Before Covid-19 pandemic struck, the U.S. health care industry suffered more than 550,000 work-related injuries and illnesses per year, or 150,000 more than any other industry in the country. Therefore, it is no surprise that health care workers have been harmed at tragic rates during the Covid-19 pandemic. According to the U.S. Centers for Disease Control and Prevention (CDC), as of June 4, 72,346 U.S. health care workers had been infected, a figure it acknowledges is an undercount. A comprehensive national analysis indicates that almost 600 health care workers have died.
Every instance of a health care worker being harmed on the job is preventable. Every single one. So it is time to finally take the safety of health care staff seriously. It is time for the industry to go from the worst to the first in safety.
A few visionary leaders and organizations have set out on that course and proven that it is possible. Drawing from their practices before and during the pandemic, we offer five leadership imperatives.
1. Set a goal of zero workplace injuries and illnesses. Setting this target provides moral clarity and alignment and can lead to breakthrough thinking and progress.
One example of an organization that’s done that is Duke Health in North Carolina. Its leaders had launched a comprehensive effort to eliminate harm across the health system two years before the pandemic struck. Every day, leaders and team members throughout Duke Health’s three hospitals and hundreds of ambulatory clinics begin their morning safety huddles by reciting a pledge “to commit to zero harm for our patients, their loved ones, and ourselves.”
Duke’s leaders began aggressive predictive modeling to ascertain teams’ needs weeks ahead of the system’s first Covid-19 admissions and knew they needed to focus on preventing employee-to-employee as well as patient-to-employee spread of infection. Realizing that the effective public health practice of social distancing was impossible in the communal living that is complex patient care, Duke Health screened all employees entering a clinical space for signs of infection and provided any employee in any clinical area with a surgical mask daily long before those practices became the standard. (Those caring for Covid-19 patients were given N95s.) Duke never ran out of N95 masks because it was one of the first in the country to show that N95s could be sterilized with hydrogen peroxide and reused. No Duke Health team member has contracted Covid-19 from an inpatient exposure.
2. Make staff safety a fundamental value that you won’t compromise for other organizational priorities. We don’t send firefighters to fight fires without the right equipment. The same should be true in health care. If people can’t function safely, they should have the power to stop work and restore safe conditions before they proceed. This means not sending anyone who doesn’t have full personal protective equipment (PPE) to care for a patient with Covid-19.
Can such a commitment guarantee that a health system won’t be overwhelmed if it is in the hotspot of a new pandemic like New York City was in March? Of course not, but it can dramatically lessen the damage. When safety is a leadership commitment, the difference is the speed at which organizations can pivot to innovate and improve safety procedures. Leaders must work to make it so — even if that means taking extraordinary measures.
For instance, leaders of Torrance Memorial Medical Center in Los Angeles County, California, redeployed 500 idled outpatient staff early in the Covid-19 crisis to build safety shields and repurpose liquid room disinfectant for wipes that staff in the intensive care unit (ICU) needed to protect themselves against the virus. The leaders’ iron-clad commitment to safety drove these efforts.
At Morningside Mt. Sinai in Manhattan, leaders’ intense focus on safety led to quick innovation during the intense crisis. Covid-19 viral particles are aerosolized with intubation and with various ventilation therapies. This places frontline workers such as respiratory therapists, anesthesiologists, physicians, and nurses — and anyone walking within a close distance of these procedures — at risk of infection. To mitigate this danger, the hospital created an additional 60 negative pressure rooms in just a few days. It replaced windows with plexiglass in order to install portable HEPA air-scrubber machines, which were vented through a hole in the plexiglass.
3. Establish processes to make staff safety transparent and to learn from every safety incident. Trust and commitment are built when leaders ensure that safety incidents are disclosed to everyone — for the purpose of learning, not blame — so that other team members don’t have to fall victim to the same circumstances.
Leaders of the International HealthCare Corporation’s health system in San José, Costa Rica, known as CIMA, set their organization on a course to eliminate workplace, as well as patient, harm five years ago and made transparency about every safety incident, understanding its root causes, and sharing solutions a fundamental part of everyone’s daily work. Relevant team members are tapped to investigate every incident down to its root cause within 24 hours and develop a solution within 48 hours. And every team member and leader in the organization participates in huddles every day in which progress is checked and learnings are shared. CIMA’s total safety performance is also disclosed to everyone in the hospital on a real time basis via structured visual boards and an electronic performance-tracking system.
It has recently achieved a lost-workday-from-injury rate that is lower than the previous world benchmark set by Alcoa. When the Covid-19 threat loomed in February, CIMA’s leaders used the daily safety system to deploy a comprehensive plan to protect staff. It included training and having peers observe each other’s work methods to reinforce processes for handling patients safely, using PPE appropriately, practicing safe hygiene, sterilizing rooms and equipment, and other behaviors. To date, no CIMA employees have been infected with the novel coronavirus.
4. Create an organization-wide daily huddle system to identify and solve problems quickly. Daily huddle systems inextricably intertwine the management and improvement systems so that they reinforce each other. Daily huddles should occur at each level of the organization, starting with the front line and going up to the C-suite. They should be brief (less than 15 minutes) and should be structured to allow the most important information to be shared among all layers of the organization.
Huddles have been particularly effective during this crisis. The pandemic put Mount Sinai Morningside’s huddle system and commitment to rapid improvement to the test. Its incident management team is responsible for reviewing the real-time data from all over the hospital, which is displayed on multiple screens in a command center. During the Covid-19 surge, for example, the team monitored how many patients with the virus were in the ER waiting for beds, how many ICU beds were available at any given time, and where PPE was needed. This team facilitated multiple daily multidisciplinary huddles, which were convened when problem hot spots were identified at the command center.
This approach spawned dozens of innovations during the pandemic. Early in March, for example, a patient went into respiratory failure and had to be intubated. The team reported at the incident management team’s huddle that they had to quickly scramble for PPE such as masks, gowns, and face shields. This information was transmitted quickly through the huddle system and led to the creation of PPE “bags-to-go.” The bags contain enough full sets of PPE for nine people and are placed on the resuscitation carts. Rapid experiments led to clearly marked clean and dirty areas within units to help staff safely don and discard PPE. This allowed staff to respond to patients more quickly in the contamination zone.
5. Don’t use frontline caregiver heroism as an excuse not to act. Heroism should be a cause for concern, not celebration. It sends the wrong message that extraordinary individual acts are the way to deal with crisis situations that give rise to workers or patients being injured or infected. It lets leaders off the hook for sending staff into harm’s way unnecessarily as the leaders of many hospitals did during the Covid-19 pandemic. It creates the risk that the problems that had given rise to the acts of heroism won’t be systematically identified and addressed.
Instead managers must create a safe environment for staff to identify safety problems. Frontline staff are best equipped to understand why the problem exists and suggest ideas for improvement and a plan for implementing the chosen solutions. Workers should be trained in plan-do-study-adjust (PDSA) thinking, and leaders should aggressively support it and encourage people to apply it every day.
By committing themselves to these five imperatives, health care leaders can create totally safe work environments. They can and should eliminate workplace injuries and illness.