Natural disasters. Mass shootings. Ransomware attacks. Nightmarish scenarios are not the typical hospital fare, but they happen. And they’re among the challenges a hospital must be prepared to face when they’re least expected.
Today, with natural disasters and increasing frequency of mass shooter events, hospital staff have to brace in the aftermath to extend beyond what school and experience can teach. From Harvey to Sutherland Springs, hospitals have found new challenges — and new goals — in investing in workforce resiliency.
So how do hospital leaders cultivate unflappable, flexible staff members who flourish during unexpected, even scary, events and bounce back afterwards? Finding the secret sauce to building a resilient workforce has been a topic at many hospitals, large and small, urban and rural, for at least five years.
“This is a fundamental call to develop leadership … and for it to be systemwide,” said Larry McEvoy, M.D., founder of Epidemic Leadership and former CEO of Memorial Health System in Colorado Springs. “As a society, we are at the front of realizing the way we’ve organized our organizations is very 20th century … Our obsessive focus has been ‘get the job done and prove how good you are’ without an equal focus on replenishing the resources — humans and our relationships — that make performance possible. We started to find out, ‘gee, we’re breaking ourselves.’”
Hospital administrators are realizing the benefits of having a resilient staff. Research shows they are more productive, less prone to illness, more able to cope with stress and better equipped to deliver care.
Resilient teams tend to be deeply connected to one another and will often huddle for support and encouragement, according to resiliency experts. They are accountable to each other and rely on one another. Trust runs deep. They talk about the good things that happened in their workdays rather than focusing on the negative. They maintain a healthy work-home balance and practice good self-care, attending to mental and physical wellness.
Resilient leaders engage and empower their teams. They also foster connections among workers and the people they serve, focus on the positive and regularly reward employees, experts say. When workers make mistakes, resilient leaders use errors as learning experiences, not to shame or punish individuals.
A resilient workplace “revitalizes people instead of exhausting them,” said McEvoy, who spent years as an emergency medicine physician before transitioning to hospital leadership.
“One thing that exhausts people is task saturation,” he said. “Our health care environment is super-saturated with tasks.”
Most of the tasks can be streamlined to make work flow far simpler, he said. For example, in one case McEvoy helped redesign a patient registration process for imaging tests that required 78 steps. “We got it down to 14,” he said.
Leaders cultivate resiliency by using positive reinforcement and regular interactions with staff. McEvoy said they’ll ask workers questions like: What are we grateful for today? What are we learning? What adjustments should we make tomorrow to do it better?
Hospital leaders need to continuously model resiliency, and that helps workers learn and adopt resilient behaviors, said Omar Reid, senior vice president of human resources for the Harris Health System. “You can’t just do it in a classroom setting,” he said.
Harris Health’s Lyndon B. Johnson Hospital, Houston, was thrust into the midst of a crisis in Aug. 2017 that tested the staff’s mettle for months. The storm — and how it forced staff to work together to problem solve — had a lasting impact.
A Devastating Hurricane
The crisis came in the form of Hurricane Harvey, which challenged hospitals across a wide swath of the Texas Gulf Coast. It brought historic rainfall and widespread devastation to Houston and the surrounding region, flooding more than 154,000 homes in Harris County alone. Sixty-eight people died statewide, tens of thousands were displaced and damages reached $125 billion, making it the second costliest hurricane in U.S. history, according to the Harris County Flood Control District.
LBJ Hospital stayed open throughout Harvey even though moisture caused it to shutter more than half of its 200 beds for several months. Some staff stayed at the hospital during the crisis, including workers who had lost their own homes or were stranded.
The LBJ staff who lived at the hospital during the crisis “were split into groups. Some would work for a period of time, and conditions permitting, would then transition to another part of the hospital to rest. Depending on patient surges and clinical needs, they could be called back to help, but most would rest at the hospital and then return to relieve those who had been working. This continued for several days until relief staff were able to reach the hospital,” said Kunal Sharma, M.D., chief of emergency services at LBJ.
The hospital found ways to make sure people were well rested, Sharma explained, “The gym hosted Zumba classes. They played board games and card games.”
