Background COVID-19 pandemic exposed leadership teams to novel challenges that required many changes to their practices. This has been the most volatile, uncertain, complex and ambiguous (VUCA) times in healthcare.
Interventions This brief report uses experiences at Oxford University Hospitals to propose that an organisation’s culture serves as a bedrock on which management of a crisis such as the COVID-19 pandemic is reliant. The other two critical factors are partnership working and clarity of the strategic intent of the organisation.
Conclusions While many of the actions described in this report are likely to be in common with those of other leadership teams across the National Health Service, some organisations seem to manage the response to the VUCA situations better than others and the three factors are repeatedly observed in these organisations. This brief report explores what actions support the three critical factors that make some organisations more resilient and their leaders’ actions more effective.
- organisational effectiveness
- medical leadership
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COVID-19 crisis has been like no other that most healthcare workers have been exposed to during their careers or lifetimes. This global pandemic has clearly affected healthcare systems and workers throughout the world, with many worse affected than others. This brief report describes some of the many actions delivered at Oxford University Hospitals (OUH) to manage the pandemic. Further, it proposes that (1) organisational culture, (2) working in partnership and (3) clarity of strategic intent are the three critical success factors that underpin and enable successful leadership during volatile, uncertain, complex and ambiguous events.1
Organisational culture is defined as the underlying beliefs, assumptions, values and ways of interacting that contribute to the unique social and psychological environment of an organisation. Culture also includes the organisation’s vision, values, norms, systems, symbols, language, assumptions, beliefs and habits.2
It is notoriously difficult to define and improve. West has consistently argued that organisational cultures are like clouds and leadership should be able to influence these constantly changing clouds.3 Culture can be influenced by wider organisational environments related to human resource policies, leadership style, accountability, communication and relationships with partner organisations.4 This argument extends to the notion that actions of leaders heavily influence the cultural tone of an organisation. OUH commenced a culture and leadership programme in 2019 and had just completed the ‘discovery’ phase of this work before the pandemic struck.
This brief report proposes that an unrelenting focus on safety, outcomes and quality improvement, coupled with consistent, clear communication with staff, and demonstrable compassion are the key factors that shape an organisation’s culture. The actions of leadership teams that demonstrate how three factors came into play during the COVID-19 pandemic are outlined below.
Focus on patient and staff health and safety, clinical outcomes and quality improvement
During the COVID-19 crisis, safe care for both, non-Covid and Covid-positive patients was equally important. Ensuring this, included dissemination of clear guidelines, implementing change to clinical practice, such as for cancer patients, and trouble-shooting any issues that arose on a tactical basis. The infectiousness of COVID-19 meant there were safety implications for all hospital staff and patients. These were manifold: creating separate areas for COVID-19 patients, ensuring adequate facilities for non-Covid patients, giving clear guidance to staff about their safety and at the same time ensuring that all safety incidents are recorded and analysed, to facilitate learning. The importance in continuation of core safety activities sent a signal to staff that the focus on safety is core to the organisation’s business and that existing safety systems and processes are tenacious and reliable in monitoring and addressing safety in turbulent times.
At OUH, safety processes such as a Ppatient Safety Response Team, continued to monitor incidents that led to moderate/major harm, with immediate mitigations put in place if root causes were self-evident.5 6 Roll out of Safety Huddles across all clinical and non-clinical areas enabled teamwork, empowerment of staff to raise concerns and cascade important messages. A safety huddle beginning with the question, ‘what went well’ confers positivity, helps reduce anxiety and restores belief in the system.
Quality improvement, done well has shown culture shifts within organisations with a change to better Care Quality Commission (CQC) ratings. Enabling front-line staff to recognise and change processes for the better promotes engagement and demonstrates a learning culture.7
Clear, consistent communication and engagement with staff
During the early stages of the COVID-19 crisis, there were anxieties about levels of, and staff training for personal protective equipment (PPE) use and there was ambiguity about national guidelines for PPE.8 Different forms of communication are always important, as no one platform appeals to all personality types on both sides of the communication chasm that exists in organisations.9 Successful leaders communicated with their staff via a combination of emails, webinars, Teams/Zoom meetings and face-to-face meetings (the last stopped when the lockdown started). Through these means, leadership remained visible and the importance of this cannot be overstated. Executive directors rounding on clinical areas to interact with staff is recognised as supportive, good practice. It gives staff an opportunity to share their concerns directly and build confidence that their individual views are taken into account. Clinical leaders sharing experiences with front-line colleagues offers staff a unique insight into organisational preparedness and provides leaders with the ability to respond to colleagues’ anxieties. Culturally, the divide between frontline staff and an organisation’s leadership is directly related to the amount of time spent on clear consistent messaging and communication between the two. At OUH, during the peak of the pandemic, daily communications went out to all intranet users on the most recent guidance, PPE requirements and offers for well-being of staff along with agile and flexible working policies being introduced. In the latter part of the pandemic, asymptomatic staff testing was made available to all staff. There were an increased number of Freedom to Speak Up Guardian (FTSUG) meetings and PPE safety team walkarounds on all hospital sites.
