How Task Division Can Build a Stronger Health System
Organizations throughout the health system must systematically split up the burden of response in order to deal effectively with immediate needs — as well as those lurking around the corner.
Healthcare organizations must split up the burden of response in order to effectively deal with immediate needs — as well as those lurking around the corner.
most health system leaders FORTUNATELY, DURING OUR CAREERS, have not faced a crisis like the current COVID- 19 pandemic. However, this also means that healthcare leaders around the world are now learning — in real time — about significant gaps in their planning processes and their ability to react.
While the initial reaction to COVID- 19 in many organizations has been an ‘all-hands-on-deck’ response, in this article we will argue that it is critical that we divide management tasks across four distinct teams to allow us to focus not just on immediate needs, but also on issues lurking around the corner.
Each of the four teams we recommend must report directly to senior leadership. Where appropriate, it will be useful to have overlapping membership across teams, to help coordinate their activities. In turn, the senior leadership team should act as a conductor, shaping and orchestrating the overall activities.
Following is a detailed look at the four teams we recommend healthcare organizations create.
The role of these teams TEAM 1: THE IMMEDIATE CHALLENGE TEAM(S). is straightforward: addressing the hourly, daily and weekly tasks at hand. A typical but not exhaustive list of tasks might include determining the care needs and staffing implications of COVID patients; developing and communicating situational information internally and externally; addressing staff training and personal protection; and dealing with supply chain and operational challenges that result.
One of us is a professor at Stanford, where COVID cases have been on a rapid rise. The hospital has set up a cross-functional team that meets daily to address situational needs. After sending out individual e-mails about this rapidly evolving situation to faculty and staff, the hospital began to publish a single daily e-mail with essential information for providers, vetted by the cross-functional challenge team. This notice includes information on evolving hospital policies; changes to services in response to the outbreak, such as the establishment of an
outdoor drive-through virus testing service; and other information that needs to be communicated to faculty, fellows and resident physicians. This notice is also linked to the local intranet, which may contain more detailed information on specific topics and links to resources such as the Centers for Disease Control website.
The fact is, many of the TEAM 2: THE REMOTE SERVICES TEAM. services that are now offered to patients in hospitals could be accomplished externally, whether at patients’ homes or outpatient facilities. Continuing to ask those patients to come to a hospital for services raises obvious risks of congestion and infection. While some elective services can be delayed until the crisis subsides, others need to be dealt with to ensure patient health during the crisis.
There are clear opportunities to increase our use of telehealth across the board. All modern hospitals now have access to telemedicine in one form or another, whether as internal practices or via external partners. Similarly, public health agencies and other actors in healthcare systems commonly have access to telehealth services. Hence, there is a robust base of telehealth services.
Historically, though, most organizations have under-utilized the potential of telehealth. While some of the challenges have been technical in nature, organizational and political barriers have been the major constraints. In the short term, the
COVID crisis has reduced many of these barriers — and we now have opportunities to turn the crisis-driven acceptance into long-term wins.
This crisis creates an opportunity to ramp up and extend our use of telehealth to new in-home and out-patient services. Many of these services can continue to be offered after the COVID crisis subsides, as a way of shifting appropriate care out of expensive and sometimes risky in-patient venues to more effective outpatient settings. The need to extend nascent telehealth services during the crisis can help overcome organizational barriers that have slowed their current expansion.
Multiple vendors have scaled up telehealth services that
Healthcare leaders around the world are learning—in real time— about significant gaps in their planning processes.
are available to organizations that do not want to manage the services internally. In the U.S., these include established generalist health companies such as Cigna, telecommunications specialists such as Cisco, and specialized telehealth firms such as Teledoc and Zocdoc. In Canada, private companies such as Maple and public agencies such as Telehealth Ontario are scaling up services.
As important as the technology backbone is the staffing model for the telehealth service, whether developed internally or contracted with a vendor. A switch from in-person to a telehealth service includes developing standard operating procedures, training staff and building provider schedules to staff the service. While this is a challenge, the COVID- 19 pressure creates an opportunity to overcome traditional barriers to dealing with these issues.
