Opinion

Fostering Hospital Resilience—Lessons From COVID-19

VIEWPOINT

Ian J. Barbash, MD, MS The COVID-19 pandemic created an unprecedented What would organizational resilience look like in the
University of number of patients who required admission to hospitals context of COVID-19? First, resilient hospitals would re-
Pittsburgh, Pittsburgh, and intensive care units (ICUs). According to recently re- spond to a surge in COVID-19 cases in ways that ensure the
Pennsylvania.
leased federal data,1 nearly half of hospitals in the US (2199
delivery of high-quality care for patients with the disease.
of 4587) operated at more than 85% capacity at some Patients with COVID-19 would be admitted to well-
Jeremy M. Kahn, MD,
MS point during the height of the pandemic, between August staffed specific units with physicians and other health care
Department of Critical 2020 and April 2021. Many hospitals struggled to main- personnel who have the skills and experience necessary
Care, University of tain standards of care under this strain, with critically illto provide appropriate, guideline-concordant care. If such
Pittsburgh, Pittsburgh,
patients treated outside of ICUs and clinicians unable to units were not available, resilient hospitals would coordi-
Pennsylvania.
keep pace with delivering needed care because of in- nate with regional hospitals and transport services to rap-
creased patient-to-staff ratios.2 Yet these problems were idly and safely transfer these patients to capable centers.
not universal. Some hospitals reportedly seemed to ac- Second, resilient hospitals would respond to COVID-19
commodate the sudden increase in demand, maintained surges in ways that preserve standards of care for pa-
care standards, and delivered high-quality patient care tients without COVID-19, such as those needing cancer
even during times of rapidly surging COVID-19 cases.3 care, emergency cardiac care, and trauma surgery. Hos-
As the pandemic begins to ebb in terms of the num- pital leaders would acknowledge that although trade-
bersofpatientswhoarehospitalizedandwhorequirecriti- offs exist, mitigating the unintended effects of surge re-
cal care, and yet recognizing the possibility of additional sponses by accommodating urgent needs of non–
surges, hospitals should examine why some centers were COVID-19 patients is as important as addressing the needs
abletosustaineffectiveoperationswhileothersstruggled. of patients with COVID-19. Third, resilient hospitals would
Traditional approaches to understanding hospital pan- preserve access to care for the entire community of pa-
demicresponsesfocusonthe“4S”frameworkofprepared- tients they serve, continuing elective surgeries and miti-
ness: staff, stuff, space, and systems.4 These are the healthgating the exacerbation of health disparities during the
pandemic. These hospitals would antici-
pate and mitigate ways in which changes
The hallmark of organizational resilience to care delivery (such as the rapid move to
is the flexibility to pivot as new and telemedicine) might differentially affect
vulnerable individuals in surrounding
unexpected challenges arise, and to communities.7 Fourth, resilient hospitals
absorb unexpected shocks that cannot would do all of this while also protecting
the well-being of frontline staff, not just by
be avoided even with proper planning.
ensuring adequate personal protective
care professionals needed to deliver care, the medications equipment but also through clear communication from
and other supplies required for treatment, the physical leaders that make staff feel valued and connected to the
rooms and settings in which patients receive care, and the organizational mission.
systems required to integrate these resources.4 A great Several factors might foster resilience at the hospital
many hospitals struggled with COVID-19 surges despite level. Well-developed, scalable clinical protocols, such as
plenty of lead time and extensive resources to implement those that guide the management of patients who require
the 4S framework.5 It is now clear that attention to these mechanical ventilation, could enable evidence-based care
factors was necessary but not sufficient. under different staffing models or in unfamiliar care loca-
A complementary approach is to understand the pan- tions. Flexible electronic health records could allow hospi-
demic response through the lens of organizational resil- talstoquicklyimplementanditerateonnewcarepathways
ience.Inthemanagementdomain,organizationalresilience in the face of novel diseases with evolving best practices.
characterizes firms that rapidly adapt in response to an ex- A supportive, interdisciplinary working environment in
istentialchallenge,enablingbothanattenuatedeffectfrom which all team members feel safe to raise concerns and
the challenge and a more rapid recovery. For instance, af- sharenewideas(aconceptknownaspsychologicalsafety)
tertheSeptember11,2001,terroristattacks,empiricalwork could have several benefits. Psychological safety might si-
revealed that airlines with more efficient business models multaneouslysupporttherapidtrustandflexibilityneeded
Corresponding andmorestablefinancesimposedfewerimmediatelayoffs for successful implementation of innovative care models
Author: Ian J.
Barbash, MD, MS,
and regained revenues more quickly compared with other liketeamnursingwhileempoweringteammemberstoraise
University of airlines.6 Although the time scales of the post-9/11 recov- concerns about overly exploratory models that could put
Pittsburgh, Montefiore ery and the COVID-19 pandemic differ, the idea that resil- patients at risk. An overarching theme is that effective and
Hospital 628 NW, 3459
iencematters,andthatstudyingvariationinpastresilience transparent leaders at multiple levels are essential to pro-
Fifth Ave, Pittsburgh,
PA 15213 (barbashij@ caninformpolicythatpromotesfutureresilience,isaprom- mote organizational alignment during a rapidly changing
upmc.edu). isingwaytoexaminehospitals’responsestothepandemic. clinical and administrative landscape.

