enablers may be technical, operational, or political.

Note: while much of the discussion for 7-1-7 is focused on identifying bottlenecks for corrective action, the value of enablers should not be underestimated. Enablers show what is working and why, and can help inform discussions on corrective actions for bottlenecks.

2.1 Performing a good 7-1-7 bottleneck/enabler analysis

A good bottleneck/enabler analysis is not difficult to do, but requires having both the right information and knowing how to get to an actionable root cause.  Without a good bottleneck/enabler analysis, it is difficult to identify the right corrective actions and the performance improvement cycle breaks down.

Individuals/teams directly involved in the initial investigation and response of an outbreak should discuss and identify bottlenecks, enablers and their root causes based on a review of the 7-1-7 timeliness data, including the narrative fields. This would ideally be done during a participatory session.

The identified bottlenecks and enablers should:

• Be specific: specific bottlenecks/enablers are needed to identify useful corrective actions. Vague bottlenecks and enablers can be nearly impossible to act on or learn from.
• Be actionable: bottlenecks should be identified for which immediate or longer-term actions can be taken.
• Identify root causes: actions should address actionable root causes of delays rather than superficial fixes.
• Focus on the system-level: 7-1-7 is not about blaming or crediting individuals, but rather what is working or not working at the system-level.

2.2 Recording the bottlenecks and enablers

The identified bottlenecks and enablers should be recorded in the tool designated for 7-1-7 data collection. In the 7-1-7 Assessment Tool (Word / PDF), bottlenecks and enablers are recorded in Step 3.

Determining corrective actions is a crucial next step after 7-1-7 bottlenecks and enablers have been identified. Ideally, the initial investigation and response team would propose actions based on the bottlenecks they identified. However, in most settings, these teams may not have the authority or resources to implement the actions, or the actions may reach beyond their work or even sector. Thus, it is recommended that the proposed actions be presented to a broader group of stakeholders to obtain the necessary buy-in and financial resources. Once the stakeholders finalize the list of corrective actions, implementation of the immediate actions should begin as soon as possible. For outbreaks that are ongoing, these actions should inform the incident action plan.

This section provides details of this process, from how to propose clear corrective actions to finalizing and implementing the actions with stakeholders.

3.1 Propose immediate and longer-term actions

Those who identified the bottlenecks and enablers for an outbreak (e.g. initial investigation and response team) are best positioned to propose corrective actions that can resolve the bottlenecks.

Two categories of actions may be surfaced through 7-1-7 use:

• Immediate actions: can be taken immediately with existing funds, staff, and programs.
• Longer-term actions: require additional resources or staffing and may require involvement from different government levels or external partners. These actions should be considered in future national planning (e.g., included in National Actions Plans for Health Security [NAPHS], budgeting, or funding requests to government or external donors).

Actions proposed should be made as clear, specific and realistic as possible, and should be directly linked to a bottleneck. Even if excellent 7-1-7 data are collected and a great bottleneck analysis is performed, performance improvement will still come to a halt if the proposed actions do not address the actual delays, or are too vague or infeasible.

The proposed corrective actions should be SMART:

• Specific
• Measurable
• Achievable
• Relevant
• Time-bound

The proposed immediate and longer-term actions should be recorded in the designated 7-1-7 data collection tool. In the 7-1-7 Assessment Tool (Word / PDF), this is done in Step 4.

3.2 Engage 7-1-7 stakeholders routinely for rapid performance improvement

Routinely engaging a broader group of stakeholders is critical to enable the political buy-in to prioritize and resolve bottlenecks and improve detection, notification, and early response systems. This section describes how 7-1-7 data can be shared with stakeholders to support implementation of corrective actions that lead to performance improvement.

Present 7-1-7 results to stakeholders

Key stakeholder meetings where 7-1-7 findings are shared and reviewed are identified during the adoption phase. During the regular review meetings, 7-1-7 findings for individual disease outbreak events should be presented.

This presentation should contain:

• Brief narrative description of the outbreak event;
• Timeline of key milestones (including the four 7-1-7 timeliness milestones) and calculation of the three timeliness metrics;
• Descriptions of bottlenecks and enablers to detection, notification, and early response;
• Proposed corrective actions to address bottlenecks and improve preparedness for future threats.

We recommend that this presentation take approximately 10-minutes, with the purpose of raising stakeholder awareness of the 7-1-7 performance and bottlenecks/enablers and facilitating a discussion of appropriate immediate and longer-term actions to improve ongoing and future responses.

Often, the head of the 7-1-7 coordination team or another member of the team will lead this presentation. The 7-1-7 Event Review Slide template are used for this presentation.

Agree on immediate and longer-term actions

The output from this stakeholder review of 7-1-7 performance is a consensus list of corrective actions. The final list of corrective actions should be written using the SMART criteria (specific, measurable, attainable, relevant, and time-bound) described in the previous section.

