Emergency

Leading through a disaster

October 18, 2013: 1:04 PM ET

How one hospital's response during the Boston Marathon bombings yielded important lessons for management under pressure.

By Eric Goralnick and Ron M. Walls

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FORTUNE -- Six months ago, on April 15, two improvised explosive devices went off within seconds of each other, just steps away from the finish line of the Boston Marathon, killing three people almost instantly. Remarkably, of the 264 injured people that reached the hospital alive, not a single one died.

The emergency preparedness community has already been cultivating the lessons learned from that tragic event. Business leaders, too, can gain insight from the experiences of the health care professionals who worked tirelessly in the wake of the bombing. Even more valuable lessons can come from those who acted long before the crisis took place.

Streamline your organization

A hospital isn't so different from a corporate workplace: Incidents occur quickly and unexpectedly. Responses need to be immediate and decisive. How rapidly can your organization respond? Who has the authority to make decisions? Who makes these decisions and who is accountable for them in the aftermath? Is your organization's chain of command clear? Does every key player have a defined and manageable role?

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Today's health care organizations rival large businesses in complexity. They include inpatient and outpatient components that may comprise multiple hospitals, clinics, and health centers. The "stakeholders" are physicians, nurses, administrators, support personnel, contractors, vendors, patients, and families. These complex organizations have matrix-style management control structures that often include separate silos for physicians, nursing, and administrators.

In September 1970, wildfires sparked by Santa Ana Winds spread across 400 square miles of California. Hundreds of firefighting agencies struggled with coordination and communication across various jurisdictions as they fought the fires with their own protocols and organizational structures.

In the aftermath, seven California firefighting agencies developed the Incident Command System (ICS), which allows first responders to establish a temporary leadership structure at the scene that consolidates and clarifies lines of command and seamlessly incorporates responders from multiple agencies or jurisdictions. Over the next 30 years, ICS was refined and implemented by most fire agencies and medical first responder agencies across the country. In 1991, The Orange County Emergency Medical Services and Hospital worked together to develop a hospital adaptation of ICS ultimately named HICS (Hospital Incident Command System). HICS establishes a clear chain of command, common nomenclature, clear reporting and clarity of roles, and the ability to quickly expand or contract a response based on the nature of the incident. HICS is not an ad hoc activity. It's the result of a determined commitment to plan, prepare, and train. On Patriot's Day, the day of the Boston Marathon bombing, every hospital in Boston utilized HICS, just as they had drilled during prior real-life events and exercises. And it worked.

Disaster response is a team sport

The successful medical response in Boston was predicated on well-developed relationships across disciplines: major hospital trauma centers, emergency medical services, fire services, local and state law enforcement, public health providers, the Boston Athletic Association, and local and state government, to name just a few.

At the hospital we work for, Brigham & Women's, designated teams of physicians, nurses, and medical assistants stood side by side, at the ready, supported by clerical, diagnostic, and transport personnel to respond to the crisis. Internal-medicine physicians and nurses helped clear emergency departments of patients to create space for incoming survivors. In our emergency department, surgeons, orthopedists, anesthesiologists, emergency physicians, and nursing leaders collaborated to ensure patients were sent to operating rooms without delay. It's what Amy Edmonson, a leadership professor at Harvard Business School, refers to as "teaming."

Wear a bright yellow vest

The initial scene on Boylston Street was chaos. But Patriots Day in Boston is an occasion on which the city plans and prepares for disaster; thus everyone has a predetermined role and wears visible identification. Prior to the start of the race, color-coded vests were issued to physicians, nurses, and others slated to volunteer at the event. Emergency medical services, police, and firefighters wore their regular uniforms, and some of them also donned the vests. When the explosions went off, responders and bystanders used the vests to identify responding leaders.

At your company, who would wear the (figurative) leadership vest during emergencies? Ordinary command and control is slow, and management by committee is not appropriate during crises. As part of HICS, leaders wear specific vests so they can be easily identified. Establish the same prep for your business: Whether it's a physical accident, PR gaffe, shareholder fiasco, or anything else, to whom do people report? Who is in charge? How does your team identify that leader?

One is none and two is one

Over 500,000 spectators attend New England's largest sporting event every year, and Boston is more than ready for it. Various organizations coordinate exercises in advance, including the nearby trauma centers and three children's hospitals, all within a 2.5-mile radius of the finish line.

But other disasters don't occur in such an environment. For recent examples, look no further than the West Fertilizer Plant facility explosion on April 17 in West Texas, the tornado in Moore, Okla. on May 20 or the Asiana Airlines flight crash at San Francisco International Airport on July 6.

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Hospitals train for these events -- rigorously and frequently. You must plan for Murphy's Law, the idea that what can go wrong will. Your disaster may strike when your CEO is out of state, or in the middle of the night, and a middle manager must step up to take charge based on minimal information. Everyone must be replaceable, and collaboration is essential. Alone, one person can do little, but two people acting together are powerful.

Communicate; then communicate again

In hospitals across the city on day one, there was a great deal of uncertainty, and it continued for days. Would there be more explosions? More patients? What was the status of the overall response? Was it working?

During multiple debriefs, communication offered a consistent opportunity for improvement. Clinicians rely on accurate and timely information to optimize patient care, but disasters wreak havoc on our usual process of collecting and transferring information. Do you have predetermined communication plans for such a scenario? And is there a backup plan, and a backup for that backup?

Manage your teams and information carefully, and you will gain control over your crisis.

Eric Goralnick is medical director of emergency preparedness and associate clinical director of the Department of Emergency Medicine at Brigham & Women's Hospital. Ron M. Walls is chair of the Department of Emergency Medicine at Brigham & Women's Hospital. Both are on the faculty at Harvard Medical School.

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