As the largest public health care system in the United States, NYC Health + Hospitals is accustomed to the challenges of caring for some of the most vulnerable communities across the city’s five boroughs. But when the first wave of patients with COVID-19 symptoms began arriving at the system’s dozens of hospitals and clinics, leaders quickly realized they were dealing with a crisis like no other in recent times. They rose to meet the unprecedented challenge by relying on tried-and-true techniques learned from previous disasters and, more importantly, by incorporating new methods that they refined through daily feedback from doctors, nurses and others on the front lines. In this opinion piece, some of the system’s leaders share their reflections on what it takes to hold a team together through a storm. (The authors’ names appear at the end of this article.)
In March and April, NYC Health + Hospitals created almost 800 new ICU beds, and our heroic clinicians took care of thousands of patients with COVID-19. Our meticulous disaster response plans had to accommodate new realities — from creating “proning” teams for turning patients on their bellies, helping them breathe, to standing up a field hospital in a tennis center. As the city’s public health care system, we were the epicenter of the epicenter, and bore particular responsibility for poor and working-class patients as the safety-net system for New Yorkers. For many of us — despite having been through 9/11, Superstorm Sandy and Ebola — it was the most intense and harrowing two months of our lives.
Like a willow tree in a storm, NYC Health + Hospitals was able to flex to meet the challenge through a remarkable orchestration of teamwork. The rapid increase in hospital system capacity was only made possible through the extraordinary actions of ordinary people. We employed a four-pronged approach, outlined below, with the central goal of holding a team together despite centrifugal forces from an unprecedented crisis.
- A Call to Action
Emergency management programs aim to reduce vulnerability to hazards and cope with disasters whether they are natural, intentional or man-made. These programs are specifically designed to maintain readiness for outbreaks of infectious diseases and make the necessary preparations. Our system’s special pathogens program began monitoring the novel coronavirus in late December. By early January, we activated the incident command system (ICS), a management system designed to bring key stakeholders together, marry resources and delineate responsibilities clearly. Dr. Mitch Katz, the chief executive officer of NYC Health + Hospitals, appointed Dr. Machelle Allen to the role of incident commander and charged all facilities to begin preparing for a surge of patients in respiratory distress. This included using traditional hospital space as medical/surgical, intensive care units and observation beds. Following a governor’s directive in late March, facilities provided specific plans to increase the total intensive care bed capacity by at least 50%, adding beds both within our facilities and in new surge spaces. A call to action was born. Each member of the COVID-19 team was assigned a set of responsibilities, anywhere from procuring more supplies and taking inventory of current stockpile, to standing up alternate care sites.
In African cultures, call-and-response is a widespread pattern of democratic participation — in public gatherings, in the discussion of civic affairs, in religious rituals, as well as in vocal and instrumental musical expression. We used a modification of this simple technique to guide, nurture and hold the team responsible. Every day for three months, we would hold Tiger Team Briefings to ascertain the needs of the entire health care system. After a system-wide intelligence report focusing on trends around COVID-19 admitted patients and surge status, facilities reported any issues around personnel, equipment and space.
As the city’s public health care system, we were the epicenter of the epicenter, and bore particular responsibility for poor and working-class patients as the safety-net system for New Yorkers.
The Tiger Team would then report on supply chain equipment status, governmental affairs, public communication, clinical guidance, laboratories and other issues. Each member of the team would give a status update but was also responsible for surfacing what was working and what wasn’t. For instance, one of our hospitals shared that they had started playing music overhead each time a patient was extubated, helping bolster spirits despite the extraordinary stress. Other hospitals rapidly adopted this practice and even started comparing notes on which songs they were playing! Facilities in dire need would “call” for help, and the “response” was always there. If there wasn’t an immediate solution, we would ensure we addressed the issue the next day. The call-and-response technique was an excellent tool to use with our team to ensure our facility needs were either met immediately or addressed as soon as possible through the appropriate channel. In other words, facility leaders knew that they could accurately describe their challenges and there would be a response.
