Being a Manager in Times of Covid the Learning after the Storm

Iris Parrao-Alcántara

Being a Manager in Times of Covid the Learning after the Storm

Iris Parrao-Alcántara

Published Date: 2022-01-31

Iris Parrao-Alcántara^*

Department of Gastroenterology, General Hospital of Zone, Nayarit, Mexico

*Corresponding Author:: Iris Parrao-Alcántara
Department of Gastroenterology, General Hospital of Zone, Nayarit, Mexico
E-mail:parraoiris@gmail.com

Received date: January 03, 2022, Manuscript No. IPJHMM-22-12237; Editor assigned: January 05, 2022, PreQC No. IPJHMM-22-12237 (PQ); Reviewed date: January 17, 2022, QC No. IPJHMM-22-12237; Revised date: January 24, 2022, Manuscript No. IPJHMM-22-12237 (R); Published date: January 31, 2022, DOI: 10.36648/2471-9781.8.1.310.

Citation: Parrao-Alcántara I (2022) Being a Manager in Times of COVID the Learning after the Storm?. J Prev Med Vol.8 No.1:310

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Abstract

Being a good hospital manager is not an easy task, and the pandemic revealed the strengths and weaknesses of the health system in Mexico. The ravages of the pandemic began in the center of the country and the rest of the states witnessed one by one what seemed like a distant scenario. Nayarit, a provincial state, opened a hospital to respond to the pandemic, facing its staff and managers with difficulties such as insufficient human resources to provide medical care on weekends and during the night shift, lack of preadmission triage, before arriving at the hospital, insufficient ventilators (including the need for ventilator triage) the emotional state of the workers and worker protection. This article collects in the form of advice, some of the strategies that proved to be a success, such as the collaborative work of "mirror teams" to reduce the exposure of staff in the COVID area, the classification of patients according to their seriousness and those areas of hospital opportunity, such as timely management of acute kidney injury, hoping that the lost battles will be experiences to initiate and improve response protocols in the event of a contingency, they will be learning.

Keywords

Hospital manager; Deputy medical director; Hospital management; Hospital administration; Motivation; Human resource COVID teams; COVID

Introduction

When Machiavelli writes "the prince" addressed to Lorenzo de Medici, he explains that the best gift that can be given is knowledge [1].

This experiential article hopes to provide all the valuable learning after responding to COVID, the triumphs and failures; looking back, to rescue something useful that can initiate some formalization process and help others in their decision making. In the moment of a storm, you cannot be sure what is the best decision, you can only be sure if you are willing to take responsibility for the consequences of your decisions making [2].

When the media informed how the coronavirus was impacting Mexico [3], many hospitals and some health workers were incredulous and apathetic to contribute, blaming the manager for their lack of capacity to manage operations, maintained a narrow vision of situation, that scenario combined with the lack of significant staffing (as high risk staff for comorbidities were given permission to retire home due) [4,5], generated a feeling of abuse of trust, without having, "the big picture" [6-8].

In Nayarit a new hospital was rushed to open in response to the pandemic becoming a 100% COVID hospital. In January 2021 for the weekend shift (which lasted almost 16 hours per day) a new deputy director was requested. This manager should have different capacities “Go one step forward and thinking out of the box”

One of the first experiences was that one worker presented “a psychotic break”, presented anxiety, depression, paranoia, fast negative thoughts, and his fears became contagious. At that moment the personnel understood what the concept of mass hysteria consisted of "prepare for the worst, but hope for the best"; however, in the worst-case scenario, not only was the co-worker at risk, but also other workers [2-13]. Fortunately, the worker was supported and all the actions were made to give him tranquility and attention [14,15].

The first learning was: "Being a good hospital manager means taking care of the physical safety, the psychological health of each patient, each worker and one´s own". Regulations exist to generate a harmonious and orderly environment of productivity. When the rules do not meet this objective, we must rethink what we are doing right and what needs to be changed or improved. “Be firm when you have to be firm and flexible when you have to be flexible".

The patients with COVID increased exponentially, personnel would leave for a week and return to find twice as many patients as it had left, 20, 40, 60. The promise of the vaccine seemed more distant as the number of patients increased. "In an atmosphere of comfort, everyone’s friend. True teamwork, you can only look at it when it is put to test".

