Clarity in Chaos: Leading effectively and clearly when your team needs you most
By Tim Johnsen, FACHE
A once-in-a-lifetime pandemic of epic proportions provided the healthcare industry with an abundance of new information and ideas for effective crisis management. But for healthcare leaders, the rollercoaster of COVID response was hardly their first brush with a crisis situation, and it will not be the last.
Crises of all sorts play out almost every day in hospitals across the United States and in our communities. In just the past few months, I found myself leading back-to-back unexpected hospital evacuations, first for wildfires, and then another a week later in the same facility for severe flooding following significant rains in the burn scar areas. This poor community couldn’t catch a break, but their local leadership did phenomenal work that saved lives during an intense month in crisis.
Cutting through the noise in times of crisis
Webster’s Dictionary defines crisis as “a time of intense difficulty, trouble, or danger.” Organizationally, a crisis is any situation that disrupts normal operations. In our industry, examples include:
Power interruptions in a hospital leaving an operating room (and surgeon) in complete darkness, even if just for a few seconds until the electrical generators engage
Aggressive or violent patients/visitors who threaten our safety and well-being (which I have written about previously)
Cyberattacks, which have seen a 45% increase in the healthcare industry over 2021 (Expert Insights, 2024)
Mass casualty events from motor vehicle accidents, mass shootings, or other harm-inducing events in the community
Like leaders in any context or industry, we need to be the steady hand at the helm and model the appropriate response in times of crisis. One could argue, too, that we need to provide this level of clarity in our daily work, not just in these extreme examples of disasters and major crises. Healthcare leaders are navigating so many intricate and interwoven issues that occur daily yet don’t rise up to the level of “disaster.”
Franklin D. Roosevelt’s quotation, “A smooth sea never made a skilled sailor,” certainly applies to us as leaders during critical times. If you find yourself leading incident command in an armed intruder event in your facility, for example, there will never be a time where you are more “on stage.”
While I have built my leadership philosophy upon the belief that healthcare is a “team-based sport” and that the best results come from doing everything in a multi-disciplinary manner, the fact is that sometimes the buck really does stop with you and all eyes in the board room or command center turn to you for the final call.
It reminds me of an anecdote I heard a speaker share at a conference:
Imagine you are on a flight and out of nowhere, the plane jolts into a hard nose-dive. As the oxygen masks fall from the ceiling and people are screaming, crying, and praying, you hear an announcement from the cockpit that says, “Hi everyone, this is your pilot speaking, and I need your help. Everyone break into small groups, perform a SWOT analysis, and then we’ll ask you to report out at the end of this exercise to illicit the best solution.”
Of course, this example is ridiculous, and that’s the point. Your team, your partner agencies, and your community will all be looking to you to offer the needed clarity in crisis, to be the steady hand, the “Captain Sully” who lands the plane safely. Even a subtle wince, a pause in response to a question, or the fraying of rattled nerves cannot be on display in these critical moments. People look to you for a sense of order, calmness, decisiveness, and hope of getting out alive.
In any crisis, there will be a lot of chaos and noise. You’ll be inundated by minutiae not relevant to what matters in the moment, people and issues coming at you in rapid fire that may or may not be the critical priority, and a litany of distractions that threaten the clarity your team needs from you. Even the most steadfast, experienced leaders may not be their best in this moment. We must rely on training, disciplined structure, and order developed over decades of learning in these crucial moments.
In order to minimize loss of life or property, we must be the leader who sorts through all the data quickly, identifies the priorities for response, and sets the tone and tenor for the rest of this crisis. We must align our teams and work, deal with media inquiries, collaborate with community leaders and politicians, and do so in a way that exudes confidence in our leadership. You need to take the noise out of the chaos to gain the clarity you will need to begin to act and respond, and to provide the critical resources and support your organization needs as it deals with the crisis at hand.
As a leader, here are six components to effectively lead your organization with clarity in the midst of a crisis:
#1: Establish and practice incident command long before you need it.
The Joint Commission (TJC), the Center for Medicare and Medicaid Services (CMS), and other regulatory agencies require hospitals to annually evaluate and priority-rank probable risk scenarios through the use of a hazard vulnerability assessment, a tool that provides a systematic approach to analyzing hazards that may affect demand for hospital services, or a facility’s ability to provide those services. Hospital emergency preparedness teams then take that information and do scenario planning, table top exercises, and community-wide drills to prepare for the most likely risks.
Don’t treat this requirement like a mere regulatory obligation. The skills it takes to lead incident command are not natural skills and must be learned. The more times you practice, the more informed and experienced you become. Let other leaders practice incident command to gain experience. Larger facilities may have the benefit of professionals trained in Emergency Management and Disaster Recovery on staff, while smaller facilities’ executive leaders typically assume these roles directly. Your organization should have multiple leaders whom you trust to be an incident commander. Staff training, running the scenarios, assigning incident command roles, and evaluating the effectiveness of the drill are all essential components of the process of preparing for the worst, and should be conducted regularly.
#2: Assess quickly and be data-driven.
The aviation industry is widely hailed as the leader in crisis management. Responses to crises in the air do not rely primarily on the individual pilot’s judgment calls, but rather on data. All those instrument panels in the cockpit are there for a reason; they are providing real-time information, the “vital signs” of the aircraft, if you will. Pilots rely on tried and tested response tactics which include pre-flight checklists, exact repeatable routines, pre-occupation with failure, and ultimately, an algorithm to respond to almost any potential crisis developed through decades of learning, failures, and experiences.
