Rising to the Challenge: Health Care Leadership and Management

Copyright EDU 2021

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EDU hosted a widely successful first public lecture this past June 24, in what was a completely open, online, and free to the public event.  

The event focused on health care leadership and management during the darkest days of COVID-19 in New York City, USA, and in the north of Israel during the recent Syrian Civil War. 

The speakers of this panel have worked in positions of leadership during some of the most trying healthcare crises of our lifetime, and thus shared with the audience remarkable experiences, tools for their practice, and details. They shared on painful personal experiences and hard-earned lessons to provide participants a deeper understanding of how to manage teams and execute strategy in times and conditions of volatility, uncertainty, complexity and ambiguity (VUCA).   

Copyright EDU 2021

The event’s speakers consisted of EDU professor Dr. med. Elliot Goodman as the event’s moderator, who opened the event by introducing the topic of healthcare leadership in times of crisis. Dr. Goodman is a general surgeon, who trained at the Maimonides Medical Center in New York. He’s been part of Mount Sinai Beth Israel for the last 17 years, and also of the faculty of Mount Sinai School of Medicine for the last few years. 

IIn his introduction, Dr. Goodman briefly discussed the importance of VUCA, a tool for military leaders designed to help leaders deal with difficult, unpredictable situations. Under the principles of VUCA, health care leaders have to deal with volatility, where a situation changes on a minute to minute and day to day basis. They deal with uncertaintiescomplexity, and lastly, with ambiguity

Following his introduction, Dr. Elliot Goodman gave the floor to Dr. Scott Lorin, the first guest speaker of the event. Dr. Scott Lorin earned his MD from the Sackler School of Medicine in Tel Aviv, Israel and is board-certified in internal medicine, pulmonary medicine and critical care medicine. In May 2018, Dr. Lorin became President and COO of Mount Sinai Brooklyn and has for the last year led them through the COVID-19 crisis. His research demonstrating how operation management tools can improve quality outcomes in critically ill patients has been presented at the American Thoracic Society and the Institute for Healthcare Improvement conferences.  

Dr. Lorin’s talked about his experience leading Mount Sinai Brooklyn Hospital through the COVID surge back in Spring 2020. He embarked his presentation by addressing the globally-shared feeling of overwhelm and impotence at the sight of COVID-19’s waves of infections. 

“When people describe COVID, you may hear they may use the term ‘apocalyptic’ or ‘tsunami’. This wasn’t just a tsunami. This was recurring tsunamis every day. See, typically, when a tsunami happens, the hardest part of it is the clean up afterwards. But it typically moves away. What we were having is a tsunami every day, of patients coming into the hospital, critically ill and sick.” 

In what can only be described as moving and striking statements, Dr. Lorin gave a sense of the volume, speed, acuity and ferocity of COVID, and how a relatively small hospital was able to weather it through perseverance, resilience, teamwork, and participation–along with a well-prepared health system. 

Back in January 2020 when the spread of COVID in Northern Italy grew concerning, doctors around the world, Dr. Lorin included, started to pay close attention. They began preparing for the worst, proceeding ‘in the dark’, without a clear understanding of the volume, extent, and potential damage of the virus. In action, these looks like daily meetings with staff to figure out surge capacity, equipment potentially needed and where to source it, available staff, etc. Even after preparing hospital beds, with 240 available for a highly probable surge, they realized that the amount of beds would not matter if they didn’t have the staff needed to tend them. 

Dr. Lorin recalls “the hospital became a war zone. We were battling an unfamiliar enemy, and we had to redo our strategy and rethink. And really use wartime strategies to be able to tackle this.” 

With that in mind, priorities and steps were instated to lead the hospital staff through what would be the majority’s first ever massive health crisis. 

“While we didn’t know how bad it was, we knew we were going to need more supplies.” 

Priority 1 was set as securing the perimeter, as well as supplies and equipment. This meant designating areas around the hospital and within it–where to use non-clinical PPE, where to doff and don PPE, and where full PPE was required at all times. Dr. Lorin also explained how supplies were highly increased: a second oxygen tanker was brought in, along with acquiring extra dialysis machines, portable oxygen tanks, small ventilators, nasal cannulas, drips and other nursing frontline supplies. Lastly, cleaning staff was increased around the hospital. 

“We had staff do everything. Whatever it was to get patient care going.” 