Actions agreed to be immediate should be designated to a responsible authority provided with the necessary resources to complete them, and start and end dates should be determined. Longer-term actions should be documented for consideration during future planning activities and designated to a responsible authority for follow-through.

All actions and their associated information (e.g. responsible authority, start/end dates, opportunities for planning/funding) should be recorded in the tracker designated during the adoption phase. If the 7-1-7 Data Consolidation Spreadsheet is used, actions can be recorded in the ‘track actions’ tab.

4.1 Consolidate 7-1-7 data across outbreaks in a single database

After each outbreak event, information originally captured on the 7-1-7 data collection tool (i.e. the 7-1-7 Assessment Tool (Word / PDF) or a designated alternative) should be stored in the data consolidation database (i.e. the 7-1-7 Data Consolidation Spreadsheet or a designated alternative). In some cases, the data may already be automatically consolidated in an electronic system. If not, the data will need to be entered by the 7-1-7 coordination team.

The data that should be entered for each disease outbreak into the data consolidation database include:

• Key outbreak details (e.g. event name, location)
• Timeliness information: the milestone dates (including for each of the 7 early response actions), associated narratives, and the calculated timeliness metrics
• Bottlenecks and enablers
• Corrective actions and associated information (e.g. responsible authority, start/end dates)

Countries/jurisdictions should actively update the consolidated database, so that as new outbreaks occur, their 7-1-7 data can be quickly entered and checked in this central database.

4.2 Verify the data

Confirm that all data have been entered: Review the list of outbreak events that occurred during the period of interest and confirm that all event data have been entered in the appropriate database(s).

Clean the data: Review the data entered in the databases and check for any missing fields or incomplete information. Obtain additional or corrected information from those knowledgeable about the outbreak, such as subnational staff, rapid response teams, or others who know this information. The sooner verification is done, the easier it is to get corrected information.

In addition, check the calculated values for each of the three timeliness metrics and confirm that any outliers (e.g., negative numbers, large numbers) are correct. For countries using the 7-1-7 Data Consolidation Spreadsheet, this can be done by reviewing outputs on the “Assess 7-1-7 Results” sheet where the timeliness metrics are automatically calculated, and blanks and negative values highlighted.

4.3 Track and discuss progress of actions across outbreaks

Tracking the progress of corrective actions is crucial for effective performance improvement through 7-1-7, and facilitates accountability.

Tracking action progress involves the 7-1-7 coordination team keeping track of the action, which bottleneck it is meant to address, the responsible authorities, the proposed start and end dates of the action, and the implementation status of the action. This can all be done through the ‘track action’ tab of the 7-1-7 Data Consolidation Spreadsheet. If another tool is designated as the action tracker instead, it is important that these data are kept updated and, ideally, in the same database as the overall 7-1-7 data in the consolidated database (i.e. timeliness data and bottlenecks/enablers).

The implementation status of the actions should be regularly assessed and updated in the action tracker. For example, the ‘track action’ tab in the 7-1-7 Data Consolidation Spreadsheet includes an implementation status field with dropdown options of ‘waiting for start date’, ‘in progress’, ‘stuck’, ‘completed’, and ‘deferred (longer-term action).

Regularly presenting the progress on actions to relevant stakeholders means solutions can be discussed for delayed or stuck actions. Ideally this progress reporting can be done in the same meetings 7-1-7 data from new outbreaks are being discussed. This will increase accountability and help ensure that actions are completed in a timely manner and lead to performance improvement.

Some actions initially selected for immediate implementation may remain incomplete and ultimately need to be considered alongside other longer-term actions in future planning activities.

By evaluating the real-world performance of detection, notification, and early response systems, the 7-1-7 target helps generate information that can be used to inform financing and planning decisions. Routine synthesis of 7-1-7 data can help demonstrate progress and highlight persistent bottlenecks. Routine reports (e.g. quarterly, annually) can also provide evidence of performance improvement to stakeholders and feedback on the value of their investments.

This section outlines how consolidated 7-1-7 data can be synthesized, and how the synthesized results can be used to monitor 7-1-7 performance, inform stakeholders of progress, and support prioritization for national planning and financing.

5.1 Synthesize 7-1-7 data

Once the 7-1-7 target has been used for multiple outbreak events, this information can be used to analyze patterns and trends in 7-1-7 performance and bottlenecks across key variables of interest.

The core analyses to synthesis 7-1-7 findings around timeliness, bottlenecks/enablers, and actions are simple to conduct and are described in this section.

Timeliness metrics

Calculating the proportion of events that meet each component of the 7-1-7 target provides stakeholders with a high-level understanding of systems performance. It can help identify whether systems used for detection, notification, or early response can routinely complete timely and appropriate actions.

