Lessons
• In order to care for patients, the top priority must be protecting the health and safety of staff.
• Staff members must be protected physically with sufficient quantities of PPE and have the knowledge that there will always be sufficient supplies.
• Staff members must be protected emotionally through the availability of active employee assistance programs that provide on-site counseling.
• Tranquility tents allow frontline workers to calm themselves as they reflect, meditate, or pray before or after shifts.
• Leaders must demonstrate through communication and via personal presence at the front lines that the work of employees is valued and that staff safety is the highest management priority.
• Prepare to have employee assistance personnel, including counselors and chaplains, readily available when a frontline staff member passes away.
North Shore University Hospital is the largest of the twenty-three Northwell hospitals. Located in Manhasset, New York, it includes 766 beds and employs more than six thousand staff members, including four thousand physicians working in a wide array of medical specialties. North Shore is a sprawling facility spread out over a fifty-seven-acre campus, with twenty-three operating rooms where every conceivable kind of surgery is performed, including the transplantation of livers, kidneys, and hearts. Much of the business at North Shore involves previously scheduled surgeries. Some are elective—a new knee or hip, or plastic surgery. Many others are medically necessary but not emergencies. At North Shore we are known in particular for our cardiac and neurological procedures. Hundreds of patients are scheduled each day with bookings taking place weeks or even months in advance. But with the virus bearing down, it was necessary to clear the schedule of all but the most urgent cases in order to open beds for COVID patients. Canceling thousands of scheduled cases was no small matter, but we got it done.
Our first COVID patient arrived at North Shore on March 7. By March 14 we had sixty patients, and five days later we had nearly 150. Two and a half to three weeks in, that number climbed to a census of four hundred patients very sick from the virus, and our projections indicated there would be many hundreds more, perhaps thousands more, headed our way. In all, we cared for 2,492 COVID patients at North Shore. Thus, we were racing to add bed capacity, a pursuit Tara Laumenede, acting chief nursing officer, likened to laying track in front of a moving train. Laumenede and her team identified opportunities to consolidate and flip units to COVID care quickly. They also moved all the patients around and staffed the units.
As the teams at North Shore converted many areas of the facility into beds for COVID patients, it was suggested that the cafeteria should be converted to a patient area. But Jon Sendach, head of the hospital, said no. “Once you do that, there’s no place for your employees to get away from the units,” he said. “And that’s when it would feel to them as if this is not the hospital they work in, and there’s an emotional component to that.” Sendach’s view was that staff members need a place they can go to take a deep breath, get a cup of coffee or a sandwich, and chat with their coworkers. Sendach would do whatever he could to protect the cafeteria for his workers.
As we have said before and will say again, caring for the safety and morale of our frontline staff was our number one priority and we did it in many different ways. We focus in this chapter on the efforts at North Shore University Hospital, but comparable efforts to care for staff needs were spread throughout our system. Jon Sendach and Dr. Michael Gitman, chief medical officer at North Shore, and their executive team recognized during the surge planning that it was important to protect the cafeteria as a refuge for staff. And Sendach went a bit further. He not only kept it open, he went to the culinary staff—“we have unbelievable culinary talent here”—and asked them to start putting together whole meals to go for employees. There were meals for two, four, even for families of eight packaged up—including plates, utensils, and napkins—and ready to go as staff members left work for the night. For staff who did not want premade meals, Sendach had the cafeteria team open what amounted to a small grocery store where staff could buy vegetables, fruits, meats, etc., without having to stop at the supermarket on the way home and risk possible contamination.
It seemed a small thing, but it was meaningful to staff and it was the kind of gesture that was consistent with how the organization had been treating employees under the HR leadership of Joseph Moscola. Moscola had made so many improvements in how staff members were treated and rewarded that, in 2019, Northwell was named one of the Fortune Magazine top hundred best companies to work for—a huge accomplishment. That hard-won designation would be put to the test in the crisis in terms of how well we were able to protect the physical and emotional well-being of our staff. Baseline safety required ample supplies of PPE. What did that mean exactly? It meant that we had to provide all of the PPE staff needed whenever they needed it. But it also meant establishing policies such as requiring masks of all patients in the ED, before any other system did so. Eventually, we required all employees across all parts of the hospital to wear masks.
