APRIL 1, 2020, was a defining day for Boston Hope, a 1000-bed field hospital located in the heart of Boston, Massachusetts. Telephone calls began at 5:30 am to the future leaders of Boston Hope describing the mission set forth by the 4 sponsoring organizations. There was a sense of urgency as coronavirus disease-2019 (COVID-19)-positive patients were rapidly filling hospitals throughout the Commonwealth. The request was to begin work that day building out the facility, hiring the team, and defining clinical and administrative operations. The 4-person executive team knew one another from working at Massachusetts General Hospital (MGH). Immediately leaning in, they met with colleagues that morning at the site of what would become the field hospital—the Boston Convention and Exhibition Center (BCEC)—one of the largest exhibition centers in the Northeast with 516 000 ft2 of an exhibition hall, soon to be a hospital.1
The 1000-bed field hospital was commissioned to serve postacute COVID-19 patients and homeless patients with COVID-19 who did not require hospitalization in an acute care facility. It was a public-private partnership led by MassGeneral Brigham Health System (MGB), the office of Massachusetts Governor Charlie Baker, the office of Boston Mayor Martin Walsh, and Boston HealthCare for the Homeless.2 In addition to the 4 sponsoring organizations, Boston Hope was supported by the US military, local health care organizations, and Home Base (a Red Sox Foundation/MGH program).3
The charge on April 1 was to convert the empty building into a fully operational, postacute care hospital. Ten days later, we admitted our first patient.
It was critical that Boston Hope be able to provide area hospitals a relief valve by providing space for those requiring life-saving acute care, to isolate and care for the unsheltered population, and to help flatten the curve in eastern Massachusetts.
Field hospitals were originally designed during the Civil War to provide comfort care to mortally wounded soldiers and give them a place to die.4 Over the years, field hospitals have been used as temporary hospitals or mobile medical units to care for casualties prior to being transported to a higher level of care; the intent is to provide life-saving care, not comfort care.5
A key issue in a medical disaster is the ability to quickly address the surge or sudden influx of patients. Part of the solution has been the use of Alternate Care Sites (ACSs), which free up hospital beds so that more critical patients can be treated in these facilities. An ACS can be any building or structure temporarily converted for use during a public health emergency to provide additional capacity outside the walls of traditional health care institutions. The development of an ACS plan, and operationalizing that plan when a disaster strikes, provides a significant solution to a medical surge (East West Protection, personal correspondence, June 3, 2020).
As wave 1 of the COVID-19 pandemic spread around the world, field hospitals were built in convention centers and other available sites. The patient population served in field hospitals varied according to capacity needs, staffing availability, and capacity in local hospitals. In a May review of US field hospitals, it was reported that many field hospitals had not treated any patients. A lack of planning around how field hospitals would be used was thought to be the cause of their low volume.6
Boston Hope, on the other hand, treated more than 700 patients and was set up after careful collaboration and assessment of potential capacity issues in eastern Massachusetts. The success of Boston Hope was the result of rapid-fire planning, strong leadership, and the robust admission criteria guided by the hospitals served, as well as the explicit culture of safety communicated to all key stakeholders, especially patients. In order for Boston Hope to succeed, exquisite communication needed to be maintained with all stakeholders, including daily calls with state and city leaders and coordination with MGB. Gregg Meyer, MD, Chief Clinical Officer7 at MGB, was the lynch-pin between Boston Hope, MGB health system leaders, and the MGB system-wide incident command structure. Having a widely respected leader available to the field hospital facilitated the rapid-fire nature of the work.
The design of the BCEC also contributed to Boston Hope's success. The exhibition center is divided into 3 halls. Hall 1 was converted to a 500-bed facility providing respite care to homeless patients who tested positive for COVID-19 but were not in need of acute care. Hall 2 also had 500 beds and was available for patients needing nonacute care. Hall 3 became the supply chain center. A quarter of Hall 2 was used for rehabilitation services, including a walking track, patient wellness programs, and spiritual care. The second floor of the convention center was used as the command center and staff support and employee wellness programs. Michael Allard,8 co-incident commander, brought operations expertise to Boston Hope. Allard's experience designing services for veterans with posttraumatic stress disorder and traumatic brain injury helped in providing robust wellness programs. Throughout the field hospital, inspiring messages and art from local school children lined the walls. Boston Hope was designed as a place for healing.
