“Hospitals must retain the agility acquired during the crisis”

The pan­dem­ic has put both our health­care sys­tem and hos­pit­al man­age­ment meth­ods to the test. Dur­ing the first wave, health work­ers adop­ted new, highly effect­ive man­age­ment tech­niques whilst work­ing in crisis mode. Will we retain these approaches? In July 2020, Étienne Min­vi­elle and Her­vé Dumez (CNRS/Institut Poly­tech­nique de Par­is), pub­lished Le Sys­tème hos­pit­al­i­er français face à la crise Cov­id-19 [“How the French Hos­pit­al Sys­tem Dealt with the Cov­id-19 Crisis”] a study based on 55 inter­views with health professionals. 

How would you sum up your field of expertise?

Health man­age­ment research is a field of social sci­ence that stud­ies key issues in pub­lic health, such as organ­isa­tion­al per­form­ance, coordin­a­tion of health pro­fes­sion­als and treat­ment plans. It is a rel­at­ively new field in France because health pro­fes­sion­als gen­er­ally have little form­al man­age­ment training. 

Why did you decide to spe­cial­ise in this field? 

Over the course of my med­ic­al stud­ies, I became pas­sion­ate about man­age­ment. I stud­ied at the Essec Busi­ness School and have a doc­tor­ate in Man­age­ment Sci­ence from the Insti­tut Poly­tech­nique de Par­is. Our coun­try has one of the best health sec­tors in the world when it comes to clin­ic­al prac­tice and research, but we have major man­age­ment prob­lems. Fix­ing these would lead to massive improve­ments, as well as increase qual­ity, lim­it waste, and reduce inequal­it­ies. The field is still a minor­ity in the health­care sec­tor. I am try­ing to devel­op a large-scale patient-centred approach to respond to spe­cif­ic needs of indi­vidu­als. And to sub­sequently make that offer as widely avail­able as possible. 

What les­sons can we learn from the pandemic? 

Our health sys­tem has had to deal with an increas­ing num­ber of crises lately: ter­ror­ism, nat­ur­al dis­asters and, in our case, a pan­dem­ic. In order to face these chal­lenges and be more adapt­able, we have to adjust our skill set to imple­ment new kinds of man­age­ment strategies. 

Do you think our hos­pit­als were adapt­able enough dur­ing the lock­down dur­ing the first wave of Covid-19? 

Yes. Our study sum­mar­ised this in six points. We observed: 

1. A great deal of organ­isa­tion­al cre­ativ­ity, includ­ing the mass devel­op­ment of tele-health ser­vices. This some­times involved a more relaxed approach to cer­tain rules, such as exchan­ging med­ic­al inform­a­tion via What­s­App, which under nor­mal con­di­tions is a viol­a­tion of patient confidentiality. 
2. For­ward plan­ning: health pro­fes­sion­als assessed the situ­ation and made decisions in real-time, high­light­ing the vital import­ance of field stud­ies. Data obtained from an assess­ment of the situ­ation in the French city, Mul­house, was used to make decisions in Par­is, for instance. 
3. Sup­port­ive man­age­ment based on listen­ing, extens­ive com­mu­nic­a­tion, the con­sid­er­a­tion of everyone’s per­spect­ive and flattened hier­arch­ies made a big dif­fer­ence. This went hand in hand with fair dis­tri­bu­tion of fin­an­cial resources between ser­vices, phys­ic­al pres­ence of lead­ers, and transparency.
4. Adapt­a­tion through autonom­ous, co-oper­at­ive group work. For instance, rap­id test­ing and eval­u­ation of new patient ori­ent­a­tion pro­to­cols were developed by loc­al teams.
5. New part­ner­ships between start-ups and hos­pit­als, and between pub­lic and private institutions. 
6. Gov­ern­ment sup­port such as remov­al of fin­an­cial con­straints and pro­vi­sion for loc­al initiatives. 

