key: cord-0942953-q42fsprr
authors: Kaul, Vivek; Shah, Vijay H.; El-Serag, Hashem
title: Leadership During Crisis: Lessons and Applications from the COVID-19 Pandemic
date: 2020-05-18
journal: Gastroenterology
DOI: 10.1053/j.gastro.2020.04.076
sha: 99b0e48219b5183bc17d17267c83055f12d3d5e2
doc_id: 942953
cord_uid: q42fsprr

nan

The COVID-19 pandemic has emerged as an unprecedented international humanitarian crisis.

Several recent publications and multi-society guidelines have focused on the clinical manifestations of this disease and best practices in gastroenterology and endoscopy during this pandemic [1] [2] [3] [4] [5] [6] [7] [8] [9] .

In times like these, there is volatility, uncertainty, complexity and ambiguity that need rapid, high impact decisions in a limited information setting. Leaders have to manage these elements, learn new lessons along the way and help develop various creative problem-solving strategies to keep their enterprise operational and our patients safe and well cared for. We have selected and summarized several characteristics and practices that effective leaders embody during a time of crisis and discussed them in the context of the COVID-19 pandemic (Figure 1 ) [10] [11] .

The macro forces that are driving the spread of the pandemic as well as the statistics and predictive models about the incidence and fatality are well publicized through mass media and social networks. It may not seem likely that the quantity or quality of communications coming from a local leader would make a difference, but it does. Uncertainty produces anxiety throughout the workforce and the leader's silence will be interpreted as bad "local" news. It is essential to communicate to define reality and reinforce a clear perspective on what is happening and what it means for the unit that you are leading, the organization and the region.

Communication needs to be clear, consistent but also adaptive.

Great leaders communicate credible hope that the group has the resources needed to meet the threats it faces each day, both material (e.g., PPE, wellness resources, ability to work remotely) as well as psychological (e.g., determination, solidarity, shared purpose). These leaders also communicate the gravity of the challenge transparently and are humble enough to admit that they do not have all the answers. Doing so bolsters their credibility, allowing them to share an optimistic vision that is both reassuring and realistic.

A crisis is an opportune time to rediscover one's core values. Our profession and organizations' mission and core values are put to the test in turbulent times and effective leaders take this opportunity to re-emphasize these values to motivate and galvanize those around them. It is also important to recognize and applaud champions such as volunteers, frontline clinical workers in the ICU, emergency responders and others who are caring for COVID-19 patients to set a visible example as those who are reinforcing the culture and values of putting our patients first.

Successful leaders cut through the clutter of conflicting data and opinions, identify the areas that need attention and allocate effort and resources accordingly. They quickly develop and communicate a point of view on the best path forward, providing a sense of direction. Effective leaders during a crisis are also flexible in changing course, adopting novel, more promising ideas, while abandoning dogma or prior diktat.

A good leader understands that no decision or a delayed decision may lead to a worse outcome. In the case of pandemics, chasing the events is an indicator of losing ground. As we now know, delays of even a few days made a considerable difference in the spread of COVID19. Since high quality data is scarce or hard to come by early on, decisions may have to be taken based on prior or best available knowledge, experience, intuition, consensus and common sense. Several opportunities to mitigate harm are missed in the initial stages of a crisis (e.g., use of face cover, canceling travel, screening employees and patients) as we tend to rely on traditional models of data and evidence-based decision-making. However, as new information becomes available, a leader has to be flexible to change prior decisions or adopt alternate pathways. A successful leadership team encourages "outside the box" thinking to deal with catastrophic events. As the crisis evolves, the successful leader makes nimble and decisive moves and subscribes to a strategy that is iterative. An example in the COVID-19 setting is allocation and use of PPE where recommendations change rapidly based on PPE availability, disease prevalence, and emerging knowledge of viral transmission.

Successful leaders have the ability to devote the appropriate short-term resources to urgent needs while maintaining a focus on long-term strategic goals. They do not hesitate to make the hard choices (e.g., work from home, social distancing, hiring freeze, canceling elective procedures and in-person meetings, or even total lockdown) to address short-term priorities.

