Whitepaper Corona Future Management is the medical scientific publishing company platform with contributions from experts of different disciplines. You can read the whitepaper of authors Dr. Christophe Vertterli and Raphael Roth in this blog. The original whitepaper in German is here and you can download it as a PDF. Note: The below text is a translation of the original.
How a hospital group has created crisis-resistant agility through design thinking and lean principles.
When Armstrong took that famous small step for mankind on the moon, many things happened. In addition to the incredible courage of the astronauts, how was it possible to plan the distance, the abundance of data, the unpredictability, and the complexity in such a way that full control over the situation was maintained? Without doubt, a central role was played by mission control, which transferred the right information to the right place at the right time to the right decision-making team. What did they need to control? It was about getting three human lives to the moon and safely landing back on earth. Admittedly, however, this was the less central part compared with the prestige, proof of technology, and innovation leadership in the head-to-head race with the then Soviet Union. Even more than 50 years later, modern and partly privately financed space travel still uses such a mission control system; it has lost nothing of its power and importance.
In hospitals, prestige is less significant in times of COVID-19. Every day is a matter of ensuring the operation is smooth and the best possible care is taken of patients under difficult conditions. Even in non-COVID-19 times, the coordination of information, problem-solving processes, and decision-making is often random and not based on real-time data. Only with enormous effort and a great deal of waste, despite scarce resources, do individuals create transparency in such situations. The bed report in the morning, for example, usually deals with capacities which haven’t been updated and are therefore largely worthless. The availability of doctors for the next day is based on the hope that the duty rosters are right. In COVID-19 times these difficulties are accentuated and the significance of up to date information and valid decision bases increases, especially true in these times of crisis security, when fast decisions about standardized processes are even more relevant. The management team needs to deliver security and be able to make the right decisions based on facts. Similar to Houston, Texas in July 1969, the “mission control” of COVID-19 concerns the greatest possible control over the situation. This should not only be reactive, but also anticipate potential challenges such as staff and bed shortages and make them continuously transparent via automated processes. The aim is to take the right countermeasures in good time, such as activating additional intensive care places, before the situation has already escalated and additional stress factors arise.
A hospital group in Switzerland was located close to a very severely affected region; it had a total of five locations and more than 400 beds. At the end of February 2020, the management team decided to use the basic principle of mission control; a COVID-19 operations center was created.
Pre-reacting so far in advance brought some positives to the emergency situation. “Things could be developed that had not been possible ten years earlier,” said the medical director on an evening in the middle of the crisis.
The development of a lean operations center for COVID-19 and beyond
The first-generation operations center became live within seven days of its initiation, with mostly analogue elements. The following core elements were included:
- physical space with decision makers
- standardized information flow from the base to the Operations Center and back
- central data aggregation logic
- structured communication channels.
1. Physical space with decision makers:
The word ‘center’ within the title operations center is not insignificant. An essential component is the physical space where the decision-makers inform and coordinate. This space contains control cockpits for presenting the facts. It is this physical proximity that really brings speed to the decision-making process. Information paths are short, the relevant functions are quickly well-informed, and rapid, fact-based decisions can be made.
To ensure that productivity is not lost due to the large number of people on site, each role owns a clear description and a clearly defined workspace. Which information is displayed, who speaks in which order, and how decisions are made are all standardized and everyone knows the process. Only in this way can speed and efficiency be maintained.
Applying these principles requires practice, but just as in the rapid spread of this crisis, the entire operations center was set up much faster than usual, and the people involved quickly got used to their roles and the tasks they had to perform. The success factor here is to visualize as much as possible; placing name badges on workstations and high desks in the meeting rooms, hanging the structure and standards for regular meetings on wall posters, and setting up signposts both inside and outside the building. Another benefit of centralization is the easy access to the physical space and the availability of retreat and meeting rooms of different sizes to discuss bilateral issues quickly and efficiently directly after larger group meetings.