Priority 2 regarded bringing in staff, as over 20% of the hospital’s personnel contracted the virus. They had 200 nurses and physicians from Mount Sinai Health System stationed at their hospital–many not in their traditional roles–as well as 90 temp visiting staff (nurses, respiratory therapists, anaesthesiologists, CRNAs). 

Priority 3 was about transferring patients out of the hospital. The hospital got easily overwhelmed, as three zip codes in its area were among the six with the highest concentration of COVID cases in all of NYC. . In total they managed to transfer more than 250 patients to various hospitals in Manhattan and to field hospitals such as the one set up in Central Park. 

Priority 4 concerned trying to improve outcomes through clinical protocols. This meant they participated in major trials and navigated other treatment options throughout the pandemic (steroids, stem cells, Plaquenil, etc.). 

It is also relevant to point out that during this time, some clinical predictors of mortality such as obesity and diabetes, and even race, became apparent very early on. 

After contracting COVID-19 himself early on, Dr. Lorin had to run the hospital from afar. At the time of his return, when walking through the hospital’s second ICU (made up of 11 beds), he noticed all 11 were Black males who were overweight. 

Discussion grew around this topic, as it became more and more noticeable across New York. 

“It was pretty clear that the neighbourhoods that had the highest rates of positive COVID-19, also had the highest rates of race and ethnic diversity. And what we see with Black and Latino and communities of colour is: they don’t have good access to healthcare, they have many types of comorbidities (such as diabetes, hypertension, and obesity). They are essential workers, and so they did not stop working. Unlike in Manhattan, where people started to work from home or moved out of Manhattan temporarily, these individuals could not stop working–and therefore the risk of getting COVID and transmitting COVID was much higher.” 

Finally, Priority 5, and definitely a crucial point in healthcare leadership, was mobilizing and supporting staff throughout the crisis. 

“What we saw is a tremendous health crisis. Staff came to work scared that they were going to die themselves. When you go to nursing school or medical school, you don’t think about your own mortality. You’re going there to help other people’s health and improve their mortality.” 

There was a constant feeling of helplessness, of burnout, stress, loneliness, sadness, and fear. Many did not see their families regularly. A looming mental health crisis became evident. People were losing hope in the ICU. 

“In the ER, patients would come and they can die within 15 minutes. The staff had never seen anything like this. And when you go to the ER to talk with the staff, they cry about it. You didn’t go into this field to take care of somebody and have them die in 15 or 30 minutes. You went into this field to help people get better. And there’s that loss, and feeling of helplessness that we had to combat.” 

Therefore, the hospital, led by Dr. Scott Lorin, started a series of actions to make sure they could provide the staff with as much support as possible. From a palliative care team, to food, flowers, massages, therapy dogs, the fire and police department cheering–anything to show support. 

“We knew that if we were going to continue to take care of this crisis, that we had to prepare for the support of the staff.” 

To uplift staff’s feelings and maintain the hope, the hospital began to collect and report on how many patients were discharged per day. By doing this, the focus was shifted from counting deaths to counting hospital discharges. The goal ultimately was to remind staff that what they were doing is indeed helping patients, and that patients do survive and do leave the hospital alive. 

“On April 1st, we had discharged 218 COVID patients. (Earlier) I told you that there were these 11 black male patients in our second ICU. 10 of them died. Only one survived. He was discharge #448. The whole staff of the hospital came by to cheer him going home. It was really an incredible event.” 

___ 

Dr. Lorin concluded his presentation by returning to the grander scope of leadership. 

“In leadership you can’t predict everything. And you have to beware not just of the complexity, but some of the ambiguities and unpredictable things to come” 

Finally, he provided remarkable insights as to how to deal with management crisis and provide the leadership that an organization requires. 

“If you lead well, and if you come in with the right temperament–there were many times where staff yelled at me: ‘we don’t have enough water, we don’t have enough staff, what are you doing?’–it’s easy to argue (with staff), but they’re not angry with you, they’re angry with the situation, and your job here is to ameliorate it, to make it better.” 

Ultimately, how to manage a crisis is what leadership is about. As Dr. Lorin put it, disaster preparedness and crew resource management are clearly important tools, but when faced with relentless and constant tsunami waves, rapid, courageous decisions have to be made on a daily, even hourly basis, for weeks on end. 