DEFINING CRITERIA AND OPERATIONS
Health and Human Services (HHS) Guidelines for Alternate Care Sites (ACS) set the stage for the initial planning.9 HHS provided a detailed plan to build an ACS and included recommendations for staffing, supplies, equipment, pharmacy, and structure. Boston Hope clinicians tailored the guidelines to meet the infection control needs of COVID-19 patients.
Although several Boston Hope leaders had experience working during times of war and disaster, they knew they needed a leader with prior field hospital experience. Retired Rear Admiral W. Craig Vanderwagen10 was brought on to guide the leadership team. His experience as Assistant Secretary for Preparedness and Response at HHS was key in defining a command structure that would enhance rapid decision-making and communication.
Co-medical directors, Giles Boland, MD,11 and Jeanette Ives Erickson, RN,12 developed a strategy for clinical operations. They knew it was important to work from core principles of excellence: understanding the environment of care, clearly defining roles and responsibilities for staff, and knowing the patient. These principles not only led to the development of an effective incident command structure, but the co-medical directors worked with the entire team to develop patient admission criteria, supply and technology standards, quality and safety programs, and relevant outcome and reporting measures.
Incident command structure
The incident command structure13 at Boston Hope followed the basic tenets of a standard hierarchy, allowing for coordination and response to multiple key stakeholders and the 1000-person workforce. Having served in Iraq and Afghanistan, incident commander, Brigadier General (ret.) Jack Hammond14 had a distinguished 30-year military career in the US Army managing during uncertain times. His experience brought mission focus to the work and was critical around ongoing engagement of stakeholder leaders and interfacing with the US Army Medical Reserve Military Task Force.
The 1034-person workforce consisted of medical and administrative professionals redeployed or temporarily hired from local health care agencies and ambulatory clinics that were adapting or shuttered at the beginning of the COVID-19 surge. Although the team of clinicians and support staff at Boston Hope had prior health care experience, most had never worked in an ACS and had never worked together in any prior situation. Their ability to advance the mission of Boston Hope so quickly was driven by their unity of purpose. Individuals came to Boston Hope with a shared commitment to serve patients and provide a safe environment of care.
Measuring clinical and operational outcomes was a major undertaking for this free-standing center and critical to guiding patient care, operations, admission criteria, and planning for closure. The establishment of patient experience and staff surveys sent a clear message to both patients and staff what was important. Early on in the development of the strategic plan and organizational structure, Boston Hope worked to support an extension of the electronic health record (EHR) used at MGB. The EHR allowed clinicians and administrators to document care and to retrieve data. Boston Hope leadership engaged Bonnie Blanchfield,15 to lead the data and evaluation efforts, create data dashboards, define and collect outcome measures to ensure transparency, and share data with the sponsoring organizations and other stakeholders. The MGB Data and Analytics team worked closely and swiftly with Bonnie to develop key metrics for reporting.
LEADING THE WAY
Other ACSs may encompass similar structures and processes, but cultures vary and develop based on the leaders' and team members' vision and experience.
Leaders felt it was important to engage young clinicians in leading the response at Boston Hope. A unique and enduring feature of Boston Hope was the introduction of conversations between leaders and staff—not just about patient care, but to develop the skills of novice caregivers and emerging leaders. During these conversations, several environmental factors were identified that influenced and encouraged these emerging leaders:
- Facility design. The convention center space provided easy access to senior leaders so that emerging leaders could observe the executive team creating a learning environment and enhanced communication. The proximity of senior leaders to clinical and support staff allowed information to flow rapidly in both directions. First, the young see the behavior of leaders and can bond with them. Second, leaders better understand the aspirations of their younger colleagues and can tailor their leadership to nurture and guide those aspirations. By demonstrating respect and commitment to the success of newer leaders in the moment, they humanize and make more achievable the possibility that younger colleagues can attain leadership more confidently.Leadership is predicated on followership as Stanley McChrystal observes in his book, Leaders: Myth and Reality.16 McChrystal makes the case that leadership, understanding, and teaching must go beyond mythology and be more analytic. He asserts that leaders do not exist without followers, and successful leaders are effective at understanding the goals and assumptions of their potential followers.
