Abstract
Due to the unique challenges of the COVID-19 pandemic and the rapid spread infection, healthcare providers caring for these patients are experiencing high levels of anxiety and stress. This can be overwhelming, resulting in mental anguish and loss of productivity during a period when the demand for healthcare is high. Medical facilities need to adopt and quickly enact evidence-based practices that are designed to keep their workforce resilient. Successful implementation of a new practice during a pandemic is challenging. This paper describes how the Medical Association of Georgia is adapting and using “Diffusion of Innovation Science” techniques to formulate their guidelines and help Georgia’s medical facilities implement evidence-based practices during the pandemic.
Overview
The U.S. is experiencing its first pandemic in over 100 years. Due to the unique challenges of the COVID-19 pandemic and the rapid spread of infection, the U.S medical community must adapt and implement quickly evidence-based best practices that are designed to improve patient care as well as the medical community’s well-being and resilience. However, widespread adoption of evidence-based practice guidelines from national medical societies can take years. 1 New evidence-based COVID-19 practices must be implemented in weeks. The Medical Association of Georgia (MAG) is attempting to assist Georgia’s hospitals and medical facilities to help their healthcare workforce (HCWF) be resilient during the COVID-19 pandemic. This paper describes how MAG and the MAG Physician Resilience Task Force (TF) is adapting “Diffusion of Innovation Science” techniques to formulate their guidelines and help Georgia’s medical facilities implement evidence-based practices during the current pandemic.
Symptoms of burnout, described as exhaustion, emotional detachment, and feeling of ineffectiveness were prevalent among U.S. physicians and other healthcare providers prior to the pandemic. 2 Surveys show that almost half of U.S. physicians and other healthcare providers had symptoms of burnout.3,4 The American Medical Association (AMA) believes that the additional stressors placed by the COVID-19 pandemic will increase the incidence of burnout on the HCWF and decrease their resilience. 5 These stressors may include an upsurge in healthcare demands, ongoing risk of infection, equipment challenges, and the need for emotional support. 6
Some experts believe that up to 80% of HCWF burnout is related to healthcare systems operations and the culture of the organization. 7 Therefore, MAG TF focused their recommendations on implementing evidence-based systems for hospitals and medical facilities during the COVID-19 pandemic. These recommendations do not address the direct provision of resources for individual cases, such as counseling or financial assistance.
Gerald Hickson, at Vanderbilt, is an expert on the “culture of resiliency.” He is advising 90 hospitals on how to keep their HCWF resilient during the pandemic. He told a TF member that to change a hospital and medical facility’s culture typically takes three to five years. He advised MAG to recommend only practices that are easy to implement when attempting to improve HCWF resilience.(Hickson, GB. personal communication 21 April 2020) The TF incorporated his advices when designing their recommendations. These recommendations include frequent data collection of HCWR during the pandemic, establishment of a 5-member multidisciplinary committee to assess the data and make decisions based on the data, a mechanism to communicate the committee’s decisions to senior leadership and HCWF, and HCWF feedback of the committee’s decisions to assess the need for revisions. 8
One senior hospital leader cautioned a TF member that given the increased burden placed on hospital leaders during the pandemic, implementing new, unfamiliar practices that no one had experience using will be difficult. Leadership are already facing new stressors. How does MAG plan to succeed in getting Georgia hospital and medical facilities to implement these new practices in a matter of weeks?
The TF is using the techniques of Diffusion of Innovation Science (DOI) in their ongoing endeavors to help Georgia hospitals and medical facilities implement MAG’s recommended practices. Teams that included MAG members have experience using DOI techniques to implement new evidence-based practices. These teams were successful in their pursuit to advance an evidence-based healthcare policy, known as Communication-and-Resolution Program (CRP). CRP can be difficult to implement by the hospital and can require significant effort by hospital personnel and financial resources. 9 The teams succeeded receiving the endorsements for CRP by the AMA and the American Society of Anesthesiologist (ASA) Advisory Group on Physician Health & Well Being.10,11 Both national organizations are now educating their members on the benefits of CRP as opposed to the commonly used medical liability practice known as “deny and defend”.
The author has a working paper with coauthors detailing the DOI methods used by CRP teams, including the MAG members, in their successful endeavor to pass state CRP laws to make it easier for hospitals and providers to implement CRP, to receive the endorsement of CRP by national medical societies, and to achieve the adoption of CRP at the local hospital level.. 12 MAG is using the insights to produce guidelines for Georgia’s medical communities and help them implement the new practice.
This paper describes what MAG has done and plans to do for each stage of DOI in their efforts to advance evidence-based practices that can improve the wellbeing and resilience of Georgia’s medical community during the COVID-19 pandemic.
Diffusion of innovation
DOI is a change model that describes the process by which a group decides to adopt an innovation instead of continuing an existing practice. For decades, social scientists have investigated how an innovation becomes widespread practice. Everett Rogers wrote a landmark text,
Knowledge stage
In the
The TF had limited knowledge regarding evidence-based systems that create a “culture of resiliency” that can be implemented by medical facilities. MAG believed the TF recommendations should be distributed to all leaders of Georgia medical facilities as soon as possible. Gerald Hickson recommends implementing the system prior to the peak, in the pre-distress stage if possible. Early implementation of the practice would have the most positive impact for HCWF.
