Operating a hospital can be challenging even on a good day. From delivering the highest quality care to administrative burden and tightening financial margins, leaders are seemingly never done putting out fires.
But what happens when those challenges are actual fires, like the raging infernos scorching thousands of acres in the west as we speak, or the floods Hurricane Harvey brought that crippled parts of Texas?
To find out, we went to the sources: Sutter Health in California, MD Anderson in Texas and a stand-alone shop also in the Lone Star State run by a wife and husband team all shared lessons learned from successful disaster response.
While exact plans no doubt vary depending on the nature of the disaster, the geographical location and resources a particular hospital or system can access, a picture emerged that surviving requires everything from thorough communication, coordination and quick thinking to high water vehicles and cloud-based EHRs when facing down mother nature.
Let's take a closer look at how Sutter, MD Anderson and Fannett Medical Center survived and what other hospitals can take away from their experiences.
Sutter Health's showdown with the Northern California wildfires
In the last couple weeks, Sutter Health staff are no doubt experiencing deja vu. As of July 30th, Sutter Health had donated $100,000 to the American Red Cross to support fire relief efforts across California, including the massive Carr Fire that has devastated Shasta and Trinity counties and killed six people including firefighters. The River and Ranch Fires, also known as the Mendocino Complex Fire, are still burning in Lake and Mendocino counties. These fires forced the evacuation of Sutter Lakeside Hospital in Clearlake last week, the second time in the system's history where a hospital had to be fully evacuated.
The first time was last October, when Sutter Health Santa Rosa Regional Hospital suddenly found itself in the path of a complex wildfire, the horrific offspring of several separate blazes which had converged to become a monster that would eventually devour more than 245,000 acres across Napa, Sonoma, Solano, Mendocino, Yuba, Butte and Lake counties, where the system serves more than 150,000 patients.
At the time, it was the worst wildfire Sutter had seen in its 165-year tenure. Their first facility opened in 1853. Jeff Gerard, Sutter Health's senior vice president of strategic services, said he called the hospital the morning of the fire and expected to hear that they were receiving fire victims in the ER. Instead, he was hit with the news that they were on lockdown, sheltering in place, and arranging the immediate evacuation of 77 patients currently in-house. Moreover, around 100 community members that had been suddenly displaced in the overnight and early morning hours had sought refuge at the hospital as well, many with pets in tow. Gerard learned his cafeteria was accommodating them.
By 9 a.m. that day, the last patients, staff and the 100 or so guests from the community had been relocated, using every mode of transportation from ambulances to city buses. No small feat. Now all they could do was hope they had a campus to come back to.
"Later I saw the security footage of the fire itself because we had security cameras on the side of the building. The fire itself came right through our campus. It burned through a building we use as a home for families whose children are at the hospital called the Shea house. It burned that to the ground and came around the side of a medical office building through the back parking lot of the hospital, came within 30 feet of our engineering building and oxygen tanks and then jumped the freeway and kept going," Gerard said.
In the end, Sutter Health closed one hospital, 17 medical clinics, 3 surgery centers and two home health agencies. When staff returned, it was clear that the damage could have been much worse than it was. The hospital was miraculously largely untouched and was back online in 8 days and 6 of the 17 clinics were open again in 48 hours.
Air quality was the biggest problem, and in the end their infrastructure served them well. A fire line engineered when the hospital was built had kept flames away from sensitive structures and the hospital itself. The fact that the facility had its own independent water source not only meant that they were not subject to complications from the failure of the city water system, but fire departments battling the fires ended up tapping Sutter's supply to the tune of roughly 500 million gallons to keep flames at bay in the immediate area. All investments that Sutter had made before the first fire proved to be well worth it.
Fluidity of staff was also crucial in managing higher than usual patient volumes in the facilities that received Santa Rosa patients. Displaced staff from Santa Rosa traveled to other hospitals to help, including the next closest hospital to them. That facility's usual capacity was 25 inpatients. Their count literally doubled with hours' notice but Santa Rosa staff was there to lend a hand. Gerard said Sutter Health was even able to reach out to other hospitals to see if they needed extra supplies. All of that was accomplished with no pushback, a phenomenon that, though rare, was essential to managing what could have been utter chaos without that level of cooperation.
"One of the things I am most proud of is during our response to the disaster was the things we didn't have to worry about. Nobody ever asked what it was going to cost. We basically just asked what do patients need, how do we pull together as a system to make that happen. If I needed an air handler scrubbed, it just happened," Gerard said. "We had calls every four hours. We were moving people around. Anything we would usually have to think through we just made happen," Gerard said.
Beyond a higher level of human cooperation, Gerard said his number one takeaway from managing the wildfire incident was that "being a system really mattered." He said their ability to respond as a system, as opposed to a stand-alone, and investments made in digital and physical infrastructure were the difference between being crippled and being capable. A common EHR meant they could still serve the patients that had been displaced and scattered to other regions.
"I had physicians in Palo Alto doing prescription drug refills, virtual visits and e-messaging with patients 100 miles away. We also started video visits through that process," he said.
With cellular phone service predictably disrupted, staff found that social media also helped with reaching out to patients.
One notable challenge was wading through the rumor mill of what was closed down versus what was operational and communicating that clearly to the community. Gerard said if they had to do it again, they might embed a public information officer with the public health department to do real-time updates of clinical capabilities for their facilities.
Maintaining service continuity for patients, including those scheduled to deliver babies or managing chronic diseases, meant getting focused around clinical triage and mining their patient base to see who needed what type of service and prioritizing outreach. That included pharmacies themselves loosening their policies temporarily so that patients had fewer hurdles to jump through to get medications. And their partnership with Lyft helped them move patients around.