A central decision point is the decision team’s 8:30 a.m. morning huddle in the operations center. The lead today is the deputy medical director. He briefly greets the group and then takes a look at the screen showing the latest figures. The IPS allocation is stable, but the material, especially the stock of FFP2 masks, lights up red. He follows the standard approach and invites the head physician of the intensive care unit to go first. He is satisfied and has not yet reported any infections among the staff. He is expecting a large number of people to come in today because the good weather of the last few days has encouraged people to go outside. So, the word is passed on to the infectiologist and head physician of internal medicine. Further functions are available via video for specific questions. Some people pass on speaking as they have nothing acute to present. The logistics manager reports that masks must not be changed during the entire shift due to the limited supply. The new mask order is currently at the border into the country. Now, the interfaces, which were switched on by video, are also reporting. The site manager of the second largest site asks when the first operating theaters could be planned. The deputy medical director replies that this is the topic of the afternoon meeting and that he is currently unable to provide any specific data. Finally, the committee takes a look at the questions from the wards, which were collected at the separate ward huddles. Station F asks what the plan is for deceased Covid-19 patients. The question is assigned to the person responsible for infectiology. He will later formulate his answer in a specially created online tool and send it back to the wards.
It is 08:44 a.m. – the huddle ends punctually in the 15-minute period and everyone gets back to work.
2. Standardized information flow from the base to the operations center and back:
The operations center can only function if it has all relevant data on current events available in a timely manner. In addition, the data must be collected in a standard way from all sources, and transmitted at the same time. Comparisons, developments, and countermeasures can only be actioned on the basis of facts.
To ensure this, clear structures and a standard escalation procedure are needed from the grassroots to the clinic and at departmental level. Within the framework of so-called huddles, short team exchange meetings, information is requested in a targeted and standardized manner. The focus here is on deviations from everyday events. These can be short-term absences due to illness, lack of bed capacity, or similar. Such “red flags” are escalated to the next higher management level, but the escalation only goes so far until the level that can solve the problem. It is never escalated further than necessary. The different leadership level huddles are coordinated in a shared calendar. Problems that cannot be solved end up in the operations center, where measures are initiated and communicated back to the affected area. Of course, the flow of information can also originate from the operations center. If a bottleneck in the emergency room is anticipated, appropriate discharge instructions are communicated to the wards. This ensures that the outflow from the emergency room remains feasible.
Sandra Werner is head of ward F. It is 3:30 p.m. and the nursing staff and responsible assistant doctors have gathered in front of the base for the afternoon huddle. The huddle cockpit is shown on a large screen. Ms Werner moderates and updates the data directly. First, she asks about changes in area A of ward F. A suspected case has turned out to be Covid-19 negative and will be transferred directly to a non-Covid-19 ward. In area B of the ward a planned discharge is still pending. Ms. Werner asks the assistant doctor why this has not yet been carried out and is told the senior physician’s signature is still missing from the report. Dr. Meissner, who is also present at the huddle, assures him he will do this immediately afterwards. Now Ms Werner reads the answer to the question about her ward which was addressed in the operations center this morning. Under strict supervision, a maximum of two relatives may see the deceased again briefly. Sandra Werner wishes a good end to the service and reminds everyone about the next huddle the following day at 07:30 am, ahead of the operations center huddle at 08:30 am.
3. Central data aggregation logic:
It is not that hospitals do not evaluate data and compile statistics; the common problem in hospitals is the disparity between different information systems across departments. It is not uncommon for the emergency room, laboratory, and pathology departments to work with different systems from the wards or outpatient clinics. It is therefore impossible to have a holistic view of bed capacities, for example. Especially in crises, however, one must be able to trust the available data. It does not help if systems display different bed capacities from the information obtained by telephone from the responsible persons. To be able to make decisions, the same data basis is needed every day. Only when a comprehensive aggregation logic is applied can this data be backed up with forecasts. This increases the quality of the data and the opportunity to work on a truly data-based basis. This, in turn, enables the management board to switch from reaction to action mode.
Data aggregation in the operations center follows a holistic logic. Real-time data from all areas are displayed in virtual cockpits on screens that are universally, simultaneously accessible, so they provide a direct basis for decision-making for all relevant staff. The first step is to decide which data sources to use. These must be the same across all locations. The goal is not only to display raw data, but also to show diagrams on the screens in the operations center, demonstrating progress to which forecasts can be attached, so that the cockpit displays trigger actions. This action orientation is central. Each person must know what to do in their role in a specific situation and how to correctly initiate problem solutions.
Laurin Matthews is the person responsible for IT and, with his team, has delivered things in just one week that had not been done before in ten years. He sits down with a developer and the maintenance person responsible for training and is working on the second version of the huddle cockpit. The needs are very different depending on the users. On the wards, the cockpit should be as simple as possible, without special functions, a fancy design, or gadgets. There is little time for training, so the fields must be self-explanatory. Everything that should not be filled in is blocked for entry.
