Prescription for Change

We asked Emory Healthcare’s CMO: Were hospitals overconfident about Ebola preparedness?

by Julie Riley

Last month, we spoke with Dr. William Bornstein, chief medical officer and chief quality officer of Emory Healthcare about his organization's experience with Ebola.

We wanted to know what he had learned so far that other CMOs should know. Here's what he told us:

Ebola care requires a zero-defect approach

One of the first things that Dr. Bornstein told us was that that Ebola treatment has to be basically flawless—something seldom achieved in the real world of hospital operations. "In health care, we tend to do a lot of things with policies, and inadequate training and preparation. But a key element [of Ebola preparedness] is the training and practice. We're not used to delivering high-reliability care in a zero-defect environment."

What is high-reliability care? High-reliability organizations (such as the aviation industry) avoid accidents despite working in a complex, risky, and often accident-prone settings. There is increasing interest in applying high-reliability principles to health care more broadly. Because Ebola treatment is highly complex, error-prone, and dangerous, targeting a high-reliability approach to Ebola care can be especially valuable.

As Dr. Bornstein points out, in normal hospital operations, "Many of the consequences of not having this approach are not visible. For example, if you have a defect in how you care for a central line, a few days later a patient is septic, but people may not connect the dots. You get into Ebola, and all of a sudden, it's like an airplane. If you have a defect in an airplane, it falls out of the sky and everybody sees that. In a way, Ebola has helped surface these issues around reliability in health care."

How can leaders develop high-reliability care for Ebola? Practice and training. "Like anything where making an error can be lethal, you've got to be practicing frequently, using an approach that identifies any defect—and training regularly, because you must be ready at a moment's notice," Dr. Bornstein said.

Hospitals are likely overconfident

Our October survey indicated that 65% of CMOs felt reasonably prepared for Ebola—but we've been hearing critical responses to that finding ever since.

In November, CMOs attending our Chicago national meeting told us this data indicated supreme overconfidence on the part of many respondents. "We have no experience to tell us whether we are truly prepared or not," one CMO told us.

Dr. Bornstein also disagreed with the survey respondents. "I read that [survey], and they're dead wrong." In the early days of Ebola preparations, many were overconfident. Dr. Bornstein shared that there was a lot of discussion about Emory's choice to use the Serious Communicable Diseases Unit (SCDU) to treat patients, with some suggesting that the choice was overkill.

The SCDU has features, such as laminar air flow, that are not needed for the care of Ebola patients, but Emory's leadership team recognized they needed a high-reliability, zero-defect approach to care, and felt that the SCDU was the environment that could best perform at that level. "We knew that our standard contact and droplet precautions had not been drilled to this level of reliability. We needed to show our staff and the community that we were taking this with the highest levels of seriousness."

Ebola HR policies can have unintended negative consequences

At our November national meeting of CMOs in Chicago, many told us they're using a volunteer staff approach, relying on a cadre of volunteers to provide treatment to a confirmed case. This allows hospitals to target resources and training to a specialized group. But CMOs also said many thorny questions remain. For example, should they potentially isolate or quarantine health care workers who care for Ebola patients?

We asked Dr. Bornstein for his thoughts. "That is a big topic. The thing about this is that there are unintended consequences to everything. When people think they're being extra careful, sometimes that makes things more risky." Although quarantining health care workers can seem safer, it may actually deter them from volunteering, which puts more people at risk.

"Ebola is unlike the flu," Dr. Bornstein said. "With the flu, patients can be infectious before the clinical illness begins. Part of the rationale for mandating influenza vaccination for staff is that someone can be feeling great, but shedding influenza virus. But Ebola's not like's not communicable during that phase. The science tells us that for Ebola, there is no benefit to quarantining health care workers who have cared for Ebola patients if they don't have signs or symptoms. What we do is mandatory temperature and symptom check-ins twice daily for twenty-one days following last exposure."

Will providers still volunteer to care for Ebola patients if there are many unnecessary restrictions or isolation rules? Anecdotally, there are reports that fewer clinicians are volunteering to help care for patients in West Africa, and failing to control the outbreak in West Africa actually puts more people at risk.

"So that's a long way of saying we don't restrict them from working in other areas of the hospital," Dr. Bornstein said. "We don't tell them to avoid public places. We require symptom and temperature monitoring."

Preparing for 'the next Ebola'

Do challenges for hospitals preparing for Ebola highlight a potentially greater problem—that the current U.S. system may be underprepared for other infectious disease outbreaks that could occur?

Dr. Bornstein thinks yes. "Relatively speaking, Ebola's not all that communicable. Let's say this was something else, more rapidly spreading and more communicable. I think what we saw were the chinks in the U.S. system. And that's something that federal agencies, CMOs and others need to be thinking about—what's the next big thing that's coming?"

Get downloadable slides on Ebola preparedness

We put together a PowerPoint template that you can download and use to structure updates to health system stakeholders on Ebola preparedness. Use it to support an organized, structured discussion at your organization.

Download the template

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