Action of MAG teams
One of MAG’s TF members was on a research team investigating the effect of culture on healthcare provider burnout. Several national experts in this field had advised her on the design of their research study. She reached out to these leaders, seeking information on evidence-based system policies that have been demonstrated to be effective to help the mental and physical wellbeing of the medical community and improve their resilience during a pandemic. From this information, the TF and MAG leaders compiled a concise, simple to read summary of evidence-based practices that they believed would be the easiest to implement and have the most positive impact for hospitals and facilities. Their Fact Sheet was published on 22 May 2020. 8
Persuasion stage
In the
Good research on an innovation can be an important first step for acceptance of the innovation by some individuals, especially those who are among the first to decide to adopt an innovation. But the persuasion stage relies more on trusted peer leaders to transmit knowledge to their stakeholder group. Individuals want to understand how the innovation will impact their specific situation. They trust their peer leaders, more than experts in the field, to explain how the innovation will affect them. Mass media regarding general benefits has little effect on their decision.13
Actions by MAG teams
TF members have begun discussion with medical facility leaders to educate their members about the potential benefits of the new policies. MAG teams are working to promote the identification of an opinion leader of each medical facility who will not only support the recommended practices, but also champion the rapid implementation/integration at their facility. Designated MAG members, who know the peer leaders of their medical facilities, specialty societies, and local medical societies will assist by contacting a respected leader within that facility. When a peer leader is identified, a TF member will educate the “champion” about the COVID-19 practice recommendations and give them the TF Fact Sheet to distribute to their medical community.
Decision stage
In the
Support by senior hospital and healthcare facility leadership is a sine qua non for the new COVID-19 practices to be implemented at their facility.
Actions by MAG teams
MAG teams are seeking to obtain the endorsement of the new practices by senior medical leadership. While some of the stressors are common to all HCWF, other factors are unique to the individual provider’s role and situation. That presents a formidable obstacle to implementing the new practices. The needs and concerns of a nurse with school-age children working in the ER setting are different than those of an older physician working in the ICU. The system should be designed with the goal to not only meet the goals of the medical community at large, but also the individual needs of the provider given that provider’s specific situation.
The rapid assembly of a multidisciplinary COVID-19 committee should include leaders from different fields within the medical facility. For example, the committee should consider including a hospital-based physician, an outpatient clinic-based physician, a nurse, hospital administrator, and public health official. Frequent data collection will be the main tool to support ongoing analysis for decision making and updating practice recommendations and internal policies. The COVID-19 committee will relay the information from analysis of the metrics and the committee’s decisions based on the data to HCWF and senior leadership. Continual communication between the COVID-19 committee, HCWF, and senior facility leadership will help the organization adapt quickly to changes that frontline workforce and the facilities will experience during each phase of the pandemic. Transparency between senior leadership and the frontline workers is the basis of trust between the two groups. Trust of leadership is a key factor to keep group members resilient.
Implementation stage
In the early phase of the
Action by MAG teams
Continued data collection from the HCWF and analysis to evaluate the outcome of the new practice and the need to revise or cancel it are key to integrating a new practice that improves the well-being of the medical facility frontline staff. TF members will be available to answer questions that arise when hospitals/facilities begin to implement MAG’s recommended new practices.
Confirmation stage
In the
Proposed action by research teams
Discussion is underway to design research studies to investigate the impact of COVID-19 policies on HCWF resilience. It is hoped that this research will help the medical community to appreciate best practices that could be utilized for any future pandemic or future crisis.
Conclusion
The author recommends that groups that wish to implement new evidence-based practices for improving the resilience of the healthcare workforce during a pandemic seek out opinion leaders at each medical facility impacted by the pandemic. They should identify peer leaders who support the new evidence-based policies and agree to champion the implementation of the policies at their hospital or healthcare facility. Simple and brief summary handouts given to the “champion” have proven an effective means for them to educate their colleagues. (Gruber J. personal communication. 22 April 2020. Garrett B. personal communication. 22 April 2020) Additionally, the state’s hospital, medical practice, and physician associations should develop a mechanism to work with the TF to address any questions raised by their members as they attempt to implement the recommended evidence-based best practices. State medical organizations, like MAG in Georgia, can facilitate successful implementation during the COVID-19 pandemic of their medical community even when there is limited time and resources to institute a new practice. It remains to be seen the extent to which processes developed and instituted by MAG, as described here, will succeed.
Footnotes
Patient/ethical consent
This is a policy-focused observational manuscript that did not involve human subject research.
Acknowledgements
The author wishes to thank Gerald B Hickson, MD, Thomas A Mroz, PhD, John S Antalis, MD, Keisha R Callins, MD, and the Medical Association of Georgia for their help with this paper. The description of diffusion on innovation is borrowed heavily from the working paper of LeCraw FL, Stearns, SC, and McCoy MJ: How teams advanced a new medical program at local, state, and national levels.
Declaration of conflicting interests
The author(s) declare no potential conflicts of interest with respect to the research, authorship, and/or publication.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
