The COVID-19 crisis: aligning Kotter's steps for leading change with health care quality improvement

COVID-19 is empowering Emergency Room teams to courageously challenge the status quo, dismantle entrenched practices, flatten archaic healthcare hierarchies, and connect across traditional silos using quality improvement methodologies. Uncertainty surrounding virus transmission characteristics and anticipated volumes of high acuity patients pressured experienced providers and administrators to shift from “this is what we’ve always done” to “this is what we’re going to try.” Engaging all frontline staff members including medical learners, nurses, allied health professionals, administrative assistants, housekeeping, physician assistants, and early-career physicians, voices that are less often heard, is transforming day-to-day care received in Emergency Rooms across the country while facilitating safe transitions back to the community. Real-time rapid cycling, trialing ideas, and continuous quality improvement (QI) are invaluable to successfully combat COVID-19.

Kotter’s 8-step process for leading change¹ helps frame our change management processes during the COVID-19 pandemic:

1. Create a sense of urgency: COVID-19 creates a sense of urgency given its largely unknown nature.

2. Build a guiding coalition: Politicians, administrators, and frontline providers mobilize to guide efforts.

3. Form a strategic vision and initiatives: The guiding coalition envisions prioritizing essential services without overwhelming the healthcare system.

4. Enlist a volunteer army: Healthcare workers courageously volunteer to design, trial, and support new initiatives and policies.

5. Enable action by removing barriers: Healthcare workers empower each other to critically reflect on our usual practices and provide care that deviated from the norm to increase safety and decrease morbidity and mortality.

6. Generate short-term wins: We track, celebrate, and reward daily successes to boost morale.

7. Sustain acceleration: By consolidating changes through dynamic policies and protocols and consistently grounding daily work in our vision, we are sustaining momentum.

8. Institute change: Institutionalizing change is ongoing with long-term effects unknown.

Using the change management literature as a platform for designing, implementing, and evaluating QI initiatives during COVID-19 is strengthening our ability to re-examine processes to achieve the Institute of Medicine’s six QI domains: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity.² Here are three brief examples:

1.Addressing inequities by repurposing underutilized hotels on a temporary basis for underhoused individuals to self-isolate.^3,4

Through front-line advocacy and QI efforts, these beds allow patients, who previously stayed in the Emergency Room for up to 48 hours awaiting COVID-19 test results, to safely isolate. Not only does this minimize the potential spread to other people living in crowded shelters and on the streets, but it simultaneously decreases wait times and improves the patient experience for other Emergency Room patients who are waiting for an available assessment room.

2.Ensuring safety of patients and providers by displaying efficiency and resource stewardship to sustain personal protective equipment (PPE) supplies.⁵

Many of our junior learners temporarily stepped back from the clinical environment to preserve PPE supplies and actively contributed to new learner safety protocols aimed at decreasing the likelihood of virus transmission among patients, visitors, and staff working in the clinical environment. Learners met this setback with enthusiasm to become part of the solution. Through learner-led PPE community drives, learners continue to demonstrate their meaningful contributions as valued healthcare team members for the benefit of all patients and providers. Their educational sacrifices and valuable initiatives contribute to our current sustainable PPE supply and have allowed their safe return to clinical training.

3.Encouraging advance care planning and providing patients with effective and scientifically grounded goals of care recommendations.⁶

The unpredictability of COVID-19 has prompted our Emergency Room providers to confront ethical challenges related to individual care and system resources. Discussions with patients and family members about goals of care for unexpected and end-of-life care is increasingly common. While this type of conversation was typically reserved for acutely unwell and medically-complex patients, the conversation is becoming normalized across all acuity and health levels and age groups, with additional training opportunities for providers to facilitate these discussions, standardized protocols and dedicated teams for quality-focused end-of-life care, and a renewed commitment to shared decision making and patient empowerment by providing recommendations based on best-available scientific evidence.

COVID-19 has accelerated much-needed positive transformation in healthcare by dismantling traditional entrenched and siloed practices in favour of collaborative, interprofessional environments that support practitioners at all stages of their training and careers with the goal of improving healthcare delivery. To foster and sustain healthcare innovation post-crisis, an ongoing commitment by senior organizational leaders to create greater urgency by encouraging small experiments, setting stimulating goals (short term, high priority, and challenging), and engaging throughout the change process, is essential.⁷ By embracing a quality improvement mindset, we will continue to innovate and reimagine healthcare in a post-COVID-19 world. Our patients are rooting for us.