In contrast, the cockpits in the operations center are more detailed and offer different filter functions. They collect data from different systems, sometimes even from Excel sheets or manually entered information. After all, this is only the first prototype that was rapidly developed during the crisis. Further development follows by learning what is really useful and what is not. This is how design thinking works; iteration over iteration to better and better solutions at a fast pace, oriented to the prevailing needs.
4. Structured communication channels:
In times of crisis, the goal is to communicate quickly and clearly at all levels in a manner appropriate to the scenario. The crisis management team needs physical proximity and the correct data basis and structures to be able to make regular decisions. Those responsible for communication are particularly dependent on physical proximity; they form the interface to the communication tool that was set up specifically for all employees. They must obtain approval for all content from the correct interfaces. After all, they are the ones who must also collect data and continuously inform the other levels, being employees, the population, media representatives, etc.
How can this be guaranteed? How can as many employees as possible be reached quickly? An app. quickly provided a solution. It worked as a front-end for all stakeholders. It was technically quick to implement and easy to load with the relevant content.
There are various providers in this market. Important criteria in the selection process are as follows:
- speed of implementation
- simplicity of user interface
Until now, most information has been shared via the intranet, but this becomes too unstructured at some points in a crisis and irrelevant information becomes distracting. The communication instrument must serve different groups of participants, must include the option of personal messages, have a live ticker on relevant key figures, etc.
The person responsible for communication, Bettina Sommerhalder, has been very busy these last weeks. Her work has changed a lot. Normally, she has days or weeks to generate content with her team, and have it approved by different interfaces. She is happy to have a filming team at her side that develops information and training films within 24 hours; it doesn’t have to be perfect but must contain the right content and be fast to deliver. She herself tries to get as many approvals as possible at the daily huddle at 08.30. The phone is constantly ringing. She calls regular media appointments. She has now outsourced the use of the app for employees. It is clearly defined who delivers which content. These are filled into templates and then posted automatically.
The advantages and challenges of embedding
The mission was to start with the greatest number of focal points and quickly create applicable options for action. A crisis offers the opportunity to tackle things that for years had not found consensus, were not considered urgent, and were repeatedly postponed. The operations center intervenes deeply in the DNA of the hospital. The complexity of the system becomes tangible and controllable in the operations center. The political and power games become palpable; but in a crisis, it is vital that everyone pulls together.
During this time, the following results have been achieved:
- Faster communication & continuous flow of information: The broad introduction of huddles in all departments, carried out twice a day, creates a direct information channel into the operations center. The departments communicate personnel and material bottlenecks, discuss unsolvable problems, and ask pertinent questions via the huddle. These are processed directly in the operations center. Over 80% of the inquiries were successfully addressed to the functions within less than 60 minutes. For the remaining 20%, the problem-solving strategy and the next discussion time were communicated. This connection led to the employees on the frontline feeling “heard.” Of course, not all problems can be solved within a day, but there is an efficient, uniform, structured, two-way communication channel for everyone. The data and information entered in the huddle cockpit is the same for all departments. In the additionally installed app, about which all employees of the five locations are regularly informed, this information is again displayed in consolidated form. This increased the commitment and understanding of the basis for the newly introduced huddle structure and it was clear to everyone why the data and information they had entered was so important for further decisions.
- Transparency: The crisis shows, more than ever, how important transparency is; transparency about the material and equipment available, about personnel changes, and, above all, about intensive care bed capacities. This makes it all the more alarming that the collection of these facts is still done by hand in most hospitals; via telephone calls with the ward managers in the morning, and via dropping by the units and departments. With the operations center, a system was set up within a few days that aggregates and evaluates all these figures in digital form (although for the time being certain things were still being collected in Excel sheets). After seven days, all decision-relevant figures were displayed on the screen at 8:30 a.m. and forwarded to the responsible accountable authority. If everyone adheres to the agreed standards, it is a powerful system. If the will and the time pressure are there, appropriate cockpits can be developed and programmed in the shortest possible time. Why wait until a crisis comes?
