In March 2020, the improbable suddenly became the unthinkable for Swedish Health Services, the largest nonprofit health care provider in the greater Seattle area, where two of us work as senior executives. An increasing number of Covid-19 patients from a local skilled nursing facility began to arrive at our Seattle hospitals in severe distress. We had been tracking the illness before the first U.S. Covid-19 patient was admitted on January 30 at a sister organization 30 miles north of our headquarters, and we knew how bad it might get — models projected that the region’s healthcare system could soon be overwhelmed.
We, along with the rest of the medical world, faced many unknowns in how best to care for the surge of patients we expected. But we were better prepared than we might otherwise have been because of an unrelated experience that had just played out across our health system: in January 2020, just weeks before the coronavirus outbreak began in the U.S., nearly 75% of Swedish’s caregivers, some 7,800 people, went on a three-day strike.
Swedish Health Services operates five acute care hospitals, two ambulatory care centers, and hundreds of clinics. Shutting down the entire hospital system during the strike was not an option. So as hospital administrators negotiated with our caregivers, we put systems in place to make sure that we could continue to safely serve our patients.
When the strike began, we activated our Hospital Incident Command System (HICS), the crisis response scaffolding that knit together each of our five campuses with the system as a whole. Throughout the strike, the thousands of physicians and other clinicians who continued to work displayed a widespread “preoccupation with failure,” a high-reliability behavior that minimizes the risk of patient or caregiver harm. During that time, we only noted two low-level safety events during the three-day strike, a nominal rate for our large system.
After the strike, we created an after-action report to analyze and capture our learnings. We synthesized the improvements in organizational practices that emerged from our response to the strike so we could incorporate them into daily operations and use them during future events. There were many such learnings, but two key practices transformed our response: communicating clearly and delegating authority. In late February, we presented the report to senior leaders and were prepared to leave it there.
And then Covid-19 arrived.
What felt like a major event — the strike — turned out to be a life-saving warm-up. As Covid-19 spread throughout Seattle, we again stood up our crisis response with the two major lessons we learned from the strike as pillars of our response. And, as we’ve continued our operations, we’ve uncovered a third pillar: focusing on people and sustainability. We believe these pillars can help leaders in all kinds of organization implement effective crisis management.
In times of uncertainty, anxiety and false rumors can run rampant, creating distractions and fatiguing caregivers.
Recognizing this, we created a source for facts: an intranet page accessible to all caregivers containing such things as the latest in Personal Protective Equipment (PPE) guidance and up-to-date clinical treatment protocols. Because senior leaders spend a significant amount of energy and attention keeping the page up to date, it works to both acknowledge challenges and allay fears.
In addition to having a source for caregivers seeking information, we send a rapid-fire stream of communication to staff through emails and craft messages that unit and practice leaders deliver. That may seem overwhelming, but in a crisis, communication is about repetition. Our heuristic is that we want everyone at Swedish Health to hear important information seven times in seven different ways. We don’t always get there, but the more information flow we have, the more likely we are to get important messages out to everyone.
Finally, we’re fostering dialogue. We have electronic discussion boards that leaders actively engage in. We also host frequent virtual town halls where caregivers can attend, ask questions in real time, and vote on them. When an important topic rises to the top (confusion around proper use of personal protective equipment, for example), that provides valuable feedback about where we need to augment or change our messaging.
Communication takes work, but we see that work as an investment. The intentionality we practiced during the strike helped caregivers across the organization coordinate better and know where to focus their energies. Communication — and the problem-solving that emerges in response to the concerns of our front-line workers — has become a major component of the work of our leadership team.
Our organization, like many, has a complex matrix structure. Each major location has leaders, as does each service line and the system as a whole. This organizational and operational complexity has historically slowed our ability to make and implement decisions.
That lack of organizational agility was something that we couldn’t afford during the strike, and something we can’t afford during this crisis. While our CEO, COO, Chief Clinical Officer, and Chief Nursing Officer all have major roles to play, we’re shifting as many decisions as possible to those closest to operational challenges.
We’ve used the RACI approach to make explicit who is “Responsible, Accountable, Consulted and Informed” on decisions. This has flattened the hierarchy and empowered caregiver teams to craft creative responses to the unique challenges that Covid-19 poses.
As an example, consider intravenous (IV) pumps, machines that deliver fluids and medicine to a patient’s bloodstream. Pumps require monitoring and frequent adjustment. In normal times, this isn’t an issue. A nurse will enter a patient’s room, wash his or her hands, and adjust the pump. But because Covid-19 patients are kept under isolation, caregivers now need to put on and take off protective gear before they enter or leave the room, which takes time and creates risk.
A group of clever nurses realized they could keep the IV pumps in the hallway outside of patients’ rooms, a highly non-standard practice, but one that allowed them to make adjustments without having to don protective gear.
Because the RACI approach creates natural paths for information to flow, we can capture and spread innovative practices. We’re now creating a standard approach for safely moving pumps and other machines outside of isolation areas. It’s a practice that has allowed us to accelerate our ability to learn and respond.
Focus on people and sustainability
We’re learning from the initial stages of our Covid-19 response and focusing on creating sustainable practices. Unlike the response to an earthquake or a plane crash, we need to be able to undertake months of response activity. Our approach consists of three strategies.
JOMO: Our organization was introduced several years ago to the notion of FOMO, or Fear of Missing Out. People don’t like to miss an important meeting or a key conversation, which limits their ability to truly rest and recover during their time off. During Covid-19, we’ve adopted a new stance: JOMO, or Joy of Missing Out. To that end, we’re taking steps to encourage key leaders to take time away and to model behaviors that make the organization more resilient in the long term. Amidst the chaos, we all need downtime to remain effective in the fight.
Express gratitude: Beyond creating downtime, we’re highlighting the actions, big and small, that people take to create a culture of capability and mutual support. We’ve taken practical steps — creating backup childcare programs as schools have closed, for example. But we’ve also focused on fostering a feeling of gratitude. Thank you notes, public praise, and pizza parties go a long way. One of our favorite forums has been a virtual “Gratitude Garden,” an internal website where caregivers share posts highlighting the people and things for which they are grateful. These symbolic gestures show our caregivers that we appreciate the contributions and sacrifices they are making.
Create feedback loops: The shorter the distance between a front-line caregiver’s concerns and swift organizational action, the more effectively the organization can learn — and the more caregivers will see their ideas and contributions translated into progress. In addition to the discussion boards, forums, and RACI approach, we have started thrice-weekly safety rounds, which include providers who have newfound capacity as a result of suspending elective procedures. These groups actively seek out problems and surface them so that they can be solved, which increases in capacity of our frontline caregivers.
We do not know how the Covid-19 outbreak will evolve and we do not have a perfect playbook for success. That said, the practices we have adopted can be used by all kinds of organizations to create the kind of resiliency that our current crisis requires.
There is a tendency in disasters to focus on concrete things, like the number of N95 masks and the logistics of staffing. Those are important, but our experience shows us that focusing on the human element matters just as much. Committing to clear communication, delegation, and sustainability can boost the ability for all kinds of organizations to serve their communities, customers, and employees in this time of radical uncertainty.