For Covid-19 Preparedness, Hospitals Need More Than Written Protocols

I've been thinking a lot about hospitals and how they're preparing for the expected tsunami of Covid-19 patients who will need ICU beds and ventilators (when it's expected that there won't be enough of either).

There have also been recent preparations (and ongoing actions) to screen patients who arrive at emergency rooms and outpatient clinics.

I was at one organization last week that was in the process of installing new protocols and procedures in an outpatient clinic setting and I was able to have a tiny amount of input into that. Now, I'm home and trying to help remotely with the situation.

I hope this blog post helps more broadly.

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It's important to think through processes deeply at a time like this. Yes, there is urgency to move now, but there's also a need to get it right. Or, to quickly improve it once we learn it's not perfect (and hardly any process is perfect the first time we try it).

I saw this quote the other day in an article:

“In theory, we're prepared. We know what we need to do. But depending on the extent and seriousness of the outbreak, knowing what to do and being able to do it are two different things. The one thing I know with 100 percent certainty: If we think we're fully prepared, people will find a way to make sure we're not.”

— Judd Hollander, MD, senior vice president for healthcare delivery innovation at Jefferson Health

There's the key thought:

“…knowing what to do and being able to do it are two different things.”

Writing a procedure or a protocol is just ONE step in the process of developing a lock-tight process. Even if you use the Lean terminology of “standardized work,” the same idea applies.

It's not only the DOCUMENT that matters… it also matters greatly how you train people and how you supervise the work… and how you continue to refine the work.

There have been news reports with stories from nurses who complain about feeling unprepared for Covid-19. One article said they were told to watch online training videos. I think Lean thinkers would agree that watching a video about properly donning and doffing protective gear is not as effective as in-person 1×1 training with practice.

If a healthcare worker gets infected because they weren't wearing their PPE gear properly, the hospital shouldn't fall back on “Well, they watched the video” as a defense.

Methods like “Training Within Industry” provide helpful frameworks for making sure that training in job skills isn't just delivered but that it's understood and effective. TWI is basically the core of any Lean or Toyota Production System-based approach for job instruction documents, instruction, and improvement.

TWI can be used to teach and confirm understanding of proper handwashing techniques, as this video shows:

We need the right procedures based on our medical and technical knowledge. But, we don't really know for sure that a procedure is sufficient and effective until it is tested in practice.

“Hospitals should absolutely make sure that they have confidence in their training for clinical staff who might be expected to care for patients with COVID-19, whether in an emergency department, an urgent care setting or in the inpatient setting.”

— Paul Biddinger, MD, chief of the division of emergency preparedness at Massachusetts General Hospital and director of the MGH Center for Disaster Medicine

I think a Lean-thinking healthcare organization and its leaders would never assume that a protocol is correct and effective. It has to be tested. And the testing has to allow for the honest assessment that it's not fully sufficient. This could mean that

• the procedure itself is not correct or
• the way it's documented or is being taught is not clear or effective
• the world has changed in some way since the procedure was written

There needs to be room for kaizen — the continuous improvement and refinement of said standard work.

Keep in mind:

• Plan
• Do
• Study
• Adjust

Writing a standardized work document is never a one-time exercise. You might also think of this as:

• Standardize
• Do
• Study
• Adjust

Or some Toyota people talk about SDCA (Standardize, Do, Check, Act). The language doesn't matter as much as the mindset.

Another key lesson from Toyota is that standardized work should be written by the people who do the work.

I'd be less confident in procedures that are written in isolation by a group of senior leaders than I would be in procedures that are written by (or with significant input and direct involvement from) front-line staff… and then get tested in real settings.

Keep in mind the ability (and need) to iterate is not an excuse to roll out something that's half-baked because we can then improve it. Lives could be on the line in these Covid-19 circumstances, so we have to do our best to be perfect (even if that's unlikely).

When we have a procedure that's imperfect, we must learn that sooner than later.

Beyond the initial evaluation, there needs to be ongoing supervision.

I was discussing this with a colleague from Value Capture, Meghan Scanlon, last week and she said:

“…once they have these standards, how will they know if they're being followed/delivering the expected outcome? Process observation will be key.”

This is part of the ongoing PDCA improvement cycles that we need to have.

Leaders need to directly observe the process… not to be distrustful of staff or to be micromanaging, but to make sure it's possible to do the right work the right way.

We can observe and collect data to see if:

• Is the standardized work being followed?
• If followed, are we getting the results that we expected or predicted?

If not, don't blame individuals — look at how to improve the system of work.

It's been concerning to see news reports like this:

Nurses Battling Coronavirus Beg for Protective Gear and Better Planning

Nurses need to be protected, for one. Thank you, by the way, to all of the nurses and other healthcare professionals who are quite literally putting themselves in harm's way.