In an atmosphere of unprecedented fear and anxiety, it was important to care for the emotional needs of our people as well. Employees need to know that their well-being is the top priority for the hospital’s leadership. They need to see their leaders with them, encouraging them at the front lines. Our employees talked about an article in the New York Post about the leader of another health system who chose to remain in Florida when the crisis broke. Our workers were putting their health and the health of their loved ones on the line, and they needed to know every shift that we were with them and doing everything possible to keep them safe.
A key element of safety is for the people running our individual facilities to know that senior executives at our corporate offices have their back. Joe Moscola and Dr. Mark Jarrett realized very early on that once staff members started getting sick the organization would fall behind, and that there could be a domino effect from staff falling too ill to work. Working in partnership with chief nursing executive Maureen White, Moscola managed the flow of staff throughout the system, contracted for hundreds of additional workers from around the country, and put in place a series of initiatives that supported the physical and psychological needs of employees. The HR team:
• established staffing standards across the system so that the professional competence of each worker matched his or her assignment;
• contracted to house thousands of our employees in dozens of hotels to support workers who did not want to go home for fear of infecting their families;
• deployed professionals from our employee assistance program to our facilities where they were readily available to meet with staff to talk through concerns and fears and in some cases to refer staff for additional counseling;
• set up what were known as tranquility tents so that workers going into or leaving a shift could sit calmly and reflect, meditate, or pray. The tents proved helpful to some of our workers for whom a brief period of calm reflection supported them in getting through the day;
• made sure staff members were well fed and that there were open lines to HR for any staff member with a concern of any kind.
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In late March, word came that our health system had been able to purchase another large supply of N95 masks from 3M. This required everyone on the front lines at North Shore to be fit-tested for the mask, a process that went on around the clock for several days until everyone needing such a mask had the proper fit. Meanwhile, Sendach was tightening procedures to keep workers safer. He announced a plan to reduce the number of times doctors and nurses would have to enter a patient’s room. The clinical team extended IV tubing to reach out into the hallway outside a room so staff in the hall could check on the IV drip. IT helped clinicians monitor patient rooms via iPads and cell phones.
The tranquility tents provided staff a needed respite from the stress of constant patient care in their units.
The tents provided ample opportunities to reduce stress and promote well-being.
In February, Sendach and colleagues joined a call with hospital leaders in Italy when the Italians were going through hell: “They told us that ‘it’s going to trickle and then, by the second week, it’s going to just over-whelm you.’ They told us it’s not exclusively older people; that they were not sure why people crashed so suddenly.” And they issued a warning: Unless you take steps to protect them, you will lose 20 percent of your staff to illness, which would require them to quarantine. Throughout our health system there was a mix of emotions as we worked to prepare for the virus. Yes, it was true that we had prepared well. We had leaders who believed deeply in the culture of emergency preparedness that is such a fundamental part of our identity. But we are human beings, and the horrors from China and Italy were frightening. Would we be able to handle it? Were we as good at this type of work as we thought we were? Or were we guilty of excessive pride, of the kind of hubris that brings one crashing down?
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Sendach was a classic Northwell executive. He had started working in the system in the back of an ambulance as an EMT, and like so many others in our system, he loves emergency work. After getting his Master of Public Administration degree, he moved up in management ranks, to the point where he runs our largest hospital. For the 2020 spring semester, he was teaching a course on health-care management at the Wagner Graduate School of Public Service at NYU. “The course was on leading change for executives,” he said, and in that course he talked about the need to respond to challenging circumstances, including emergencies. “And I said to myself when all this started, ‘well, you know what? You’re about to find out if you actually know how to do it.’”
