Broken but Stronger

Original version in the April 5th edition of Modern Healthcare with accompanying podcast available here.

“The world breaks everyone, and afterward many are strong at the broken places.”

You’ve seen Hemingway’s famous words before, perhaps in a dramatic Instagram post about resilience.

I’m here to tell you that Instagram lied.

The famous quote is pulled from A Farewell to Arms. The rest of the passage is, to say the least, a bit darker. It reads “But those that will not break it kills. It kills the very good and the very gentle and the very brave impartially. If you are none of these you can be sure it will kill you too but there will be no special hurry.”

For me, Hemingway’s words (the full version) capture COVID’s greatest leadership lesson.

With patients afraid of our hospitals and clinics, guidelines changing on a daily basis, and no guarantee that we had what we needed to protect our community or ourselves, health systems faced a choice. We could dismantle our own structural pillars, redesign and rebuild them, and survive. Or we could refuse to change and watch the pillars collapse before our eyes.

That choice was like jumping off a cliff without knowing for sure that your parachute would deploy. At WakeMed we swallowed our fear and jumped. But first, we had to trust our people to break down and rebuild core aspects of how we function, interact and lead in ways that have made us remarkably stronger.

WakeMed has always been grounded in service to our community. Since opening our doors as the first integrated community hospital in North Carolina, WakeMed has attracted exceptional service-oriented people. This “Wake Way” is our primary differentiator. In a region blessed with multiple world-class health systems, it helps us recruit and retain people by offering opportunities to blend passion, purpose and progress. Delivering on that opportunity has yielded a complex and matrixed structure, with myriad cascading goals and organizational charts with solid and dotted lines crisscrossing like the lattice on a pie. Our formative principle—to serve the people of Wake County and the surrounding region—permeates all we do with the firm foundation of core purpose.

Like most health systems, the fight against COVID threatened WakeMed’s very survival. We stood up our Command Center in January 2020 and were operating 24/7 by early March. By its nature, running the health system from our Command Center required focusing on the few “must-win” objectives needed to sustain our core purpose. At the peak of our battle, these objectives boiled down to urgent, vital goals like “We will keep serving as wide a spectrum of community need as we safely can for as long as we can” and “We will maintain a CDC-defined ‘low-risk’ encounter for as many people, in as many situations, as long as possible.”

We frequently didn’t know exactly how to deliver on each objective. Turns out that didn’t matter. What mattered is that we said them aloud and took actions that repeatedly showed we meant them. We had record numbers of staffers reading company-wide emails, checking dashboards, and tuning in to each virtual update. Still, we had to communicate each change multiple times in multiple ways given the sheer speed, volume and seismic nature of pandemic change. We let team members ask questions until the questions ran out. Sometimes this lasted minutes, sometimes an hour, because no matter how many ways we thought we had communicated an action and its reasoning, someone was always internalizing the message for the first time.

Some of those actions required huge leaps of faith. We wrote multimillion-dollar checks for backup PPE we weren’t sure we would receive or adequately protect us. We launched a partnership to support independent practice vaccination efforts knowing it was the right thing to do but without knowing exactly how to make it successful.

We sustained significant short-term financial harm to preserve our long-term culture, knowing full well that if “short term” lasted long enough we might not have a “long term” to preserve.

Making those words play out into actions proved our commitment and encouraged individual teammates to do the same, making thousands of independent decisions and taking thousands of independent actions that together enabled us to deliver on each and every objective.

The people we entrusted to accomplish each “must-win” were nurses, doctors, pharmacists, operators, engineers, emergency managers and data scientists. All were asked to go far beyond their role descriptions to create, join and lead entirely new multidisciplinary teams focused on achieving discrete, time-bound outcomes. They made decisions that in normal times would have required months of debate and the most senior levels of leadership approval.

One night in January just after North Carolina expanded vaccine eligibility, I asked my team to build a drive-through vaccination clinic from scratch. They had less than 96 hours. They began work on a Wednesday night with no playbook, no place, no product and no patients. By Sunday morning, hundreds of people safely drove through a vaccine clinic staffed entirely by volunteers. The next Sunday—with double the volunteers and triple the product—they served nearly 1,200.

The same was true for our performance engineers when they learned that KN-95 masks could filter appropriately but couldn’t seal to most people’s faces. They started experimenting at home on nights and weekends with customizable 3D-printed braces that could seal a KN-95 to anyone’s unique facial structure. We said, “go forth,” bought them the plastic and commercial-grade 3D printer to experiment at scale. They ultimately produced a model that helps nearly anyone pass a seal test and costs less than a quarter to produce.

Can a team transform an observation unit into a skilled-nursing facility in a week? Sure. Can another turn on thousands of telemedicine visits in a matter of days? Why not?

How? Teams were multidisciplinary, inspired by our core purpose, and committed to achieving a discrete, must-win objective. Each was free to bring in resources from across WakeMed and the community, breaking down any silo needed to fulfill their objective. When faced with problems, they repeatedly asked “why?” and then repeatedly asked “why not?”

WakeMed has many stories like these, proving how a complex, highly regulated, matrixed enterprise can cut through its own complexity and rapidly achieve the outcomes needed to sustain survival. We now know that this strength has always been there. It’s been latent in our people, just waiting to be called into action.

In doing so we’ve seen person after person grow, flexing and expanding their talents while engaging with corners of the organization they’d previously barely known existed. These same people will continue growing post-pandemic, moving into new roles with new responsibilities. As they do, the battle-tested bonds of trust they’ve built with each other will only strengthen our ability to thrive through whatever challenges we face next.

Let this fact be the pandemic’s greatest gift. When faced with the gravest of crises, we trusted our people. We trusted them to break our structure down and build it back better, to make us stronger and faster, to help us serve more people in more innovative ways and drive better health for entire populations.

We can do this again and again, but only if we have the audacity to accept that sometimes—even when we are not facing a mortal threat—we must be willing to trust each other and break ourselves, and afterward become stronger at the broken places.

Dr. Chris DeRienzo is a physician leader from Raleigh, North Carolina and author of the book Tiny Medicine. He’s on Twitter at @ChrisDeRienzoMD

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