Crises are among the most daunting challenges for
leaders. The very nature of true crises – complex, high-consequence
events that threaten physical, emotional, economic, and/or reputational
health – test a leader’s ability to discern what is happening and what
is to be done. The word “crisis” derives from the Greek “krisis” or
decision. The contemporary understanding of the word stems from Middle
English usage of the medical Latin variant that means “the turning point in a disease,”
when the patient either lives or dies. These are the types of decisions
today’s crisis leaders are asked to make in situations ranging from
forest fires to active shooter incidents.
Faculty at the National Preparedness Leadership Initiative (NPLI)
at Harvard have studied leaders in crisis situations for the past 15
years. The first field research was conducted in the aftermath of
Hurricane Katrina in 2005 and has continued through Harvey, Irma, Jose,
and Maria, the sequential hurricanes of 2017. Between those events were a
variety of incidents – natural and manmade – ranging from infectious
disease outbreaks to terror attacks as well as National Special Security
Events (NSSE) with high potential as crisis situations. Five common
pitfalls emerged from a meta-analysis of those events. In response,
tools and techniques to turn each into an opportunity have been
developed. These tools are now the foundation of NPLI educational
curricula to help prepare leaders to make better decisions and take more
effective action during crises.
Many emergency management leaders have risen through the ranks. Along
this journey, they have developed great operational experience and
expertise. In routine emergencies, this serves them well as they grasp
the contours of the incident and the steps to take. In a true crisis
where much is unknown, however, such rapid certainty can create blind
spots that obscure important information, the concerns and needs of
certain stakeholders, and clues to how the event may unfold.
Further, leaders may revert to their operational comfort zone because
it fosters a sense of certainty amid chaos and provides the
satisfaction of taking action. In interviews after the Boston Marathon
bombings on 15 April 2013, several senior first responders related that
they felt drawn to help treat the wounded. It took intentional effort
for them to pull themselves back because, in their leadership roles, it
was necessary for them to leave some tasks to subordinates in order to
grasp the big picture and see as many of the moving pieces as possible.
The tool to stimulate such mental positioning is a “situation map.”
This is a simple visual depiction of the central incident – for example,
a bombing, tornado touchdown, or cyberattack – surrounded by the
secondary and tertiary situations likely to unfold. In the case of the
Boston Marathon, the bombings were at the center. Around them were the
medical, investigation, political, media, runners and families, business
continuity, and other situations. When mapped against each of these
stakeholders, connections and interdependencies would emerge. Such a map
may be sketched quickly on a piece of paper at the beginning of an
incident. Over time, people may be assigned mapping responsibilities,
which may take over a white board in the emergency operations center. No
matter how sophisticated, a situation map helps the leader orient to
the larger picture and identify critical gaps in the response.
Even with a situation map, leaders may fail to grasp the evolution of
a crisis over time and thus fail to adapt their thinking and actions as
well as those of their teams. The classic example is Hurricane Katrina.
Initially a wind event, Katrina became a water event in New Orleans
once the levees broke. The dynamics of those two contingencies are
divergent. The failure of leaders to make the mental shift from one to
the other distorted their perceptions and priorities. It slowed the
decision-making process, and gaps in the response became chasms.
An effective leader employs a disciplined process to continually test
assumptions and recalibrate activities as necessary. For example, wildfire fighters have adopted a system
to ensure that anomalies are rapidly and accurately reported up the
chain of command. This helps leaders understand when a fire is behaving
as expected – and when it is not. The NPLI tool is the POP-DOC Loop.
Initially based on Boyd’s OODA Loop, which is used in air forces and other organizations around the world, the POP-DOC Loop is tailored to the needs of leaders.
The OODA Loop has four steps: observe, orient, decide, and act. The
POP-DOC Loop has six steps, each aligned with a distinct cognitive
function essential to effective leadership. Perceive is a more active
version of observe, involving data gathering. Orient is common
to both models and refers to pattern-finding and meaning-making –
turning the relevant data into useful information. Once a pattern is
identified and verified, it is possible to predict what is
likely to happen next. In a complex event, several possible scenarios
may present. POP is the thinking half of the loop. After predicting and
assigning probabilities, the leader can decide, the first stop on the acting half of the loop. Decisions alone are not sufficient. The leader must next operationalize
those decisions. This may entail marshalling resources, forging
connectivity with other entities, and securing authorization for
activities. This step turns intentions into realities on the ground. The
final step is to communicate with all relevant stakeholders to ensure that they understand the leader’s intent, their role, and the ramifications.