The initiative to protect staff started in the emergency department where sick patients congregated, some shedding virus in the vicinity of staff members. The ED clinical team worked to get patients moved into, through, and out of the ED as expeditiously as possible on the theory that the less time sick patients spent in the vicinity of ED employees, the safer those workers. Sendach had seen pictures and video of hospitals in New York City—notably Elmhurst—where the emergency department was overrun, frontline workers inundated with highly contagious patients. “We could not let the ER get overrun here,” he said. “We just made a commitment that we were going to have an operationalized team so that when patients were brought in, once evaluated, we would whisk them out of the ER as quickly as we could up to the units and those extra beds. Because once it backs up in the ER, then you end up in a situation where that workforce gets sick and infected and you start getting into a situation where emotionally, they feel as though they’re wide open, that no one’s protecting them.”
A similar threat existed with nurses in open spaces where new beds had been installed. This was the case in some recovery areas. Nurses at a station in the vicinity of a dozen ICU patients would be vulnerable. There would be no doors to close between the nurses and the patients, and the virus would be swirling in the air around the nurses. “What is our message to you as an employee if we allow that to happen?” Sendach asked. Sendach got the engineering team in to build walls around the makeshift nursing stations and pump purified air into that space. These enclosures were not pretty—“they look kind of like prisons,” said Sendach—but they protected the staff. “You cannot ask people to sit there for twelve hours, even with their N95s on, in an environment where they don’t feel remotely protected.”
On the calls to Italy, the Italian doctors had warned of potential harm from aerosolizing the virus. This was a serious problem for clinical staff in close contact with COVID patients. A clinician intubating a patient would pass a tube down the throat causing many patients to cough or gag, sending streams of virus into the air directly at the clinician. No matter how well gowned and masked workers were, this was a hostile environment. Once again, the engineering shop came to the rescue. There was a picture online from Taiwan of a Plexiglas box that looked like a square helmet that a Martian might wear. By placing it over the patient’s head, the clinician could then reach through arm holes and perform the intubation protected from the spray of virus. At North Shore, the idea of using such devices was proposed by Kelly Treacy, the nurse executive in charge of the operating rooms. Treacy proposed the idea on Monday, March 23. She discussed it with anesthesiologist Dr. Rich Grieco that day and the next. They engaged two outside vendors to design four prototypes. Early on Thursday, March 26, Treacy, Grieco, and a number of other clinicians reviewed the design, offered a few modifications, and by Friday completed devices were arriving at the hospital. Over the next two weeks twelve devices were built internally in our workshop while an additional seventy-five were manufactured externally and distributed throughout the Northwell system. The last step was to post the device’s CAD drawings on an open-source site so that anybody could copy it.
This is an example of the Plexiglas box used for patients at North Shore University Hospital.
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During the crisis, the availability of PPE was the issue for staff. Without the proper equipment, how could they possibly come to work and do their jobs? The availability of protective material for the staff is key to staff engagement and morale because they’re worried about their safety, and legitimately so. At a certain point, Sendach saw that “there was constant nonsense back and forth about masks and gowns on the units and which unit was running out and who was hoarding and who was grabbing an extra box.” Sendach’s colleague Will Corrigan, associate executive director for hospital operations, had a solution: Set up a PPE station at the entrance where employees arrived for their shift. “So, when you come into work through our team entrance, we have someone handing you snacks to make your shift that much better. And the next thing you walk past is a huge PPE depot. You need a mask? You need a gown? You need more gloves? Whatever you need, no questions asked. Please, stop right here. And we’d just feed the depot instead of having staff members running around delivering boxes and boxes and boxes up to units.”