Staff also turned “a potential linen shortage into a ‘go-green’ campaign,” said Patricia Darnauer, the hospital’s chief administrator and executive vice president of Harris Health System. “Thinking creatively was a big part of it.”
The system’s wellness programs and culture that were in place before the storm helped to nourish the staff’s resiliency, she added. “The physicians and medical staff have a wellness committee to identify things that can cause burnout and how you overcome burnout.”
The hospital had disaster plans in place, defining who would monitor staffing, bed space and other needs. “Practicing and knowing what your role is in advance of the disaster helps with that resiliency,” said Darnauer, a retired U.S. Army Medical Service Corps colonel. “You can anticipate and develop a more flexible mind.”
Throughout the crisis, the hospital’s then-chief, Alan Vierling, DNP, was present and listened to staff, including those who recounted personal losses. “That speaks volumes,” Darnauer said. “When something became stressful or challenging, Alan was there.”
Vierling was a calm presence who provided positive feedback to staff and would tell them, “We’re going to make, it’s going to be OK, we appreciate what you’re doing,” Reid said. That motivated staff and gave them “the impetus to go forward.”
In the midst of the storm, the hospital transformed its emergency triage system to be more efficient. The more seriously ill or injured patients lay on gurneys; those who could sit were “kept vertical,” Sharma said.
That change is still in place. In addition, Hurricane Harvey prompted the hospital to revamp its ED. An article Sharma co-authored in the
Harvard Business Review describes how the hospital converted ED space into 16 private patient rooms and created a “results waiting” area for patients awaiting test results or a consultation with the treatment staff before discharge.
Sharma said those and other changes got significant results. “The average time patients wait until they see their first provider decreased by 22 percent,” according to the article. “Boarding hours dropped by 52 percent. Serious safety events have declined, suggesting that the changes have driven safer, not just more efficient, care. Morale among ED personnel is higher than ever before.”
How Others Coped with Harvey
In Beaumont, which was devastated by Hurricane Harvey, Baptist Hospitals of Southeast Texas, which is licensed for 475 beds and staffs 300-plus, stayed open until the city lost access to clean water. Then it closed for three days and evacuated nearly 200 patients.
The staff rose to both challenges, said Jerry Kersey, chief human resources officer for the system. The Christian hospital attracts resilient people who are committed to the mission and culture of doing “sacred work” in caring for others, Kersey said. They also knew the administration would help care for them.
Some workers had lost homes and stayed at the hospital where they were given a bed and food. Fishing boats and amphibious “duck” boats were employed by the hospital to help those staff members who needed a safe way to reach the hospital. The hospital’s foundation and partners contributed funds to help them, Kersey said. Employees who needed time off to take care of their families got it.
“It was a balancing act between getting this hospital open and supporting our community and also supporting our staff,” Kersey said.
Even small hospitals were touched in big ways by Harvey.
El Campo Memorial Hospital, which is licensed for 49 beds and has an average daily census of 10 to 12 patients, stayed open during Harvey and was the only hospital in El Campo at that time, said Sherrie Hardin, RN, the hospital’s quality resource manager. Awash in the crisis, the administration reorganized sections of the hospital to accommodate the influx of patients, Hardin said.
The ER grew from five to 11 beds, with two triage chairs, and staffing was increased, she said. Beds around the hospital filled up, and more bed space was created. “We had patients in therapy rooms, we had patients in day-surgery rooms, we had patients in day-recovery rooms, and we doubled up all the rooms,” Hardin said.
The El Campo staff is close-knit and saw friends and neighbors, some of whom had lost everything, pour in. “We didn’t feel so much like we had to be there, we wanted to be there,” Hardin said. “We did a lot of crying and telling each other, ‘We can do this.’”
She has worked at the hospital for 31 years, and most of her close friends work there, too. Some staff stayed overnight. During the crisis, staff members’ titles fell away. Hardin, who once served as an ED nurse, helped staff the department. Operating room nurses took shifts there, too.
The CEO of the hospital was there at night and directly recognized workers and their effort. The administration thanked the staff with meals and bonuses, Hardin said.
“One of the biggest assets leaders have is their staff,” said Anne Herleth, MSW, MPH, associate director of research at The Advisory Board Company in Washington, D.C. “The Harvey response is an example of why health care workers are among the most resilient” of all industries.
