Webinar | Leadership Through Crisis Interview Series – Sue Anderson and Eli Quisenberry

Chris Backous

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Sue: Early on, the infection control guidelines were changing all the time. We had our leaders out and rounding much like we would any other time because we knew how important it was to be there for our teams. As we started to cohort patients, particularly the COVID-positive patients, then clearly the guidelines changed. We began rounding in different way to be mindful of infection prevention requirements. All leaders are capable of understanding what PPE is required and what they need to do to get out on the genba that they need to get to. Eli: There is the leader rounding piece and then there is the group interaction with the huddle. We had a very short window of a hiccup of how, for the larger group huddles, to do some combination of virtual while maintaining that visual control production board aspect.

Sue: In general, our staff had the range of reactions to the pandemic that you see and hear in other organizations, but I would say that we had really good connections between the administration of the incident and the clinical care that was provided. We heard lots of stories in other hospitals about how “the leadership isn’t allowing us to do this,” or “it’s not providing us with the equipment we need to be safe,” and I would say it was probably much less here. That’s not to say it didn’t pop up from time to time, but we were very clear about what our supply status was, what the changing requirements were for keeping our staff safe, and I think they felt supported by leaders because the leaders were present, they were able to ask questions, we gave them all of the information we had at the time even if it wasn’t complete. So I think the general tenor of the organization has been that we’re all in this together trying to provide the best care we can for our patients.

Sue: Things came in in a variety of ways. We had a daily communication that went out to the entire organization, so a lot of the issues that were raised when we had something that we had resolved and could communicate, or the fact that it was still an open issue, through the daily debrief calls we got the information to leaders so that they could get that information to their teams. We had a COVID site, even today, on our intranet so people have all of the resources we’ve developed. We had a daily COVID communication that went out to all leaders that they could also distribute or talk to their staff about. That’s now down to once a week and targeted communications. We had a function where the communications team was very critical to our command center structure so they were there at the table. It was the incident command that was responsible for making sure that things got out as needed. Eli: Behind the scenes, the command center was set up almost like a mini flow station of someone’s ideas, the draft standard work, who is going to edit it, and then who we are waiting for approval on. It became really visible, who is waiting for someone to approve this before it can go out, what’s already been pushed, are we on version two or version 20. Like anyone, we had some hiccups in those first weeks and slowly got smoother as we went on.

Sue: I’m only thinking of a few kind of bottleneck areas. One of them was in our pharmacy and prescription renewals that came in. As shelter at home orders were coming in, people were advised to get three months’ worth of medications, which said instead of filling their prescriptions on some regular sequence, we had a bolus. And so that was one of the areas that we were monitoring, but our pharmacy team through their daily management, knew what that was. I think we were only in red status a couple of days related to that, often in yellow, until it got under underway. They had a plan and it didn’t require incident command to manage it. It was just the awareness of what was happening. Especially early on, the testing capacity and the length of time to get our test results back before we were able to set up our own testing, was really problematic. Our patients were safe, we just didn’t have all the information that we needed to move them along in their care maybe as quickly as we could later on.

Sue: Immediately, we cleared our calendars. We did not try to do normal work during the early days of COVID. Even if I was not incident command, I lived in the Command Center for the first month. And when I wasn’t incident command, I was helping to shepherd some work that would support whomever was incident command. I think that’s one of the ways to free up bandwidth when things are coming to you so fast. The other thing that we realized maybe about 2 to 3 weeks into the pandemic – we really started emphasizing "How are we going to support our staff through this?" Getting back to our Respect for People behaviors, recognizing that people are not always on their best behavior in moments of crisis, but I think that our Respect for People work allowed people to talk to others when they felt they weren’t being treated with respect. It also allowed us collectively to develop compassion for people and recognize “Okay, I can see someone – Sue’s at the end of a rope,” and somebody else would step in to help. That situational awareness was also helpful during this. Eli: We think our frontline leaders obviously play such a critical role in the spread of both information and respect. They are really the ones that feel the crunch, if they’re getting mixed messages from the top or if their staff are unhappy, you know, the frontline, nurse managers, for example. The leaders and communication team worked hard to develop huddle cards – we really worked hard to synchronize our flows of information. If we were changing PPE standards, for example, every single day, and by the time you got the new standard you’d already missed your daily huddle for the day and so you had to hurry up and scramble. There was a lot of work just to figure out what’s the right order of information that people get and how do we have mechanisms to provide feedback? That, obviously, wasn’t smooth every single day but I think got smoother each week, because we had the listening mechanism of “Where is it not working?” The senior leaders were awfully synchronized every single day so they weren’t sending mixed messages unintentionally.

