Why change? Lessons in leadership from the COVID-19 pandemic.

The coronavirus disease (COVID-19) pandemic has placed the European healthcare systems under a stress of incomparable magnitude. Within the span of a few weeks, the demand for beds in intensive care and infectious disease wards increased by a factor of 5. Staffing was an even greater challenge than usual because many healthcare professionals became infected with the severe acute respiratory syndrome coronavirus 2 themselves. In Sweden, the Public Health Authority recommended not to close the community—primary schools, shops and cities have largely been kept open, and regulations have primarily been aimed at protecting the elderly. Although the everyday life of our citizens has been only moderately affected, the healthcare system has been under great pressure, similar to that occurring in other European countries. The number of deaths in Sweden due to COVID-19 exceeded 4200 as of May 28: it is evident that the measures taken to protect the elderly have been insufficient. In Sweden, the highest incidence occurred in the Stockholm area, and the Karolinska University Hospital has been the largest national centre for COVID-19 care, taking care of over 3000 patients with COVID-19 so far. How has this affected the care of patients with cardiovascular diseases?

In the middle of March, the admission of patients with COVID-19 to the Karolinska University Hospital increased rapidly, and at the same time, our admissions for acute coronary syndromes decreased (Fig. 1A). A similar decrease was seen in the number of cardiac surgical procedures (Fig. 1B)—mainly an effect of postponing elective surgery, whereas the admittance for acute cardiac surgery was unaltered. Interestingly, the waiting list for an operation has not increased, which may be explained by a reduced capacity for preoperative investigations during the COVID-19 pandemic. The decreased incidence of admissions for acute coronary syndromes has been noted in many countries [1], but, during the last month, it has returned to more normal levels at Karolinska (data not shown). Overall, there will most probably be a debt to pay, and we must prepare for an increase in the demand for cardiovascular care in the post-COVID-19 period.

Figure 1:

(A) The number per month of PCI for acute coronary syndromes at Karolinska University Hospital for the years 2019–2020. (B) The number per month of open heart surgery procedures at Karolinska University Hospital for the years 2018–2020. PCI: percutaneous coronary interventions.

Hitting a world largely unprepared, the COVID-19 pandemic has confronted us with many open questions and will be the subject of studies in all fields of science for years to come. An interest in leadership issues [2-4] is already emerging, and the momentum of change may create unexpected opportunities. As US politician Rahm Emanuel has pointed out: ‘You never want a serious crisis to go to waste. … [it is] an opportunity to do things that you think you could not do before’.

In my experience as a cardiac surgeon and leader in healthcare, I have never before witnessed a change like this. Within weeks, more than 200 doctors and nurses at Karolinska were relocated to new departments, new tasks and new teams. Our infectious disease doctors rapidly educated their colleagues on how to take care of COVID-19 patients, and refresher programmes for healthcare professionals were instituted within days. Figure 2 shows the expansion in intensive care bed capacity at Karolinska University Hospital during the pandemic. What made this unique increase possible? What were the mechanisms behind this dramatic change?

Figure 2:

Intensive bed capacity for patients with COVID-19 compared to number of patients at Karolinska University Hospital. COVID-19: coronavirus disease 2019; ECMO: extracorporeal membrane oxygenation; ICU: intensive care unit.

It is often stated that healthcare is progressive and adaptive to new treatments and methods. Although this may be so, the opposite also holds true. If we were able to move Theodor Billroth from 19th century Vienna to 21st century Stockholm, he would be astonished by the scientific developments in diagnostics and radiology; he would note the gender equality among doctors and the funny clothes. But as soon as the ward rounds started, he would feel at home. For anyone trying to change ways of working, healthcare can be very conservative.

Introducing new treatments and methods while securing financial stability is impossible in a non-adaptive healthcare structure. We often spend enormous amounts of time and effort gathering information and facts and surprisingly often neglect the most important factor—the human factor. Failure to make adaptive changes often results from failure to understand human psychology. Defence mechanisms of important stakeholders can easily turn any project change into project failure.

The transformation at Karolinska University Hospital triggered by the COVID-19 pandemic is remarkable and exemplifies the unprecedented response of the healthcare community. Under normal circumstances, the rapid changes in ways of working, the overnight increases in the numbers of beds and the related adaptive changes, would have taken years to accomplish, if ever. What are the secrets behind this transformation? Some general principles emerge:

A common sense of urgency. The ‘why do we need to do this?’ was evident from the very start to everyone in the hospital as well as to those in society. If we want to make a change, the ‘why’ should be precisely answered and the answer should be emotionally grounded—it should be felt by everyone. As was so wisely expressed by Friedrich Nietzsche, ‘He who has a why to live for can bear almost any how’.

The return of professionalism. First you are a doctor, then a cardiac surgeon. Or, as the COVID-19 pandemic has necessitated, first you are a healthcare worker, then a doctor, then a cardiac surgeon. In our tertiary academic hospital, physicians and nurses are highly specialized, but within days our neurology and cardiology staff were acting professionally as specialists in infectious diseases, having full command of patients with COVID-19. Never have the professional call and the old question of why we studied medicine been so relevant and so close to our hearts. The profession has taken the lead, and the administrative structure has been supportive [3].

Competence first. The adaptive change in intensive care unit (ICU) beds was only possible by relocating a significant number of nurses and doctors to intensive care and not allowing the shortage of key personnel to be the end of the debate. We expanded the territory and responsibility of specialized ICU personnel by building teams around them with non-specialized nurses and junior doctors—and got rid of boundaries regarding who does what. The expansion of beds would never have been possible without this change in approach, and this change would in normal circumstances have taken years to accomplish—now it was, by necessity, solved within weeks.

There will be a post-COVID-19 era, but Karolinska University Hospital will never go back to what it was pre-COVID-19. We will find confidence in the fact that fast and dramatic changes were possible when we needed them. If the ‘why’ question is clearly answered and felt by everyone in the organization, there is absolutely no limit to what can be accomplished. This message also carries a negative implication—if the ‘why’ in a transformation project cannot be answered clearly, then we should not be wasting our and everyone else’s time.

Although the dimensions of this dramatic change hopefully will not be repeated for a long time, the message is clear: he who is unable to adapt will stand to lose everything.

Conflict of interest: none declared.