Resilience is like a muscle that develops over time, Herleth said. “One of the most powerful things is (for leaders) to ask people what they need, rather than saying, ‘Let’s do this.’”
The Las Vegas Massacre
On the night of Oct. 1, 2017, a shooter, targeting a Las Vegas music festival, killed 58 people and wounded 422. Another 429 were injured in the ensuing panic. Local hospitals quickly were swamped with patients; at least one got as many as 200, said Christopher K. Lake, Ph.D., executive director of community resiliency at the Nevada Hospital Association in Reno.
The first patients arrived while the shooter was still firing. No alert or notification to hospitals had yet gone out, Lake said. Wounded people simply pulled up to the ER in private vehicles.
“That was our defining moment, and we realized we couldn’t look at events in a silo, whether it’s a shooting, it’s a (pandemic) flu or a flood,” Lake said. “We needed to build resiliency in the community.”
Hospitals ran out of linens and other supplies. The registration clerks couldn’t enter or establish a medical record (EHR) as fast as the patients were arriving.
But the hospitals drill regularly on disasters, and the event “showed us we were much more resilient than we thought we were,” Lake said. “We had never drilled with 800 patients, and the majority of them needed surgery.”
What the hospitals didn’t have in place was a plan to help traumatized hospital workers recover. “From a mental health standpoint, that was our biggest hole. We didn’t have a mass mental health plan and had never thought of such a thing,” Lake said.
The hospitals asked the local veteran’s affairs hospital for help. The VA sent counselors who work with suicidal veterans and wounded warriors, Lake said.
“They stayed for days,” Lake said, telling the staff their intense feelings were normal and helping them cope with residual pain and grief. “That really saved us.”
Afterward, stakeholder conferences were held to dissect the response. Hospitals followed up with resiliency training and education focused on issues that had caused anxiety and confusion when wounded people were coming in. Many workers mistakenly thought they could not legally give patient information to law enforcement without violating HIPAA rules, Lake said. All of the hospitals now have a HIPAA expert on their call-in lists.
Attention also was given to expanding “John and Jane Doe — trauma alias” slots on health records and making registration easier so that patients can be seen faster. Hospitals are solving problems in collaboration and focusing together on resiliency, Lake said.
Using Resilience to Curb Hackers
While natural disasters and mass shootings are infrequent, cybersecurity is a daily worry at hospitals, said Brian Doerr, senior vice president of information technology, security officer and privacy officer at the Community Hospital Corporation in Plano.
Hospitals are the most common business targeted by ransomware hackers. Smaller and rural hospitals are especially at risk.
In 2016, St. Mark’s Medical Center in La Grange, one of the hospitals the corporation manages, was hit by a ransomware attack because of a flaw in a program that physicians used to gain remote access to electronic health records, Doerr said. When his team alerted him about problems accessing the system on a Sunday morning, he immediately thought, “This sounds like a serious problem.”
It was. The incident ended with the hospital paying a Bitcoin ransom and spending months correcting problems. “Ultimately, we ended up losing a few hours of electronic charted data in one area, but we got everything else back,” Doerr said. “It just took a lot of work, money and time.”
Some hospitals have shut down for weeks after a ransomware attack. If St. Mark’s had closed temporarily, it might not have had the resources to reopen, Doerr said. “These are life-and-death decisions not only for that hospital but for that community.”
Hospital officials spoke to the staff and community about what happened. In public comments, the hospital CEO praised the IT staff for its hard work. Doerr said it’s important to understand workers’ habits and nudge them, in a positive way, to secure their computers and patients’ data.
Discussions are underway to have a phishing email-writing workshop, along with a contest for the best phishing email, he said. Attention also is being given to promoting stories about staff who do the right thing to avoid a hack or who report suspicious emails. CHC advocates those kinds of actions to engage and empower, Doerr said. They build resiliency.
“A punitive measure may work for 12 to 18 months and after 18 months you see it fall off,” he said. “Promoting positive habits, that sticks for a long time. If you continue to do creative interesting, unique ideas that fit with your culture, it takes work, but it’s the only way to create lasting changes in behavior.”