PC: Andy Lyons

Highly Reliable When Disaster Strikes

South Carolina Hospitals Prove to be Highly Reliable Organizations in Crisis During Hurricane Matthew
PC: Andy Lyons

One week before Hurricane Matthew arrived on the shores of South Carolina, many of the state’s residents were piled high into football stadiums cheering on their favorite college teams, a cherished tradition in the state. Most were not thinking about the storm making its way across the Atlantic toward them.


Other residents, though, were not only thinking about the storm but actively preparing for the natural disaster likely to occur when it hit. Chief among them were healthcare and hospital workers who needed to execute complex plans of action to ensure the health and safety of their patients.


As that first week of October 2016 continued, states up and down the Eastern seaboard of the United States braced for the storm, predicted to make landfall as a category 4 or 5 hurricane with winds up to 155 miles per hour. Matthew had already brushed across Cuba, the Dominican Republic, the Bahamas, and Haiti with enough force to causes enormous loss of life and property throughout the entire Caribbean. Meteorologists were predicting that damaging winds and unprecedented storm surges would cause major destruction along the coastal areas of Florida, Georgia, South Carolina, and North Carolina. 


While there is never true certainty as to the location or severity of such a powerful storm before landfall, the governors of these states knew to implement disaster preparedness protocols and communicated their high levels of concerns to the public, mandating extensive evacuations along the coastline. As this incredibly aggressive storm system strengthened and headed toward the South Carolina coast, healthcare systems across the state were organizing systems of their own to predict, prepare, and mitigate against the threat.


While hospitals have long been sensitive to the effects of natural disasters on their systems, Hurricane Matthew was also a chance to see evidence of many of these hospitals’ commitment to embracing the principles of Highly Reliable Organizations (HRO). HROs are known for avoiding harm in highly complex work environments where accidents or errors are most likely to occur. According to Weick and Sutcliffe (2007), the five guiding principles or traits of HROs are: preoccupation with failure, reluctance to simplify, sensitivity to operations, commitment to resilience, and deference to expertise. 


To keep these principles in focus, hospitals have cascaded a safety mindset throughout their organizations, intertwining safety as a core value of the work they do every day. A key element of creating highly reliable systems of work is transparency. Sharing best practices across the state has proven to be of great value to organizations. This exchange of ideas broadens collective mindfulness to problem solving that would otherwise not exist.


And evidence of high reliability was everywhere in South Carolina’s hospitals’ emergency preparedness and responses. One of the most valuable practices these healthcare organizations have adopted is the organizational safety huddle. Although huddles have become a daily routine in some hospitals, they can be particularly meaningful in preparation for catastrophic events. Such was the case with many hospitals across South Carolina before Hurricane Matthew hit. To keep hospitals informed throughout the week prior to and during the storm, the South Carolina Hospital Association (SCHA) worked in tandem with the SC Emergency Management Division (SC EMD) and SC Division of Health and Environmental Control (SC DHEC) to provide continuous updates to hospital leaders. Conference calls allowed a forum for hospitals to coalesce and stay abreast of statewide information and avoid rumors and speculation. Conducted by SCHA's CEO and Senior Vice President of Regulatory and Workforce, the conference calls were similar to safety huddles hospitals convene every day to share information across the entire spectrum of the organization. 


On Thursday, October 6, Hurricane Matthew was expected to strengthen to a category 4 as initially predicted. As the storm approached, it began working its way up along the Florida coastline. With this news, it was anticipated that the entire coast of South Carolina was at extreme risk for taking the brunt of the storm. Faced with tough decisions, hospitals in the lower coastal regions began activating evacuation plans, instituting command centers, and closing emergency departments. As the sun disappeared and clouds took their place, these hospitals and healthcare facilities were drawing down their patient populations and canceling elective surgeries, procedures, and appointments. Although Hurricane Matthew had weakened to a category 1 before nearing the coast of SC, it proved disruptive to the operations of many hospitals. Many of them experienced power outages and flooding. And, to no one’s surprise, experiences of adversity became stories to be told and lessons learned for the future. 


There were four hospitals that evacuated prior to the arrival of Hurricane Matthew and others that moved patients from one facility to other locations within their own system. Hospitals depended heavily on their phone systems and command centers to disseminate information which consequently created issues when those systems failed. Gathering for face-to-face communications proved to be valuable within the walls of the hospital when phone communications became less than dependable. Other means of communication were also instrumental in relaying information. Roper Hospital in Charleston, SC, tells the story of using Apple’s Facetime to communicate with MUSC Health when their telecommunications systems lost connection. A patient was displaying stroke symptoms and desperately needed a CT scan, but the hospital’s scanner was not functioning, which prompted the hospital to seek an alternative to obtain a diagnosis. MUSC Health, a major teaching hospital close by, was contacted via Facetime to arrange the patient’s transfer. 