They also demonstrate the courage and foresight to preserve investments that are essential to the long-term health of the organization. In the face of uncertainty, some leaders are guided primarily by concerns over the "optics" of their decisions; strong leaders are guided by a view of the sacrifices required to preserve strategic direction.

Great leaders engage purposefully with those around them to harness the energy of the broader workforce. This engagement creates a sense of togetherness by having the humility to listen to a wide range of opinions and focus on asking questions. It also connects with colleagues and shows that you genuinely care about them and their welfare. With stress of crisis, it is easy to assign blame, find fault and criticize. Purposeful engagement enables leaders to steer the process in the chosen path through the power of respectful dialogue emphasizing connection over correction. A crisis is not the time to dwell on mistakes, but rather to instill confidence in the team members through empathy, support and reassurance.

The organization needs many leaders in times of rapid and unpredictable change. During a crisis, senior executives have a natural tendency to assert control, stripping away leadership responsibility from their direct reports in an effort to reduce risk and increase efficiency. As a result, others become operators and executors, not leaders and decision-makers. The resultant weakening of the team's leadership skills may echo through the ranks for years afterwards.

Strong leaders who enable others to leads are catalysts for widespread change. This is referred to as "horizontal" or "agile leadership.

The best leaders actively resist the instinct of withdrawing inward. They look outward to colleagues, employees, suppliers, and customers and other organizations for gathering the insight required to enable better decision making. 

Early assessment of the overall impact of a crisis such as COVID 19 on clinical practice is an essential and complex exercise. The initial decisions revolve around determination of clinical urgency and understanding true capacity. While multi-society guidelines have been proposed on this topic, triaging the timing of patient care (urgent, semi-urgent, elective) is a difficult exercise with potentially significant clinical, ethical, medico-legal as well as financial implications 13 . These decisions need to incorporate the nuances of subspecialty GI practices and are best taken with the input of the provider teams and institutional leadership.

On the operations front, the capacity depends on staffing levels, personal protective equipment (PPE), COVID19 testing, degree of redeployment of providers and staff to other clinical areas, availability of consumable supplies and inventory. It is advisable to put together an "operations" team that addresses these issues in real time and moves nimbly to address problems that arise both in the hospital, clinic and endoscopy unit.

The considerable negative financial impact is felt throughout the system. Division administrators (and practice managers) and Chiefs/Chairs (and managing partners in private practice) need to grapple with this reality and work in partnership with senior leadership at the institutional level, factoring in revised revenue projections and strategies to mitigate the losses. It is in this arena that effective communication, addressing staff and provider anxiety and maintaining transparency are essential tools to help keep the team together and focused on their main missions. The strategies vary by place and time and include redeployment (e.g., hospitalists, employee health), change in delivery (e.g., telehealth), and transparent equitable reductions in compensations as a last resort.

Training and education, which are critical missions for academic programs, have been disrupted during COVID-19 crisis. Core program leadership has to define priorities for teaching and education that need to be fulfilled and implement a strategy to achieve that goal. Fortunately, there are well-established platforms available to deliver remote learning digitally and these must be harnessed to facilitate curricular needs both now and in the future. In addition, key clinical rotations need to be identified and trainees rotated through those in a limited fashion, to maximize trainee safety. Endoscopy simulators might be a good training platform to consider during this time. Such times may represent opportunities for trainees to catch up on research or academic projects or examination preparation. Downtime due to COVID-19 also represents an opportunity to have deeper discussions on strategy and transformative change going forward with re-imagined educational models to test post-crisis.

Most institutions have provided regulatory guidance, including a moratorium on non-critical human subjects enrollment, for a specified time period. Communication with research subjects and the importance of PI compliance with crisis mode regulatory guidance needs to be emphasized at all levels. Budget reassessment, reallocation of research staff to other areas of the program and communication with study sponsors are priorities in this realm during a crisis. This relative "hiatus" represents a good opportunity for the research teams to re-assess their portfolio, develop new or revised strategic priorities and ensure that the regulatory documentation is complete. The hiatus is also an ideal time to re-evaluate one's competitive advantage and value proposition of their personal and departmental research strategies, and develop new focused multidisciplinary groups to pursue new areas of research. It provides an opportunity to leverage COVID-19 relevant work which will have increased value for at least the mid-term future.

