By Lisa Yerian M.D. and John Toussaint M.D.
There is great concern throughout the U.S. that health systems will not be able to meet the demand of the potential exponential growth of critically ill patients with COVID-19. This is playing out in New York where some hospitals have full ICUs and too few ventilators to meet the patient demand. Many of these hospitals are in a crisis management mode yet only a few, such as Morningside Mt. Sinai (listen to our podcast), have actually built a standardized management system that can support the front line in this crisis. In other parts of the country there are shining stars that have been building a standardized management approach that has readied them for just such a crisis. In Cleveland, Ohio, the Cleveland Clinic provides nearly 10 million patient visits a year. Leaders and staff there recognized the gravity of the situation at the end of February and acted quickly and decisively to help stave off the chaos that is now crippling other health systems.
For years Cleveland Clinic has been on a journey to excellence. It has built a series of standardized systems that are based on the core principles of organizational excellence. Principles such as respect for people and pursuit of a “culture of improvement,” which has led to engaging employees (“caregivers”) in everyday problem solving. A core principle to Cleveland Clinic’s work has been using scientific problem-solving methods to identify and solve difficult problems. Over 20,000 Cleveland Clinic employees have been trained to use scientific methods to tackle all kinds of daily issues, drive innovation, and maintain stability.
So COVID-19 was a new problem – a new and particularly challenging problem - that staff unleashed their problem-solving skills and creative ideas to solve. Supported by a robust improvement system, these ideas could be rapidly and effectively trialed and have led to some remarkable almost overnight changes.
Cleveland Clinic is guided by an overarching “True North” – a clearly articulated purpose that drives all decisions: Serving our patients and our caregivers. This focus helps to provide clarity in decision-making every day and has been the overarching guide to attacking COVID-19.
Leaders at Cleveland Clinic have looked at serving caregivers in terms of the needs they have for information flow, equipment, and support. One of the many systems created to achieve True North is a management system that involves tiered daily huddles. Since their inception in 2018, tiered huddles occur each day across the enterprise at every level from CEO to “bedside” teams. In the case of COVID-19 this system allowed for rapid capture of critical operational information across large, geographically separated business units (hospitals and outpatient facilities) in order to identify and solve problems quickly at all levels of the organization. The huddles disseminate information, updates, gratitude and support – consistently, and rapidly. COVID-19 required rapid updating of the standard content of every huddle to include information on staffing, the number of patients testing positive in the hospitals, in which units they were being cared for, and the number of persons under investigation at any given time. Since these huddles were developed and standardized long before the crisis, changes could be rapidly implemented and backup was in place for times when the huddle leader was pulled to other COVID-19- related activities. In addition, now some teams are huddling virtually because a number of people are now working from home for “social distancing.” Although the virtual huddle is new for many, the Cleveland Clinic staff are quickly learning a lot about how to do that effectively.
The result of rapidly cascading management decisions has included the rapid implementation of drive-through testing sites for COVID-19. This was initiated on March 14, one of only a few of the first drive-through testing sites in the nation. Since then public health departments and other health systems have copied it. The process is designed to test patients in a “drive-through” fashion, in a car, while keeping patients and caregivers safe. The improvement teams worked with staff and leaders to develop a new process and use rapid cycle kaizen to improve from 30 to 115 patient samples collected per hour over the first five days with the same staffing. Staffing the drive centers was a challenge and improvement teams came up with ideas such as staffing the site with volunteers from multiple locations, functions, and skill sets including people with clinical and nonclinical backgrounds. Staff were quickly trained and integrated into the process of safely registering a patient, doing a nasal swab, and safely packaging it for transfer to the lab – all while maintaining safety precautions to protect both the patient and the caregiver.
The importance of staff safety in this scenario cannot be overstated. If staff aren’t safe patients aren’t safe. A recent article in Bloomberg news tells the story of caregivers going to Home Depot to construct their own masks. The supply chains in the U.S. are not keeping up with needs for our staff to be safe. Leaders’ No. 1 priority must be safety. In another example a colleague and primary care doctor in Wisconsin is taking the mask he uses during the clinic hours and placing it in a Tupperware container at night not knowing if he will have access to a fresh mask in the morning. Tiered daily huddles and gemba walks enable leaders to deeply and rapidly understand the challenges faced by staff and patients in outpatient clinics, emergency departments, and hospital floors. Safety remains paramount, and leaders must remove barriers quickly on issues and questions arising from the front line as Cleveland Clinic does with daily tiered huddles.
Cleveland Clinic’s improvement team has been redeployed to help leaders and front-line team members map existing processes and create new future state processes, and scientific problem solving, visual management and standard work are broadly applied at the hospital’s command centers. This thinking will be required to rapidly assess patient demand, resource needs and staffing as well as to triage patients while keeping our patients and caregivers safe.
We know for certain that we will need the ideas of every caregiver, manager and leader at Cleveland Clinic to identify and solve the many new problems that arise in this crisis. But by applying the new standard work processes created from rapid improvement cycles and continuing to encourage all staff to experiment with novel ideas not thought possible before, Cleveland Clinic staff and leaders are confident this challenge will be another problem that can and will be solved.
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