"Ask the opinion of the expert, get advice from those who have more experience". The manager sought the council of directors of the capital. The pandemic had made landfall there first and the city was already beginning to come out of its wave:

Carlos Salazar Lozano with experience in hospital manager of hospital suggested:

•Planning and classification, identify how many patients are going to be able to be hospitalized, how many beds, ventilators, what kind of ventilators and how many anesthesia machines you have.

•Integrate an area where the most serious patients are located and the staff that is most qualified to see that type of patient, as if it were a large intensive care unit; integrate what you have at your disposal, you cannot be too demanding, today this is war medicine. In another area, make sure that less serious patients can be treated with nasal prongs, masks, reservoir masks, and high-flow nasal prongs.

•Classification from first contact, adapt the care protocol to your context, so that it is easier to identify patients who can have ambulatory management and follow-up with video calls; use guiding parameters, such as partial pressure of oxygen.

•Consider that this is a situation that can overwhelm us in many ways, a situation for which our health services were not prepared. Use your common sense and your intelligence, if you do, whatever decision you make, will be done very well.

However, insecurity in the management decision making was left on the sidelines unable to act. The COVID areas were a mosaic of seriously ill patients along with convalescent patients, of course this did not help the mood of the patients either. The weekend staff was concerned about the possibility of supporting more time in COVID area.

When a new manager arrives and arrives with the flag of kindness, the next step for the subordinate is to test his or her limits and retracting an indication may cause that the manager lose the trust of his team, the support that despite the storm you can bring the ship to land, to firm and not sink it with everything on board. In short, a good manager must have openness, be willing to negotiate; but a Machiavellian manager gets people to follow directions without giving them.

It’s not easy to be a good manager, it can be attributed to lack of time, the large number of responsibilities, the bad elements that contaminate the hive, but at the end of the day, a good manager knows how to recognize his limitations [16]; however, that is not an excuse that prevents him from fulfilling his obligations, he will have to draw on his strengths, on what "has worked before."

The peak was reaching, and the team organization was insufficient. There were days that the ambulances did not stop arriving, sometimes they only needed an oxygen intake, others came almost only to change stretchers to intubate and although the income exceeded the available staff, how could a bed be denied? "Time is, prognosis."

Meanwhile, ventilators were beginning to be insufficient, inversely to the mortality due to renal injury. Finally, if weekend shifts struggled for a breath of air, night shifts became desolate wards, the hospital had several problems:

•Insufficient human resources to provide medical care on weekends and during the night shift.

•Lack of pre-admission triage, before arriving at the hospital.

•Lack of triage in the emergency room.

•Lack of delivery of on-call and shift liaison.

•COVID patient management training for surgical physicians.

•Timely management of acute kidney injury.

•Insufficient ventilators (including the need for ventilator triage).

•The emotional state of the workers.

•Worker protection; vaccination, Personal Protection Equipment (PPE).

•Effective pre-discharge.

Facing the problem of insufficient human resources to medical attention an alternative was brought to reduce exposure and optimize time "the mirror teams"; while one team was inside the COVID area, it’s mirror team collaborated with everything they could, requests for studies, reports via telephone to relatives, explain discharges, write prescriptions, certificates, etc. It seemed an excellent plan, but when it was applied it was chaotic, lacked coordination, and knowledge of the processes. “The mirror team” was an excellent strategy, but there was no time to perfectionate it. The highest point of the wave was there and the best thing for the patients was to have as many hands as possible. However, when the wave overtook us not even with all the hands available it was containable. A gloomy atmosphere of sadness and helplessness pervaded the hospital. Several of the team leaders kept their nerve to face the situation, but others left the area with red eyes, not because they were tired, not because of the PPE, "but because they had left everything on the field, without having won the game".

True admiration for all the colleagues, but a very special thanks goes to leading internists and intensivists, their work was a motivation for trying to be a better director. A good manager must be able to bring out the best in his team and a good team must demand the best from its manager. The greatness of a hospital depends on the greatness of its people.

"A good manager is a good captain; he leads his crew and his ship to dry land; not losing direction and having a true coordinated team are the key to surviving the storm"

"A good manager knows how to make decisions when decisions have to be made, he is not passive in the face of the storm, nor is he imprudent, he is not only reactive to the storm, but also proactive and looks for the perfect climate to navigate".

