“Hospitals must retain the agility acquired during the crisis”

The pan­de­mic has put both our heal­th­care sys­tem and hos­pi­tal mana­ge­ment methods to the test. During the first wave, health wor­kers adop­ted new, high­ly effec­tive mana­ge­ment tech­niques whil­st wor­king in cri­sis mode. Will we retain these approaches ? In July 2020, Étienne Min­vielle and Her­vé Dumez (CNRS/Institut Poly­tech­nique de Paris), publi­shed Le Sys­tème hos­pi­ta­lier fran­çais face à la crise Covid-19 [“How the French Hos­pi­tal Sys­tem Dealt with the Covid-19 Cri­sis”] a stu­dy based on 55 inter­views with health professionals. 

How would you sum up your field of expertise ?

Health mana­ge­ment research is a field of social science that stu­dies key issues in public health, such as orga­ni­sa­tio­nal per­for­mance, coor­di­na­tion of health pro­fes­sio­nals and treat­ment plans. It is a rela­ti­ve­ly new field in France because health pro­fes­sio­nals gene­ral­ly have lit­tle for­mal mana­ge­ment training. 

Why did you decide to spe­cia­lise in this field ? 

Over the course of my medi­cal stu­dies, I became pas­sio­nate about mana­ge­ment. I stu­died at the Essec Busi­ness School and have a doc­to­rate in Mana­ge­ment Science from the Ins­ti­tut Poly­tech­nique de Paris. Our coun­try has one of the best health sec­tors in the world when it comes to cli­ni­cal prac­tice and research, but we have major mana­ge­ment pro­blems. Fixing these would lead to mas­sive impro­ve­ments, as well as increase qua­li­ty, limit waste, and reduce inequa­li­ties. The field is still a mino­ri­ty in the heal­th­care sec­tor. I am trying to deve­lop a large-scale patient-cen­tred approach to respond to spe­ci­fic needs of indi­vi­duals. And to sub­se­quent­ly make that offer as wide­ly avai­lable as possible. 

What les­sons can we learn from the pandemic ? 

Our health sys­tem has had to deal with an increa­sing num­ber of crises late­ly : ter­ro­rism, natu­ral disas­ters and, in our case, a pan­de­mic. In order to face these chal­lenges and be more adap­table, we have to adjust our skill set to imple­ment new kinds of mana­ge­ment strategies. 

Do you think our hos­pi­tals were adap­table enough during the lock­down during the first wave of Covid-19 ? 

Yes. Our stu­dy sum­ma­ri­sed this in six points. We observed : 

1. A great deal of orga­ni­sa­tio­nal crea­ti­vi­ty, inclu­ding the mass deve­lop­ment of tele-health ser­vices. This some­times invol­ved a more relaxed approach to cer­tain rules, such as exchan­ging medi­cal infor­ma­tion via What­sApp, which under nor­mal condi­tions is a vio­la­tion of patient confidentiality. 
2. For­ward plan­ning : health pro­fes­sio­nals asses­sed the situa­tion and made deci­sions in real-time, high­ligh­ting the vital impor­tance of field stu­dies. Data obtai­ned from an assess­ment of the situa­tion in the French city, Mul­house, was used to make deci­sions in Paris, for instance. 
3. Sup­por­tive mana­ge­ment based on lis­te­ning, exten­sive com­mu­ni­ca­tion, the consi­de­ra­tion of everyone’s pers­pec­tive and flat­te­ned hie­rar­chies made a big dif­fe­rence. This went hand in hand with fair dis­tri­bu­tion of finan­cial resources bet­ween ser­vices, phy­si­cal pre­sence of lea­ders, and transparency.
4. Adap­ta­tion through auto­no­mous, co-ope­ra­tive group work. For ins­tance, rapid tes­ting and eva­lua­tion of new patient orien­ta­tion pro­to­cols were deve­lo­ped by local teams.
5. New part­ner­ships bet­ween start-ups and hos­pi­tals, and bet­ween public and pri­vate institutions. 
6. Govern­ment sup­port such as remo­val of finan­cial constraints and pro­vi­sion for local initiatives. 

How can we fos­ter crea­ti­vi­ty in an envi­ron­ment which is unders­tan­da­bly high­ly regulated ? 