One aspect of the response that Gerard said changed his thinking and opened his eyes to their position in the community as a safe haven was the mass exodus to the hospital's doorstep.
"It makes total sense to me that the community would see us as a safe harbor but I didn't think about it until I got there and realized that our cafeteria was filled with people and their pets because we were the place they would flee to in the short term. That is something that is part of our readiness now."
Supporting the Sutter community itself also proved a learning experience, with 350 employees and physicians who were displaced and in temporary housing and 127 who lost their homes. There were more hoops to jump through than expected when it came to working with the IRS on creating policies and a mechanism to use the roughly $1 million in funds raised to help get their own people back on their feet without incurring penalties, something leaders might want to have in place before disaster strikes.
Gerard said the bottom line is in healthcare operations, if an ounce of prevention is worth a pound of cure, then systems would do well to have a ton of plans in place.
"Training matters. I would be incredibly clear on your priorities during an event. We had clear structure, priorities and work plan around that. Even though it might have seemed to the outside that there was chaos, there was a degree of calmness and structure that allowed us to work through that incredibly well."
MD Anderson sees benefits of lessons learned long ago in face-off with Harvey
Considering the damage done by one of last Fall's most aggressive intruders, Hurricane Harvey, MD Anderson Cancer Center came through the storm largely unscathed. Other than some minor flooding thanks to back-up in the sewer system, the system came through with minimal damage or interruption to service. There was no stoppage in care for the 500 inpatients present when the storm hit and according to Matt Berkheiser, their associate vice-president for environmental health and safety, sustainability and emergency management, by Monday afternoon if you could get to the medical center you could drive around it.
"Water had already started to drain off and people were showing up to work," he said. Those who couldn't get there were likely struggling under challenges created by the city's infrastructure, like the public transit system temporarily shutting down, an understandable glitch considering Harvey stayed long enough to dump 11 inches of rain on the region overnight.
Staff worked through Labor Day weekend to get appointments rescheduled as patients were not able to actually reach the campus, which owed its comparatively dry state of being to floodgates that had been installed after Tropical Storm Allison did major damage back in 2001. Seeing the writing on the wall about weathering future storms, the system took advantage of FEMA funds granted them and got an engineering company there to design floodgates.
Those gates made them an island amidst Harvey's wrath, and for a 15 million-square-foot campus, it saw only about $4 million property damage. But those gates didn't block out the chaos all by themselves. Over time, Berkheiser said a sophisticated and vigilant communication system has evolved including weekly rotations of incident command leaders that are primed and ready to handle all manner of incidents that might arise.
"We have more things to prepare for now than we used to not just storms and hurricanes. We have cyber threats and violence and other things."
They also have ride-out teams of roughly 1000 staff in place for running the institution so there is no interruption in patient care, like during Harvey, though adjusting those numbers might be a work in progress as well as figuring out how best to accommodate them and minimize the use of patient care areas for sleeping.
Prioritizing information, ramping up communication and conducting multiple training exercises called "table tops" are all part of what has become a very well-oiled machine. But there are always things to improve. The system does have a new high-water vehicle to help transport staff and even patients if needed. They also now contract with a company called StormGEO to have access to the expertise of a meteorologist when tracking potential weather threats.
But Berkheiser said what's clear to them is that becoming that well-oiled machine was actually as powerful a weapon against disaster as those physical flood gates. He said they had a FEMA team come in and evaluate their preparedness and response after Harvey. The FEMA team commented that it was clear to them that all the MD Anderson teams, including emergency planning, facilities, construction and project management and even maintenance, were "clearly talking to each other all the time and all on the same page."
"If you don't have that relationship at your organization, you need to evaluate that," Berkheiser said.
Being nimble in the face of disaster needs technology
Nurse practitioners Daisy and Zeus Arco are a married couple who last year bought a 40-year-old stand-alone medical clinic in the small community of Beaumont, Texas called Fannett Medical Center. Their first year in operation wasn't so much a trial by fire as a trial-by-wind-and rain. Just months after they took over, Harvey hit.
The area around Fannett was 40 percent flooded. Luckily, the clinic didn't flood but there were power surges that damaged their phone system and a few of their computers. The clinic did have to close down because they had no power after the storm, but when it came back they could still operate and re-opened that Friday.
A big reason for the quick rebound was, after having worked in larger facilities and witnessing first hand the complications caused by office or server-based EHRs and destruction of paper records in storms past, as soon as the Arco's took the helm at Fannett they moved to what they considered to be a more versatile system, a cloud-based EHR called AdvancedMD. They also purchased portable wifi stations so that no matter where they were, they could access patient records and communicate.
Fannett had its own water source but no electricity thanks to massive power failures. Zeus Arco said if they'd had a backup generator they could have opened up even sooner. Lesson learned there, as they will be purchasing one for the clinic shortly. He also said they'll be converting to laptops that can travel with their small staff instead of bulky desktop equipment which is harder to move. Their phone system will also move to a cloud-based platform and the Arcos said they are working to educate patients, especially older ones, on greater use of their patient portal for patient communications during the next storm.
The couple still works with larger area hospitals, who hesitate to make technological upgrades because innovation is expensive. Training staff takes resources too. But the ability to function in the face of catastrophe is crucial to patients, especially those with complex needs.
Daisy said the lone staff member who does their billing was stuck in her house because of flooding after the clinic reopened, but thanks to the cloud and a laptop, she was still able to communicate with patients and verify insurance so they could receive care.
They are looking into telemedicine through AdvancedMD to provide services during weather events. For them, it's not size that matters. It's being nimble in how you overcome challenges to continue serving patients no matter what.
"They need to be innovative, plan ahead and be more creative when it comes to any kind of evacuation plan. They don't necessarily need to spend a lot of money but they need to research and invest wisely," she said.