Sendach wanted to know about any concerns on the part of the staff; any fears about unsafe working conditions. To find out what was on the minds of employees and to inspect working conditions throughout the facility, Sendach created a small team of inspectors led by the chair of emergency medicine, the vice chair of surgery, and a RN. These men and women wore bright teal vests upon which were printed Healthcare Personnel Safety Team. They would check in with employees—hey, how’s your mask? Your gowns? Any questions about what you should be doing with your masks and gowns? Sendach wanted employees to know without any doubt that there was a major effort being undertaken to protect them.
At the peak, there were 715 COVID patients at North Shore, which made the hospital one of the largest COVID specialty facilities in the United States. At the same time we were caring for more than a hundred patients with conditions other than COVID who needed urgent or emergency care, including lifesaving surgeries. We kept these patients secure in non-COVID areas of the campus. In all, at the peak, Sendach had a total of nine hundred beds available with the ability to push it all the way up to 1,200 had it been necessary.
In mid-April, North Shore had 150 COVID-positive patients in the ICU on ventilators. These patients would end up staying for close to three weeks on average. Most would not make it. It was another one of the surreal things happening in the time of this pandemic. Normally, patients who are intubated spend a bit of time on the ventilator and are then extubated and recover. With the virus, however, during the crisis an estimated 60 percent of ventilated patients did not survive. Such a tragedy, Sendach thought, families losing a spouse, parent, sibling, grandparent and in some cases, God forbid, a child.
The external mobile tents were just an example of the many alternative treatment areas created during the height of the crisis.
Sendach and Dr. Gitman, the North Shore chief medical officer, work closely together, and Sendach watched as Gitman had one conversation after another with physicians and family members about decisions in treating patients. “What do we do about intubating, not intubating, talking about Do Not Resuscitate, trying to withdraw care on patients?” asked Sendach. There were many difficult decisions doctors had to make, said Sendach, “ethical choices and decisions about patient care. Is there a medical benefit to putting another person on a ventilator so that they can then spend three or four weeks on it and have a poor prognosis? It’s just staggering.”
On a Saturday in mid-April, Sendach joined in a North Shore celebration for the one thousandth COVID patient discharged from the hospital. Celebrating success turned out to be important throughout our system. It was brutal for doctors and nurses to have so many patients on ventilators dying. When patients did survive and were able to go home from the hospital, it was time for celebration. “Leaders have to be celebrators,” said Dr. McGinn. “You’ve got to celebrate heroics and you’ve got to celebrate success. And you’ve got to do it very consistently. We’re constantly thanking people and creating camaraderie and when any patient gets off a respirator, we try to make time to celebrate that and highlight that.” McGinn and other doctors have been impressed with the level of camaraderie among the frontline doctors, nurses, respiratory therapists, transporters, cleaning crews, food service workers, and on and on.
Pictured is the thousandth patient discharged from North Shore University Hospital.
It was not long before the ten thousandth patient was discharged from Northwell Health.
The celebration of the one thousandth discharged patient was a happy occasion for the patients, families, and staff. And when it took place, in mid-April, there was also a growing sense that the crisis was just beginning to ease in the New York area. On April 15, Sendach and Dr. Gitman wrote to the North Shore staff:
We are seeing an increase in the number of patients going home and those who progress toward recovery. It is critical that we balance that against the growing number who require critical care and advanced respiratory support. We understand for those of you actively on the frontlines and at the bedside, the news outside may at times feel incongruent with your perspective. Our hope is that in the coming days, the positive impact on what has now been a ten-day trend of slightly lower ED volume and resultant hospitalizations will be felt in a softening of our census throughout the hospital. We all feel better each time we hear those chimes overhead, announcing another patient has been discharged . . .
Yesterday we had the opportunity to visit several units with a small crew from CBS News . . . and were again reminded what an incredible spirit exists here. For a short piece that aired this morning on CBS This Morning . . . the producer and reporter . . . told us as they left that they came here to cover a story of crisis at a major medical center in the county that now has the most cases of any county in the nation outside of New York City. Their visit forced them to change their story line somewhat. What they reported this morning was that they found a place where professional people are managing a crisis with class and a sense of calm purpose.