The steps of POP-DOC are arrayed along a figure-8 loop because the
leader must return to the beginning to perceive whether decisions and
actions are having their intended effect. The leader reorients to see if
patterns have shifted and so on back around the loop. Leaders have used
POP-DOC to discipline their individual activities and serve as a guide
for team meetings in the midst of crisis.
The C in POP-DOC is significant as communication failures are perhaps
the most common pitfall for crisis leaders. These failures have
occurred both internally and externally, involved all levels of
leadership up to political leaders, and expanded out to the general
public through the media (traditional and social). Some leaders become
so focused on the operational aspects of a crisis that they fail to
communicate and thus leave people unsure of what is happening and what
they should do. Other leaders become extremely cautious, insisting that
all communications go through multiple rounds of checks and
double-checks. This can slow messaging such that it fails to keep pace
One of a crisis leader’s principle duties is what Karl Weick of the
University of Michigan calls “sensemaking” – that is, understanding the
dimensions and dynamics of the incident and ensuring that others
understand them along with the credible plan for moving forward. Weick wrote in a 1988 article in the Journal of Management Studies,
“The less adequate the sensemaking process directed at a crisis, the
more likely it is that the crisis will get out of control.”
The technique here is to make the mental shift from control to flow.
Many emergency management leaders and first responders operate in formal
chains of command. In a crisis, they situate in a formal management
structure such as Incident Command Structure (ICS) or the National
Incident Management System (NIMS). Each of these serves a useful
purpose. However, within these environments, the pace of a crisis
requires that information, decisions, and resources flow so that
appropriate action can be taken when and where the appropriate people
need it. One global organization with which NPLI faculty have worked has
implemented an online system and repository to capture information,
analysis, decisions, and actions for each of the emergencies and crises
it faces. Automatic alerts are sent up the chain of command when
triggered by the incident leader and the repository allows responders to
consult detailed notes and outcomes from similar prior events. That is
Another observation is that leaders think that their executive
position requires that they have all of the answers and make every call.
They aggressively assert control over every decision, expense, and
media release. Although some assume this posture as a signal of
heightened accountability, the message sent is one of distrust in those
around the leader. Such an attitude limits the capacity and capability
of the overall response enterprise. In an environment overly reliant on
control, people can be paralyzed waiting for permission to do something.
Effective crisis leaders instead seize the opportunity to assemble
and utilize a competent, empowered team and delegate decision-making
except for those decisions that only they, as the top person, can make.
When speaking at the NPLI, former U.S. Coast Guard Commandant Thad Allen
called such team members, “dogs that hunt” – loyal, smart,
Such a team can mitigate risk and increase the odds of success when
the incident commander’s intent, organizational values, and operational
principles are clear. The result is having one commander, with many
people acting as leaders – that is, thinking and acting proactively
within the parameters of intent, values, and principles to resolve or
even preempt problems.
Related to becoming a single point of failure is the tendency of
crisis leaders to act like superheroes who need no rest or recuperation
time. It is possible to go around-the-clock for a day or two. After
that, leaders become more likely to lose the ability to regulate their
emotions leading to shortness of temper and impaired judgment. The
leader also becomes vulnerable to decision fatigue, a well-documented phenomenon in which the ability to make good decisions degrades over time.
In the response to the H1N1 pandemic, the Acting Director of the Centers for Disease Control and Prevention (CDC) Dr. Richard Besser
made sure to take a day off from time-to-time. When he did so, he did
it publicly so that his example would cascade down through the ranks. He
knew that others would be leery of stepping away from the emergency
operations center or other response duties if he did not do so himself.
The move also provided Besser the opportunity to express his confidence
in his second-in-command, whom he left in charge while he took a break.
