Cartoon – The View from 30,000 Feet
Category Archives: Leadership
Cartoon – Vague Generalities and Meaningless Half-Truths
Another week on the exponential curve
https://mailchi.mp/a3d9db7a57c3/the-weekly-gist-march-20-2020?e=d1e747d2d8
As efforts to increase testing for COVID-19 ramped up this week, the number of cases in the US rose exponentially, and the number of deaths increased sharply as well. Early but incomplete data from the Centers for Disease Control and Prevention (CDC) indicated that the virus was impacting younger people in greater numbers than had been seen in China and Italy, and concerns grew that asymptomatic but infected people could be spreading the virus to those with compromised health status. In response, many cities and states moved aggressively to put in place stricter measures to keep people in their homes to mitigate spread.
Several flashpoints have emerged across the healthcare system. Supplies of personal protective equipment (PPE) are in short supply, raising concerns about putting healthcare workers at risk. Testing supplies—particularly collection swabs—are also running low in many places, forcing some newly-launched testing locations to close after just a few days. Hospitals across the country began to gear up for a wave of patients, with the number of potential cases likely to far exceed existing capacity of hospital beds, intensive care beds, and, in particular, ventilators.
In response, the President invoked the Defense Production Act, which will allow the government to direct private sector production of critically needed equipment. Hospital leaders have been advised by the government to cancel elective surgeries and minimize non-emergency utilization of healthcare resources, to preserve supplies and capacity for the coming wave of cases.
The Centers for Medicare and Medicaid Services (CMS) loosened several key regulations to allow more care to be delivered virtually, in an attempt to relieve pressure on the system (more on that below). By week’s end, hospitals in several areas—including Seattle, San Francisco, New York, and New Orleans—were reporting that they were perilously close to being overwhelmed.
As many have pointed out, we are faced with a decision of which curve we want to be on: one that looks like Italy, which responded late with mitigation and suppression efforts and has found their healthcare system collapsing under the volume of hospitalizations; or one that looks like South Korea, where aggressive measures to suppress spread, including extensive testing, strict social distancing, and isolation of infected people, seem to have “flattened the curve”.
The next two weeks will be critical in determining what the next year looks like in America.
“We’re looking at a tsunami”
https://mailchi.mp/a3d9db7a57c3/the-weekly-gist-march-20-2020?e=d1e747d2d8
Yesterday we spoke with a senior healthcare executive leading the COVID-19 response for a regional health system on the West Coast. Their area is now experiencing exponential growth of new cases, with the number of local diagnoses doubling every couple of days. In all likelihood, they’re less than two weeks from having the number of cases seen in harder-hit areas like San Francisco, Seattle and New York City. She said the “anticipation of what is about to happen” is the scariest part of the around-the-clock work they are doing to prepare.
But that two-week lead time has given them precious time to organize, and she generously shared key elements of their action plan. Their preparation work—surely similar to what hundreds of health systems around the country are doing—impressed us not only with its breadth, depth and comprehensiveness, but also the level of energy and confidence conveyed by the hundreds of actions and decisions, large and small, the system is making every day. Here are some of their important learnings so far:
- Even though the surge of patients has yet to begin, staff are “worried and scared”. They are concerned about PPE shortages and personal safety and stressed at home with schools and daycare closed. Detailed and regular communication is more critical than ever—and they’re trying to answer every inbound concern or question from associates directly. They are funding and expanding childcare options for staff, through partnerships with community organizations and daily stipends for home-based care.
- As the system works through worst-case scenario planning, they anticipate the need for critical care nurses, respiratory therapists, and emergency physicians will be the worst bottlenecks, and they are working to cross-train adjacent clinicians and build new staffing models to increase capacity. While most providers are deeply dedicated to providing care for COVID-19 patients, a small number have already “called off” and refused to report—creating unanticipated questions around how to manage these difficult situations.
- As they prepare to implement new surge staffing models, the system is now navigating through a period of downtime. With elective procedures cancelled and some ambulatory sites closed, they currently need fewer nurses and clinical staff than a month ago, and are creating policies, like allowing staff to go negative into PTO, to maintain income while they wait for the surge. Staff who must work in-person are working variable shifts to reduce crowding. They are also working to credential nurses and staff furloughed from local ambulatory surgery centers, so they have them ready to deploy when needed.
- IT staff are working nonstop to quickly make it possible for all eligible employees to work remotely, and to enable staff to safely gain access to the system’s intranet while guarding against new cybersecurity threats. The system is training and enabling hundreds of doctors to deliver care virtually, including affiliated independents.
