Learn­ing the lessons of Ebola as events con­tinue to un­fold

Modern Healthcare - - COMMENT - By Mike Leav­itt

In years to come, Ebola’s im­pact on Texas Health Pres­by­te­rian Hos­pi­tal Dal­las will likely be­come a riskman­age­ment clas­sic. Business cases will be writ­ten and stud­ied at univer­si­ties akin to how a pathol­o­gist per­forms an au­topsy to learn what went wrong and the path­way through which the de­struc­tion oc­curred.

How­ever, we are still in the early stages of th­ese events and many other hos­pi­tals could find them­selves deal­ing with sim­i­lar cir­cum­stances. We can­not wait for his­to­ri­ans to do their anal­y­sis. We need to learn all we can as it un­folds.

Ev­ery­one rec­og­nizes that Ebola rep­re­sents a global hu­man tragedy. The only rea­son that the fi­nan­cial im­pli­ca­tions on health­care in­sti­tu­tions are im­por­tant is that they have a crit­i­cal role in help­ing peo­ple and they are vi­tal eco­nomic en­gines in their com­mu­ni­ties.

Much has been writ­ten about how the Ebola virus kills a pre­vi­ously healthy per­son. The virus pro­duces pro­teins that block im­mune cells from sig­nal­ing an­ti­bod­ies to at­tack as well as pre­vent­ing de­vel­op­ment of adap­tive im­mu­nity. In­fected in­di­vid­u­als ex­pe­ri­ence mul­ti­or­gan fail­ure, ter­mi­nal bleed­ing and ul­ti­mately death. Un­der­stand­ing this process is im­por­tant in learn­ing how to treat it and also how to pre­vent it.

We have learned in the past few weeks that Ebola not only in­fects pa­tients, it can in­fect the cor­pus of hos­pi­tals as well. While the first U.S. man­i­fes­ta­tion of this in­fec­tion emerged at Texas Health Pres­by­te­rian Hos­pi­tal Dal­las, it could have hap­pened any­where. This cor­po­rate ver­sion of the Ebola in­fec­tion can, in a mat­ter of days, bring healthy hos­pi­tals to the verge of business mor­tal­ity as well. Ex­am­in­ing the dam­age one case of Ebola is hav­ing on Texas Health Pres­by­te­rian Hos­pi­tal Dal­las can help hos­pi­tal man­agers in­oc­u­late them­selves from a sim­i­lar mis­for­tune.

When I was HHS sec­re­tary, I de­voted a sig­nif­i­cant amount of time to learn­ing how to pre­pare for pan­demics. From my stud­ies, I con­cluded that there are four crit­i­cal cat­e­gories of risk that must be con­tem­plated: rep­u­ta­tional risk, staffing risk, clin­i­cal vol­ume risk and fi­nan­cial risk. In the cur­rent Ebola cri­sis, and specif­i­cally the Texas Health Pres- by­te­rian Hos­pi­tal Dal­las case, we learn that that th­ese risks ex­po­nen­tially mul­ti­ply, each one com­pound­ing the other.

Rep­u­ta­tional risk: Brand is a frag­ile thing. It is the essence of a hos­pi­tal’s rep­u­ta­tion. It is earned over many years, yet it can be se­ri­ously dam­aged with one high-pro­file in­ci­dent—fairly or un­fairly. The only way to mit­i­gate rep­u­ta­tional risk in a cri­sis is prepa­ra­tion. More rep­u­ta­tional dam­age is done in the early stages of a cri­sis than at any other time. A fun­da­men­tal tenet of cri­sis com­mu­ni­ca­tion is en­sur­ing that the first pub­lic ex­pres­sions are ac­cu­rate. In the con­fu­sion of the first chaotic mo­ments, there is no sub­sti­tute for train­ing and prac­tice.

Two im­por­tant lessons can be drawn from the Dal­las ex­pe­ri­ence: In­fec­tious­dis­ease episodes should be added to the list of emer­gency preparedness drills, and pub­lic re­la­tions teams should be or­ga­nized in ad­vance with pro­to­cols and train­ing.

Staffing risk: My pre­vi­ous study of pan­demics in­di­cates that with in­fec­tious-dis­ease emer­gen­cies, hos­pi­tals al­ways suf­fer an ero­sion of staff re­sources. It is ev­i­dent with Ebola in West Africa as health work­ers with­out ad­e­quate re­sources or pro­tec­tion ei­ther be­come ill them­selves or refuse to ap­pear at work out of fear. There have been nu­mer­ous me­dia re­ports of con-

flicts be­tween Texas Health Pres­by­te­rian Hos­pi­tal Dal­las and its nurs­ing staff. Again, the way to min­i­mize this risk is train­ing and ad­vanced prepa­ra­tion.

Clin­i­cal vol­ume risk: In the re­cent out­break in Texas, clin­i­cal vol­umes at the in­sti­tu­tion where Ebola pa­tients pre­sented have se­verely de­clined both for emer­gency and elec­tive vis­its. The longer-term con­se­quences re­main to be seen.

Fi­nan­cial risk: The fi­nan­cial im­pli­ca­tions of th­ese events can­not be un­der­es­ti­mated. Global stock mar­kets have seen sig­nif­i­cant de­clines in re­sponse to the cur­rent events. Dal­las County au­thor­i­ties have al­ready es­ti­mated the high costs to their com­mu­nity. Hos­pi­tals in Dal­las are cer­tainly fac­ing mul­ti­mil­lion­dol­lar or po­ten­tially sig­nif­i­cantly more un­bud­geted costs.

If the av­er­age hos­pi­tal has 100 days of cash on hand, a shut­down of its emer­gency depart­ment and se­vere dis­rup­tion of nor­mal ad­mis­sions and rev­enue streams can drain those funds very quickly, plac­ing the in­sti­tu­tion in im­me­di­ate fi­nan­cial cri­sis. Busi­nesses plan for dis­as­ter re­cov­ery, but it is un­likely that pan­demic sit­u­a­tions are in­cluded in their sce­nario anal­y­sis. They need to be.

The cur­rent sit­u­a­tion is a crit­i­cal re­minder that pan­demics hap­pen reg­u­larly. We have ex­pe­ri­enced at least three world­wide in the past 100 years (HIV, in­fluenza in 1918 and H1N1 in 2009) as well as other out­breaks.

Th­ese in­fec­tious-dis­ease episodes of­ten re­shape geopol­i­tics and eco­nomic wealth. They pro­foundly af­fect cul­ture, eco­nomics, sci­en­tific thought and med­i­cal care. I rec­om­mend that hos­pi­tal ex­ec­u­tives read The Great In­fluenza: The Story of the Dead­li­est Pan­demic in His­tory by John M. Barry to gain a full ap­pre­ci­a­tion for the im­por­tance of pan­demic readi­ness.

Mike Leav­itt is the founder and chair­man of Leav­itt Part­ners. He served as HHS sec­re­tary from 2005 to 2009, EPA ad­min­is­tra­tor from 2003 to 2005, and gov­er­nor of Utah from 1993 to 2003.

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