“I think that COVID, bad as it was, really galvanized the hospital. The only way the hospital could get through this was perseverance and teamwork. And that really starts with the leadership of the hospital.” 

Dr. Lorin’s portion of the lecture was followed by Prof. Salman Zarka’s presentation on the humanitarian crisis in Israel’s northern border with Syria. Prof. Zarka graduated from the Faculty of Medicine Technion in 1988, and served as a Colonel in the Israeli Defense Forces for 25 years, where he occupied a variety of positions, including Head of Medical Corps of the Northern Command. He also holds a master’s degree in Public Health and Political Science. In 2016, he helped to launch the humanitarian aid initiative by the State of Israel for Syrian casualties during the civil wars in Syria. More recently, as an advisor to Israel’s National Coronavirus Task Force, he played an important role in Israel’s battle against COVID-19. 

Prof. Zarka focused his presentation on leadership challenges as part of Ziv Medical Centre’s humanitarian project. He provided a simple, focused definition of leadership as the accomplishment of a goal through direction; that a successful leader is one who can understand his or her people’s motivations and enlist participation that supports the group’s purpose. The Ziv Medical Centre’s humanitarian efforts demonstrate the four principles of VUCA that Dr. Elliot Goodman covered at the beginning of the lecture. In such situations, there is a high level of volatility, uncertainty, complexity and ambiguity; and to deal with these situations, one must be prepared to present a “high dose of leadership”. 

In Prof. Zarka’s particular case, this overall stand on leadership became a pilar for his way of leading. 

“First, in order to make your staff, whether it is military or civilian, to be part of the mission and to do what is needed in order to achieve your goals, you have to be very clear about what is the mission. You must be sure all the staff is familiar with the mission and talk about it in different situations, times and occasions.” 

In other words, a good leader makes sure that the staff understands and is clear on what is each individual’s role in this mission, as well as collective roles. The clearer this is, the better they will do their assigned jobs and cooperate with each other in order to obtain a better outcome. 

Aside from having a clear understanding of the mission, understanding the values behind it is just as crucial. To understand, as staff, why are you doing what you are doing. “Why are you we at the border with Syria providing medical support to Syrians? Why is this important in our mission?” The relevance of this is that it motivates personnel and makes sure they provide the best health care wherever they are stationed–be it at a large regional hospital or at a make-shift field hospital. 

“My kind of leadership requires me to be there. You have to be part of the location, the staff has to see you, be part of the mission, in order to understand the mission and its values.” 

Furthermore, Prof. Zarka talked of the importance of a leader being seen. Dr. Lorin in his presentation discussed how with all the PPE used throughout the day, people became unrecognizable, and thus started to write their names on their masks, and he started wearing a white Mount Sinai Brooklyn hat so people would recognize him. The point of this was for staff to see that their leader was there, present, and participating just as much as they are. Prof. Zarka highlighted this as well, as he considers leadership is about being there with your staff–to deal with the conflicts that arise, to set an example, and to guide them through the unexpected. In essence, you must guide your staff, show them the reality of things to create a better understanding. 

Finally, Prof. Zarka closed his portion of the lecture by suggesting that leadership should be collective. In times of uncertainty “you are not the only wise man that can deal with the mission”. One can be seen as an individual leader, but that leader must be surrounded by other to help him or her deal with issues and conflicts. Leaders should deal with the uncertainty themselves, so that their staff is presented with more certainty and can thus provide better help and aid. 

____ 

This lecture ultimately showed how effective crisis management in healthcare can be boiled down to just a few areas of concentration: putting people first, managing operations flexibly and creatively, focusing on teamwork and communication, creating  partnerships, and embracing clear and humble leadership.  

Lectures like these, with experience provided by such prominent speakers, really focus on the importance for future medical practitioners to be trained as leaders. As our very own EDU professor Dr. Goodman puts it: “It doesn’t matter what sort of doctor you are: whether you are a first-year resident, an intern on the first day on the job, (or) whether you’ve been in practice like me for 30 years. Doctors are necessarily leaders and people look to doctors to provide leadership.” 

Future doctors can learn a lot from how leaders handle catastrophes and crisis, and can take lessons in leadership of the very extreme examples such as the ones portrayed in this lecture, and use these lessons to become better leaders in everyday health care.

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