Over the past several weeks, the COVID-19 pandemic has challenged routines in all of our lives and has brought into focus the need for rapid change as we race to re-define and improve how we are delivering health care. At Mount Sinai Morningside (MSM), an urban community hospital in New York City and a member of the Mount Sinai Health System, we have started up a traditional incident management team (IMT), including an Incident Commander and Section Chiefs for Planning, Operations, Logistics, Safety, Medical Specialty, Finance, and Communications. In addition to the traditional structure, we have connected real-time data and rapid tests of change to our incident command response.
The IMT hub of operations is The James Jones Daily Management and Incident Command Center (DMC). The DMC, created in 2018, houses 10 digital dashboards which display real-time information for both clinical and non-clinical operations, pulled directly from our electronic health records. The data displayed on the dashboards were chosen by numerous facilitated interdisciplinary design workshops. Since inception, the information from the DMC has been connected to daily management and standard work. One of the dashboards is reserved for emergencies and is known as our Disaster Tile. Since opening the DMC, we have practiced using this dashboard for mock mass casualty events but are now using it for real-time management of our COVID-19 response. The IMT huddles multiple times daily and reviews the information below, which has now been added to the Disaster Tile:
- Total number of COVID-19+ patients and their bed location (ICU, non-ICU, and ED)
- Total number of Persons Under Investigation (PUI) and their location
- Total number of COVID-19 or PUI patient expirations (ICU, non-ICU, and ED)
- Total transfers from ICU to non-ICU and vice versa
- Total discharges to home or other facilities
- Total number COVID-19 tested (Admitted, Discharged, and Admission Decision Pending)
- Total number of ED patients ordered to self-isolate but not tested
- Number and location of negative pressure rooms
- Total number of surge critical care beds and occupancy by location
- Total number of surge non-critical care beds and occupancy by location
- Total number of patients on invasive and non-invasive ventilation
Since we do not have an electronic process that connects to our morgue, we review but must manually account for census and LOS for decedents.
In addition to connecting our information framework to our incident management, we have been actively engaged in numerous rapid tests of change to solve issues identified in the command center. As problems are identified, a workgroup of stakeholders is quickly convened in the Lean lab and solutions are identified within one-two hours. The solutions are presented to the IMT for awareness. The Lean team has taken an active role in operationalizing the process changes with the appropriate stakeholders, shifting from our usual coaching/teaching model.
It is impossible to catalogue all of the rapid cycle PDCAs that have occurred. In one example, early in our journey, we needed a solution for protecting resuscitation teams attending to patients with unknown COVID-19 status. Our solution was a PPE “go” bag. We have included the specifics of this tool/workflow and a few other tools and process changes in the link below. As the pace quickens and our needs evolve, much of our work is already outdated, however, we hope that by sharing some of the changes made, we can inform and inspire other process improvement teams who are on this same journey across the globe.