- Guidelines for coronavirus patient management and recommended PPE practices change daily; it’s a full-time job for clinical leaders to keep up. Doctors are eager to try novel and creative treatments for very sick patients. (For instance, one doctor is developing a 3-D printed device that will allow one ventilator to be used for four patients simultaneously.) This eagerness to “do something” is understandable but creates a bit of chaos as leaders work to create policies around how to best manage patients.
- While leaders communicate with other health systems and local and state authorities daily, the vast majority of decisions are made internally, on the fly. For instance, the system is connecting with now-empty local hotels and universities to provide options for low-acuity patient capacity, but leaders hope that parallel efforts at other organizations can be brought together into a more unified regional response. For now, however, coordination would likely create unacceptable delays.
- Long-term health and stamina of staff is top among the system’s concerns. “If I borrow worry from the future”, this leader said, “I am worried that we are facing years-long trauma, both emotional and financial, and I’m not sure how we will sort it out”. For now, efforts to support staff and provide moments of relief and joy, are critical, and very appreciated by front-line team members.
We left this conversation emotionally overwhelmed ourselves, and with a huge sense of gratitude for clinicians and health system leaders. Americans can take comfort in the amount of work that is taking place even before critical patients begin to appear—and that doctors, nurses and hospitals are truly dedicated to providing us the best possible care under circumstances they have never faced before. If you know about creative approaches or new ideas organizations are putting in place to contend with the current situation, please let us know. We’re eager to share great ideas!
To solve the economic crisis, we will have to solve the health-care crisis
The distinction may sound academic. But understanding it is actually vital to designing the policies that should follow.
In an economic crisis, you could imagine a situation in which people lose their jobs and are unable to spend money. That’s called a demand shock, which is what happened during the global financial crisis of 2008. Or producers could raise prices (for various reasons), making it harder to buy their goods. That’s a supply shock, and it describes the oil crises of 1973 and 1979. But what is happening now cannot be addressed primarily by economic responses, because we are witnessing the suspension of economics itself.
Today, even if you have money, increasingly you cannot go into a shop, restaurant, theater, sports arena or mall because those places are closed. If you own a factory that hasn’t already closed for health reasons, you may still have to shut it down because you can’t get key components from suppliers or you can’t find enough stores open to sell your goods.
In these conditions, cash to consumers cannot jump-start consumption. Relief to producers will not jump-start production. This problem is on a level different and far greater than the recession of 2008 or the aftermath of 9/11. If it were to go on for months, it could look worse than the Great Depression.
This is not an argument against any of the economic measures being proposed. People need to be able to eat, buy medicine and pay their bills. New York Times columnist Andrew Ross Sorkin has canvassed experts and concluded that the best approach would be a zero-interest “bridge loan” to all businesses and self-employed people as long as they keep most of their workers on staff. It is probably the right course of action, massively expensive but cheaper than a full-blown Great Depression.
But even that might not work if we do not recognize that first and foremost the United States faces a health crisis. And that crisis is not being solved. China is now reporting no new domestic infections. South Korea, Taiwan and Singapore have also made progress in “flattening the curve” — the phrase of the year — because they have prioritized dealing with the health-care crisis over enacting a grand economic stimulus.
The United States is still dangerously behind the curve. A headline in Thursday’s Wall Street Journal is, “Coronavirus Testing Chaos Across America.” The article details how the country still has “a chaotic patchwork of testing sites,” with testing proceeding “far slower than experts say is necessary, in part due to a slow federal response.” The U.S. testing rate remains shockingly low, well behind the rates of most other rich countries and far behind those of the Asian countries that are handling this crisis best. Across the United States, hospitals are warning of a dire shortage of beds, medical equipment and supplies. And the worst is yet to come. With infections doubling every two to three days, the U.S. health-care system will face what New York Gov. Andrew Cuomo correctly described as a “tsunami.”
The Trump administration is still acting slowly and fitfully. Experts predicted weeks ago that cities would need thousands more hospital beds, and yet the Navy is still performing maintenance on two hospital ships and figuring out staffing. The president says he will invoke “defense production” powers only if necessary. What is he waiting for? He should direct firms to start production of all key medical equipment in short supply. The armed forces should be deployed immediately to set up field testing and hospital sites. Hotels and convention centers should be turned into hospitals. The federal government should announce a Manhattan Project-style public-private partnership to find and produce a vaccine. After decades of attacks on government, federal agencies are understaffed, underfunded and ill-equipped to handle a crisis of this magnitude. They need help, and fast.