The number of patients started to drop, and a second opportunity for the "Mirror" strategy showed up, but it was not the only thing that was placed into action.

•A formal request was made to change the schedules of the personnel who worked during the week as a temporary response during the contingency; in such a way that the breaks would remain during the week and the percentage of personnel would be more balanced between shifts.

•Look for personnel who could temporarily move to the weekend or night shift.

•Mirror team, performed a triage with the 1st level care clinics, analyzing the status of patients before they were referred to unit, optimizing beds and times, as well as more orderly admissions.

•Overtime was paid for personnel from other shifts to support the night shift.

•Shift liaison supervised by the manager was performed with formal on-call handover between managers.

•COVID patient management training was initiated for surgical physicians.

•In that second wave the manager was not able to respond with the best results, for acute kidney injury, as well as for the problem of insufficient ventilators, things just improved due to the decrease in cases.

•Vaccination arrived, which brought some peace to physicians.

Once again, the hospital was hybrid, relief came for a moment, the nightmare was over. It was that moment of tranquility that led to the lowering of the guard, and it came, the worst of all, the third wave. But at least this time there was more experience and the second wave had left many lessons. The first step was to devote time to the doctors' state of mind, because the wave that was coming was bigger than the one that had overtaken us once. This collective anxiety could not be allowed to break out and become contagious.

"We knew that the situation was going to overtake us once again, but we had to face it as best we could, with planning and strategy”

"We are going to do what we can do; but let it be, the best we can."

The team was able to foresee the wave coming in, the first and most useful strategy was to coordinate with another hospital that would take care of non- COVID pathology and the hospital became 100% COVID. If there is no person to direct and supervise, no matter how good the ideas are, actions will not be implemented. The orchestrator must always be accompanied by a common language, the information of the actions in progress must be downloaded [17].

The weekend shift, in less than 48 hours approximately, many patients were admitted, a floor of stable patients dependent on oxygen, and another floor that was just beginning to admit serious patients. This arrangement of patients was extremely functional, especially in the night shifts, shifts that became support shifts, where non-clinical physicians could watch up to 50 patients.

Managers and their weekday staff had not sized up what was happening. They were tense, anxious, that feeling of the situation getting out of hand without knowing why you feel that way, collective anxiety grew as the beds, fans and drawers of the mortuary filled up.

The apathy attributed to the new generations lies in the lack of exposure to the catastrophe. At that moment of the Pandemic lessons, it was understood by Dunant's "Tutti Fratelli” [18]. A willingness to forget the differences, because the situation demands it, you can see the wave, you feel the impact of the wave, its strength and you take the hand of your partner, "we must do what we can do, but let it be the best we can do, and let's do it together”. Individually, actions are taken, together, synergy is created.

Administrative visitation is necessary, behind a desk the doctor is depersonalized, it is necessary to go to the field to identify problems and make situational diagnosis. It is an example of being willing to expose yourself to the same circumstances as your team and that does not stop you from performing your duties with the patient.

A good manager must be a strategist and visualize how each of the processes takes place, who are the actors, what tools are used and not being used. Identifies where everything is and records the memory to access it when needed, everything that is not being used and maps where it can be used; with his hands he places the first gear that spreads its energy and movement to each element [19]. Synergy is the key to success. It is a good manager who is the engine, whose will, and passion move the gears of a hospital, needs strength, energy, vision, strategy, but above all a good team [20]. It is a good manager who can transmute his vision into reality.

Conclusion

Although the 3rd wave was bigger, it faced better, because of the lessons learned from the 2nd wave. In time there were anesthesia machines available for when the ventilators ran out. The "mirror" strategy and having more staff improved the work environment. A no less important point was to try to treat the medical area better, to show them in every possible way that their work and safety were valued, and even to try to have certain areas set up with comfort for them to rest after they entered the COVID area. As a next step, it is necessary to initiate an administrative investigation and analyze how these strategies impacted the outcomes.

When the storm approaches, you cannot know if you will be able to overcome it, many times you only aspire to reach dry land. If you succeed, triumphantly or at the cost of great losses, you are obliged to learn from it and be better prepared the next time a storm comes. At the end of the 3rd wave, the manager only can be grateful for the learning, regain strength, and be aware that "When you overcome an adversity, another greater one will surely come”.

A calmed sea has never made a good sailor.