Eli: I think our fastest cadence was the daily change, or the two-times-a-day change. I think as we’ve adjusted, the Command Center at some point made the decision that we just can’t push out. The change was slowing down and we were becoming a little more stable, but then we said, "You know, Wednesday will be our key time to push out new standards." We actually were able to kind of meter every single point change improvement. Part of it was consolidating the messaging and putting it out the same way and I think our ability to have the capacity for all of our leaders to have daily management practices to receive news and having a standard way and structure and deliver it to teams. Sue: We talked about, in our management system, the creating alignment or the management policy part of that slide. There were a lot of questions with no clear answers. There still are a lot of questions with no clear answers. The seven of us who are meeting often dealt with those types of topics because we needed to make a decision, and we weren’t always in agreement. By having that smaller group where we could say, “Okay, here’s our decision,” so that the rest of the organization didn’t necessarily see that sausage making, [it] helped with the communication downward. Normally the seven of us would not see each other on a daily basis. We’re all off, doing our own things, and yes, we have our regular meetings where we come together, but it was essential that we create that alignment at the top. Leading through ambiguity is one of our leadership competencies that we’ve identified here. Leading through ambiguity is not how comfortable I feel in the situation of ambiguity. It’s “how well do I create clarity for my teams when things are unclear?” so that they know what path we’re going down. And that was really essential during this time. Even today, I think where we still continue to have ambiguity is related to infection prevention. I think that’s just going to be an everyday issue for us. So we still do twice a week huddles with that leadership team and our infection prevention team. So this morning was one of those. We met and talked about what mitigation, if any, are we still going to do in some of our physical spaces – not necessarily direct patient care but in other areas so that we’re consistent across the organization and sending the same message to our teams.

Sue: The easy answer for us is our pyramid, our strategic plan – it was very essential that we keep our patients at the top throughout this. What are we doing to provide the highest quality care in a time when the patient care protocols are changing? Because there weren’t any when this first began. Our Respect for People, which we pulled up, says that the impact on our team members is equally important – so Respect for People, for both our patients and our team members, and I think we kept that front and center the entire time and continue to keep that front and center. Eli: Sue mentioned we dropped most of our regular meetings and really solidified what we wanted our priorities to be, but we also purposely kept a few traditions for us. Our Friday report-out – where all of our events and leaders usually come together to hear what are the successes from a VMPS perspective every week – through Sue’s leadership we made the first full decision that we were going to come together every week, virtually, whether we have an event to talk about or not and we’re going to reinforce the sense of normalcy but also that VMPS is the way. I found myself in my office doing more communication and reinforcement of “Hey, there’s VMPS,” and these types of skills happening all over this medical center even if we’re not seeing these big five day events. I think just capturing and spotlighting “Hey, we know how to do this, we know how to see waste, we know how to run daily management, we know how to prioritize and communicate.” It could have easily gone the other way if we didn’t have kind of that maturity and depth, but we really leaned on VMPS as the way in that column and backbone and common spirit on how we’re going to capture this. I think it gave us a little sense of normalcy sometimes. Sue: The other thing I might add is – part of our tradition is we have a Tuesday morning stand-up, and so we’ve continued that going virtually. But once a quarter, we get together and do more reflective work around what’s happened over the last quarter in our VMPS work, and on April 28th, exactly two months after we received our first patient was our quarterly stand up, and it was a review of some, not all, of the application of the VMPS to the COVID pandemic at Virginia Mason. Anyone who went to that session or watched it virtually afterwards, I think, was blown away by the breadth and depth of VMPS in all of our work surrounding this pandemic. It was really a lovely opportunity to reflect, because when you’re seeing it every day, you don’t actually have an full appreciation for how much VMPS affected everything that we did.

