“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