One hospital that we are familiar with offers services in which specialists employed by a private telehealth vendor provide consulting services to remote communities in its region. The telehealth clinicians guide local clinicians to provide sophisticated care that is beyond their normal practice. This same hospital now has an opportunity to provide the same services to referring clinicians in its local community – explaining the criteria for COVID screening as testing becomes available and explaining treatment and referral options as those issues arise.
At this hospital, beyond COVID treatments, the telehealth applications can be used for other patient services. Bringing telehealth local will avoid burdening the hospital with patients who do not really need to be there and also risk becoming infected at the hospital. As it ramps up to address the immediate
COVID needs, the hospital is working with its referring clinicians and with relevant payers to adjust the financial structure of their services.
The changes in volume can be striking. One major east coast U.S. hospital, for instance, moved from only about 100 monthly telehealth appointments before COVID- 19 to over 2,000 daily video and telephone consultations in May 2020. The hospital has worked with state and federal regulatory authorities to allow clinicians to provide the services and with
major insurers to cover telehealth treatments.
Where telehealth had limited flow before the pandemic, barriers arising from regulatory roadblocks to reimbursement and credentialing have now been removed. Removing these regulatory dams — together with a reduction in opposition from stakeholders within the hospital who have previously felt threatened by the changes — has led to the more than 600-fold increase in monthly telehealth usage at the hospital.
The key point is that expanding telehealth services — in addition to being critically important parts of the response to the COVID- 19 challenge — also lays down a pathway for longer-term remote service innovations. Providers in countries throughout the world are actively scaling up telehealth services with the goal of long-term implementation.
Multiple oncology services, for instance, are expanding their use of telehealth applications to support treatment and post-treatment surveillance. These services are substantially more convenient for patients than forcing them to deal with transit, parking, maneuvering through a hospital and relying on family members to help deal with clinical visits. Moreover, clinicians using telehealth systems can observe their patients in their homes, gaining insights about the full context of services that they need.
In China, meanwhile, telemedicine services such as Alibaba’s Ali Health, Jd.com’s JD Health and Tencent’s WeDoctor quickly created online coronavirus clinics to treat patients across the country. These private sector vendors are now maintaining and scaling up the systems to provide ongoing clinical services as the viral pandemic subsides in China.
In parallel to the creation of telehealth services, payers in the U.S. and elsewhere are beginning to adapt their policies to provide coverage for the services. Again, the revisions are being driven by the immediate COVID- 19 pandemic. But, in the longer term, the efficiency of telehealth and the gains in individual welfare are creating incentives for the payment innovations to continue post- COVID.
By moving now to expand telehealth services, hospitals, public health agencies and other organizations in the health system can position themselves to provide more efficient and effective services once the pandemic passes. Therefore, in addition to being part of immediate COVID responses, remote services teams are a key element of future-looking strategy.
Many of the services that are now offered to patients in hospitals could be accomplished externally.
The idea that TEAM 3: THE EXTERNAL COORDINATION TEAM.
‘all healthcare is local’ is an old adage. COVID is again bringing this issue to the fore, while highlighting the organizational complexity of local healthcare environments. The external coordination team needs to work with external stakeholders to link their hospital’s activities with those of other organizations in the health system that are engaged with the COVID challenge.
Relevant external organizations include hospitals, out-patient facilities, local and national public health agencies, political bodies and many others. Joint responses can include designating specific COVID care sites or, as importantly, non- COVID care settings; shared efforts to support population health; ensuring the availability of post-acute care services; and developing regional telemedicine programs. The external coordination team will need to gauge where it makes sense to be the leader in facilitating system-based activities and where it makes more sense to follow the lead of other actors.
Early in the pandemic, one of us was involved with a panel discussion of initial steps towards addressing the COVID-19 crisis, involving experienced leaders from multiple relevant organizations. Reassuringly, each individual had a compelling message of how their own organization was responding. Much less comforting, though, was the fact that each person’s organization faced real struggles in coordinating their activities with others.