- Relevant competencies in place: In normal times, every clinic has its own premises and managers have their own office, their own secretaries, and their own way of doing things. During a crisis, critical decisions must be made more frequently and more quickly. Thus, the unthinkable is overcome and all relevant areas including nursing management, medical management, personnel planning, logistics, HR managers, bed disposition, finances, IT, etc. come together in one large room. Each role has its workplace separated from the others by a plexiglass panel. It takes some getting used to at the beginning, but from the very first day there are intermediate meetings that make the work more efficient and productive. There is less need to pick up the phone, and fewer e-mails are written. And at several points in time the representatives come together in a huddle to discuss unsolved problems, communicate decisions, and create transparency together. Interfaces from other locations are connected via video. A feeling of togetherness develops in a very short time. Of course, discrepancies do not suddenly disappear, but the physical presence of all relevant functionaries makes it easier to hold focused discussions and make decisions. The time constraints for the consistently structured exchange vessels help to focus on the essentials.
- Change management: In a crisis, things have to move quickly. There is not much time for everyone to get up to speed. While the tension and uncertainty are high, everyone is collectively in crisis mode. But when this tension gradually eases off, all too familiar machinations emerge from the business areas taking the form of resistance from the wards that do not agree with the intervention in their everyday structure and resistance from senior physicians who want to have a say in decisions. In short, resistance cannot be avoided in this situation; only delayed. Change management must always play a role and be universally considered. If it is neglected in the crisis, it must be made up for later.
- Close cooperation between IT & base: The topics of information flow and central data aggregation logic must be well coordinated. If these two develop solutions independently of each other, the result is incompatible systems. Data can only be embedded in cockpits as long as they are available in the systems. In crises, processes that were already difficult beforehand the work even less efficiently or not at all. So, if the timeliness and completeness of the data entered into the hospital information system are problematic, the cockpit cannot be created based on them. For this purpose, an emergency solution may have to be developed as a transition (in the above example of a quickly available Excel logic), where it can be controlled one to one relating to which teams enter their data and which do not. For this, both topics must be developed as an integral package. IT and the base have to improve the prototypes of their solutions in joint workshops. Fast learning is central.
- Demand presence: The success of the operations center depends on the presence of the relevant departments at the agreed times. For this reason, it is of utmost importance to start setting up the room, bringing in screens, and pushing the development directly on-site on the first day. If no such room is available, it will be very difficult to bring the whole thing to life. Once the space is made available, being present at the defined times (e.g. huddle) from day one must be mandatory. If important functions are missing, decisions cannot be discussed. Consequently, the effect of these meetings decreases, and huddle relevance reduces for the other areas as well. Therefore, complete attendance is mandatory.
Transformation to an operations center after COVID-19
The post-crisis transformation represents an important step and must be considered during the crisis. What has been learned, namely fast decision-making processes, clearly defined and standardized information flows, and increased controllability and predictability, are naturally also relevant after the crisis. The basic elements remain the same, but the focus shifts to the optimal management of existing capacities. An operations center offers the opportunity to ideally coordinate all resources along the patient process, from consultation hours or emergency rooms, through to the operating room and diagnostics, to the wards. Today, most of these areas function independently of each other, which leads to major frictional losses. If the logic that has been successful in the crisis can be applied here, everyone benefits – patients, employees and, not least, hospital managers. Leading hospitals around the world, such as John Hopkins Hospital in Baltimore, are leading the way. The stabilization and control of day-to-day operations, which an operations center makes possible, is the basis for overcoming the challenges that lie ahead like shortage of skilled workers, digitalization, economic pressure, etc. and also allows us to understand the transformation into the new normal as an integral part of the crisis and to conceptualize it in this way.
The landing on the moon in 1969, and the docking of Dragon with the ISS in spring 2020, were based on a perfectly functioning mission control. This has to be embedded in the hospital environment in an analogous way and not just maintained during a crisis. The lack of transparency, the asynchronous information retrieval, and the poor data quality are all wasteful elements that can be addressed within the logic of an operations center, based on lean design principles via standards, flow orientation of information and decisions, real-time data, and having the right people in the right place at the right time helping with the design. In a crisis, it is not possible to create everything perfectly in a first version. That’s where the leading innovation method design thinking comes in which uses prototype-based development iterations to give key people the opportunity to quickly go live with a first working version and to continuously improve on it. Prototype by prototype, more and more waste is eliminated. The Swiss example described above shows how design thinking has facilitated an incredibly high development speed and how lean design principles set the framework for solution development. This approach works not only for the establishment of an operations center, but also increasing numbers of hospitals are combining these two approaches into a winning formula to continuously drive forward process innovation.
If you would like to learn more from the project and medical management of the operating centers described above, the authors recommend the following recording of the webinar of the International Hospital Federation: https://www.youtube.com/watch?v=i6UlyrkFD_k&feature=youtu.be