Despite the celebrations, Sendach also realized the toll the disease had taken. The same weekend as the discharge ceremony, thirty patients at North Shore died from the virus. At North Shore, our teams took care of thousands of COVID patients and never got overwhelmed. The teams laying track managed to stay well enough ahead of the roaring locomotive that was the virus. This was a victory as well as a relief. After the calls with the Italians, Sendach hadn’t been sure what was coming exactly. Nobody was. At the worst point during the crisis, hundreds of North Shore staff members were out sick with the virus. By mid-April that was down to 1 percent, an impressive accomplishment given that at Forest Hills, at the peak, 6 percent of the workforce was out with the virus.
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One other aspect of employee morale relies on the actions of the most senior executives in the health system. At Northwell, for example, our chief nursing executive, Maureen White, invested time walking the wards, encouraging the nursing staff, engaging in conversation, listening, and commiserating. Typically, nurses work in a crowded, bustling environment with patients’ visitors often crowding hallways and patient rooms. But all of that visitor traffic was gone now and it was an oddly freeing thing for nurses to be able to move around without any interference. At the same time, many missed the human contact with families.
With so little human contact, it became especially meaningful when our senior executive leaders made a point of visiting units and spending time talking with nurses and doctors. Many of our senior physicians—Drs. David Battinelli, Mark Jarrett, John D’Angelo, Lawrence Smith, and Thomas McGinn—did this. Perhaps most notable was the presence at the front lines of one of us (Michael Dowling), who made it a point during the crisis period to go to the front lines, walk the wards, and encourage staff in the ICUs and emergency departments. During many of these sessions, nurses would ask to have photographs taken. These clinical and administrative leaders initially found nurses and doctors virtually unidentifiable as they were buried under layers of PPE. Then many began to scrawl their first names on the outside of their PPE. And then a great trend among many nurses started—they blew up pictures from their ID badges and displayed them on the front of their PPE – a nice humanizing touch in an intimidating atmosphere.
Pictured here is Michael Dowling meeting with nursing staff at Mather Hospital.
It is hard to describe how great these frontline workers were. We tried throughout to demonstrate our gratitude to them. We did it in many ways and one especially meaningful action we took was to provide a bonus of $2,500 to every frontline employee, along with an additional week of paid vacation. For our staff members who tragically passed away, we continued to pay full salary to the family for an additional six months, and we covered all funeral expenses. We held a major internal fundraiser with all funds directed to the surviving families. And we have constructed a beautiful memorial honoring those who died in front of our main office. These were tangible ways to express our gratitude.
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Keeping employees safe meant they were better able to meet the complex needs of our patients. COVID patients were not only very sick, but they were also separated from loved ones. One of the key questions for our patient experience team was to figure out how to create a human connection. It was not only COVID patients, but all our patients who were isolated and cut off from the outside world. Our only option was to do whatever was necessary to set up virtual visits for patients and their families.
“We couldn’t get enough devices into the buildings fast enough, so we worked very closely with IT to break some rules to make sure that we did the right thing for the patients,” said Sven Gierlinger, chief experience officer. We had been focused on using Android-based tablets for security reasons in part because the data from a very private visit between patient and family was wiped clean. Unlike Apple’s iPad, with an Android, “there’s no information left on the device.” A nurse asked Gierlinger to waive the Android rule but he said he was unable to do so for security reasons. “When I told her that she said, ‘that’s really a shame and that’s really tragic because I have now a family driving down from upstate New York to see their family member. And they’re probably not going to make it in time. They’re in the car right now. We can’t do a Skype session with them or anything else. All they have is FaceTime and we have to do FaceTime.”
Gierlinger knew they had to change the policy immediately. He went to John Bosco, head of IT, and said that we have a moral responsibility to enable the family to connect via FaceTime. Bosco totally understood, and right away enabled the technology so that the family could have their final words together. “It was gut-wrenching and a beautiful thing at the same time,” said Gierlinger.