Unfortunately, the lack of coordination in that region became painfully clear as the pandemic spread. Despite heroic efforts on the part of individual people and organizations within the region, coordination gaps led to shortage of testing, gaps in services for high-risk populations such as people in long-term care facilities, limited contact tracing and other major issues. External coordination teams can address this lack of integration.
Let us be clear: The presence of organization-by-organization external coordination teams is only one part of the solution to the integration challenge. Any health system — whether regional, national or global — also needs strong central leaders who work with experts to establish relevant goals, communicate clearly and honestly, and hold themselves and others accountable for meeting standards. But even the most effective central leaders need robust touchpoints with each relevant actor in the system. External coordination teams within individual organizations can provide this touchpoint with health system leadership.
Our current challengTEAM 4: THE SCENARIO PLANNING TEAM. ing state of affairs will be part of a marathon as well as an immediate sprint. The epidemiology underlying this infection is unclear, with tremendously uncertainty about its impact over time. Given this set of challenges, a separate team should be established to begin the difficult scenario planning that will support further decision-making at the organization level.
These scenario exercises need to consider contingency planning for alternative cases including staff shortages due to illness or the lack of child care; financial implications of cancelling profitable elective services to care for critically important but less financially valuable COVID patients; operational issues such a co-location of infected patients; and availability of local nursing home beds for patient transfers.
Many other uncertainties highlight the need for scenariobased attention. As regions begin to open up in search of economic recovery — with different ability to test, track, and maintain discipline in social distancing — we need to consider how to address different levels of possible resurgence of COVID cases. We need to consider how the return to international travel might affect diffusion, particularly if recovery efforts are less effective in some countries or regions.
In addition, we need to assess how other infectious diseases such as influenza might mask ongoing COVID infections, ideally assessing how vaccination programs for influenza can facilitate ongoing COVID programs. And, unfortunately, we need scenarios for how anti-vaccination resistance by parts of the population might affect recovery.
In light of the tremendous uncertainty, these scenarios need to consider a broad range of outcomes, ranging from a rapid decline in cases to an evolving pandemic with new incident cases over an extended period of multiple months or even years until reliable treatments and vaccines are available. Central public health agencies and political authorities have part of the responsibility for the scenario planning. In addition, though, scenario planning by individual organizations within the health system can contribute to their own sustainability and to the strength of the overall system.
A simple example from outside healthcare provides relevant insights about the benefits of scenario planning: A few years ago, one of us brought their children to Disney. When a toddler jumped into the pool before their parent, the lifeguard blew their whistle and jumped in. But the amazing thing was that this did not leave a coverage gap at the pool. Instead, the whistle signaled other guards to shift and cover the vacant chair because there could have been another child in the water. Disney’s training developed a procedure to address immediate needs and also deal with contingencies that might arise. It’s a lesson that can help those on the front lines of this uncertain crisis.
In another example, we are familiar with a pharmaceutical company that has long used scenario planning as part of its strategic activities. The intriguing point about the scenarios is that none ever comes exactly true. Instead, the biggest value of this planning is that it highlights major building blocks of possible futures and identifies resources within the firm and its partners that can be brought to bear as needed. In the face of the COVID crisis, this company was able to respond quickly in bringing key people together for internal efforts in developing multiple potential new treatments. Moreover, it was able to rapidly identify staff members that it could release to help provide external clinical services. Hence, the scenario planning exercises helped build a shared understanding of how to respond to a major unexpected event.
In closing
Individuals in health systems around the world are unambiguously committed to meeting the challenges of COVID- 19. An uncountable number of people are working tirelessly, often at risk of their own health and lives. But success requires far more than individual effort.
Organizations throughout the health system must systematically split up the burden of response, while working internally and externally to coordinate the activities that we require for a robust response to this challenge. If we do so effectively in response to COVID- 19, our actions will also lay down a base for longer- term gains, both in healthcare and in health itself.