One of the big cultural changes for many clinicians has been the use of video consultations to replace clinic attendances.10 This also required changes to clinic organisation but all happened within 2 weeks (when historically, change of this magnitude in the National Health Service (NHS) can take years). Medical staff were smoothly redeployed across specialties and medical students recruited to work clinically, along with a return of recent retirees. All this demonstrated strong cohesive response and innovation in the face of adversity.11 Several services were required to change physical locations, offer care differently and there was rapid transformation of entire services. For example, there was an expansion of number of beds required for COVID-19 patients in parts of hospitals that were previously occupied by non-medical or non-infectious disease specialty beds. In many ways, this crisis provided an opportunity for a much-awaited digital transformation of the NHS12 which will bring many benefits in terms of improved quality, better patient experience and cost savings and is a change that will be retained in the NHS post-Covid. OUH went from a standing start to being one of the largest users of virtual platforms for communication with patients over the pandemic. The redeployment team at OUH created a platform for all doctors and nurses to add their competencies and proficiencies such that the intensive care and general medical areas were supported.
Development and deployment of an ethical framework to aid clinical decision making in difficult situations was important and done in collaboration with staff.13 This not only applied to clinical situations like offering ICU care and resuscitation but also when changing the locations of clinical services and how these services were offered. Both patient and staff perspectives had to be addressed. Empowering change at this scale and pace demonstrates trust in teams and compassionate, agile decision making on part of leaders.
As new data emerged, it became apparent that Black, Asian and Minority Ethnic (BAME) staff were at a higher risk of COVID-19-related intensive care unit (ICU) admission and death.14 A decision to offer all BAME staff adequate risk assessments with their line managers and access to staff testing, whether symptomatic or not (viral RNA and serology), showed that leaders took their responsibility for their staff seriously. At OUH, 100% staff risk assessments were completed and over 12 000 asymptomatic staff were tested. The results allowed OUH to draw up guidelines for infection control to prevent nosocomial spread. This level of accountability and responsibility demonstrated credibility, an ability to stand up to scrutiny and acknowledge that leadership is not easy.
Listening is a very powerful way to demonstrate compassion. Meeting various multiprofessional clinical teams to understand the challenges they faced and attending their workplace to thank them displays compassion and understanding. Making this a consistent behaviour at all times is the key.
All NHS trusts and leaders demonstrated partnership working at very high levels during the COVID-19 crisis. This included working with NHS partners within Integrated Care Partnerships, Universities, the Independent Sector and charities.
The independent sector helped nationally by accommodating elective surgery in, essentially, Covid-free hospitals and this benefited many cancer patients. University employees (research nurses, doctors and administrators) helped in the hospital in clinical and non-clinical roles, and medical schools released medical students, who assisted with triage in emergency departments, laboratory Covid-related research, and helped clinicians with testing, and donning and doffing of PPE. Regional leadership was visible and helped manage mutual aid for equipment like ventilators, anaesthetic drugs, PPE and haemofilters. Charities helped source food and accomodation for staff and distribute it in hospitals.
OUH worked extensively with the University and the Charity expanding the research—clinical interface for the benefit of patients and staff. It is hoped that such partnership working, visible to staff and patients and clearly working for their benefit, becomes ‘the new normal’ for the future in healthcare.
Clear strategic intent
OUH has recently launched a 5-year Trust strategy which looks at patients, populations and their people as the three main pillars with clear objectives to meet their vision of delivering compassionate excellence in all three contexts. Strategic intent, here relates to the position of the organisation in the regional/national context and in particular the preparation for the peak/surge of COVID-19 cases based on national modelling.15 Inclusion of clinicians in developing plans, such as those for increasing intensive care capacity or for the management of non-Covid vs COVID-19 cases, gave all stakeholders confidence in the final plans. Leaders, therefore, needed to select clinicians who provided clarity and summarised their colleagues’ opinions succinctly. The articulation by leaders of the final plan and the state of preparedness reassured staff that the organisations were ready with a clear steer. One that took responsibility for operational implementation of changes to in-patient areas across the hospital, prepared staff with simulation training and protective equipment and worked collaboratively with all stakeholders. The emphasis was on openness to admit that COVID-19 presented a novel challenge: previous, old draft plans for pandemic influenza were never used because they were not fit for purpose. Furthermore, various teams positioning themselves differently in the first few days and the task of establishing a ‘single’ clear plan was not straightforward and almost impossible. Therefore, willingness to be transparent about decision making and an ability to review and change plans in response to circumstances required maturity and willingness to respond to adversity. All this required constant, daily monitoring of bed numbers, staff sickness, patient stories and rapid decision making.
In setting strategy, leaders are required to be one step ahead of events, indeed overprepared. Proactive involvement in research networks, development of polymerase chain reaction (PCR) and antibody testing, recruitment and participation in the national research studies such as the vaccine trial set the scene in terms of an organisational intent to aid recovery.16 It offered staff hope and further motivation in what was an extremely tiring and traumatic existence for many.
The practices discussed here would apply equally to macro and micro-environments within healthcare systems such as national bodies or regulators, regional teams and local healthcare providers. However, these practices work only in circumstances where staff understand the vision of the organisation, trust that their leaders will make the right decisions enabling them to navigate the uncertain times. This trust usually develops over time and that is how cultures are set, however, in conditions like those of the pandemic a strong stable leadership team that is compassionate to staff, that works in partnership with staff and other agencies and takes responsibility for its decisions will have quickly set the tone for the organisation that jointly comes through volatile, uncertain, complex and uncertain situations with demonstrable learning and success for the future.
The author would like to thank all the OUH staff and OUH partners organisations for their extraordinary work and collaborative working demonstrated throughout the pandemic.
Contributors MP is the sole author of this manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
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