How does a large physician group prepare for a crisis such as Ebola? Tatum K O'Sullivan, director of ambulatory risk and patient safety at North Shore Physicians Group in Peabody, Massachusetts, gives a personal account of the experience that helped her continue to develop and grow as a risk manager.
Those working in risk management have learned to master the unexpected, even when it occurs on a Friday afternoon as we are rushing to get out the door to begin our weekend. As awful as those events can be, they pale in comparison to the hours, days, and months of anxiety and uncertainty that the 2014 Ebola outbreak brings to my mind. During October that year, I was working in ambulatory risk management and patient safety for North Shore Physicians Group (NSPG), a large physician practice group in Massachusetts. The news that Ebola had surfaced in the US left many residents panic stricken. Healthcare workers faced an even scarier challenge.
The question everyone was asking was, “How do we prepare for this deadly epidemic?” and unfortunately there wasn’t a handbook or guidance immediately available for the physician practice setting. The Centers for Disease Control (CDC) and Department of Public Health (DPH) were working feverishly to develop guidelines, but in the first few days of the crisis, most of the information shared was geared towards emergency room level care and inpatient hospitals.
For the practice setting, obtaining the recommended personal protective equipment (PPE) would be extremely costly and very difficult to order because supplies were quickly dwindling as hospitals stocked up for the potential outbreak. At the same time, we were learning from the news media that the PPE that provided the strongest barrier from Ebola also contributed to healthcare worker coming in contact with the Ebola virus and becoming infected with it.
One intervention that was successful was increased screening of patients. Broadcast emails were sent out to all staff on a regular basis instructing them to ask screening questions about patient travel when booking appointments for patients and when patients arrived at the office for a visit.
Making a plan
As we watched the news and considered our options, frontline staff began asking many questions and wanted to know that we had a plan to keep them safe. At the same time we were concerned that it was only a matter of time until a patient who may have been exposed to Ebola walked through the doors of one of our physician practices.
My concern was that if we developed a plan too quickly without having all of the facts as they were developing, we would add to the confusion when we tried to update the information we had shared. It took several attempts and discussions until we finally determined our best course of action.
Once we agreed on what PPE should be purchased we faced more challenges as we rapidly learned that supplies of these items were on back order from our usual vendors. We quickly needed to be creative and find other suppliers that could immediately provide all of the items we needed. Having strong leaders in upper management was key in getting this done. They empowered those working on obtaining supplies to make decisions and get tasks accomplished without the usual red tape that is involved when making purchases.
We also decided that each healthcare provider should have an opportunity to practice applying and removing the PPE so that there would be less confusion if they ever needed it to care for a patient who may have been exposed to Ebola.
Organizing the equipment
Once all of the supplies were obtained we needed to find a way to get everything to the offices. One of the greatest blessings during this time was the team from our Kaizen Promotion Office (KPO). The KPO at NSPG comprises three individuals who focus on process improvement utilizing the lean methodology from the Toyota Production System. In many healthcare settings the quality or process improvement department would not be involved in preparing for an outbreak of a deadly disease, but this team was willing to help and became key players in the process.
The team agreed that placing all of the items in a kit would be best for any healthcare provider who would need to enter an exam room of a patient who presented to the office and there was a possibility that they had come in contact with someone who was experiencing symptoms of the Ebola virus. Individuals who worked in the administrative office made themselves available for a few hours one morning and the KPO helped us create our very own production line.
Instead of building cars, we were creating Ebola PPE Kits that consisted of a clear bag that contained instructions on what to do when caring for a patient who may have been exposed to Ebola and how to safely don (put on) and doff (remove) the PPE contained in the bags. Along with the PPE, the bag also contained a red biohazard bag to be placed in the room by the door so that the equipment could be discarded when leaving the room and personal size bottle of hand sanitizer since each step of removing the PPE required sanitizing hands.
Finally, the bags were sealed using an elastic band that could also be used if the healthcare provider had long hair and needed to tie it back. Using the production line to assemble over 250 kits made the task effortless and within a few hours we were ready to deliver them to the offices and begin education on how to properly don and doff the PPE.
Coping with stress
There were many stressful days during the Ebola outbreak. Thankfully we were surrounded by strong leaders who empowered the team to make decisions, move forward, and helped remove obstacles enabling us to move from uncertain times to feeling prepared. Using the foundation of our lean training to deliver our supplies to the front lines quickly was also vital to helping staff feel assured that we were addressing their concerns and working to keep them and their patients safe.
The process of donning and doffing the PPE was complicated and it was crucial that it be performed correctly to prevent accidental exposure. There was positive feedback from providers about the training and having their own kit so that they could have a practice run of donning and doffing the attire. Another crucial element for staff during the training was knowing that instructions and important phone numbers were also included in the kit. The positive impact of strong teamwork helped to improve patient safety and decrease the likelihood of Ebola having a devastating impact on our organization.
In the days and months that followed the initial scare of the Ebola outbreak, we were able to reevaluate and discuss lessons learned. One of the biggest lessons I discovered was that it’s okay to not have all of the answers. The gravity of this situation added anxiety and online resources did not provide answers to the questions we were encountering. I have always believed that a successful risk manager must be considered responsive and credible by others within the organization.
During a dire situation like this, I struggled to develop a plan quickly, knowing that it would be revised as more information became available from government agencies and other resources. In the heat of the moment I had to balance my responsibility to be responsive by getting information out to staff and providers, with the knowledge that recommendations were changing daily and that the plan would need to be revised along the way.
In hindsight, I should not have spent so much time worrying about how my reputation might be impacted. We worked hard, developed a plan that we were all comfortable to roll out, and felt confident that if a patient who may have been exposed to Ebola entered one of our practices, we could protect our patients and staff while determining if the patient required transfer to a higher level of care for testing.
Thankfully we never encountered an actual case of Ebola in the offices and I feel that I am better prepared to perform in a situation of uncertainty. Preparing for Ebola was certainly one of the biggest challenges in my career. Even so, it also provided me some valuable experience and insight about myself that I will take with me as I continue to develop and grow in the profession.
Tatum O’Sullivan, RN, MHSA, CPHRM, FASHRM is director of ambulatory risk and patient safety at North Shore Physicians Group in Peabody, Massachusetts. NSPG is a large physician practice group with offices in 22 locations, and is a Partners Healthcare affiliate. O’Sullivan works with healthcare providers, staff, and organizational leaders to help mitigate risk and promote patient safety.
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