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 Opinion Viewpoint

Resilience might also be fostered in the interactions among hos-
pitals. For example, regional transfer networks could enable hospi-
tals to notify regional systems that they are overwhelmed and rap-
idly identify hospitals with available beds to which they could transfer
patients. For instance, Arizona implemented a “surge line” during the
pandemic to coordinate patient care across more than 100 hospitals
and multiple health systems.8 This system also included an option for
bedside physicians to obtain specialty telemedicine consultation, en-
abling high-quality care without transfer in appropriate cases. Dur-
ing the initial surge in New York City, the pandemic catalyzed the rapid
deployment and scaling of larger telemedicine programs to project
expertise across systems and states.9 Despite the potential in these
approaches, there remain limited data on their effectiveness, mak-
ing empirical research an essential component of efforts to develop
evidence-based policy based on hospital resilience.
Hospital resilience, in this context, differs from traditional con-
ceptions of disaster preparedness. In disaster preparedness, hospi-
tals plan for a relatively narrow set of operational challenges, such as
flooding, structural damage, communication system failure, and dis-
ruption of the power grid. Responses are often algorithmic: if a spe-
cific event occurs, there is a specific response. But it is impossible for
a hospital to preplan a response for every potential operational chal-
lenge, and algorithms do little good when the threats evolve in unpre-
dictable ways. For example, a hospital that was well prepared only for
an Ebola virus outbreak would not have been prepared for COVID-19.
Preparations for Ebola virus focused on relatively small, high-level con-
tainment units for treating patients with a disease transmitted primar-
ilybydirectcontact,10 whereasCOVID-19presentedhospitalswithhun-
dreds of critically ill patients with respiratory failure from an airborne
pathogen. Likewise, preparedness for COVID-19, such as having a large
stockpile of ventilators and N95 masks, is unlikely to translate into an
effective response to the next emergent pathogen.
Rather, the hallmark of organizational resilience is the flexibility to
pivot as new and unexpected challenges arise, and to absorb unex-
pected shocks that cannot be avoided even with proper planning. Re-
silient hospitals have more degrees of freedom, allowing them to con-
siderarangeofsolutionstoeachproblemandquicklypivotwhenapre-
planned strategy is not working. The hospitals could then rapidly and
effectively implement novel solutions instead of simply relying on pre-
planned solutions that might not fit the current problem. Hospitals can
be resilient even if they are unprepared, and can be prepared but not
resilient. Unlike preparedness, which is useful only in the event of di-
sasters and pandemics, the factors that lead to resilience are likely to
support high-quality care during routine operations.
In this context, hospitals should resist the temptation to simply
prepare for the next pandemic only by creating the infrastructure and
procedures they lacked during COVID-19. Efforts to stockpile supplies
andincreaseICUbedcapacitywillbeusefulifthenextpandemicissimi-
lar to COVID-19 but would also be redundant and inefficient, increas-
ing health care costs without improving day-to-day quality.
Instead, hospitals should implement changes that will be of value
no matter the challenges they may encounter and that will be useful
even during normal times. Among these changes may be more ro-
bust supply chains, cultures of excellence and collaboration, and sys-
tems for coordinating operations within and across hospitals. At the
same time, the health services research enterprise should conduct rig-
orous studies investigating which organizational elements are most
important for fostering hospital resilience. The factors that create re-
silient hospitals remain poorly understood, and a more nuanced un-
derstandingofwhatitmeanstobearesilienthospitalwillprovidenovel
strategies to create resiliency ahead of the next pandemic.
COVID-19 will not be the last large-scale public health threat of
the 21st century. In addition to infectious diseases, hospitals and
health systems will confront climate-mediated extreme weather
events, cyberterrorism disruptions, and other threats in the de-
cades to come. Hospitals can never be truly prepared for these
events. But if hospitals understand and build sustainable resil-
ience, they will be ready.

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Conflict of Interest Disclosures: Dr Barbash
reported being employed by the University of
Pittsburgh Medical Center (UPMC) Health System.
Dr Kahn reported receipt of personal fees
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Funding/Support: This work was funded in part by
Agency for Healthcare Research and Quality grant
K08HS025455 to Dr Barbash.
Role of the Funder/Sponsor: The Agency for
Healthcare Research and Quality had no role in the
preparation, review, or approval of the manuscript
or decision to submit the manuscript for
publication.
Additional Contributions: We thank Rachel
Sackrowitz, MD, MBA, and Don Yealy, MD, both of
the University of Pittsburgh School of Medicine and
the UPMC Health System, for their discussion of the
concepts involved in this article. They were not
compensated for their contributions.
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