The Road Less Travelled – Outcome-based emergency planning in hospitals

Team²

Rainer Stens

 

Overview
I was asked to advise the operational leadership of a hospital on the evaluation and optimization of its in-house emergency planning system. The term “hospital emergency planning” refers to the prepara­tion for internal and external emergencies that affect the structure or procedures of a hospital.
There were already corresponding concepts in place with checklists for every possible type of hazardous situation. These checklists and concepts were originally formulated on the basis of a standard laid down by the Federal Office of Civil Protection and Disaster Assistance in Germany.
In the meantime, however, it had become clear to all involved that a set of plans filling several folders was not ideal in the event of an emergency. Previously, when an emergency occurred, it was customary to first hand out a “role-appropriate” checklist to all key people. However, due to the need for urgent action in emergencies, which are not everyday occurrences, this approach was not deemed beneficial because too much valuable time would be wasted searching, finding, sorting, issuing, reading, and understanding.
That is why the so-called “outcome-based ­model” is used today. This model no longer involves prepar­ing for all potential damage separately. Instead, the multitude of possible events is reduced to only two outcomes for the hospital: disruption to the oper­ational functionality of the hospital and running out of capacity to treat patients. Both outcomes influence each other and have an interdependent and reciprocal relationship. The outcome-based model of hospital emergency planning focuses on maintaining or restoring operational functionality and adapting capacity as quickly as possible to meet the required demand.

 

Topic
The members of Incident Command had previously worked on a simulated operation involving a vehicle being driven into a crowd that resulted in a large number of casualties. Due to the proximity to the crime scene and the time of the event (Friday evening), an appropriate response from a so-­called off-peak unit of the hospital was necessary in order to quickly treat self-admitting patients and casualties brought to the hospital by the emergency services. To do so, the corresponding checklists of the hospital emergency plan were retrieved and put into use as described above.
Systematic analysis of the first 45 minutes of the incident response revealed clear weaknesses. Particularly due to the inability to handle the information and instructions in the checklists, while at the same time the volume of patients was increasing rapidly, a critical time delay occurred. Although those involved described the standardized approach as the method of choice, they also felt it was structurally and situationally unsuitable.
Hence, our consulting assignment was to present and support the implementation of the modified outcome-based hospital emergency plan approach. To do this, I used an experiential learning metaphor centered around Team².

 

Staging
a. Preparation
Team² was placed on a large table in such a way that each participant was sitting in front of a separate field, leaving a common area of about 20 x 30 inches in the center (designated by 1-inch wide masking tape). The number of participants was equal to the fields that formed a circle around the marked center of the table. Tip: for small groups (less than ten participants), several squares per person can be used.
The number of squares used corresponded to the number of people. One or two non-matching pieces of Team² were placed in each separated ­square, the rest of the pieces were placed in the marked center of the table.

 

b. Performance
“Before we start the next activity, let’s take another look at the analysis on the flip charts. The strategy you used in the drill, based on your existing hospital emergency plan, has a high level of detail. Many checklists and forms are prepared for each different incident and are stored in multiple binders and as laminated cards in your HIC box.
You were personally able to witness how cumbersome your hospital emergency plan was to implement, especially in the first crucial 30 minutes, because of the large volume of material in the overall plan. This was mainly due to the fact that it was difficult to navigate the highly detailed documentation, consisting of several file folders and checklists, during a stressful non-routine emergency situation.
You personally realized that what was needed were:
• A quick grasp of the situation.
• Dynamic instructions on the strategy.
• Measures that can be individually implemented depending on the damage.
• Short-term measurable successes and interim goals.
• Easy-to-implement initial measures.

As you know, hospital operations consist of many small cogs that have to interlock neatly when need­ed. Particularly under stress or in emergencies, this is a challenge that you as the HIC need to address. In the following activity, I would like to invite you to re-think the experiences you gained from the previous activity.
In front of you, on a table, you see a kind of grid. In the center there is the so-called pool. Each of your work areas is grouped around it. In the work areas and the pool, you will see plastic parts of differ­ent sizes. Please all take a seat in front of one field and then look over to me.
I have put the rules and goal for this activity on this flip chart for you to follow:
• No speaking allowed.
• Each player is only allowed to build his or her square in his or her own field.
• You can only take parts out of the center and must put any parts you don’t need back in the center.
• It is allowed to put back parts in the center for others to use, but it is forbidden to take parts directly from others for yourself.
• The activity is not over until each player has a square of the same size in front of him/her in his/her own field.
• At the end, the goal is for the squares of all players to be the same size, with each player having one square in front of them.”