Self-care is not a sign of weakness. It is an expression of
commitment to a positive outcome and acknowledgment that one’s physical,
mental, and emotional endurance have limits. No one person can do it
all. Self-care shows respect for oneself and the others who need and
expect the leader to be at his or her best. Research from Northeastern University
has shown that workplaces with compassion outperform those that focus
solely on technical expertise. The goal is to be kind to oneself and to
others. Even brief breaks to meditate or walk in nature have been shown to have restorative benefits. Make them a priority.
This is not an exhaustive list of the perils of leading through
crises. However, understanding the most common ones and mastering ways
to overcome them equips the leaders to handle most situations. The
people who do so – those NPLI calls “meta-leaders” – are true assets to their organizations and communities.
Eric J. McNulty is associate director of the National Preparedness Leadership Initiative,
a joint program of the Harvard T.H. Chan School of Public Health and
the Center for Public Leadership at Harvard’s John F. Kennedy School of
Government. Many of the program’s more than 750 executive education
alumni hold senior preparedness and response positions across the
public, private, and nonprofit sectors.
Amid unrelenting chaos and violence, scientists and doctors in the Democratic Republic of Congo have been running a clinical trial of new drugs to try to combat a year-long Ebola outbreak.
On Monday, the trial’s cosponsors at the World Health Organization and
the National Institutes of Health announced that two of the experimental
treatments appear to dramatically boost survival rates.
While an experimental vaccine
previously had been shown to shield people from catching Ebola, the
news marks a first for people who already have been infected. “From now
on, we will no longer say that Ebola is incurable,” said Jean-Jacques
Muyembe, director general of the Institut National de Recherche
Biomedicale in the DRC, which has overseen the trial’s operations on the
last November, patients in four treatment centers in the country’s
east, where the outbreak is at its worst, were randomly assigned to
receive one of four investigational therapies—either an antiviral drug
called remdesivir or one of three drugs that use monoclonal antibodies.
Scientists concocted these big, Y-shaped proteins to recognize the
specific shapes of invading bacteria and viruses and then recruit immune
cells to attack those pathogens. One of these, a drug called ZMapp, is
currently considered the standard of care during Ebola outbreaks. It had
been tested and used during the devastating Ebola epidemic in West Africa
in 2014, and the goal was to see if those other drugs could outperform
it. But preliminary data from the first 681 patients (out of a planned
725) showed such strong results that the trial has now been stopped.
receiving Zmapp in the four trial centers experienced an overall
mortality rate of 49 percent, according to Anthony Fauci, director of
the NIH’s National Institute of Allergy and Infectious Diseases.
(Mortality rates are in excess of 75 percent for infected individuals
who don’t seek any form of treatment.) The monoclonal antibody cocktail
produced by a company called Regeneron Pharmaceuticals had the biggest
impact on lowering death rates, down to 29 percent, while NIAID’s
monoclonal antibody, called mAb114, had a mortality rate of 34 percent.
The results were most striking for patients who received treatments soon
after becoming sick, when their viral loads were still low—death rates
dropped to 11 percent with mAb114 and just 6 percent with Regeneron’s
drug, compared with 24 percent with ZMapp and 33 percent with
Drugs based on monoclonal antibodies have become a mainstay of modern medicine—fending
off a variety of diseases from cancer to lupus. But it takes many years
of painstaking reverse-engineering to make them. Zmapp, for instance,
was developed by infecting mice with Ebola and then collecting the
antibodies the mice produced against the virus. Those antibodies then
had to be further engineered to look more like a human antibody, so as
not to provoke an immune reaction. Ebola infiltrates its victims’ cells
using spiky proteins on the virus’s outer shell, so researchers screened
the antibodies for the ones that did the best job of binding to those
proteins. Block access, and the virus can’t replicate and spread. But
compared with other viruses, Ebola is large and has the ability to
change shape, making it difficult for any one antibody to block its
infection. That’s why a cocktail approach has become favored, like the
Regeneron product—a combination of three monoclonal antibodies generated
first in mice.
“Today’s news puts us one more step to saving more lives.”
