Case Scenario: The administrator on call at a hospital is awakened at midnight with reports of rapidly spreading wildfires in the area due to multiple lightning strikes on a hot, windy night. First responders are mobilizing, and a helicopter has started dropping off people rescued from engulfed hilltops on the hospital’s helipad, as it is the closest one available. Hundreds of people are being evacuated from the surrounding areas, and thick smoke is rapidly filling the air. The only other hospital in the area is preparing to evacuate due to the rapidly approaching fire. How does the hospital leadership respond to this potential crisis? Who should be part of the collaborative response?
Physician engagement, partnership, and collaboration are the bases for the success of any healthcare organization, including group practices, hospital organizations, insurance companies, and accountable care organizations (ACOs). Studies have shown that a collaborative environment benefits the patients and the community at large through better clinical outcomes, patient and staff satisfaction, reduction in error rates, decreased length of stay, physician recruitment, growth, and retention.
Three categories of factors influence inter-physician collaboration: personal factors, professional factors, and organizational factors.(1)
Personal factors include language, gender, age, culture, autonomy, personal goals and challenges, and reluctance to change. Being part of an organization with appropriate support, coaching/mentoring, onboarding, and monitoring is one way to tackle these factors if they become obstacles to collaboration.
Professional factors that affect inter-physician collaboration include medical specialty, hierarchy, responsibilities, workload, stress, and stereotypes. Organizational factors include leadership, culture, communication, and shared goals.
Effective leadership centers around having quality champions who are inclusive, transparent, and open-minded; who can address challenges to collaboration, building a culture of inclusion and transparency; and who are invested in and committed to employee growth.
ENHANCING INTER-PHYSICIAN COLLABORATION
The pathway to success for inter-physician collaboration requires addressing the categorical challenges listed above. Understanding the importance of collaboration to organizational success and dedicating the necessary resources to enhancing collaboration ultimately benefits everyone. Leaders can promote collaboration through positive communication, inclusive goal-setting, and teamwork.
A culture of collaboration requires open and frequent communication to build trust and rapport. Increased emphasis should be placed on listening to and acknowledging physicians’ concerns and being empathetic. Rather than making an issue personal, the leader should listen to understand the root cause, provide honest and direct communication, be prepared to offer solutions, be supportive and encouraging, and be fair and consistent. Giving feedback with positive reinforcement and physician recognition is a good strategy, and gratitude and appreciation go a long way.
Involving physicians and physician leadership in the early discernment process for setting goals, protocols, and changes in policies and procedures promotes engagement and fosters collaboration.
In general, physicians are trained to be individual thinkers. They often take charge of a situation and find solutions. It is important to have strong organizational leaders who can not only communicate well with physicians and physician leaders, but also who are willing to get them involved.
LEADERSHIP AND CONTINGENCY PLANNING
Many new leaders don’t know what they need to know about emergency preparedness and disaster management until they need to know it. One event can cause an emergency and a disaster; the difference in outcome is related to preparedness and relative resources.
Disasters can be natural or technological.(2) Natural disasters include weather and climate events with acute onsets such as hurricanes, floods, extreme heat, tornadoes, tsunamis, volcanic eruptions, blizzards or extreme cold, droughts, earthquakes, and wildfires. Technological or man-made disasters can include nuclear accidents, explosions, bioterrorism, cyberthreats, and epidemics.
The two categories can overlap. Recall the 2011 earthquake in Japan that triggered a tsunami that caused a nuclear accident at the Fukushima Power Plant.(2) As technology advances, so does the risk of concurrent or sequential emergencies between natural and man-made disasters.
Threat Assessment
A critical element of emergency preparedness is the hazard risk assessment (HRA) tool, which determines what events are most likely to occur in the area where a facility is located. For example, hurricanes are more likely on the East Coast, and earthquakes are a threat on the West Coast. Internal disasters include utility failures or fires; external threats of ransomware attacks are becoming more prevalent, especially in the healthcare setting.
An effective HRA examines the stability of the organization and the most likely threats to a community. This analysis includes using historical data to review incidents and their severity, as well as scientific data to look ahead at predictive threats. The assessment is critical to creating plans to mitigate and manage these hazards.
Emergency management plans should include provisions for the specific facility, contain policies for different scenarios, and consider partnerships with other responding agencies. The critical elements are structure (resources, equipment, and staff), process (response and communication), and outcomes (restoration of operations and maintenance of health status).(3)
Emergency Response
Similar to the ABCs of CPR, immediate response to an emergency in a facility is centered on three main questions:
Is the building structurally intact and safe?