- Scaling Up Through Coordination
Our patients benefited when we functioned as an integrated system, whether it was moving “staff or stuff” to where the patients were or drawing upon collective clinical expertise. With so much unknown about the novel coronavirus, it was particularly important to stand up channels to rapidly share information across hospital sites. In some cases, this drew upon existing fora, including an Intensive Care Unit (ICU) Council that adjudicated both operational issues, such as how to quickly surge ICU beds, as well as clinical issues, such as appropriate criteria for using blood-thinning medications. In other cases, rapidly-emerging issues, such as dialysis shortages, cut across organizational boundaries in a way that required seamless collaboration. An unprecedented need for dialysis required clinical guidance, recruitment of dialysis nurses, and sourcing of materials and equipment to scale up dialysis services across multiple sites.
While the size and scope of our system sometimes presents challenges to such coordination, during COVID-19 response, it was an asset as we could quickly test solutions at one location (e.g., a tele-ICU pilot at Bellevue Hospital) and then scale across the entire system. Our partnership with municipal government was another strength in this respect because resource needs — particularly related to staffing shortages — could be communicated to city partners, who in turn could make requests to state and federal government. While all of our care was delivered person-to-person, on the ground at each of our sites, these emergent system properties allowed Health + Hospitals to be greater than the sum of its parts.
- Using “New Power” to Meet Challenges
“New power operates differently, like a current. It is made by many. It is open, participatory, and peer driven. It uploads, and it distributes. Like water or electricity, its most forceful when it surges. The goal with new power is not to hoard it, but to channel it.” – Jeremy Heimans and Henry Timms in “Understanding New Power”
We met the surge of patients with a surge of “new power.” For instance, even with the structured Incident Command System, each member of the team had the agency to reinvent their role depending on the needs of the system. This was particularly true at each of our hospitals, where the real work of caring for COVID-19 patients was done. At Bellevue Hospital, under the guidance of CEO Bill Hicks and Chief Medical Officer Nate Link, examples of new power abounded. The staff of the emergency medicine department not only took care of thousands of patients seeking care, but they also worked the phones to track down all discharged patients to make sure they were safe. Those in the surgery department gave up all of their usual work to take over care of all non-COVID ICU patients, and they stood up a new peritoneal dialysis program for patients whose kidneys were failing. The social work department facilitated video communication between hundreds of patients and their families, including the most difficult end-of-life conversations, with palliative care and chaplaincy colleagues.
As we grapple with our new reality, including uncertainty about subsequent waves of infection, we have a collective strength forged from making it through this crisis.
The entire team thrived on new power values, using networked governance, group wisdom and sharing. Our facility leaders particularly embraced radical transparency. When the data forecasts were saying we needed additional capacity, despite already Herculean efforts, they channeled another wave of innovation. Alternate sites were screened and secured, a new hospital was established, tents were set up, and we coordinated with military and other federal leaders.
As with all crises, there are the physical details and activities that need to be addressed. There is also the psychology underpinning how the team will respond. Both the physical and psychological are crucial to success. In his article “The Psychology Behind Effective Crisis Leadership,” Gianpiero Petriglieri, associate professor of organizational behavior at INSEAD, writes that “holding” is a psychological term to describe the way in which a person in authority contains and interprets what is happening in times of uncertainty. This skill was imperative during our COVID-19 response: We were facing a virus with no effective treatment and dire forecasts for how many New Yorkers would become ill. But through the storm, hospital leaders and team members conveyed thinking transparently, offered reassurance where it was realistic, and acknowledged tragedy. “Holding” allowed the rest of the team to have the mutual support they needed and to create a new vision for their work. It also meant that there was psychological safety when raising areas where we were falling short, like the need for better and more rapid vertical communication. We continue to grieve the loss of too many of our patients, colleagues, neighbors and family members. But as we grapple with our new reality, including uncertainty about subsequent waves of infection, we have a collective strength forged from making it through this crisis.
This article was written by Katie Walker, assistant vice president of Health Care Simulation; Nathan Link, chief medical officer, Bellevue Hospital Center; William Hicks, chief executive officer, Bellevue Hospital Center; Syra Madad, senior director, system-wide Special Pathogens Program; Machelle Allen, senior vice president and chief medical officer, NYC Health + Hospitals; Dave A. Chokshi, chief population health officer, NYC Health + Hospitals and attending physician at Bellevue Hospital.