Mike Ryan, WHO director of health emergencies
An even better solution, some have posited,
would be to mine the serum of Ebola survivors and harvest the DNA from
the white blood cells that make antibodies. That would yield a set of
genetic instructions for making antibodies with a proven track record
against the Ebola virus. That’s what the NIH’s mAb114 is—an antibody
isolated from the blood of a survivor
of a 1995 outbreak in Kikwit, DRC. Scientists discovered it a few years
ago—they had been circulating in his body for more than a decade.
the WHO’s announcement a new trial will now kick off, directly
comparing Regeneron to mAb114, which is being produced by a
Florida-based company called Ridgeback Biotherapeutics. And all Ebola
treatment units in the outbreak zone will now only administer the two
most effective monoclonal antibody drugs, according to the WHO’s
director of health emergencies, Mike Ryan.
news puts us one more step to saving more lives,” said Ryan. “The
success is clear. But there’s also a tragedy linked to the success. The
tragedy is that not enough people are being treated. We are still seeing
too many people staying away from treatment centers, people not being
found in time to benefit from these therapies.”
the ongoing outbreak began last August in DRC’s North Kivu province,
more than 2,800 people have become infected, with 1,794 confirmed
deaths. It is the second-largest Ebola outbreak ever recorded. On July
17, the WHO declared it a “public health emergency of international
concern,” after a case showed up in Goma, a large city bordering Rwanda.
The risk of transmission across international borders remains high.
by Jessica Perlo, MPH & Derek Feeley, DBA Institute for Healthcare Improvement
Health care leaders know that for their organizations to successfully adapt to the rapidly changing payment and service landscape, they need a motivated, engaged, and productive workforce — a workforce that finds joy in work. Caring and healing should be joyful activities, not sources of stress.
However, burnout is reaching epidemic proportions across health care. For example, burnout is now estimated to affect more than 50% of physicians, and one-third of new registered nurses seek another profession within a year. Burnout is a measurable syndrome that lessens staff engagement and can, in turn, lower the quality and safety of patient care. Increasing joy in work can help mitigate burnout and turnover.
By applying community organizing principles to improve joy in the workplace, and then testing our approaches to make sure they're effective, we have the potential to empower our health care workforce to drive changes that it seeks and to deliver the quality care our patients deserve."
Since its inception, the Institute for Healthcare Improvement (IHI) has been advocating for creating a joyful and productive health care workforce. Because caring for patients is a team effort, we need to optimize the experience of all health care workers. There is ample evidence that having a joyful, engaged workforce translates into fewer medical errors, better patient experience, higher productivity, reduced turnover, less waste, and better financial performance.
Fostering joy in work is about creating systems that promote staff engagement, satisfaction, and resilience. This should be a shared responsibility of caregivers, leaders, and organizations. To that end, IHI designed and tested a Framework for Improving Joy in Work that was based on published literature, expert interviews, site visits, and results from a prototype testing program developed by IHI and conducted in 11 health systems nationally.
Through the process of delving more deeply into this topic, we've discovered that lessons from the field of community organizing are readily applicable in health care. Community organizing is a set of collaborative leadership practices designed to enable a community of diverse actors to mobilize toward a common goal, according to longtime organizer and Harvard Kennedy School faculty member Marshall Ganz. In this view, community organizing is a tool for building the capacity of people to work together to create change.
Here are four lessons we've learned from community organizing to nurture joy in the health care workforce.
Know Why You Care
Motivating others to join in action requires answering (1) What will we do? and (2) Why should we do it? What we do is a matter of tactics; why we do it is a matter of heart. Together, they make for a successful strategy. As Marshall Ganz teaches, we need to convey our motivations to elicit them in others. Communicating why we care in the form of stories provides staying power that no strategy alone can achieve.
Motivating others to join in action requires answering (1) What will we do? and (2) Why should we do it?"
For example, staff from the Frankel Cardiovascular Center at Michigan Medicine who were involved in IHI's prototype program aimed to engage colleagues in a discussion about joy in work to discover what matters to the team. To do this, they shared stories of what called them to this profession and what was getting in the way of experiencing joy. Small groups of nursing staff, cardiology fellows, and “scribes" then checked off echoed comments to identify top priorities for testing small changes. This process gave everyone a chance to explore shared values and concerns and to weigh in on what to tackle first.