And here’s another idea: President Trump could forge an international effort to unite the world against this common threat. If the United States, China and the European Union worked together, prospects for success — on a vaccine, for example — would be greater. China in particular produces most of the supplies and medical ingredients the world needs. Trump should remove all of his self-defeating tariffs so that American consumers don’t have to pay more for these goods and China can ramp up production. This is a war, and in a war you try to find allies rather than create enemies.
Coronavirus will radically alter the U.S.
Here’s what may lie ahead based on math models, hospital projections and past pandemics.
“They were terrified. And that was the best-case scenario.”
Experts around the country have been churning out model after model — marshaling every tool from math, medicine, science and history — to try to predict the coming chaos unleashed by the new coronavirus and to make preparations.
At the heart of their algorithms is a scary but empowering truth: What happens next depends largely on us — our government, politicians, health institutions and, in particular, 327 million inhabitants of this country — all making tiny decisions on an daily basis with outsize consequences for our collective future.
In the worst-case scenario, America is on a trajectory toward 1.1 million deaths. That model envisions the sick pouring into hospitals, overwhelming even makeshift beds in parking lot tents. Doctors would have to make agonizing decisions about who gets scarce resources. Shortages of front-line clinicians would worsen as they get infected, some dying alongside their patients. Trust in government, already tenuous, would erode further.
That grim scenario is by no means a foregone conclusion — as demonstrated by countries like South Korea which has reduced its new cases a day from hundreds to dozens with aggressive steps to bolster their health system.
If Americans embrace drastic restrictions and school closures, for instance, we could see a death toll closer to thousands and a national sigh of relief as we prepare for a grueling but surmountable road ahead.
An alarming new model
Doing that will require Americans to “flatten the curve” — slowing the spread of the contagion so it doesn’t overwhelm a health-care system with finite resources. That phrase has become ubiquitous in our national conversation. But what experts have not always made clear is that by applying all that downward pressure on the curve — by canceling public gatherings, closing schools, quarantining the sick and enforcing social distancing — you elongate the curve, stretching it out over a longer period of time.
Success means a longer — though less catastrophic — fight against the coronavirus. And it is unclear whether Americans — who built this country on ideals of independence and individual rights — would be willing to endure such harsh restrictions on their lives for months, let alone for a year or more.
This month began with U.S. officials recommending actions such as hand-washing and social distancing. By Sunday, the Centers for Disease Control and Prevention was warning against gatherings of 50-plus people. By Monday, President Trump had made an abrupt turn from encouraging Americans to go on with their lives, to urging them to work from home, not meet in groups of more than 10, and calling on local officials to close schools, bars and restaurants. (Getting the public to comply has been alarmingly difficult. Young revelers from Bourbon Street to Miami have ignored those pleas, as have some elderly, who are at highest risk.)
Trump’s sudden shift was driven by an alarming new scientific model, developed by British epidemiologists and shared with the White House. The scientists bluntly stated the coronavirus is the most serious respiratory virus threat since the Spanish Flu of 1918. If no action to limit the viral spread were taken, as many as 2.2 million people in the United States could die over the course of the pandemic, according to epidemiologist Neil Ferguson and others at the Imperial College Covid-19 Response Team.
Adopting some mitigation strategies to slow the pandemic — such as isolating those suspected of being infected and social distancing of the elderly — only cuts the death toll in half to 1.1 million, although it would reduce demand for health services by two-thirds.
Only by enacting an entire series of drastic, severe restrictions could America shrink its death toll further, the study found. That strategy would require, at minimum, the nationwide practice of social distancing, home isolation, and school and university closures. Such restrictions would have to be maintained, at least intermittently, until a working vaccine is developed, which could take 12 to 18 months at best.
The report’s conclusion: This is “the only viable strategy.”
What hospital planning tells us
Here is another thing that hasn’t been spelled out in our national conversation about flattening the curve: There will probably be more than one curve.
If we’re lucky, the coming months will probably look more like string of hilly bumps, say epidemiologists. If authorities ease some measures in coming months or if we start letting them slip ourselves, that hill could easily turn right back into the exponential curve that has cratered Italy’s health system and that U.S. officials are desperately trying to avoid replicating.
Climbing this first bump is in many ways the most challenging because it involves persuading people to change their individual behaviors for an abstract larger good — and because no one knows how far we actually are from the peak.
On Tuesday morning, New York Gov. Andrew M. Cuomo (D) said infections in his state are expected to peak in 45 days — at the start of May. The state has roughly 53,000 hospital beds, including 3,000 intensive-care beds — way short of the projected need for as many as twice that number of beds and as many as 11 times the number of ICU beds.
