18 Aug Management And Leadership In Emergency Plan For The Covid-19 Pandemic: The Experience Of Young Leaders In Different Countries
This article is the first of the IHF Young Executive Leaders’ subgroup, working on Leadership issues in times of Covid-19. Since the working group members bring in professional experience in hospital management, healthcare leadership and nursing management, they quickly defined the most urgent issues that they, as leaders, want to work on, using their different perspectives and personal experiences. They will discuss what makes a good leader in a special situation such as the pandemic and what – people-centered – actions have proven to be effective and indispensable to keep a hospital going. Which are the challenges and lessons learned for hospital leaders? What to focus on and what precautions and changes in leadership should be taken for/in the future? To start responding to these questions, this first article focuses on Management and Leadership in emergency plan for COVID-19.
Authors: Alhammadi, S. (UAE), Bartolo, A.M. (Portugal), Braga, V. (Portugal), Castela, E. (Portugal), Lahuerta-Valls, L. (Spain), Obwaka, Ch. (Kenya), Rodriguez, O. (Spain), Trummer, F. (Austria), Ulrich, K. (Germany), Edited by Bogues, R. (UK)
Since February, hospitals around the world have but one mission: the fight against the COVID-19 virus. These hospitals cared for patients with Covid-19 whilst trying to prevent the dissemination of the – mostly unknown – virus. Mastering the first major COVID-19 phase needed fast decision-making, some deep changes in organizational structures and great solidarity of the hospital staff.
In this article, we will discuss and highlight some steps taken by hospitals in Spain, Austria, Kenya, Portugal, Dubai (UAE) and Germany to handle the pandemic from a leadership perspective. Our experiences reflect different impacts of COVID-19 in each of our countries and hospitals, different types of hospitals (public and private), as well as our experiences from different roles in our organizations. We share our experiences of challenges and best practices to prepare hospitals to respond to the pandemic and which areas need further strengthening.
Decision-making Challenges During COVID-19
Hospitals and health centers around the world have had a real stress test in this crisis caused by COVID-19. From primary care centers to tertiary care hospitals, the challenge has been to respond to a new virus that has changed our way of life today. The annex provides an overview of figures related to our countries and the impact of COVID-10 so far.
In Spain, one of the most impacted European countries, hospitals have been overwhelmed by an admissions avalanche into intensive care units. In Germany, Austria and Portugal, schools and kindergartens were closed, just as many other public facilities (“lockdown”), attempting to reduce the contagion rate (“flatten the curve”) and to gain time for the health institutions to prepare. Furthermore, many countries and hospitals chose to postpone predictable operations and interventions and to raise the ICU capacities (beds, ventilators, staff), in order to be ready for a large number of critical patients.
Therefore, all of us faced the same basic difficulties:
- An exceptional health situation, that no one had ever experienced before: Kenya, for instance, was not affected by SARS or MERS – so everyone in the healthcare system had to learn on the go deriving knowledge from international organizations such as CDC and WHO, and also keeping up with the latest research from around the world;
- A lot of new information about the pandemic situation and the virus every day, that had to be taken into consideration for decisions.
However, all of us experienced common core strategies:
1- Switch from the conventional mode of leadership and management to crisis mode with other command structures
A COVID-19 task force was formed in most hospitals, many of them with multidisciplinary teams, to assess the pandemic situation and decide about the necessary actions on a daily basis.
At Hospital Sant Joan de Déu in Barcelona, the team was made up of people in charge of the hospital’s key healthcare departments and services that could respond to the health crisis, not just medically but also with regards to logistics, such as warehouses, shopping, cleaning, communication and audio-visuals, and engineering. A COVID-19 response team was formed at the Nairobi Hospital in Kenya, too, and it consisted of nurses, infectious disease specialists, executive managers and housekeeping staff. The COVID-19 task force at the Jewish Hospital Berlin in Germany included the Executive Board, medical staff e.g. the head of ICU, the head of ER, hygiene experts, the communication officer, the head of HR, and other executives. There was a backline of deputies for every member of the task force. In Dubai, a command center was established where a group of major health leaders and administrative managers developed a full structured plan of controlling the pandemic spread.
The task forces met daily to discuss and decide how to maintain the hospital functionality in terms of staff, space and supplies and how hospital treatment capacity can be maintained or reduced or increased, accordingly with the situation.
Moreover, appropriate communication and a different information management were also a special issue. The Centro Hospitalar de Leiria in Portugal established a meeting of the task force with all the medical service directors twice a week to keep them updated. Besides new protocols sent by e-mail to all professionals, there was a daily report on the intranet about the present numbers of infected patients in the institution. The Jewish Hospital Berlin implemented a daily e-mail-newsletter to communicate the decisions and new rules quickly into the organization (“Corona Ticker”). The Nairobi Hospital in Kenya designed a COVID-19 policy, giving guidance on how to handle all hospital departments from security to the emergency department, to laboratory, intensive care and isolation/quarantine facilities. Shared documents included issues due to social distancing, hand hygiene, respiratory etiquette, case definitions, testing protocols and more.