However, as good as these pre-determined responses may be, they are only as good as the data received, assessed, and observed. The same is true in healthcare. If a doctor fails to assess the patient adequately and makes the incorrect diagnosis, the treatment she provides may be contradictory or even fatal. Hence the reliance upon the tools we have at our disposal: the diagnostic imaging, the blood work, the vital signs, and every other data element you can find to assure you are responding to the correct diagnosis or situation.
Whatever kind of disaster you are facing, get the most accurate, real-time information you can, and ask for updates frequently.
#3: Stay calm and lead with a steady hand.
Early in my career, I served as a med-evac flight nurse. I recall seeing some of the most horrific traumas, death, pediatric emergencies and other tragic situations almost daily. Add to that an unstable environment outside the walls of a hospital with far fewer resources, and I was living a crash-course in crisis management. My early crisis-management skills were honed in this environment where my composure, or lack thereof, could set the tone for not only gaining clarity for what was most needed in the moment, but to provide others a sense of stability in situations that were anything but stable.
I still cringe at one of the first times I took on the responsibility of calling report over the airwaves for everyone in the EMS community to hear. As a flight team, it is crucial to call ahead a report on the patient in a calm, succinct, effective, and clinically relevant way so that whatever trauma center or hospital you are bringing the patient to can ensure the patient receives optimal care upon arrival.
On this occasion, however, my heart was racing, my breathing was labored, and the intensity of the responsibility for saving a human life left my voice shaky and likely an octave higher than normal. The panic I was experiencing amongst this chaos was clearly coming through in my radio communications. I was showing very real human reactions to trauma, but letting those hurtle out of control during this short report not only hurt my own credibility, but misrepresented the abilities and professionalism of a well-polished flight team who provided exceptional care to each patient they served.
Before we even made it back to the helicopter after transporting the patient to the hospital, my chief flight nurse (and new boss) spoke to me about how to appear calmer during the crisis, to take a deep breath or two before the mic went “live.” He emphasized the importance of steadying myself so that instead of sounding the way I actually felt, I could convey the facts and the treatment we had provided, and instill confidence in our treatment of the patient.
I learned a lot from that moment and through many missteps in my leadership journey along the way. As a leader, you will almost certainly be faced with something you’ve never experienced, and you’ll have your own human reactions. Be mindful of what those are, take the deep breaths needed, and get a few moments outside the command center to clear your head to gain composure if you need it. Force rest breaks into your incident command structure. Even the most seasoned leaders need to “tap out” to recharge during critical incidents.
#4: Provide the capital and human resources needed.
This is the ultimate moment to be the servant-leader; you are there to remove the obstacles and barriers for your teams to do their best work. Assign duties and functions, set clear expectations, and then get out of their way. Secure the necessary resources for them to do their jobs well, and make decisions swiftly and confidently.
#5: Wrap up every incident with an evaluation.
Evaluating what went well and what needs to be improved after the situation is resolved is the best way to be one step better the next time. This is best conducted within two weeks following the end of the incident—not too soon where people don’t have enough distance from the trauma to be objective, but not too far out where key learnings or opportunities for improvement have been forgotten.
In my experience, communication failures (or at least gaps in communication) inevitably end up as the top opportunity for improvement in all after-action evaluations of what we could have done better. Communication systems may be inoperable. Inter-agency communication may be haphazard. People pass along the wrong information, and social media’s prevalence in our daily lives allows information (and mis-information) to spread quickly.
When you are in command and in control, if you don’t know all the facts, the exact order in which they have occurred, who has been impacted, and how long the event may go on, it makes it even harder to lead clearly and to make the right calls in an industry where we rely heavily on data to make decisions. Consider with your team how you might put systems in place to mitigate inaccurate data in a future crisis situation.
#6: Be kind and be human.
Strong leadership doesn’t infer mean leadership. Thank everyone involved frequently. Be humble. Share openly that this is a stressful time, but you have confidence in your people and processes. Assure mental health resources are at the ready for those directly impacted. Provide critical incident stress debriefing to encourage everyone involved has an emotional outlet.
The work we do in healthcare often feels like we’re on the edge of a crisis all the time. Many of these crisis response skills will have application in the day-to-day responsibilities of leaders, even if a major disaster is not at your doorstep. But when real crises hit, remembering these steps will ensure that you are giving your best. Relying on many years of training will benefit you greatly.
An awareness of your strengths and weaknesses allows you to lead more calmly, and can even help you recognize that while you may be an effective and talented leader in many circumstances, crisis response is not one of them. That’s okay too. Leadership is a team-based sport, and there are many qualified people on your team who may be better suited in leading incident command. If so, by all means let them! There’s no shame in recognizing deficits and substituting your best players when needed.
Although our days are filled with so many competing priorities, regularly scheduling time for drills, scenario planning, and ensuring multiple leaders have the opportunity to practice serving as incident commander of your mock disaster will always be time well-spent. I’ve yet to meet an experienced healthcare executive who hasn’t had to sit in this chair at least once in their career. Make sure you and your team are prepared when it’s your turn.
Resources
Healthcare Cyber Attack Statistics 2022: 25 Alarming Data Breaches You Should Know, Expert Insights