Caregivers at hospitals in pandemic hotspots around the world have performed heroics to treat the tidal wave of Covid-19 patients, improvising on the fly as they have struggled to cope. But this approach is not sustainable. It’s time for them to reinvent their operating models so they can care for both Covid and non-Covid patients in the months ahead without heroics. The S-curve, a seminal business concept, can help them do this. It involves three steps: 1) experimenting vigorously and broadly to discover what works and how to streamline and improve operations; 2) sharing the results of failures and successes quickly to avoid the waste of repeat failures and to scale up successes; and 3) documenting and formalizing processes that work to speed their implementation.
Those on the front lines of Covid-19 care have been working impossibly long hours. Many have taken on new tasks and roles for which they have had no formal training. They have had to cope with emotionally devastating failures and face unprecedented levels of uncertainty. What health care providers have been enduring, albeit heroically, is not sustainable. They have made it work because they have had no choice. But at some point, exhaustion will overwhelm duty. Too many health care workers’ own health will suffer, leaving insufficient numbers in place to carry on. And now comes a new challenge: With their numbers of Covid-19 patients falling, hospitals now have to figure out how to resume elective procedures and continue to care for Covid-19 patients. It’s time to invent new ways. A central business concept — the S curve — can help.
Every new business is subject to S-curve dynamics that delineate distinct phases of organization that characterize companies that succeed over time. Considered by some the most important concept in business, the S-curve describes three common phases in organizations. Phase 1 is the startup “figuring it out” period, when people experiment freely in search of a formula for success. In Phase 2, the organization uses the winning formula to efficiently and reliably deliver value at scale. Phase 3 ushers in a period of reinvention (“devising what’s next”) driven by the approaching obsolescence of the old success formula.
How do these dynamics relate to what health care organizations are going through in the present crisis? The parallels are several and illuminating.
People working in startups are notoriously able to withstand long hours, low pay, high uncertainty, frequent failures, and a willingness to pitch in to do almost any task that needs to be done because they are truly engaged in what they’re creating and profoundly motivated to succeed. But exciting as Phase 1 can be, it must come to an end. Startups face two pathways out of the chaotic early period: They exhaust their resources (financial or human) before they find a formula for success or they transition to Phase 2, with its discipline, order, and structure.
Similarly, those on the front lines of Covid-19 care have been living through their own Phase 1, mirroring the chaos and overwork of the classic startup. This means — like it or not, believe it feasible or not — it’s time to figure out how to get from the unsustainable workloads and chaos of the Phase 1 period that characterizes Covid-19 hotspots around the world to Phase 2, a sustainable, viable way of operating that includes caring for other (non Covid-19) patients as well, supported by systems and processes that function without full-time improvisation.
Here’s the challenge: Hospitals don’t yet know how to do this. The situation is unprecedented and came without a playbook. Health care leaders must take a collaborative and iterative approach to figure it out.
Here’s how new companies survive the transition from startup to viable business:
- They experiment vigorously and broadly to discover what works and how to streamline and improve operations.
- They share the results of failures and successes quickly to avoid the waste of repeat failures and to scale up successes.
- They document and formalize processes that work to speed their implementation.
In general, reaching Phase 2 is about systematizing work to minimize the need for on-the-spot decisions about what to do moment to moment. It’s a period of intense learning that promotes efficiency and quality at the same time. The biggest barrier to getting it done is the belief that it cannot be done. Medicine is vulnerable to embracing this belief. Many clinicians relish the importance of expert judgment, and resist efforts to codify. But health care has prior experience with this transition; some two decades ago, leading hospitals or health care systems began to implement protocols (care paths) to ensure that busy clinicians don’t miss any crucial treatment steps. (Intermountain Healthcare has been a leader in doing this.) Today, it’s similarly vital to identify new operational protocols to remove the need for improvisation and heroics.
Unlike a business, the experimentation process for hospitals immersed in the pandemic is not occurring within a single organization. Instead, it will benefit — so long as discoveries are shared — from a diversity of local experiments as teams around the world try to figure out how to allocate tasks, streamline processes, and alleviate chaos. This will speed the discovery of new ideas but require thoughtful coordination to test and spread them.
The experimentation is already underway. For example, to triage patients, some health centers are implementing AI. Instead of highly trained nurses staffing the phonelines to direct patients, Boston-based Partners Healthcare system and a number of hospitals around the world have experimented with interactive voice response systems and chatbots to foster patient self-triage. Similarly, several Boston hospitals are deploying intelligent robots to perform simple tasks that are otherwise done by trained clinicians, and offering expanded use of telemedicine where possible. The Betsy Lehman Center in Boston has published new protocols for checking in with coworkers at various points during a Covid-19 care shift.
Broadening the field of health care workers by bringing back retirees or graduating medical students a semester early is another way hospitals are seeking to shift into more sustainable operations. And, recognizing that they may need to ramp up and down on a moment’s notice to accommodate an influx of patients, some hospitals are working with design firms to develop a process for converting non-clinical spaces to patient-ready facilities quickly. Such projects should include careful documentation of new systems and processes — so that the wheel doesn’t have to be reinvented the next time around.
Disseminating the results of these worthy experiments is vital to ensuring that good-enough (not perfect) systems spread quickly. Several leading organizations are doing just that. For instance, the Institute for Healthcare Improvement offers guidance on how to ramp up Covid-19 care in centers that have not yet hit peak loads; an association of children’s hospitals offers recommendations for converting pediatric beds to adult Covid-19 care wards. Governor Andrew Cuomo explicitly points to learning the lessons of New York’s traumatic experiences to enable quicker responses in future epidemics. The National Institutes of Health is convening leaders from government health agencies and pharmaceutical companies to coordinate accelerated research efforts to discover treatments and vaccines. These kinds of cross-organizational associations are the best way to ensure systematic spread of practices and avoid wasteful reinventing of the same solutions around the world.
Unlike entrepreneurs, hospital caregivers don’t have the luxury of opting out of the startup that fate has placed them in; consequently, necessity is giving birth to invention. Because the invention is as much organizational as medical and scientific, teaming up across disciplines and sectors is vital to making progress toward solving the wicked problem posed by the pandemic.
The S-curve has primarily been used to explain why successful Phase 2 businesses miss the signals that it’s time to shift to Phase 3 and reinvent themselves. But it’s equally easy to fail the transition from Phase 1 to Phase 2, which is why most startups fail. A major hurdle is that everyone is simply too busy working to focus on rigorously collecting data on what has worked and what hasn’t and using it to standardize the work. Compounding this is the gratifying psychology of feeling necessary, and even heroic, in addressing the day-to-day challenges, which implicitly devalues the work of creating a standard system that can be replicated. Frontline clinicians have been shown to prefer firefighting and workarounds over taking time out to implement process improvements. It takes creativity to design and discipline to implement management systems. This is the challenge that today’s health care systems are facing.
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