People can't follow the procedures for using PPE if that equipment isn't available.

“Nurses in Washington State and California said they have had to beg for N95 masks, which are thicker than surgical masks and block out much smaller particles, and have faced ridicule from colleagues when expressing concerns about catching the highly contagious virus. Some have complained about being pulled out of quarantine early to treat patients because of staff shortages.”

Nurses shouldn't have to beg for the correct equipment. That's a supply chain issue that the hospitals (and vendors) to address.

Another article talked about the N95 masks:

“Hospital administrators recently restricted practitioners' access to N95 masks, claiming it was “because of the national shortage”, this nurse said. Now, healthcare workers there have to seek a manager's permission to obtain one of these respirators – even if someone walks into the ER who presents coronavirus concerns.

Upon being screened in the triage area, patients with concerning symptoms would be isolated. Logistically, this means that nurses' requests for masks would come after potential exposure.

Right after access to N95 masks was curtailed, nurses would have to find the day's supervising nurse, who would have to call a unit manager, who would then have to call the supply room for masks. At that point, somebody would have to get these masks from the supply room, and bring them to the ER, she said.

After nurses protested the onerous process, some N95 masks were placed in a locked cart on the floor, and some with the supervising nurse. But they were only size regular, which would be too big for her and some other nurses – rendering them useless, she said.

Back to the previous quote… needless to say, people should never be ridiculed for expressing concerns about the safety of themselves or their patients.

The Guardian article had a story about that too:

When this nurse voiced concerns to management, she claims to have been warned: “stop freaking out and stop scaring everybody”.

Pulling people out of quarantine early is, of course, not the best way to address staff shortages (another systemic problem that's owned by senior leadership).

Back to the NYT story, there was detail on the alleged violation of quarantine:

“Ms. Shepler said that after quarantining some workers who were exposed to coronavirus patients, the hospital determined that the extent of the quarantine was unrealistic because it left shortages in a needed work force. They brought nurses back who were asymptomatic — an approach deemed reasonable by the C.D.C., she said — and are testing them twice a shift. They are also required to wear masks while treating patients.”

It seems that standards for quarantining a nurse should be based on the medical criteria. The variable of short staffing shouldn't enter into it, right? I realize that patients need nurses. But they also need nurses who aren't sick, even if the nurse is wearing a mask to prevent the spread of their own droplets (and to protect them from the patients).

Let's hope this has changed since March 5 (when coronavirus was already a known concern on the West Coast):

“Of the 6,500 nurses who participated, 29 percent said their hospitals had a plan in place to isolate potential coronavirus patients, and 44 percent said they had received guidance from their employers about how to handle the virus.”

Maybe some of the planning has occurred over the past ten days — “better late than never,” but again having a plan is only the first step.

We need a plan (a procedure).

We need effective training.

We need continuous improvement of those procedures.

We need supervision that helps make sure people are able to do the right things the right way.

These are critically-important issues in this day and age. They were critically important before this crisis… and they'll remain important in the future.

This was a sobering article:

U.S. Hospitals Say They're Ready for Coronavirus. Their Infection Control Violations Say Otherwise.

When patients were sent to a New Jersey hospital from a cruise ship in February:

“The hospital is following proper infection control protocols while evaluating these individuals,” Gov. Phil Murphy said in a statement. 

That's easier said than done. I wouldn't expect a Governor to know, but who is telling him that the protocols are being followed? Do hospital leaders know or are they assuming?

It was different circumstances, but the same hospital:

“Less than two years ago, a deadly bacteria made its way through the facility. Three babies in the neonatal intensive care unit got infected and died. Government inspectors cited the hospital for being short of staff; failing to maintain a sanitary environment, including improper hand hygiene and sterilization; and inadequately isolating patients with respiratory conditions. They determined the hospital had put patients in “immediate jeopardy.”

Maybe that's all indeed been fixed… but have problems like that been fixed at your local hospital?

As we know, hand hygiene compliance is a widespread problem. Many times, in various hospitals, I've observed staff and doctors ignore or violate isolation PPE guidelines or other practices that would impact infection rates.

“But infection control has been a recurring problem at some of the very hospitals that would likely be called upon to treat COVID-19 patients, a ProPublica review of hundreds of hospital inspection reports found. This raises concerns that they could become hotbeds for disease, putting patients at risk and rendering infected workers unable to care for others.”

Let's hope hospitals have this figured out… many many lives depend on it.

“Medical providers across the country told ProPublica that they're worried about their safety and their hospitals' lack of preparation. They spoke on the condition of anonymity because they were not authorized to speak on behalf of their hospitals.”

And they probably fear retaliation for speaking up… internally or externally.

What are you seeing in your healthcare organization, if you work in one? You can leave an anonymous comment if you like. Are you using Lean methods to ensure that training is effective?

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