A day earlier, Northwell Health — whose 23 hospitals and 800 outpatient centers make up New York’s largest health system — canceled all elective surgeries in its hospitals to free up staff and space. It has 5,500 beds.
“We’re looking at Italy, which is currently 10 days ahead of us, and what they’ve had to do,” said Maria Carney, Northwell’s chief of geriatrics. Carney was health commissioner for New York’s Nassau County during the 2009 H1N1 outbreak and has worked furiously on Northwell’s plans to prepare for the coming tsunami.
One reason she and others are alarmed: In China, the fatality rate in Wuhan, the raging epicenter, was 5.8 percent. But in all other areas of the country it was 0.7 percent — a signal that most deaths were driven by an overwhelmed health system.
And U.S. hospitals are pinched as it is, with some already running at 95 percent capacity pre-coronavirus, Carney noted. As cases surge, Northwell plans to place multiple beds in single rooms. Its ambulances will also shuttle patients to less crowded satellite sites. Those suffering from ordinary emergencies — strokes, heart attacks, car accidents — may find themselves routed to other facilities away from ERs to avoid transmission.
But it’s unclear if it will be anywhere near enough.
Staffing shortages are already developing: As of Tuesday, 18 Northwell employees had already tested positive for the coronavirus. More than 200 were self-quarantined as a result of potential exposures, foreshadowing what is likely to come.
If the numbers next month get truly crazy, cities may look to convert stadiums into isolation wards, as in Wuhan. Cuomo has talked of turning the six-block-long Javits Convention Center on New York City’s west side into a medical surge facility. Others might take Italy’s approach and split hospitals into those treating coronavirus and those treating all other medical problems, to reduce transmission.
In San Francisco, we may see coronavirus patients put into RVs. In Takoma Park, Md., the old Washington Adventist Hospital site, which shuttered in 2019, could suddenly find its doors reopened.
‘Pandemics aren’t just physical’
As America enters this utterly unfamiliar territory, some experts have turned to history for glimpses of what to expect in the months ahead.
Initially leery of alarming the public, they have increasingly compared this pandemic to the 1918 Spanish flu, the deadliest in modern history. It infected roughly a third of the world’s population and killed at least 50 million people, including at least 675,000 in the United States.
Like the hilly bumps experts foresee in coming months, the 1918 pandemic hit America in three waves — a mild one that spring, the deadliest wave in fall and a final one that winter.
With each wave came a cycle of denial, devastation, community response finally kicking into overdrive — always followed by finger-pointing and blame among leaders and the public.
“Every outbreak is different,” said medical anthropologist Monica Schoch-Spana, who spent months digging through archives to study how Spanish flu played out in Baltimore.
Like coronavirus is likely to do, the 1918 flu overwhelmed hospitals. Unable to get help, desperate families waited outside to beg and try to bribe doctors for treatment. In a three-week period, 2,000 died in Baltimore alone. Mortuaries ran out of caskets. When the bodies finally reached cemeteries, the gravediggers were so ill, no one could bury the dead.
Economic pressure on business owners and workers caused public resistance to adopt — and stick with restrictions. The crisis brought out the best in Baltimoreans — with sewing circles churning out gauze masks and hospital bedding, and neighbors donating food and services.
But it also brought out the worst — xenophobic conspiracy theories that nurses of “German extraction” were deliberately infecting people. African American patients were kept out of most hospitals under Jim Crow-era segregation.
“Pandemics aren’t just physical,” said Schoch-Spana. “They bring with them an almost shadow pandemic of psychological and societal injuries as well.”
The power of the individual
Stanford virologist Karla Kirkegaard said she has tried to stave off dread from the projected U.S. death toll with a case study she teaches in her classes:
Amid a cholera outbreak in mid-19th century London, as panicked residents fled one hard-hit neighborhood, a doctor named John Snow calmly entered the breach. He deduced that the source of hundreds of deaths was a single contaminated water pump and persuaded authorities to remove the pump’s handle — a strategy that ended the outbreak.
Controlling the covid-19 pandemic will take much more than a single water pump, Kirkegaard acknowledged as she sheltered in place at her Bay Area home.
But the story, she said, reminds her how powerful the simple act of one individual can be.
Cartoon – Maybe We Can Turn It Around
Cartoon – Chaos Theory of Management
Cartoon – Not a great Mission Statement
Cartoon – Business as Usual
HENRY KOTULA 