Are the utilities working to allow function, and is the air safe to breathe? Does additional equipment need to be set up?
Do evacuation or shelter-in-place measures need to be taken immediately, and can appropriate resources, including staff, be adequately mobilized and moved throughout the facility?
Healthcare workers’ response to emergencies is critical to response capacity.(4) Workers are less likely to respond if they fear for their personal safety or that of their families, if they feel they don’t have adequate training, or if they believe they are not important to the outcomes.(5) Clerical and support staff tend to feel less important than clinical staff. Drills and training can improve these outcomes.
Self-efficacy is a psychological attribute that empowers people to be confident in high-stress situations.(6) Workers are nearly 10 times more likely to respond to an emergency if they feel it is important to the response. The sense of efficacy outweighs the perception of risk of the threat in a worker’s willingness to respond. When training in responding to specific hazards includes a discussion on willingness, not just readiness, response rates drastically improve.(4)
The elements of the response process involve the successful operational performance of the plan and depend on preparation, training, and drills to ensure teams know their roles in an emergency and can activate the plan quickly and efficiently.
Emergency Communications
Communication is a critical component of the process, as it is necessary to mitigate panic during an emergency. Communication needs to be bidirectional, with messages coming in and being transmitted. Because many disasters can disrupt phone lines, the ability to go “analog” is important. Pagers, Wi-Fi calling, and radio stations that broadcast locally can mitigate digital and cellular downtime.
Perception of risk decreases when people feel some sense of control and familiarity. Information going out should be simple and easily digested. Use the “rule of threes” in effective message mapping:
Identify the audience and their questions/concerns.
Develop risk messages.
Deliver your messages.
Communicate three key facts in descending priority to keep information organized and concise.(7)
The outcomes of an emergency response plan are based on the preparation work. The ultimate goal is restoring normal operations and the subsequent health and safety of the community and the response team, including mental health. For every person physically affected by disasters, 4 to 50 times that may suffer psychological effects, and the distress is greater in man-made disasters than natural ones.(4)
Mitigating psychological effects early in a disaster can help prevent overloading available resources with the “worried well.” Effective risk communication and mobilization of support resources into the community can reduce long-term psychological effects for victims and responders. These effects can range from mild symptoms of fear, worry, and transient sleep disturbance, to moderate symptoms of insomnia, anxiety, and increased alcohol or tobacco use, to severe symptoms of PTSD and major depressive disorder. Children can become regressive or aggressive in response to disasters.(2) Disaster plans should always provide behavioral health resources and reunification plans for children.
The National Incident Management System (NIMS), provided by FEMA for all responders to a disaster, offers training in structure, resource availability, response frameworks, and mutual aid.(8) A sub-training program called the Hospital Incident Command System (HICS) covers setting up an incident command center, the roles necessary to manage the incident, and the forms mandatory to submit to local and federal authorities, especially if FEMA reimbursement will be sought for expenses.(9)
This training is important not only to better understand how to manage emergencies locally and in collaboration with all other agencies who speak the same “language,” but it is also mandated by the Centers for Medicare and Medicaid Services (CMS).(10)
CMS created an Emergency Preparedness Rule with four requirements:
Risk assessment.
A communication plan: internal, external, and interagency.
Policies and procedures.
Training and testing.
Returning to the case study, now that the wildfire emergency has been identified, the critical first steps are:
The hospital incident command center is opened.
All necessary personnel are informed of the command center’s opening and location, and staff are called in.
Roles in the command center are assigned.
The facility is inspected for structural integrity and safety, and to ensure that utilities or the backup systems are functioning. Rooms with ventilators must be adequately powered to ensure patient safety.
Windows and doors are secured to prevent contaminated, smoky air from entering the facility. Air scrubbers are deployed to high-risk areas (ICU, OR, NICU) with vulnerable patients.
Communication is initiated with internal unit leaders at a scheduled cadence to ensure continued operational integrity and identify needs for resource deployment.
Communication channels with external agencies — county, state, and fire — are established with a schedule for check-in times.
All units follow their internal emergency management policies.
Triage areas are set up for the potential influx of patients: the injured and the evacuated.
ORGANIZATIONAL SYSTEMS
A high-functioning organization adopts a structure to bring clarity, efficiency, and optimization to its operations. This structure helps employees and leaders understand job responsibilities, decision-making, communication, and intra-departmental and inter-departmental interactions. Recruitment and retention are also salient features of a well-structured organization.
A variety of structural models are available; their success depends on the organization’s culture, size, needs, market environment, and other factors. It is common for an organization to implement a conglomerate of various models.