2- Cohorting patients, organizing new areas, new teams and new patient flows
Hospitals used different strategies to maintain medical services and – at the same time – to prevent the spread of the virus or even an outbreak inside the hospital: putting professionals in cohorts in the different hospital areas and changing work shift patterns to reduce the cross-infection risk between professionals, setting up triage tents outside the emergency department building, where the screening and identification of potential cases could be done before the patients accessed the main hospital to keep COVID-19-patients and non-COVID-19-patients separated – just to name a few that have proven to be very helpful – although they brought up other challenges.
Since the availability of trained nursing staff and doctors in intensive care may become a problem during the pandemic, staff from other specialties was trained in some hospitals. The Jewish Hospital Berlin in Germany and the Nairobi Hospital in Kenya immediately decided to redesignate wards, once the cases started, to have an isolation and quarantine facility if the need arise. The ward chosen in the Nairobi Hospital was remotely located from the main hospital, however it also housed the cancer unit and the renal unit in close proximity, and this posed a challenge. At the Centro Hospitalar de Leiria, ambulatory areas of the hospital were occupied by the non-COVID emergency rooms, making it difficult to respond to the hospital’s routine essential health services. In Dubai, one of the most important changes was to allocate each hospital to a specific speciality – one hospital was only for maternity and children care of those who are COVID positive, another one was for immune compromised patients on chemotherapy / dialysis / major medical co-morbidity, and the biggest hospital, the Rashed Hospital was made into an ICU centre, where all critical cases were sent to.
The urge of rapid identification and diagnosis was another challenge globally. Previous to the new laboratory organization and equipment, some hospitals implemented protocols with private labs. The Hospital of the Brothers of St. John of God in Vienna, as well as others, decided that staff vacations could not be consumed. The clinical staff was divided into two groups, so that even with COVID-19 related failures, medical and nursing staff was always available.
3- Staff Protection
The pandemic posed several threats to the medical employees: the virus itself and the workload due to the new work situation described above. Keeping people healthy, protecting the staff from infections and from burnout was an important leadership task.
There were different reactions among employees to new information and new decisions – some were very afraid and uncertain about the situation and others were almost careless. Therefore, it was very important to create policies for accessing the hospital and to reorganize infection prevention and control (IPC) protocols in the hospital staff routine.
In Portuguese hospitals, working groups were created across the main hospitals and started to implement awareness action to healthcare professionals. Emergency plans were performed and being adjusted over the days. In Kenya, like in many other countries, it was made mandatory for all people accessing and moving in the hospital to wear surgical masks and no one could not access the main gate if they did not wear a mask. Thermal temperature screening was done at various points at the Nairobi Hospital and anyone with a temperature of above 38 degrees was moved to a designated area for further evaluation. In many hospitals, within just a few weeks, sometimes even only days, the staff got used to wearing a mask all the time while on duty, and to no more presential meetings with large number of people in small rooms. Wherever possible, remote work was implemented, esp. for the administration staff.
Assuring Personal Protective Equipment (PPE) was a global challenge. At the beginning of the pandemic, hospitals faced a PPE shortage and very soon some health professionals got positive COVID-19 tests. In many countries the supply chains broke down in almost no time and prices for PPE went up enormously. Stockpiling and providing PPE for all employees were central topics.
The Nairobi Hospital in Kenya was able to bypass the bureaucracy of procurement of surgical consumables to be able to quickly provide hand sanitizers, PPE and both surgical and N95 masks for all its staff, esp. to those working in the COVID-19 wards and those working in the emergency department. Initially, there was no checks and controls on the issuance of the masks and the hospital soon realized that people were picking large numbers of masks to take home, and then a system was introduced whereby the nurse in charge of the unit was responsible for the distribution of the PPE to ensure that the stocks were not depleted due to hoarding and frivolous use. Other hospitals handed out masks and disinfectants to the employees and their families.
Assuring psychosocial support was an issue in some hospitals as well. To provide mental support by psychiatry and mental health service, special hotlines were available. Social support and volunteers organized donations, like houses and hotel rooms for health professionals to stay or provided food or self-made masks to the hospital staff. In Dubai, the majority of the healthcare workers were provided hotel accommodation to protect their loved ones including food and other facilities. Moreover, they were honoured by showing the names and pictures of those who worked in crucial places in the entrance of the major mall in Dubai.