- The explicit modeling of leadership behaviors, including transparency. The 4 leaders had never run a field hospital, nor had they dealt with a pandemic. “I haven't ever done this before” became a statement leaders used when making decisions and dialoguing with staff to solve problems, modeling leadership as a human, not mythologic, endeavor. There is clear recognition that humility and willingness to invite problem-solving collaboration are useful attributes to leaders. A secondary mantra, “We worry together,” was used to encourage openness around identifying problems that needed to be resolved in a thoughtful but timely manner. This creates bonding to the group mission in a very personal way. It accepts that the leader and follower are on the same plain, and success is a collective effort, not due to the personal attributes of a single individual: the leader. We are disrupting historians' tendency to attribute success to “great men,” without crediting the actions of the rank and file. Proximity invites dialogue and diffuses mythology.
- The ease of correction. The leadership team knew that decisions needed to be made with all of—and only—the information they had at the time. The rapidly shifting clinical situation required a tolerance and management style that supported trying something, and if it did not work quickly, making corrections. Logic dictates that accepting humility and demonstrating trust in the group makes failure less threatening. Importantly, in the event, decision-making must be done in real time because of the pressure of events; leaders know they will be making decisions with less data to support decision-making than is routinely expected. Leaders all accepted some ambiguity. This was clearly different from our routine training and prior work. In this environment, the success or insufficiency of a decision became quickly clear, and the press of events determined whether revision of the decision was required or not. Humility was an important characteristic necessary to do the work successfully.
- Delegation of authority. The explicit delegation of leadership authority to the emerging team. (“Here's the problem. Put together a team to develop a fix and let me know how I can help.”) As executive leaders developed greater confidence in themselves and recognized and trusted their “followers,” they were willing to delegate some of their responsibility and authority to others. This changes the role of senior leadership from hierarchical decision-making to one of guiding and nurturing the decision-making of others. This was about the confidence, humility, and trust developed by senior leadership.
- The impact of moral distress. During this pandemic, moral distress has been pervasive in many health care settings. Health care providers encountered morally distressing situations when witnessing the inequities in care they knew existed but perhaps had not seen first-hand so robustly. Language barriers and fear of not being able to meet standards established to protect patients and team members were daily challenges. A constant shortage of N95 small-size masks left leaders struggling to negotiate with local, state, and federal regulators who were calling for the use of various vendors' products leading to constant fit-testing of staff and worries by leadership, especially those responsible for the supply chain.
The concept of moral distress has been associated with negative consequences for both people and systems.17 At the individual level, moral distress may cause burnout, lack of empathy, and job dissatisfaction, while at the organizational level it can lead to reduced quality of care and poor patient outcomes.18
Instead of this being a purely negative experience, the potential for moral distress became a catalyst for positive action leading to resiliency. Generally, resiliency refers to, “the ability to recover or healthfully adapt to challenges, stress, adversity, or trauma: to be buoyant in adverse circumstances.”19 Specifically, the leaders for Boston Hope's supply chain and the safety officer, led by having the capacity to sustain or restore system integrity in the mist of confusion or periodic setbacks. They and others learned to respond positively to challenging situations by building their capacity for new relationships and by staying true to established standards and values.
LEADING DURING UNCERTAIN TIMES AND LESSONS LEARNED
Serving the people of Boston during the pandemic is viewed by many as the job of a lifetime. It was evident that clinicians and support staff joined Boston Hope knowing this was something we needed to do. One could assume that one of the attractions of working and practicing at Boston Hope was the personal value of being a lifelong learner or the pursuit of new knowledge.20 Indeed, each member of the team came to Boston Hope curious about what was happening in the external environment, how patients were improving, and how we could improve while working in this austere environment. While we did not measure the impact that working at Boston Hope had on practice as people returned to their prior roles, the authors did reflect on the impact that working at a field hospital had on them, both personally and professionally.
IN THEIR OWN WORDS
Jack Hammond incident commander: When operating in an expeditionary environment such as this, I learned a long time ago that it all comes down to people and stuff. You need the right people to complete the mission and effectively work together, and the proper resources for them to succeed in accomplishing the task. This began with our leadership team, each of whom was an expert in their field, and a group of amazing advisors with whom we conferred on a daily basis. My role as incident commander was to provide purpose, direction, and resources.