Start with Your People, not Your Problem
Too often, we begin our efforts to enhance staff joy by looking at staff satisfaction survey results. The data is helpful, and we'll need it for improvement, but it's better to start with the same question we've been urging our care teams to ask patients: “What matters to you?" Only by understanding what truly matters to staff will leaders be able to identify and remove barriers to joy in the workplace. When we begin with asking “What matters?" we demonstrate that we value staff members' feedback and ideas for improvement. We also tap into strengths or bright spots — what's already working in the organization — that offer energy for change. As an example in the food industry, Starbucks encouraged employees to use a special postcard to report decisions that they feel don't support the company's mission.
Do “With" and not “For"
The biggest barrier for many in asking staff “What matters to you?" is what to do with the responses. There is a very real fear that the challenges that come up will feel more like boulders than pebbles in our shoes — such as cumbersome electronic health records or perceived inadequate staffing levels. We can't ignore these issues, but we can also empower local teams to identify and address impediments they can change without having to wait for external resources. This process converts the conversation from “If only they would . . ." to “What can we do today?" It helps everyone see the organization as “us" and not “them."
The IHI Framework for Improving Joy in Work asks leaders to make joy in work a shared responsibility at all levels of the organization. Shepherding this work and moving to what IHI President Emeritus and Senior Fellow Donald M. Berwick envisions as a new era in medicine means we need to support leaders at all levels of the system, from frontline workers to the C-suite. This concept, called “distributed leadership" in organizing, is a social process by which many people across group boundaries and levels within a social system create the conditions for collaboration. In this definition, leadership is a set of social functions, not a position. It is shared among many people in a system and is exercised by sharing resources, expertise, and authority. When guiding change at the unit level in health care, creating a distributed leadership team means we can sustain the effort, even when our energy for the work wanes.
“Only by understanding what truly matters to staff will leaders be able to identify and remove barriers to joy in the workplace."
At IHI, the responsibility for nurturing staff joy in work is shared, not just with our executive team, but with supervisors and project teams collectively aimed at improving the staff experience. By moving from the traditional top-down approach of responding to staff satisfaction data, we were able to increase the percentage of staff who believe IHI is an excellent place to work from 87% to 92% in one year — with an added equity aim of closing the gap in satisfaction between white staff and staff of color.
By applying community organizing principles to improve joy in the workplace, and then testing our approaches to make sure they're effective, we have the potential to empower our health care workforce to drive changes that it seeks and to deliver the quality care our patients deserve. What's more, we might be able to start moving the needle to combat burnout and restore the joy that is at the core of our profession.
Jessica Perlo, MPH
Director, Institute for Healthcare Improvement
Derek Feeley, DBA
President and Chief Executive Officer, Institute for Healthcare Improvement
Marc S. Rovner, MD, MMM, CPE
Very nice article. A community of health care providers should be no different than any other community with a shared purpose.
However, unlike people in a neighborhood who are all just "neighbors" - equal in their standing among each other - in medicine, there is often a hierarchy of power and position to overcome.
Whether derived from a title (Professor vs. Associate), patient care focus (Clinician vs. Researcher), age ('A white hair"), specialty (Pediatrics vs. Cardiothoracic Surgeon), division (Teaching vs. Non-teaching), financial comfort (Close to retirement vs. Heavy in debt), position (Doc vs C-Suite) creates barriers to a shared purpose and open dialogue about burnout and joy.
How best should we organize such a heterogeneous group of leaders and followers into a level set "neighborhood"?
June 05, 2018 at 4:40 pm
Very good points. One should add that the “authority gradient" is even steeper when all health care professionals are included - not just physicians.
The solution starts with the institutional leadership - at all levels; with sharing power and flattening the hierarchy; with respect. There is no doubt that asking “what matters to you?" is very important. Even more important though is the implicit promise: “You matter to us". I don't believe the above listed differentiators (academic rank, age, specialty, teaching status, profession) are by themselves true barriers. It is breaking that promise (you matter to us!) that hinders trust-building and the development of shared purpose.
June 06, 2018 at 8:46 pm
Heather Agee MD
I agree, very nice article. I, too, would like more detail into how you create the distributed leadership. How do you create the "social process" when time is so limited and efficiency is so prized? Is there a road map for this?