Prerequisites for Developing an Organizational Structure
A leader or leadership team needs to address the question, “What is the purpose of the organizational chart, and is it clear?” The fundamental principles for an organizational chart are as follows.
Alignment of Goals and Culture. The model must represent goals and cultural values.
Chain of Command. A detailed chain of command helps develop protocols and brings clarity and accountability.
Roles and Responsibilities. In addition to clarifying a job description, descriptions of roles and responsibilities help with recruitment and accountability, which leads to higher retention and better job satisfaction.
Decision-making and Scope of Control Authority. Defining parameters fosters efficiency and optimization, which helps an individual employee, team, or department appropriately escalate concerns or address them through the proper channels.
Intra- and Inter-Departmental Operations. A model should reflect how the structure addresses the needs of an employee, team, and department. Furthermore, it should foster a culture of collaboration for the success of the organization.
Organizational Structures
Organizational structures vary by organization.(11)
Centralized versus Decentralized. The centralized model is traditional and more commonly used. Senior leaders are responsible for making major decisions and guiding the organization. Well-defined responsibilities are cascaded down to individual teams and employees. Clear communication, transparency, and chain of command are well established and are essential for its success.
The decentralized model, in contrast, provides more autonomy to individual divisions, departments, and teams. This structure is commonly seen in geographically dispersed organizations or conglomerates.Hierarchical versus Circular. The hierarchical model is a pyramid-based organizational chart with a well-established chain of command. Moving down the pyramid, authority and responsibilities become more granular, limited, and focused on the specific department.
In a circular model, the core leadership is at its center, and information flows out in all directions.Vertical versus Flat. In the vertical model, core leadership is at the top/center of the organization chart and has a clear chain of command and escalation path.
In the flat model, an employee can have responsibilities in multiple departments and can report to more than one manager across departments.
Span of Control
The span of control is defined as the number of employees who report directly to a manager or leader. It is calculated by dividing the total number of employees the supervisor manages by the number of supervisors. Independent of the organizational structure or model, a span of control plays a vital role in productivity, efficiency, motivation, and culture building. Strong, experienced leadership with good communication skills is essential for success in engaging employees and inter-departmental collaboration.
There are two types of spans of control.(12)
Wide Span of Control. In this model, fewer managers oversee many employees. This is generally seen in organizations with flat structures. Some benefits are more direct communication, lower overhead costs (lower manager salaries), a feeling of employee empowerment due to less oversight, more accountability and decision-making authority, and increased engagement and innovation.
Narrow Span of Control. In this setup, a manager is responsible for a smaller team. This is generally seen in departments requiring closer supervision, especially those handling complex jobs. A manager can provide closer attention with direct oversight, which helps with employee development, team guidance, and communication. Multiple layers of leadership, high cost (more managers), more bureaucracy, and a slower decision-making process are some of the potential challenges. This type of span of control is generally seen in organizations with centralized, hierarchical structures.
Chain of Command
A chain of command is a ladder of authority in which those in charge of an organization or company direct and control employees below them. In the business world, the hierarchy delineates the reporting structure and the roles an individual plays within the organization. Generally, there are three types of roles in the chain of command: senior management, middle management, and regular employees.
Pros of a chain of command structure include(13):
Clear structure of authority.
Quick decision-making.
Specialization of skills and function.
Accountability.
Increased stability.
Cons of a chain of command structure are(13):
Lack of flexibility and delayed reactions.
Decreased employee morale.
Communication breakdown.
Micromanagement.
Misuse of power.
When developing, reviewing, and implementing a well-defined chain of command policy, the following factors should be considered(14) :
Eliminating/limiting the barriers.
Structured communication.
Employee education.
SBAR reporting (Situation, Background, Assessment, Recommendation).
CUS Statement (I’m Concerned; I’m Uncomfortable; Stop the line).
Evaluate effectiveness.
Inter-Departmental Collaboration
Inter-department collaboration is fundamental to the success of any organization.(15) It can bring efficiency, optimize resources, create a positive culture, increase employee satisfaction, and increase retention. Experienced leadership with strong communication skills plays an important role in fostering collaboration. It is important to keep this in mind when recruiting for leadership roles. Challenges to inter-departmental collaboration include:
Communication barriers.
Conflicting priorities.
Lack of accountability.
Resistance to change.
Potential power struggles.
Conflict.
Inter-departmental collaboration is essential for a successful, financially stable, and growing organization. Strategies that bring efficiency, optimization of resources, employee growth, and satisfaction to the organization and promote inter-departmental collaboration include transparency, trust and rapport, celebration of wins, and collaborative decision-making.(16)
CONFLICT MANAGEMENT
Being well-versed in conflict management (or resolution) is an important component of effective leadership. A strong leader sees conflict not as a barrier to overcome, but as an opportunity for growth and deeper understanding. A leader who manages conflict effectively prioritizes the growth and well-being of individuals. This leader actively listens, empathizes, and empowers team members, fostering a culture of collaboration and trust.