Once this course of action was decided upon, another challenge had to be overcome. The streets were flooded, impeding the ability to smoothly transfer the patient across the street. The hospital had to literally place a ruler in several areas of the road to find a location where flood waters did not reach the exhaust on the transport vehicle. By working together to problem-solve under duress, the patient was transferred safely to MUSC within 30 minutes of displaying symptoms. According to Roper Hospital’s Chief Nursing Officer, Carolyn Donahue, the hospital depended on frequent communication including safety huddles to share real-time updates and ensure safety for patients and staff. 


Tidelands Health, which operates three hospitals along the coast, also found huddles and communication to be critical. During the hurricane, they used text messaging to communicate and held two daily senior leadership calls. 


"Daily safety calls also continued and provided additional means for updates," reveals Philip Dulberger, MD, Chief Medical Officer. 


MUSC also held frequent huddles to provide an outlet for consistent, up-to-date information to the entire system. 


We did every four-hour safety huddles and think it made a huge difference in the safety and operations throughout pre-, peri-, and post-hurricane timeline," explains Danielle Scheurer, MD, Chief Quality Officer. 


Pat Cawley, MD, CEO, concurs. "We began using huddles more frequently during major events, so people were used to the increased frequency and knew that this was a major communication element. For this event, we ran huddles every four hours around the clock, led by our incident commander (chief operating officer). Even with the additional information, the calls were rarely more than 10 minutes. This huddle now has become so integral at MUSC on a daily basis that most leaders can't fathom working without it." 


Cawley goes on to describe increased attendance during the event. “Even though the calls were about 10 minutes, there was a lot of informal connections and sidebars pre-and post-meeting."  


Beaufort Memorial Hospital, situated mere feet from the Intracoastal Waterway, made the decision to evacuate its remaining patients when storm surge predictions were believed to be a threat to the hospital’s boilers and chilling systems. Incident command leaders shared information through multiple safety huddles with staff who used every communication channel available to report the impending closure to the appropriate state and local authorities, the community at large, and to evacuated staff who relied on e-mail and social media for local updates. Working with officials from DHEC and a multitude of transportation companies, hospital staff began the evacuation process. 


“At one point we had 20 ambulances lined up to transport patients,” said BMH CMO Kurt Gambla, MD. “We evacuated 68 patients to 11 facilities in 12 hours, a highly coordinated feat that could not have been accomplished without the team’s commitment to communication, safety and reliability.”


Hospitals along the coast were not the only organizations impacted by the storm. Several hospitals received patients that were evacuated from hospitals in the hardest hit areas of the state. AnMed Health in Anderson, SC, received patients from Beaufort Memorial Hospital and relied on organizational huddles to provide overall situational awareness for their team. They used them as a platform to communicate both onsite and off-site and prepare to care for additional patients. AnMed successfully set up an entire nursing unit with only a few hours notice, receiving both patients and staff at their facility. 


"We deferred to front-line clinical staff to identify basic elements needed to operationalize the additional unit, hence allowing the experts to make decisions regarding the most appropriate unit set-up," Robert Pierce, Director of Performance Improvement explains. "We readily admit that the five principles of high reliability factored into the strategy to prepare and execute necessary processes upon discovering the need to accept patients from another hospital."


In addition to handling the operations during the hurricane, there are also heartwarming experiences that clearly indicate the compassion and dedication of these healthcare workers. Amid extraordinary chaos, physicians, nurses, and other staff across the state volunteered to work for the duration of the storm. Patients were entrusted into the care of healthcare workers that demonstrated unmistakable devotion to their chosen profession. 


While some utilities failed and operations seemed dauntingly challenging during Hurricane Matthew, hospitals in South Carolina found ways to communicate within the walls of the hospital and across the state to share lessons learned from previous storms. Just one year before Matthew, the state experienced a monumental flooding event that captured national attention. Putting past experiences to good use, collective problem solving was key to finding solutions to major challenges during both storms. The competency of leaders and hospital teams was particularly helpful during these trying times, contributing greatly to the resilience needed to overcome such major events. 


There will continue to be natural disasters that interrupt our healthcare systems. One conclusion, however, is undebatable: the competitive nature of the healthcare industry takes a back seat in such times and safety takes precedence as we all ride the waves of these storms. We pay tribute to those that freely share lessons learned from previous experiences, enabling us to mitigate the risk to the greatest extent possible when crises come our way. When circumstances are at their most trying, our resilient commitment to the health and safety of our patients shines through above all else.