Humi­li­ty and doubt must be valued above all things. Crea­ti­vi­ty can only hap­pen when there is a willin­gness to let go of pre­vious assump­tions. And errors must be recognised. 

What did we see during the second wave of the pandemic ?

First off, it was slo­wer and more wide­ly spread. Because of its re-appea­rance after a short per­iod of calm, heal­th­care teams who are often tired are being tes­ted again. The word that comes back most often is ‘wea­ri­ness’. An abi­li­ty to adapt is still neces­sa­ry but with an empha­sis on sup­por­tive mana­ge­ment. The ini­tial soli­da­ri­ty is waning thin, so it is impor­tant to sup­port teams on a dai­ly basis and address wor­ries of heal­th­care professionals. 

Bet­ween the two waves, were we seeing mana­ge­ment return to the way it was before ? Or were ser­vices retai­ning the know­ledge learnt from pre­vious crises ? 

Under nor­mal cir­cum­stances, per­for­mance relies on spe­cia­li­sa­tion, hie­rar­chy and eva­lua­tion ; contra­ry to adap­ta­bi­li­ty which relies on short net­works and quick reac­tions. Howe­ver, if we take a clo­ser look, we can see that proxi­mi­ty mana­ge­ment is essen­tial in both cases. It encou­rages adap­ta­tion and can work to resist the loss of attrac­ti­ve­ness we are seeing in the health professions. 

Condi­tions at hos­pi­tals have dete­rio­ra­ted ; the orga­ni­sa­tio­nal struc­ture is unclear and under­mi­ned by poli­tics. This makes heal­th­care a tough work envi­ron­ment, and the ongoing cri­sis high­lights the urgent need for proxi­mi­ty mana­ge­ment. The boun­da­ry bet­ween nor­mal condi­tions and those of the cri­sis is now blur­red. For that rea­son, we could say that the mana­ge­ment chal­lenge needs to deal with a ‘nor­mal crisis’. 

Does the entire culture have to change ? 

I don’t real­ly like the word “culture”. There is no manual for chan­ging a culture. To me, trai­ning is para­mount. A head of depart­ment, for example, is often cho­sen on their exper­tise as a resear­cher, which does not neces­sa­ri­ly make them a good mana­ger who can unite staff, fos­ter crea­ti­vi­ty, encou­rage intros­pec­tion, and so on. For me, the key is on-the-ground mana­ge­ment training. 

Is there a “post-Covid cri­sis” in public health ? 

Yes, because we have rea­li­sed that large scale threats are real, some­thing that would have been impos­sible without the pan­de­mic. Think back to the begin­ning of the year : the signs were there, in Chi­na, in Ita­ly, but people were often in denial. 

Will we see more crises on the same scale ? 

Pro­ba­bly. We will face other threats, such as bio-attacks, new epi­de­mics, cyber-attacks, cli­mate change, and ter­ro­rism. We live in an uncer­tain world, and we must be pre­pa­red. During the cri­sis, the army built an emer­gen­cy mili­ta­ry hos­pi­tal (in Mul­house) in record time, as part of a test for a che­mi­cal attack res­ponse. Staff wore very uncom­for­table NBC suits. We need to unders­tand that each cri­sis is unpre­ce­den­ted, that each situa­tion requires a new stra­te­gy. But we are lear­ning. We saw, for ins­tance, that staff who had lived through the 2001 che­mi­cal explo­sion at the Tou­louse AZF plant retai­ned good cog­ni­tive reflexes and adaptability. 

How did they behave ? 

They were resi­lient. They had a way of remai­ning construc­tive under pres­sure, which is abso­lu­te­ly essen­tial. In times of sud­den, short-term crises, soli­da­ri­ty is per­va­sive. In chro­nic situa­tions, howe­ver, that soli­da­ri­ty erodes. Orga­nic soli­da­ri­ty (“we are all in the same boat”) gives way to a more mecha­ni­cal soli­da­ri­ty (“we are in this toge­ther, but rela­tion­ships must be nego­tia­ted”). Unless mana­ge­ment finds a way to coun­te­ract this, we will lose our effectiveness. 

Interview by Clément Boulle