How can we foster cre­ativ­ity in an envir­on­ment which is under­stand­ably highly regulated? 

Humil­ity and doubt must be val­ued above all things. Cre­ativ­ity can only hap­pen when there is a will­ing­ness to let go of pre­vi­ous assump­tions. And errors must be recognised. 

What did we see dur­ing the second wave of the pandemic?

First off, it was slower and more widely spread. Because of its re-appear­ance after a short peri­od of calm, health­care teams who are often tired are being tested again. The word that comes back most often is ‘wear­i­ness’. An abil­ity to adapt is still neces­sary but with an emphas­is on sup­port­ive man­age­ment. The ini­tial solid­ar­ity is wan­ing thin, so it is import­ant to sup­port teams on a daily basis and address wor­ries of health­care professionals. 

Between the two waves, were we see­ing man­age­ment return to the way it was before? Or were ser­vices retain­ing the know­ledge learnt from pre­vi­ous crises? 

Under nor­mal cir­cum­stances, per­form­ance relies on spe­cial­isa­tion, hier­archy and eval­u­ation; con­trary to adapt­ab­il­ity which relies on short net­works and quick reac­tions. How­ever, if we take a closer look, we can see that prox­im­ity man­age­ment is essen­tial in both cases. It encour­ages adapt­a­tion and can work to res­ist the loss of attract­ive­ness we are see­ing in the health professions. 

Con­di­tions at hos­pit­als have deteri­or­ated; the organ­isa­tion­al struc­ture is unclear and under­mined by polit­ics. This makes health­care a tough work envir­on­ment, and the ongo­ing crisis high­lights the urgent need for prox­im­ity man­age­ment. The bound­ary between nor­mal con­di­tions and those of the crisis is now blurred. For that reas­on, we could say that the man­age­ment chal­lenge needs to deal with a ‘nor­mal crisis’. 

Does the entire cul­ture have to change? 

I don’t really like the word “cul­ture”. There is no manu­al for chan­ging a cul­ture. To me, train­ing is para­mount. A head of depart­ment, for example, is often chosen on their expert­ise as a research­er, which does not neces­sar­ily make them a good man­ager who can unite staff, foster cre­ativ­ity, encour­age intro­spec­tion, and so on. For me, the key is on-the-ground man­age­ment training. 

Is there a “post-Cov­id crisis” in pub­lic health? 

Yes, because we have real­ised that large scale threats are real, some­thing that would have been impossible without the pan­dem­ic. Think back to the begin­ning of the year: the signs were there, in China, in Italy, but people were often in denial. 

Will we see more crises on the same scale? 

Prob­ably. We will face oth­er threats, such as bio-attacks, new epi­dem­ics, cyber-attacks, cli­mate change, and ter­ror­ism. We live in an uncer­tain world, and we must be pre­pared. Dur­ing the crisis, the army built an emer­gency mil­it­ary hos­pit­al (in Mul­house) in record time, as part of a test for a chem­ic­al attack response. Staff wore very uncom­fort­able NBC suits. We need to under­stand that each crisis is unpre­ced­en­ted, that each situ­ation requires a new strategy. But we are learn­ing. We saw, for instance, that staff who had lived through the 2001 chem­ic­al explo­sion at the Toulouse AZF plant retained good cog­nit­ive reflexes and adaptability. 

How did they behave? 

They were resi­li­ent. They had a way of remain­ing con­struct­ive under pres­sure, which is abso­lutely essen­tial. In times of sud­den, short-term crises, solid­ar­ity is per­vas­ive. In chron­ic situ­ations, how­ever, that solid­ar­ity erodes. Organ­ic solid­ar­ity (“we are all in the same boat”) gives way to a more mech­an­ic­al solid­ar­ity (“we are in this togeth­er, but rela­tion­ships must be nego­ti­ated”). Unless man­age­ment finds a way to coun­ter­act this, we will lose our effectiveness. 

Interview by Clément Boulle