Adopt a crisis command culture during the coronavirus pandemic

By Christopher Cheney, HealthLeaders Media

At health systems and hospitals, adopting a crisis command culture has operational benefits during the coronavirus pandemic, a pair of experts say.

Across the country, health systems and hospitals have established incident command centers to manage the challenges of the pandemic. At Northwell Health last spring, incident command leadership was a key element in the health system’s response to the hottest hot spot in the first coronavirus patient surge.

The crucial aspect of crisis command culture is the ability to make good decisions quickly, says Stephanie Mercado, CEO and executive director of the National Association for Healthcare Quality in Chicago.

“Decisions in healthcare—especially those related to any type of policy or procedure—have often been decided by committee and consensus with long timelines. Before the pandemic, it could take months or years to change a policy. The pandemic has shown everyone in healthcare that they need to be more flexible. They need to be more agile. Good decisions can be made on a much shorter timeline than what was previously thought,” she says.

With a crisis command culture, it is possible to make good decisions on policies without putting them through a lengthy process of review and editing by multiple committees, says Nidia Williams, PhD, vice president of quality and safety at Providence, Rhode Island–based Lifespan. The health system operates several hospitals including an academic medical center and has about 17,000 employees.

“We cannot give people editing power after most people who are the key stakeholders have already said a policy is ready to go. We must streamline the decision-making process for policies. Now, we have policies that would have taken weeks if not months to approve that can be approved in hours. It is possible to approve policies in hours and still do it well. We can get more done faster—that is the lesson from crisis command culture,” Williams says.

Rapid cycle improvement is an important aspect of crisis command culture decision-making, Mercado says. “We must make a decision at a point in time, but it does not have to be something decided upon forever more. Rapid cycle improvement tells us that we can go back and reevaluate decisions that were made when we have new information or circumstantial change, so we can improve decisions.”

Trust and attitude are indispensable ingredients in rapid decision-making, Williams says. “A lot of it comes from trust that you have the right people playing the right roles in making decisions. It is also attitudinal. We tell ourselves we do not have the luxury of time. We do have the luxury of having everyone’s talent. … We have learned that we can do the best that we can, and it can be enough so that you are not waiting for perfect before you do what you have to do.”

Capitalizing on talent

In addition to rapid decision-making, a pivotal part of crisis command culture is elevating talent over hierarchy in filling key roles in incident command centers, Williams says. “The secret sauce is having the right people with the right training.”

At Lifespan and other health systems, quality and safety staff are well-suited for leadership positions in incident command centers, she says.

“I am the patient safety officer at the health system. I started out as the incident commander and planning section chief at the health system–level incident command center in March. My direct superior, who is the executive vice president of quality and safety, is the person who co-led the opening of our alternative hospital site at the Rhode Island Convention Center. Now, the planning section chief at our academic medical center—Rhode Island Hospital—is my quality and safety director. We are playing important roles,” Williams says.

Quality and patient safety staff have the appropriate training and experience to succeed in incident command centers, she says. “We have to document and archive our decisions over time. In addition, some of our analysts for quality and safety are most uniquely suited for not only documentation and archiving but also the analysis and reporting of our COVID-19 data both internally and externally.”

The skill sets of quality and patient safety staff are an excellent fit in incident command centers, Mercado says. “The skills and competencies that those individuals have are very well-suited to provide systems, processes, and structure and order to an otherwise chaotic situation. Quality professionals do this kind of work all day, every day in their ordinary jobs; but when it comes to the pandemic, they are contributing on an order of magnitude.”

Assigning quality and patient safety staff to top incident command center roles is an example of elevating skill sets over hierarchy in a crisis command culture, Williams says.

“Most of the C-suite does not take on command center structure roles—even at the affiliate hospitals. At our academic medical center’s incident command center, the section planning chief is the director of clinical excellence and patient experience. So, she is a quality and safety professional first and foremost, but she has a key crisis command center role at our biggest hospital,” she says.

Incident command center metrics

During the pandemic, a primary metric for incident command centers is whether they are reporting COVID-19 data to state and federal agencies on a timely basis, Williams says.

“That data is important because if you miss a day or a series of days, your CEOs and presidents and other top executives will get an email that the reporting has not been submitted. This reporting is tied to our reimbursement from the Federal Emergency Management Agency and the Cares Act, for example,” she says.

For health systems and hospitals, the reporting requirements related to the pandemic include the following data sets:

• How many coronavirus-positive patients are in hospitals
• How many people have tested positive for the coronavirus
• How many people have been given a coronavirus test
• How many coronavirus patients are in ICU beds
• How many coronavirus patients are in medical beds
• Critical staffing shortages in hospitals

There is significant reporting about COVID-19, the population Lifespan is serving, and the health system’s resources, Williams says.

“There are personal protective equipment numbers such as how many masks you have and how many gowns you have. We must report how many beds we have available to reflect our capacity. When you turn on the news at night, and they tell you how many people tested positive that day or the positivity rate that day, that information is coming from individual organizations like ours submitting data every day,” she says.

Christopher Cheney is the senior clinical care​ editor at HealthLeaders.