No one person can drive success; it takes a team. At Boston Hope, we had an amazing team of mission-driven people who clearly understood what was at stake and knew that failure was not an acceptable option. This rapidly evolving situation required agile and adaptive leaders who worked together in a collaborative manner to challenge every premise and build effective solutions. To be successful in this type of environment, you must be able to effect change at the speed of relevance. As our operations matured and confidence in subordinate leaders grew, decision-making authority was powered down to the lowest operational level to ensure timely resolution.
Michael Allard co-incident commander: There are few times in our lives when we are able to choose or be called upon to serve a higher purpose for our community. The Pandemic of 2020 and success of creating New England's largest COVID+ field hospital was one of those rare times. It is truly amazing what a few people with common mission and a sense of selflessness can accomplish. Professionally, one of our greatest successes at Boston Hope was that we did not lose one patient to this insidious disease—despite all expectations otherwise. And personally, I had the privilege of helping to lead and work alongside an extraordinary set of women and men—all of who gained a lifetime of experience in 3 exhausting months of performing extraordinary acts of professionalism, devotion, and kindness to our patients and one another.
Gregg Meyer, MD, Consultant to Boston Hope: The challenges of meeting what was both an acute and uncertain need for our community required a new way of working together. The Boston Hope experience was a powerful reminder of what dedicated professionals, working under extraordinary pressure but with clear objectives, can accomplish. The ability to plan dynamically, fail fast, learn quickly, and extend leadership across the team were essential elements of an approach that met the moment. John W. Gardner, a distinguished public servant and founder of Common Cause, captured the experience well in these quotes:
“We are continually faced with a series of great opportunities brilliantly disguised as insoluble problems.” And, “We are not at our best perched at the summit; we are climbers, at our best when the way is steep.”
Bonnie Blanchfield, Consultant, Data Outcomes and Evaluation: Although not on the front lines caring for patients, the cross-sectional team members I worked with were dedicated to the mission, never said, “No” or “Why,” and only worked harder to get what was needed with speed and excellence. In all my years working at MGB, this was the best experience I have had and one where I felt we were all pulling together. I think it was due to the extreme commitment to the patients and mission, to the institution, and to the leadership team leading the effort.
Craig Vanderwagen, Consultant to Boston Hope: While the leaders were acquainted with each other, they did not work day-to-day as a unit. They would need to come together as a team if the ACS was to be a success. Although they were senior leaders in their “day jobs,” this was a totally different experience than operating within a large academic medical center with prescribed roles and processes. This was a “green field” and different reality requiring clarity of mission, swift decision-making, and flexibility in thinking. It seemed clear to me from that first encounter that the group was extremely capable and well skilled, and understood that their “usual” approach to leading and managing would not be the most useful strategy in executing this mission. This was to be a learning experience, and they accepted a confident, but humble posture from the outset.
The Section Chiefs at Boston Hope were younger, less experienced, but very smart and motivated. The senior team cultivated the confidence level of this younger tier by delegating decision-making very early and supporting creative failure as well as success, thereby empowering the younger leaders to assume greater responsibility and control of their area of effort. This was very energizing and was reflected in swift decisions, quick ability to change the process as needed, and an increasing sense of understanding and belief in the importance of all team members in achieving the mission in word and deed. This distributive approach to leadership and problem-resolution persisted throughout the 10 weeks that active patient care was in play.
The challenge of undertaking a totally new experience and approach to patient care became a real growth experience for leadership and staff involved in this alternate care site. New ways of relating to each other created a stronger sense of mission commitment and fulfillment. Many of the staff were energized to consider new means to manage and provide patient care in their “usual” care settings. Paradoxically, they finished the experience more focused and determined to improve the process of patient care using the skills and concepts learned through this disaster-related response. The challenge will be to find a means to implement the lessons learned in the existing medical bureaucracies to which they return.
Giles Boland, MD, co-medical director: Boston Hope was an experience like none other. I am committed to taking the lessons learned and implementing them in my everyday practice. This is a gift of a lifetime.
Jeanette Ives Erickson, RN, co-medical director: Anchoring to the core values for clinical excellence and exceptional teamwork from the start afforded all of us the opportunity to accelerate teaming and create an effective practice model in service to patients impacted by COVID-19 and the broader community. It was an absolute honor to serve.
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