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Hindsight Is 2020, or Maybe 2021—It’s Still Too Soon to Tell

Ford, Eric W. PhD

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Journal of Healthcare Management: March-April 2021 - Volume 66 - Issue 2 - p 77-79
doi: 10.1097/JHM-D-21-00038
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Eleanor Roosevelt said, “Learn from the mistakes of others. You can’t live long enough to make them all yourself.”

In my January/February editorial, I presumed that there would be issues with the COVID-19 vaccine rollout, but I had no idea the process would encounter as many problems as it has. So, what have we learned with the benefit of hindsight from the closing days of 2020 and the start of 2021? For starters, the trope that “if you build it, they will come” (inspired by the 1989 film “Field of Dreams”) is total nonsense. The scientists in the pharmaceutical industry developed effective vaccines in record time—they built it—and they are to be commended. What did not happen are the engineering or policy/management tasks necessary to get the public to come to the needle’s end. Why is that?

In health services research, moving discoveries from lab bench to populations is called “translational research.” Scientists did an outstanding job of finding the new vaccines using mRNA strategies that had not previously been applied on a wide scale (Translation Stage 1—Discovery). With special dispensations from the U.S. Food and Drug Administration, the scientists moved through the clinical trials at a record pace (Translation Stage 2—Evidence-Based Effectiveness and Guideline Development). The process fell down when “Operation Warp Speed,” as the project was called, had to transition from bench scientists to engineers and managers. The actual delivery and distribution were afterthoughts because “if you build it, they will come.”

In the research field, Translation Stages 3 and 4 are Implementation and Outcomes Research, respectively. In the case of COVID-19 vaccines, Translation Stage 3 required heavy doses of engineering and high-precision manufacturing to produce medications that have problematic handling and storage requirements. By and large, the engineers did a fairly good job once they got started—but they could have started far sooner if there had been better communication with the scientists.

From the policy/management perspective, the public interface was woefully underdeveloped and Translation Stage 4 was a failure. Prioritization plans for vaccine recipients were so complex and restrictive that many doses sat in storage longer than necessary. Very few sites had contingency plans for expanding the eligible population list to ensure doses went out as fast as possible. Moreover, most sites underestimated how long it would take to screen and inoculate individuals. They also underestimated the space required for physical distancing (so that the effort to vaccinate people does not contribute to the virus’s spread). In short, nobody did a dry run prior to the vaccine’s arrival. Granted, pulling frontline clinical staff out of hospitals to practice vaccine delivery was not practical, but at least some modeling could have been done; the vaccination effort was likely to need additional staffing anyway.

Back to my original question: Will we learn anything from the COVID-19 vaccine distribution experience with the benefit of hindsight? In short, probably not. The infrastructure to effectively distribute a mass vaccination campaign is too costly to maintain in an ongoing fashion, so there is no Maginot Line of virus defense. Bear in mind, we went nearly a century between pandemics that had this type of impact on the U.S. population. In addition, even better technologies than mRNA treatments may be available by the next pandemic that would render such a system useless. Therefore, the next time a mass vaccination system is needed, it would look very different from the one we have today. What is needed is greater flexibility.

The current response to the vaccine distribution issue is calling for the creation of a single, federal control of the process. Such a solution is the opposite of building greater flexibility. Managing the public’s health is invariably a local matter, with each community needing solutions that fit its environment. Having multiple systems striving to meet a public health need can provide both policymakers and health services researchers with a variety of solutions to determine what works best.

The interview in this issue of the Journal of Healthcare Management is with John M. Haupert, FACHE, president and CEO of Grady Health System in Atlanta, Georgia. We spoke as the vaccine was being rolled out in his market and his safety-net hospital was scrambling to handle the influx of COVID-19 patients following a disastrous flood.

In the second column in our yearlong series on Essential Innovation, Luke Beirl, PharmD, FACHE, CEO of Hayward Area Memorial Hospital & Water’s Edge in Hayward, Wisconsin, describes how his organization identified the need for a new approach to leadership development. He further explains how it now applies its progressive True North framework in training current and future leaders.

The Great Comebacks series continues with an inspiring column by Eugene A. Woods, FACHE, president and CEO of Atrium Health in Charlotte, North Carolina. He writes about the deeply felt effects of the pandemic and racial injustice on the people working in his organization—and how his leadership team has stepped up and responded to the challenges.

The first research article comes to us from a team led by Aaron Spaulding, PhD, of the Mayo Clinic. Spaulding and colleagues—Hanadi Hamadi, PhD, Jing Xu, PhD, and Aurora Tafili from the University of North Florida in Jacksonville, and Xinliang Liu, PhD, from the University of Central Florida in Orlando—studied Medicare’s ever-changing Hospital Value-Based Purchasing program and how organizations respond. One of their major takeaways is that constant changes make it difficult for any policy to be fully realized in the field. More purposeful and deliberate program administration is warranted.

Timothy P. Seay-Morrison, EdD, from Stanford Health Care in Stanford, California; Kimberly Hirabayshi, PhD, and Courtney L. Malloy, PhD, from the University of Southern California in Los Angeles; and Catherine Brown-Johnson, PhD, from the Stanford University School of Medicine in Stanford, California, present the second research article. They assessed a survey instrument for measuring burnout among medical assistants. They note that the effects of high-stress environments are not limited to doctors and nurses. Indeed, most people who interact with patients are sure to be at risk for burnout.

Next, Nandita Nadig, MD, from the Medical University of South Carolina (MUSC) in Charleston, Liz Hynden from Cardovia Health in Cincinnati, Ohio, and Katherine Sterba, PhD, James McElligott, MD, Shawn Valenta, Emily Warr, Rebecca Beeks, and Dee Ford, MD, all from MUSC, look at the use of balanced scorecards to assess intensive care unit (ICU) performance. Given the growth of ICU beds as a total share of the typical hospital’s capacity, better management models are needed. The balanced scorecard is effective in many clinical settings, and this article makes a valuable extension to the literature.

Another major trend in hospitals is the merger of rural facilities into larger health systems. David M. Sarcone, PhD, from Dickinson College in Carlisle, Pennsylvania, and Chad M. Kimmel, PhD, from Shippensburg University of Pennsylvania in Shippensburg, provide a case study of how mergers can be successfully established and managed. When mergers work, smaller hospitals can offer better coordination of care for patients who need to be transferred to larger facilities for specialty services—and everyone wins.

© 2021 Foundation of the American College of Healthcare Executives