How Physicians Lead Through a Crisis

^{By Eva Luo, MD, MBA, Christopher Awtrey, MD, MHCDS, Alexa Kimball, MD, MPH}

Eva Luo, MD, MBA, Christopher Awtrey, MD, MHCDS, and Alexa Kimball, MD, MPH, all a part of the Harvard Medical Faculty Physicians at Beth Israel Deaconess Medical Center, describe how their organization has been affected by COVID-19, and what steps were taken to ensure patients received quality care while physicians battled unprecedented circumstances.

Since late February of 2020, the novel coronavirus has been the single item on our agenda as we debrief internally what has since consumed every facet of leading a health care provider organization.

As a physician’s organization with over 1950 clinicians with thirteen clinical departments practicing across thirteen different hospitals, including an academic medical center, COVID-19 thrust our clinicians onto the frontlines. As physician leaders, in addition to clinical management of COVID-19, we simultaneously needed to navigate our operations in the context of new demands, a changed economy and an intense need for social support systems.

To make these decisions, our medical training, which requires us to perform critical thinking and take decisive action in the face of uncertainty every day, prepared us well. We outline here a physician’s approach to crisis situations: safety first, analyze the problem using data at hand and develop a differential diagnosis, employ evidence-based approaches, innovate and be creative, be decisive, communicate often and with empathy, and be responsive to changes.

Safety First

Patient safety is a central tenet of the profession—first do no harm. Our first priority and commitment to the physician’s organization is the safety of our providers and patients.

In the first few weeks of the crisis, we stopped elective cases and began to make plans for increasing our ICU bed capacity with repurposing of spaces and redeployment of staff.

In parallel, we had to identify and secure supplies of personal protective equipment (PPE). Having adequate PPE was not just necessary to reduce disease transmission, but critical in messaging to our providers that we cared and would do everything possible to ensure their safety while caring for patients. We mobilized our outpatient clinics that would be closed in the interim to collect available masks, viral swabs, gloves and hand sanitizer and redirected that supply to the hospital. We next turned to our community, including affiliated physicians and dentists, who responded magnificently with donations and volunteerism.

As the hospital worked to identify new supply chains for PPE, we then directed our efforts to activate the local innovation community to create and develop new PPE. Through connections with local universities, designers, engineers, and 3D printing companies, in a matter of weeks, we had several new prototypes for masks, face shields, and nasopharyngeal swabs to add to our supply. Some of our own physicians led the charge in creating these new products and devices, which was encouraging for our entire community.

Analyze Data, Embrace Innovation and Act Decisively

Creating a clinical care plan for a patient requires careful analysis of data, developing a list of possible causes (clinically referred to as a differential diagnosis), systematically testing your differential diagnosis, and employing known evidence-based approaches as first steps.

In the first few weeks of March, our knowledge and understanding of SARS-CoV2 and COVID-19 were still evolving, but given the experiences in China and Italy, we had some data about the biology of the virus and disease to make initial decisions. The data indicated that COVID-19 was highly transmissible, even before symptom onset, putting health care workers at particular increased risk.

Armed with data about our bed, personnel, equipment, supply, and medication capacity, we developed our hypotheses and took that straight into action. To maintain safe operations for our essential services and COVID-specific services, we continually collected data, allowing us to adjust our strategies as necessary. For our emergency room and urgent care facilities, we relied on a cohorting strategy, a known effective strategy to reduce infection exposure to patients and clinicians by creating separate areas dedicated to COVID-19 testing, assessment, and care.

Based on data from Singapore and South Korea and new studies on the efficacy of face masks, we adopted a universal masking policy for all patients and staff. As data on community transmission rates were available, in some areas of high volume such as Labor and Delivery, we adopted a universal screening protocol to keep patients, their support persons and providers safe while maintaining the joy of childbirth.

In situations like COVID-19 or challenging conditions like recurrent cancer, where evidence-based guidelines are in development, physicians must embrace innovation thoughtfully and carefully while maintaining the safety of the patient. In essence, what was described is how physicians and scientists design clinical trials. Clinicians are comfortable operating in this space of uncertainty and by reinforcing this environment that encourages innovation, our organization was able to thrive during COVID-19.

To ensure that patients could remain in safe contact with their providers, we swiftly moved towards innovation. Building on experience with an in-house urgent care telehealth service, BIDMCOnDemand [Beth Israel Deaconess Medical Center], in just two weeks, we had three platforms available for our providers to use. Over the subsequent month, we developed operational workflows for each of the video platforms, documentation templates, and billing pathways that met rapidly changing regulatory and compliance requirements to make it as easy as possible for our providers to reconnect with their patients safely and effectively. With several of our providers working from home with little to no administrative support, the processes put into place allowed providers to get started from home.

