How do we make organizational decisions, amid pandemics and other crises, when constant change and uncertainty obliterate the status quo? These trying times call for an "Agile" mindset.
Decades ago, software engineers introduced Agile to develop software in short cycles interspersed with feedback from customer testing. Agile supplanted the "waterfall" approach, which like its namesake was a top-down, unidirectional process. Waterfall entails long periods of planning and assumes "father knows best," leaving little opportunity to rework a product when the assumptions prove faulty. In times of uncertainty and constant change, waterfall is no match for Agile's pace, flexibility and emphasis on experimentation.
The Agile approach can be adapted in healthcare operations. Several principles of this mindset have emerged.
Making progress in sprints
Agile healthcare organizations form front-line semi-autonomous teams with the necessary tools and decisionmaking authority to rapidly assess situations and innovate, experiment and fail quickly. These teams quickly prepare a working approach that is "good enough" for immediate testing. Testing is done in the local environment in sprints, or bursts of design, testing and redesign. The process repeats as needed in rapid cycles.
Sensors and feedback loops
Learning from sprints requires having people inside and outside the healthcare delivery organization to operate as "sensors." Such sensors would ideally capture reliable signals of unambiguous outcomes (e.g., documented infections and deaths in a pandemic), as well as noisier but influential information channels such as gossip, rumors and hallway conversations. Agile healthcare organizations act on sensor data through timely, nonjudgmental and actionable feedback.
Safe team culture
The adoption of this mindset is only possible in a psychologically safe climate, where leadership has truly empowered the semi-autonomous teams and trusts these front-line experts to do their job without interference. Psychological safety permits teammates to give and receive frank feedback and direction, appreciate "good enough" rather than perfect solutions, and learn from rather than cover up failures. Moreover, the teams need protected time and space with each other to collaborate and exchange information.
Agile success with COVID-19
At Eskenazi Health in Indianapolis, a team of critical-care physicians, nurses and scientists with Agile mindsets recognized early on that many COVID-19 patients would require intensive care, leading to strains on personnel and resources. Luckily, the team was supported by leadership who trusted their judgment, empowered them and provided logistic support. To achieve speed and agility, the team instituted daily "huddles" and allowed local teams to perform repeated iterations to fail fast and learn lessons to be reapplied on a daily or even hourly basis. The Agile team understood that a full solution was unlikely to be discovered at the outset under so much uncertainty and change, so instead small teams made local decisions and incorporated continuous feedback to save time and promote small successes to build upon. Using this approach, within less than two weeks the team doubled Eskenazi Health's capacity to care for intensive-care patients from 48 to 96 beds.
Waterfall failure with COVID-19
Unfortunately, organizations under stress often resort to more comfortable habits of linear, top-down waterfall decisions and processes. This is evident in the top-down mandates that delayed and hindered COVID-19 testing in the U.S. As CNN reported, "over January and February, agencies within HHS not only failed to make early use of the hundreds of labs across the U.S., they enforced regulatory roadblocks that prevented nongovernment labs from assisting." Other bureaucratic hurdles included requiring the Centers for Disease Control and Prevention to obtain Food and Drug Administration approval before distributing tests to public labs. These and other failures, including shortages of essential equipment, demonstrate how the waterfall approach stifles creativity and slows progress during times of crisis, sacrificing local adaptation for centralized control.
Achieving Agile healthcare
To overcome habits, traditions and shortcomings rooted in the traditional waterfall approach, change agents must be identified and nourished by their organizations, as they were at Eskenazi Health. They must be mentored and coached by the organization to organize and experiment locally, not used as a go-between for top-down decisions. The best agents are those who embrace nonfatal failure as a learning opportunity, model psychological safety in difficult and uncertain times, and empower others. With mentoring and coaching they become master storytellers with high emotional and social intelligence who know how to network, nudge, frame and otherwise engineer their settings to promote buy-in. Once buy-in is secured and this new mindset is established, success will follow, in crisis and beyond.