Inspiring Surprises During COVID
Great solidarity of all employees
In spite of the difficult conditions at work (adaptation to new routines, time-consuming activities, lack of air conditioning, and many more), clinical staff have helped each other, e.g. with contributions to emergency rooms from several doctors and nurses from other departments and services.
At the Hospital of the Brothers of St. John of God in Vienna, despite the massive workload, there was a decrease in sick leave (which was not associated with Covid-19). Employees volunteered to work in different working groups and crisis teams in different functions. Tasks such as the implementation of a COVID-unit, the implementation of triage recording systems, etc., could be implemented very quickly and efficiently. At the Hospital Sant Joan de Déu in Barcelona, the Paediatric ICU team managed to treat adult critical patients who were transferred from other hospitals.
Use of technology
Although there was also a lack of logistic supplies, tele-work has increased significantly and promises to be an important base for hybrid work in the future. In Portugal as in many countries, acute outpatients were accompanied also by phone or video-call.
Some Portuguese hospitals promoted virtual visits for inpatients supported by a psychosocial team, facilitating communication through tablets, reinforcing the importance of patients maintaining proximity to families. A family support telephone line was also created. Likewise, psychological support was provided to support patients and their families. The same was accomplished in Berlin, where the hospital provided iPads to allow inpatients to keep in touch with their own families.
COVID-19 has spurred significant research. At the Hospital Sant Joan de Déu in Barcelona, three research projects have been designed during the COVID-19 outbreak: the first project focuses on the seroprevalence of employees by monitoring IgG and correlating their presence with sociodemographic, occupational and lifestyle variables; the second project was designed to examine the anxiety of children during the confinement brought on as a result of COVID-19; the third project intends to put together a clear picture of the perception of professionals towards the various institutional initiatives which have come about during the pandemic.
Areas That Need Further Thinking and Strengthening
Due to the instruction to postpone predictable operations and interventions, and with raising costs for PPE and testing, for many hospitals the financial effect of this pandemic for them and the healthcare system was very unclear. Only a few governments guaranteed financial support right from the beginning.
At the Nairobi Hospital in Kenya, the bed occupancy was reduced from 70% to 30% at some point and this impacted hospital cash flows. An attempt to mitigate this was to increase the doctors’ number of working hours without a concomitant raise in salaries. This resulted in acrimony, demoralization and legal action. Through their union representatives, the doctors at the hospital were able to go to court and overturn this unfair decision. The laboratory opened up testing for the general public as well at a cost of $100 per test, for example if someone wanted a pre-employment certificate or had a close contact who had tested positive. This provided an extra revenue stream for the hospital.
In general, we have to develop strategies to “survive” as a hospital while cutting the business 25-75%. Here we have an opportunity for innovative use of technology and new ways of treating patients.
Response to Non-COVID-19 positive patients
At the patients’ level, in parallel with risk of infection and sectorizing positive cases, the main focus was still ensuring equal quality and humanized care. Continuity of essential support services is essential and imperative. Non-COVID-19 patients should not be harmed.
We should review access criteria for primary care units to select patients that must come to the hospital and get medical care, even under pandemic circumstances.
Managing and leading in these unprecedented times has inherent arduous challenges, as hospitals have a significant challenge in time balancing national, regional, business, employees and patients’ best interest. Our experiences highlight the importance of inclusivity at every step and prepare rigorous protocols, policies and procedures, in order to standardise care and ensure safety of all. Take care of your staff, then your staff take care of the rest.
Through this pandemic crisis, there were key learnings – good and bad practices – that should be shared. Speed beats perfection. This pandemic has shown us that good leadership is of the essence.
Annex (August 13th 2020)
1Sources: OECD Labour Force Statistics: Population and vital statistics, 2018 or latest available: https://data.oecd.org/pop/population.htm, Aug 13th 2020; Kenya National Bureau of Statistics, 2019 Kenya Population and Housing Census Results, https://www.knbs.or.ke/?p=5621, Aug 13th 2020; Population of the United Arab Emirates (2020 and historical), https://www.worldometers.info/world-population/united-arab-emirates-population/, Aug 13th 2020
²Source: wikipedia.org, Aug 13th 2020
³Sources: 1) OECD Health care resources, 2019 or latest available, https://data.oecd.org/healtheqt/hospital-beds.htm, Aug 13th 2020; 2) WHO Hospital bed density Data by country, https://apps.who.int/gho/data/view.main.HS07v, Aug 13th 2020; *in 2017
4Source: Johns Hopkins University, https://coronavirus.jhu.edu/map.html, Aug 13th 2020
5Source: Timeline of first confirmed case by country, https://en.wikipedia.org/wiki/COVID-19_pandemic_by_country_and_territory, Aug 13th 2020