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"Quality, to me, is not a project. It’s not a program. It’s part of your culture."
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Preparing for Crisis Should Be Part of Your Quality Agenda

By Jo Ann Endo | Wednesday, October 14, 2020
Preparing for Crisis Should Be Part of Your Quality Agenda
Photo by Kerstin Riemer | Pixabay

Michael Dowling is Northwell Health’s President and CEO and IHI’s Board Chair. In a new book, Leading Through a Pandemic: The Inside Story of Humanity, Innovation, and Lessons Learned During the COVID-19 Crisis, Dowling describes how Northwell’s history of disaster preparedness was essential to their COVID-19 response. In the following interview with IHI, Dowling shares some sometimes surprising insights from an early epicenter of the pandemic.

In Leading Through a Pandemic, you advise leaders to go beyond preparing for the worst case scenario. What would that look like?

If you think [a crisis is] going to be bad, assume it’s going to be doubly bad. For example, we have put together detailed plans assuming we might get a resurgence sometime later in the fall or the beginning of next year. [Editor’s note: This interview was conducted in mid-September.] At the height [of the surge earlier this year] on April 6th, we had 3,500 patients. Our plans now outline what we would do if we had 5,000 inpatients. We also have a plan for if we had those 5,000 patients on the same weekend we had a hurricane. In other words, you prepare for the worst of the worst. Then, if it doesn’t happen, you’re in a very good position.

If you think you need a million masks, have four million. Why? Because we were using 150,000 masks a day [in April]. If you have a million masks and you use 150,000 a day, it won’t be long before you have no masks. So, take your estimate of that you need, double it, and triple it.

How did Northwell Health become so focused on disaster preparedness?

We are the largest health care provider in New York, and we have evolved into being the largest private employer in New York. Our locations are spread through the New York area.

In the 90s, it became obvious to me and others that — with so much international travel and major transport hubs nearby — we should be prepared for any kind of major crisis. In 1998, we hosted a conference on weapons of mass destruction.

I’ll never forget one of the presentations. One of the speakers put up on the screen pictures of terrorists from around the world. The largest photo was about three times the size of the others. The presenter said, “This is the guy who will attack the United States.” It was a photo of Osama bin Laden. This was about a year or a year and a half before 9/11.

[Before September 11], I don’t think any of us thought these things would really happen, but we decided to behave as if we did. Over the years, we’ve had staff members who are former emergency management technicians and people who worked with the Federal Emergency Management Agency (FEMA). They helped create an emergency management infrastructure in the health system. As a result, we all know who would take responsibility for various aspects of a disaster when it occurs. We do tabletop exercises on an ongoing basis. We run mock disaster drills.

We’ve been tested multiple times. We’ve had to deal with SARS and H1N1. We’ve been through Hurricane Sandy and Hurricane Irene. We had chances to refine our system before COVID.

Why is a commitment to continuous quality improvement important during this pandemic?

Quality, to me, is not a project. It’s not a program. It’s part of your culture.

Getting prepared for a crisis should be part of any organization’s quality agenda. You’ve got to develop what I would call the “quality infrastructure” to deal with future potential events. A strong quality infrastructure should be part of your culture so you’re fully equipped to deal with whatever disaster comes your way, and you’re not making up [your response] on the fly.

You start and end the book with stories from your employees. Why was that important for you?

During COVID, the stories of the individual employees and the work they did, and the relationships they had with the patients and families, have been extraordinary. When you read those stories, it’s like the case history to learn what individual employees suffered through and what they did. And they made so many sacrifices to protect their families from being infected. They talked about completely disrobing before going in [their homes], taking showers, washing their clothes, social distancing, living in the basement, and not partaking in normal relationships with their family members.

Some had parents die. I remember talking to one nurse who came out of a patient’s room. I said, “How’s it going?” And she said, “Not that well right now. My mother just died in that room from COVID.” I said, “You’ve got to take a break.” She said, “No. There’s nothing I can do at the moment. I’m going to finish my shift. I’m going to stay working with my team.”

You can only hear these kinds of stories if you’re out there among the staff on the frontlines. If you stay in your office and hide behind your computer, you’re not going to hear those stories. It’s very important for leadership to be out front and to hear from people on a daily basis.

In the chapter focusing on Northwell’s culture of preparedness, you make a bold statement: “In a crisis, throw the budget out the window. Deal with it later.” What has that meant for Northwell?

One of the things we made very clear in one of our first [COVID] meetings is that we were going to, as an organization, commit whatever resources it took to provide the optimum care we needed to provide, and purchase the services and supplies in whatever volumes we needed to take care of the problem.

We said, “You cannot use the budget as a decision-making criterion during the middle of a crisis.” So, we forgot about the budget. In extra expenses, we spent more than $300 million. Our losses as a result of COVID were almost $2 billion. We’re now trying to build back the business, which will take us a year or two to do.

Given the challenges every health care system is facing, why is it important for health care leaders to think beyond their own organization?

In health care, I believe we have a mission to support our communities. We should be helping hospitals and health care facilities that are struggling, especially those in poorer communities. We’ve always known there are inequities, but COVID’s disproportionate effects demonstrated this clearly.

We are currently working in tandem with about six hospitals and many other facilities around New York. We don’t own these hospitals, but we provide as much assistance as we possibly can. Many safety net hospitals have been disastrously affected by COVID. Most of them can’t survive unless they get extra government support. We should all be lobbying to continue [this support] because these hospitals provide essential services. We have an obligation to help communities in need.   

What does it mean to lead in a crisis?

You should not divide; you should unify. You should not demean others; you should support others. You should not deny reality; you should accept reality. You should be a purveyor of good news, positivity, kindness, collaboration, and teamwork, and not a purveyor of hate and grievance. And you should tell the truth and not continuously lie.

Editor’s note: This interview has been edited for length and clarity. To learn more leadership lessons from IHI Strategic Partner Northwell Health and others, join us at the IHI Forum 2020 (December 6-9), a four-day virtual conference.

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