A disruptive, chaotic event of such magnitude will leave institutions, teams and individuals with varying levels of trauma. The most important priorities for a leader in the early post-crisis phase include a rapid assessment of the existing landscape at all levels (administrative, clinical, academic and financial) as well as the humility and wisdom to recognize the lessons learned.

How did we do? What did we do well? What did we not handle well? These are critical questions that will guide the rebuilding process and help prepare the team for recovery and resumption and possibly future events. The forward-thinking leader will use this opportunity to incorporate innovative strategies and systems into the re-building process, such that the new product is a stronger, more robust and progressive version. The instinct of "returning to normal" may not be the best philosophy. However, crises generate a "burning platform" that is often the opportunity needed to drive transformational change. Indeed COVID-19 may eventually be known as the event that finally tipped medicine and education into the Digital-care era!

The progressive leader will identify new paradigms and opportunities that present themselves as a result of such a crisis. An example of this is the jumpstart of the telemedicine platform during the COVID crisis. Prior to COVID, telemedicine was not mainstream in American medicine, despite having been around for more than a decade. However, the rigors of this pandemic have sharply focused the attention of administrators, providers and insurance companies. It is because of telemedicine, that the "work from home" platform may finally be adopted in a meaningful way in our medical field, which may have significant implications for reducing provider burnout while enhancing efficiencies in care delivery.

Based on the best information, data and trends available, it is important to establish a target date for resumption of operations, in alignment with institutional as well as societal and governmental plans. Decisions will need to be taken regarding a graduated versus more acute ramp up of activities. One example of a post-surge challenge is how to manage the clinical backlog. This will require a formal operational strategy, additional resources and institutional support. It will require creativity, flexibility and the ability of the leadership team to develop innovative approaches to problem solving. New schedules may need to be developed, evening and weekend work shifts may have to be contemplated, and providers may have to work from different locations to allow consolidation of activities and economies of scale. An effective leader will champion these novel solutions, and facilitate in the implementation.

A key observation from the COVID-19 crisis is how underprepared we were as a profession and as a country to deal with such a crisis. Building strong relationships with key stakeholders, having a clear understanding of each leader's role in a future crisis, developing effective supply chains and other processes are a few examples. These plans need to be at the divisional, departmental, institutional and regional levels. Key questions to ask would be: How do we ensure that we maximally prepare for known threats? What are the tools? What are the systems in place? What is the playbook? The answers will be unique for each individual scenario, but the exercise has to be undertaken proactively and the basic principles will be the same.

Leading during the acute COVID-19 crisis has been a stress-test for leaders. This test will hopefully allow GI leaders, teams, and institutions in healthcare to be better prepared for managing a sustained period of pandemic related disruption that many are now anticipating. It will also stimulate proactive planning for crisis preparedness and a renewed commitment to leadership training in medicine.

COVID-19) outbreak: what the department of endoscopy should know

Considerations in performing endoscopy during the COVID-19 pandemic

A New Epicenter of the COVID-19 Pandemic

Gastrointestinal endoscopy during COVID-19 pandemic

What Should Gastroenterologists and Patients Know About COVID-19?

COVID-19: Gastrointestinal manifestations and potential fecal-oral transmission

COVID-19 in gastroenterology: a clinical perspective

Covid-19 and the Digestive System

AGA Institute Rapid Recommendations for Gastrointestinal Procedures During the COVID-19 Pandemic

Here Are The Top Five Leadership Challenges During The Coronavirus Pandemic

Gastroenterology Professional Society Guidance on Endoscopic Procedures During the COVID-19 Pandemic. Joint statement of the AASLD, ACG, AGA and ASGE