 

c. Progression
The group initially drew on their performance in the previous activity and in a short time managed to create four out of seven of the squares. The participants who had completed a square sat back and watched their colleagues who had not yet finished. After about six minutes, one of the previously finished colleagues began to give instructions by gesticulating with his hands. However, this didn’t appear to have an effect.
The participants who had not yet finished their work were becoming increasingly frustrated, which I picked up on: “I would like to offer you some help. You see, there is an obvious simple way that has already led to success for some of you. But is this way the right way?”
The group tried to speak, but I referred them to the rules on the flip chart. As a result, the group engaged in a nonverbal exchange that ultimately bore fruit. Several squares were then formed in the pool in the center of the table. It was not until one of the participants from the hospital’s technical department discovered the last missing and only matching piece in an already completed square in front of a colleague and pointed to it that the group instigated the required change in strategy. After about 15 minutes of puzzling: success!

 

Reflection
The primary question after each sequence of activity was: What did you experience? After they answered this question, I gave the participants a short break. Following the break, I developed the connections between the Team² activity and the group’s perform­ance from the previous contextual activity.
With the help of FacilitationBalls, for example, I elicited the factors that led to success and whether it was possible to incorporate the success factors from the previous contextual activity.
As a result, I posited: “For us, Team² is a met­aphor for the issues facing the detailed hospital emergency plan and the problems it caused that we experienced in the previous activity. The experience you had with Team² demonstrated that sometimes it is better to look at things from a different perspective or to first share insights in the team before putting into practice any actions based on these insights.

 

Transfer to the real World

Elements in the learning projectElements in the real world
The individual parts of Team2Individual elements and components of the hospital emergency plan, checklists, and incident-related instructions
Pool (center of table)Established recurring leadership meetings with relevant crossover points; follow-up leadership processes
Own workspace (separated area for building
one’s own square)
Own field of activity, in which decisions have to be made within one’s own sphere of competence and reports have to be submitted to the relevant contact people/units
Flip chart with rules and goalsLegal and regulatory framework for maintaining hospital operations in exceptional circumstances as part of public service obligations; guarantor status; objective: core process of patient care
Completed squaresSuccessful application of the hospital emergency plan; mastery of the situation
1st phase: each player searches for and
exchanges parts for themselves
Unclear implementation of tasks, performance of tasks, communication between interfaces
2nd phase: individual participants are already
finish­ed, others don’t have the parts they need; unsolv­able situations
Hospital Incident Command does not receive any feedback from the relevant units
3rd phase: participants discover that parts in
seem­ingly finished squares are required to
complete their squares
Lack of resources in the early phase; so-called chaos phase and subsequent structuring phase in an exceptional incident
4th phase: participants discover that squares
that have already been completed need to be
dismantled and made available to the group
in order to jointly implement the solution.
Stepping back is necessary to move forward.
Adaptation of situational approach; shift of resources and change of perspective through change of perception or “leading from the front” instead of in a closed room with technical communication interfaces to the outside

 

Now please give some thought to your hospital emergency plan. As you have rightly recognized, it is very detailed. That is why it is difficult to properly put it into practice under time pressure.
So let’s now take a few steps back. We are looking for the lowest common denominators that result from emergencies and crises in your hospital. All incidents can be reduced to two outcomes for your hospital:
Either you are confronted with more patients and therefore more demand than you can cope with at once. Or you are forced by various disruptive influences to partially or completely evacuate the hospital.
Now, as the decision-makers in HIC, I would like to ask you to consider how the plans we have here can be adapted so that they can be better applied to the criteria that you have developed.”

 

Conclusion
I concluded the consulting session by means of so-called chronological feedback and through the use of four questions. I facilitated the experiences and also confirmed the results from the sequences of activity:
• What went well?
• What can we improve?
• What do we not have that we need to be even better?
• What would we do the same way again next time because it worked or was a factor in our success?

It is important to follow the order of these questions because they are all phrased positively. In add­ition, they begin by reinforcing good performance and encourage self-awareness and self-reflection.
Finally, I followed this up by identifying potential and needs and finished off by focusing on the strengths of the participants, which remained as the final impressions.