Sue: For a while, some of our operations were “shut down” under a governor’s order that required that we not do certain elective services for our patients. But, you know, patients continue to have strokes and heart attacks, and need their cancer care, and other things that are just part of healthcare and life. And those were always fully operational throughout this time, and it was really, “how do we need to adjust any of these in the time of COVID?" By the end of April, we were coming out of the immediate feeling of crisis and knowing that we were moving into the “new normal” crisis. That thinking has continued to evolve over the last few months and now we’re really thinking about how we get even closer to normal in terms of recovering our operations because there’s a lot of pent up demand. The other thing we’re really dealing with this fear. There’s still people that are afraid to come to the hospital, who really do need to come to the hospital so we’re spending time thinking about how we recover to whatever the new normal is today, and then anticipating what it might be in the fall. So continuing to do some surge planning exercises, if in fact we do have the what could be predicted around the double whammy of flu and COVID later in the fall.

Eli: While we never officially said, “No kaizen events” or five day workshops, we certainly didn’t see much for about 2 or 3 months there. A number of events were postponed, a number of them moved into what we would call in-flow kaizen. So, they would come together for two hours to really get a boost of work going. And then, what we’re doing right now is trying to support our teams with new kinds of tools and ideas on how you can do semi-virtual and virtual events when it doesn’t make sense to bring a group together. We’ve got a pretty robust patient-family partner volunteer pool that partners with us and we’re figuring out which ones of them feel safe to come in and which ones of them do we make more virtual connections. We’re also both reinforcing to all leaders and working with our senior leaders, that this is the method, we do want to get back to this, but we’re really looking for our leaders to help set the priorities for their teams in alignment with many of the things that Sue talked about. In some ways we’ve tried to not change and we are certainly being more adaptive as much as possible. And for areas that have many staff on furloughs we’re not driving the same pressure that we might have, and for those areas that really need it we’re trying to respond with more speed than we could before.

Sue: Washington state has a pretty good emergency network process in place and we’ve seen that because one of our hospitals is in Yakima County which is one of the hotspot counties in the US. We had daily co-ordination with them around what their needs were. We took a number of patients transferred out of that community just when they became at capacity. But there became a point where we couldn’t be the complete relief valve and so we coordinated both through the hospital association, which is a fabulous organization in Washington State, and this emergency network so that other hospitals could also help as our hospital in Yakima needed to transfer patients. Because, in Washington, state, all of the hospitals came together and said, “No, no. We’re not going to let any hospital reach crisis on its own. We’re going to work together as a community to support each other and to support the communities so that we will all get to crisis at the same point if that happens, and we’re doing everything we can to avoid crisis.” And we’ve been very successful – and my understanding is that there are other states that have not had that same relationship across hospitals and it’s created issues.

Sue: I think two pieces of advice. One would be to identify those tools that you’re comfortable with and use them to their fullest. So the more that you can really focus and makes things visible, it will help with communication. My second piece of advice is something Eli said, which is keep your rituals that you have that are really important to your culture because as the pandemic is raging and people’s responses are raging, there needs to be grounding in the organization. And so, identify what are those things that will help keep you grounded at the same time you’re trying to move forward with the work at hand. Eli: The other thing that we’re finding successful, as you know, we normally have a fairly rigorous annual planning cycle and accountability each month throughout. I think we’ve given ourselves the grace to say, “Well, what just isn’t going to be on the plate this year?” So of our priorities, which ones are going to help us through this new world, which is virtual care, team member wellbeing, the types of things that we’re going to work on anyways – we can boost efforts there – but then give ourselves grace to save some of this stuff for next year, or when we can, when it makes sense.

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