Core calculations to synthesize timeliness results are:

• # of outbreaks reviewed
• The proportion of events that meet the detection target
• The proportion of events that meet the notification target
• The proportion of events that meet the early response action completion target
• The proportion of events that met all three components of the 7-1-7 target;

Optionally, the proportion of events where the early response action was completed within 7 days can also be assessed for each of the seven early response actions. This helps provide nuanced information on whether some of the early response actions tend to cause more delays than others.

It is recommended that countries present the proportion of events meeting each component of the 7-1-7 target, rather than presenting medians. Median results may be misinterpreted by stakeholders as success when they in fact indicate that only half the events have met the target and critical system strengthening needs may still exist.

Bottlenecks and enablers

Core analyses to synthesize bottlenecks are:

• the most common/frequent bottlenecks
• the most common/frequent enablers

To facilitate prioritization, countries have found it useful to categorize bottlenecks, the most common categories suggesting the areas most likely in greatest need of actions and investment. A bottleneck classification list of 8 bottleneck themes, each further classified into key bottleneck categories, has been developed to support this process.

The ‘Analyze BNs’ sheet of the Data Consolidation Spreadsheet can be used to list bottlenecks and assign them to these categories. A table is then automatically generated showing the frequency of each category of bottleneck.

Immediate and longer-term actions

Core calculations to synthesize progress on actions are:

• Proportion of immediate actions completed
• Proportion of longer-term actions included in national planning documents (e.g. NAPHS)
• Proportion of longer-term actions completed

Additional variables for disaggregation

The core analyses described above on timeliness metrics, bottlenecks/enablers, and actions can be further disaggregated by key variables of interest. Caution should be used when deciding to conduct these analyses and in interpreting any results if small sample sizes occur for some disaggregation categories.

Variables of interest may include:

• Outbreak event type (e.g. respiratory, food-borne, viral hemorrhagic, etc). The specific categories should be decided by the 7-1-7 coordination team based on country context, with input from stakeholders as needed.
• Geographic area (e.g. region, province, district)
• Time: countries/jurisdictions that have used the 7-1-7 target over multiple reporting periods can evaluate timeliness metrics and performance over time. This can demonstrate progress (or lack thereof) to stakeholders.

Examples of variables of interest when reviewing bottleneck categories include:

• Level(s) of the health system where they occur (e.g., community, health facility, intermediate, or national level)
• 7-1-7 interval (e.g. detection, notification, early response)

Countries have found disaggregation by bottleneck category in this way can help inform where and how corrective actions are implemented to efficiently address common bottlenecks.

5.2 Routinely disseminate synthesized 7-1-7 findings to stakeholders

Synthesized 7-1-7 data across outbreak events should be routinely disseminated to a broad set of stakeholders and policy makers both for awareness and to drive forward performance improvement. Countries have found that a synthesis report is useful for such dissemination.

Objectives of this synthesis report include:

• Providing a high-level summary of the most important learnings from 7-1-7 use. These can be prioritized based on observed frequency of bottlenecks or anticipated system-wide impacts of interventions;
• Informing stakeholders of performance against the 7-1-7 target;
• Reviewing progress in completing immediate actions;
• Consolidating and highlighting longer-term actions to inform planning and financing, including integration into NAPHS or similar plans and alignment with funder priorities.

The 7-1-7 Synthesis Report template is available to use, or a designated alternative can be used. The ideal frequency of Synthesis Report dissemination will vary based on the number of outbreak events, available human resources, and the periodicity of planning activities and funding opportunities that can support completion of corrective actions. At a minimum, a report should be developed and disseminated shortly before each planning cycle.

5.3 Use 7-1-7 findings to prioritize activities for planning and financing

The 7-1-7 target helps identify bottlenecks and corrective actions that can feed into the development of operational (annual) or strategic (multi-year) planning cycles, including National Action Plans for Health Security (NAPHS). Integrating the 7-1-7 target into the NAPHS process, and focusing on areas identified for performance improvement, helps define a more feasible number of priorities per IHR technical area for financing and implementation. This approach —such as the State Parties Self-Assessment Annual Reporting (SPAR) and Joint External Evaluation (JEE) tools.

To facilitate the process of using 7-1-7 findings to help prioritize planning and financing activities, 7-1-7 corrective actions should be assigned to relevant IHR technical areas since, commonly, technical area priorities are defined before consolidation into national plans. In determining what to prioritize during an implementation period, 7-1-7 bottlenecks and actions can be incorporated as additional items or included as a result of reprioritization of relevant actions from the previous cycle.

7-1-7 findings can also be used to make the case to donors for funding longer-term actions.

The 7-1-7 Synthesis Report is designed to include information needed by stakeholders to support these steps and should be disseminated to stakeholders before national planning and other relevant meetings.