June 06, 2018 at 8:50 am
I think this "Health care leaders know that for their organizations to successfully adapt to the rapidly changing payment and service landscape, they need a motivated, engaged, and productive workforce — a workforce that finds joy in work. " is an over estimate. Based on my observations of many years at Duke, I see it rarely occur in newly appointment "Health Care Leaders". These individuals have to take a huge amount of learning. Evolutionarily, a small proportion become "good". Many fail. Unfortunately their failure ruin many health care providers! I think training focusing on development of empathy, active listening, and put self into another's shoes are key elements for these who are or want to be leaders in health care field.
June 06, 2018 at 12:34 pm
Dike Drummond MD
"What matters to you?" is an important question to ask. Even more important is the follow on question that you can actually use to build positive change.
"What gets in the way of you doing more of what matters?"
Surveys of satisfaction, engagement or burnout do not provide actionable data. If these surveys are repeatedly sent out by the employer, they will be come useless as the physicians simply fill in what they think leadership wants to hear.
Leaders must go several steps further.
- Ask question two above
- Take the answers and launch a pilot project to quickly address one of the blockages to doing more of what matters
- Project selection and roll out are done WITH the providers and not TO them
- Disseminate the innovation you produce to the whole organization with full fanfare and trumpets blowing
-- REPEAT AD INFINITUM
My two cents,
June 06, 2018 at 1:33 pm
Dawn Ellison, MD
"If all that leadership does is remove the pebbles from their shoes; we miss the opportunity to discover with them, the real solution, which is to pave the road" DME 2016
We use participatory leadership methods to work on what matters to healthcare workers across CentraCare Health. Engaging all of us using conversations that matter to us is the key to finding wise solutions. Several resources exist to learn about how to "engage" in these meaningful conversations. Liberating structures(http://www.liberatingstructures.com/), Art of Hosting (http://www.artofhosting.org/), World Cafe'(http://www.theworldcafe.com/key-concepts-resources/world-cafe-method/) amongst others.
We are teaching these hosting methods to our leaders across the organization. When we can make meetings meaningful, we can get their involvement!
Provider Engagement Officer
June 19, 2018 at 10:34 am
Jerry McShane MD
Excellent piece and responses.
From my view I found that what is called "Self Determination Theory" helps frame the psychological needs that underpin engagement (joy) as seen through the eyes of any worker. Relational needs, autonomy needs, competency needs being met are those 3. Autonomy doesn't mean sole actor.
Your emphasis on voice - what is important to the worker (aka Physician) is it's essence. When I think about what to do I think about that framework.
Another interesting concept is what is called relational coordination. Which are tactics of a team to achieve a common goal. It requires a common goal as in Patient Care goal for a Patient that the team shares vs each silo has their own goal. Lastly it requires robust transactional communication activities.
Participating in that type of care model paradigm would raise the joy (engagement).
Unfortunately the truth is the individual -
Who they are, what their challenges are, their formation as a person, their role models all go into the mix.
Organizations can and will do their part to alleviate the suffering of any of their employees. It's a long way.
June 21, 2018 at 11:04 am
Thank you for this concise guide to ways of addressing some of the root causes of burnout and disaffection among healthcare staff members. One commonality of interactions between staff members and their patients and leaders and staff members is communication. When communication is respectful, empathic and person-centered, it creates an environment that supports problem-solving and caring. This is essential for clinical interactions as well as employer-employee interactions. While everyone who has survived toddlerhood has an impressive array of communication skills, it is also true that even the most highly skilled among us can benefit from reflection, skills practice and feedback. The Institute for Healthcare Communication has been been designing and conducting continuing education programs for healthcare team members since the 1980s. We invite you to visit us at http://healthcarecomm.org/ for information about our brief, intensive communication skills enhancement programs.
June 21, 2018 at 1:48 pm
Nestor A. Ramirez, MD, MPH
I agree with most of the comments. I think we always talk too much about "Leadership", but forget that in order to lead you must know how to follow. Followership is a skill, trainable and reproducible, not just the blind lemur-like follow-the-leader attitude. We tend to emphasize the role of the leader leading, but a true valuable leader rolls up the shirtsleeves and goes into the trenches and shares actively in the doing. A true leader doesn't tell you what to do, the leader shows you how we do it together. It's not so much the view, as the vision.
June 21, 2018 at 3:25 pm
Just checking in with everyone:
How well is your organization doing in meeting standard compliance expectations for emergency preparedness and response?
Do you feel you have adequate information on: