By Eric Fontana, Taylor Hurst, and Gillian Hughes
Hospitals and health systems across the country are facing new surges of Covid-19 cases. To help you prepare, we sought insight from the experience of leaders at Mount Sinai Health System, an eight-hospital health system that was at the epicenter of the first Covid-19 surge in New York City this spring.
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We sat down, virtually, with Vicki LoPachin, Chief Medical Officer and Senior Vice President of Mount Sinai, and Cameron Hernandez, Chief Medical Officer of Mount Sinai's Queens campus, to hear their reflections on leading Mount Sinai through the first wave and how they plan to remain agile for future surges. Below we break down their top five lessons learned—and key questions to ensure your own readiness.
1. Monitor key indicators to determine when to proactively boost capacity.
Thinking back, LoPachin recalled how the first wave of Covid-19 spread throughout New York City: "Queens and Brooklyn—the wave hit them first, then rolled to Manhattan … everybody had Covid patients." To handle this influx, Mount Sinai expanded its capacity and implemented a centralized transfer system to quickly test and move patients from hard-hit sites in Queens and Brooklyn to sites in Manhattan that hadn't been hit yet. By the time the first wave began to recede, Mount Sinai had more than doubled its ICU capacity by converting shuttered units, repurposing lobby space, and transitioning PACUs into Covid step down units.
Hernandez reflected, "We learned a lot, and now we've been able to take a proactive approach to what a surge looks like by asking ourselves what the triggers are to stop one thing and start another." Today, Mount Sinai's leaders are tracking a set of system and facility-level indicators to determine when they'll need to flex up capacity and staffing again and each site has a detailed plan of how and when they should respond to changes in key indicators. By tracking measures such as ICU census, ED census, and elective surgical volumes, they can anticipate when to turn on beds in their step down unit and when to turn on negative pressure rooms again. They've also continued communication with their transfer center so that plans are in place should they need to handle another surge.
Ask yourself: Are there 2-5 key indicators you're monitoring to determine when to flex space or staffing? Are leaders across your system in agreement about the tipping point for each indicator—and what steps to take in response?
2. Extend intensivist expertise by redeploying providers through a flexible, tiered staffing model.
Hernandez recalls how Mount Sinai redeployed specialists to meet the spike in patient demand: "It's about looking at who is in your footprint and who is not working at full capacity because things are being shut down. We had cardiologists and oncologists who weren't seeing patients, so they became the hospitalists and intensivists." To upskill ambulatory staff, Mount Sinai built clinical teams in a pyramid structure with an intensivist at the top. Each intensivist oversaw multiple hospitalists, who in turn, oversaw a group of non-internal medicine providers. The pyramid structure allowed them to overcome skills gaps and support redeployed staff delivering hands-on care.
Although Mount Sinai was able to flex staffing within two weeks last spring, to prepare for future spikes they're proactively building and training teams that can be deployed in the event of a future surge.
Ask yourself: Do you have teams you could quickly redeploy in the event of a surge in your community? If so, are there any key competencies you can upskill now to prepare for a surge?
3. Sustain newfound 'systemness' to centralize communication and expedite decisions.
Like many health systems, the urgency of a Covid-19 surge pushed Mount Sinai to a new level of collaboration. LoPachin reflects: "The pandemic helped us create more systemness than before. We were able to break down silos that had been there for the last five years." To expedite communication, they combined a centralized command center with their existing tiered huddle structure. Mount Sinai's unified command group included the Chief Clinical Officer, Chief Medical Officer, Chief Operating Officer, VP for Medical Affairs, and VP for Emergency Management, and met twice a day to summarize and review key individual responsibilities such as supplies, staffing, changing guidance from the state and city, clinical protocols, policies, and HR challenges. Daily huddles created a structure to rapidly elevate issues from the frontline to system-level leadership. Mount Sinai's combined, centralized structure facilitated the rapid implementation of changes across the system—including clinical guidelines. For example, LoPachin and her team standardized an anticoagulation protocol in just a week: "I was able to standardize care in seven days that would've taken me seven years before this. People worked together, we came to consensus, we spread it out across the system, and we were done."
To stay agile, leaders at Mount Sinai know they need to keep their command group intact—though they have scaled back their meeting frequency to once a week. Mount Sinai's leaders continue to emphasize the importance of clear, timely deadlines for decisions—and it's allowed them to continue making strides toward other key initiatives such as standing up a system-wide suicide prevention program amid the pandemic.
Ask yourself: What centralized structures, like your command center, have you maintained after your initial Covid-19 surge? Are all necessary perspectives included in your current structure, and do you have the ability to elevate information to the system level?
4. Streamline telehealth workflow by seeking detailed feedback on what providers need.
As leaders at Mount Sinai bolstered their telehealth capabilities, they partnered with frontline staff to solve workflow challenges and understand barriers to use. As Hernandez recalls, "You had to listen to the staff on the ground. It was looking unit by unit, really understanding the process and asking providers what support they needed at the bedside." With clinicians' help, Mount Sinai's Queens campus implemented tele-infectious disease capabilities, the first of the entire system. And, they're using that foundation to expand tele-psychiatry services beyond the ED and into the inpatient setting.
One of Mt Sinai's big priorities is centralizing and using telemedicine to share expertise with facilities where they may not have had coverage before. Hernandez explained that now that they have the infrastructure in place, it's easier to "turn on" inpatient telehealth capabilities when needed. And although outpatient visits have dipped slightly, they aim to sustain virtual visits at 25% as they continue to expand it across other sites.
Ask yourself: Given the rapid upscaling of telehealth, what major obstacles face your frontline staff when it comes to workflows? How could care be more seamless for clinicians and patients?
5. Proactively provide staff with accessible emotional support and transparent communication about their top concerns.
Recognizing that overwhelmed staff may not have the bandwidth to seek support, Mount Sinai proactively invested in a widely accessible emotional support system. They designated rest areas for staff, implemented mandatory breaks at 10 a.m. for staff to decompress, and stood up a hotline dedicated to psychiatric support. To reduce uncertainty among staff, they shared frequent updates, such as protocols to safely return home after treating Covid-19 patients and installed scrub machines in all their hospitals to mitigate fears of taking Covid-19 back to their families on their clothes. LoPachin candidly described the realities faced by those on the ground: "There were many people who were afraid to come to work. It was a real challenge and there was no perfect answer except education, supporting them, and making them feel as safe as you can."
Reflecting on their experience, one of the supports that Mount Sinai leaders are focused on moving forward is bolstering leadership rounding. As LoPachin explained, clinical staff "should not have to worry about anything except the patient in front of them."
Ask yourself: Are you regularly doing leader rounding today? Are the majority of emotional support services at your organization opt-in or opt-out?
As LoPachin and Hernandez reflected on their lessons learned, they also shared some of their big questions moving forward that do not yet have a complete answer, including: how to expand testing access in underserved communities, communicating to patients that it's safe to seek necessary medical care, providing adequate ongoing support for staff with children at home, and hardwiring the astounding systemness gains they achieved in response to the crisis.