By looking out for their team’s needs, leaders cultivate an environment where individuals feel valued and motivated to contribute their best efforts. When team members see their leader exemplifying these qualities, they are likelier to adopt similar approaches in their interactions, contributing to a better work environment.
Conflict resolution involves navigating disagreements to find a mutually acceptable solution. Doing so helps maintain team cohesion, enhances performance, and promotes a culture of respect. Leaders who excel in conflict resolution can transform potential negative situations into opportunities for growth. They recognize that conflict, if managed well, can lead to innovative solutions, strengthen relationships, and improve overall team dynamics.(17)
Conflict resolution:
Fosters a positive work environment.
Improves team performance.
Encourages open communication.
Develops problem-solving skills.
Essential strategies for conflict resolution include:
Practicing active listening.
Remaining neutral.
Encouraging collaboration.
Addressing issues early.
Establishing clear processes.
Empowering team members.
Best Practices for Leaders
The following strategies can help leaders develop their conflict resolution skills:
Develop emotional intelligence (EI). EI is the ability to recognize and manage one’s own emotions and the emotions of others.
Lead by example. Leading by example focuses on maintaining composure, showing respect, and focusing on solutions rather than blame.
Receive conflict resolution training. Such training introduces leaders to important communication skills, negotiation techniques, and conflict resolution strategies.
Seek feedback and reflect. Feedback from team members, mentors, and colleagues provides insights into what worked well and what could be improved.
Promote a culture of respect. A culture of respect helps prevent and resolve conflicts.
RESOURCE ALLOCATION METHODS
A scarce good is a good that has more quantity demanded than quantity supplied at $0.(18) Scarcity falls into three distinctive categories: demand-induced, supply-induced, and structural. Demand-induced scarcity happens when the demand for the resource increases and the supply stays the same. Supply-induced scarcity occurs when the supply of a resource is very low compared to the demand. Lastly, structural scarcity occurs when part of a population does not have equal access to resources due to political conflicts or location.(19) Throughout history, the need has arisen to decipher how best to allocate scarce resources, whether it was food during World War II, water in the African desert, or oil to different parts of the world; however, the COVID-19 pandemic, more than any other occasion, highlighted the glaring need to have a transparent, ethical, and evidence-based process in place.
The COVID-19 pandemic highlighted the importance of conflict management in the context of scarce resources. Strategies such as open communication, collaborative decision-making, and equitable distribution were used to resolve disputes that arose when individuals or groups competed for limited resources, such as vaccines and therapeutics like Remdesivir. These techniques helped mitigate tensions and found solutions that benefited all parties involved.
When resources are limited, individuals or groups may perceive a need to compete for access, leading to conflict due to differing priorities or perceptions of fairness in distribution.
Such scenarios tend to result in competition where individuals or teams feel pressure to prioritize their own needs over the collective, miscommunication because of a lack of transparency, and perceived inequity if resource allocation is seen as unfair, leading to resentment and conflict.
Strategies used to manage these conflicts during COVID-19 included:
Open communication where transparent discussion about resource constraints and individual needs was encouraged. An important component of this was incorporating active listening to understand different perspectives.
Collaborative decision-making by involving stakeholders in the decision-making process to identify potential solutions and compromises. The stakeholders involved often brainstormed to generate creative options for resource allocation.
To ensure fair distribution, clear criteria for resource allocation based on objective factors and organizational goals were established. Needs based on urgency or impact were considered.
In addition, mediation provided a neutral space for parties to discuss issues and reach a mutually agreeable solution, and negotiation strategies helped parties find a middle ground that satisfied everyone.
The experience at Providence Holy Cross during the COVID-19 pandemic illustrates how several of these strategies and techniques were implemented successfully.(20)
SUMMARY
This article reviews several important leadership techniques and skills. Successfully responding to real-life scenarios, such as the one highlighted at the beginning of this article, often requires a leader to have mastered the art of collaborating and engaging with physicians and being well-versed in contingency planning. In addition, leaders should understand the concepts of chain of command and span of control, be cognizant of resource allocation methods, and know how to manage conflict. A leader who has a good command of each of these concepts will more often than not be set up for success.
Excerpted from Healthcare Administration, Leadership, and Management (HALM): The Essentials, First Edition, edited by Daniel A. Handel, MD, MBA, MPH, CPE.
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