We also developed a provider referral guide that reflected the availability of specialty services for urgent and telehealth visits and shared this widely across the community to reduce any risk of delays in care during this time.

Through six organization wide virtual training sessions in addition to several department specific and sometimes individual provider training sessions, our telehealth volume has grown to about 50% of our normal ambulatory volume. We continue to see these numbers grow and are excited about the role telehealth will play in the future to improve access to care by extending the reach of our providers.

We emphasized being nimble and agile and gave our providers the permission to innovate these new workflows for their practices while collecting data along the way. In the emergency room, one such innovation was outpatient monitoring of oxygen saturation. Patients were sent home with a portal oxygen saturation device and medical students called patients for close monitoring. During the peak of the COVID-19 crisis, the team monitored about ninety four patients safely at home. We collaborated with one of our intensivists and the Massachusetts Institute of Technology to host a virtual COVID-19 Datathon event that brought together clinicians and data scientists to spend a week analyzing publicly available datasets to develop algorithms to address immediate policy issues and create predictive models. One of those predictive models has been adopted by Beth Israel Deaconess Medical Center to predict a second wave of COVID-19 cases.

Our focus at the moment is identifying barriers to telehealth whether it be device or internet access, private spaces to connect, or language services and better incorporation of interpreters to improve equity with use of these new technologies Innovation and data science has been at the core of clinical progress and is in the DNA of physicians. Our goal during COVID-19 was to provide the right environment to allow our clinicians to do what they do best. 

Communicate Often and With Transparency

Communication is the cornerstone to patient care, and in challenging situations, it is essential to communicate frequently and honestly, while listening and responding rapidly to needs and concerns. Social distancing requirements forced us to rely on new tools to communicate vital information that was changing on a daily basis and build a sense of community across the organization.

We increased the frequency of an existing organization-wide email newsletter and carefully curated information pertinent to changes at work and home. We also hosted weekly Zoom conferences that allowed us to provide an overview of the clinical situation and highlight efforts to address operational changes throughout the organization clearly and honestly. The Zoom conferences have also helped to break down traditional departmental silos as department chairs were featured to share the changes each department had undergone to adapt to COVID-19.

We have had between 150 to 440 people attend these weekly conferences and over 800 unique individuals attend at least one. Questions during conferences were collected and then published as frequently asked questions documents. Recordings of the conferences were also shared. The newsletters and Zoom conferences have also served to celebrate the community’s efforts in the face of COVID-19.

As an organization, we have had much to be proud of as our colleagues have been on the leading edge of innovation in developing new diagnostic devices and vaccines for COVID-19 and leading clinical trials for treatments for COVID-19. Each of the departments have also adapted so quickly to ensure that patients and staff are cared for in a safe and compassionate way. These small celebrations acted to unite our larger community and provide hope.

Be Responsive to Changes

The best tool any physician has at their disposal is their ability to observe and listen. Our providers were not immune to the societal changes created by COVID-19. With the closure of schools and nonessential businesses and recommendations to shelter in place, our clinicians were forced to navigate the blending of work and home with the added concern of bringing the virus home and endangering their families. We were keen to address these concerns proactively and assembled new resources for child and family care, food delivery, temporary housing, and mental health resources. Resources were shared on a weekly basis through our email newsletter.

We also created an anonymous survey that allowed members of the organization to share their concerns with us so that we could readily address them. Since mid-March, we have received a total of seventy seven comments. A separate child and family care email listserv was created that allowed our clinicians to remain in closer contact with our human resources team. We devoted one of our weekly Zoom conferences to provider wellbeing that shared local resources to address the anxiety of caring for patients during COVID-19 and also resources for self-care such as free yoga and meditation services.

In many ways, leading a health care organization through a crisis is not dissimilar from managing a patient and their disease condition. It requires an agile and data-driven environment coupled with compassion and the ability to actively listen. Like caring for patients, leading a physician’s organization is an incredible privilege. Every one of our clinicians is smart, compassionate and cares deeply about their patients and work. Unsurprisingly, the COVID-19 crisis is no exception and we saw our clinicians selflessly go above and beyond the call of duty.

Despite the great uncertainty the organization faced, our focus on safety, data analysis, hypothesis generation and taking swift and systematic action, embracing innovation, communication, and being responsive to our providers helped us make tough decisions. This allowed our clinicians to focus on caring for their patients, while we focused on caring for them. 

Eva Luo, MD, MBA is a health policy and management fellow at Harvard Medical Faculty Physicians (HMFP) at Beth Israel Deaconess Medical Center (BIDMC). Christopher S. Awtrey, MD, MHCDS serves as vice president of network operations and provider experience for HMFP. And Alexa B. Kimball is the president of physician performance LLC (PPLLC), and CEO of HMFP at BIDMC, and a professor of dermatology at Harvard Medical School.