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Becker’s Healthcare Podcast
Beyond Checklists: Readiness vs. Reality, Leading MCI Change with Ben Toombs & Nicholas Bell
00:25:33
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- [00:02]
A
This is where healthcare leadership comes together. Becker's 16th annual meeting brings more than 3,500 hospital and health system executives and nearly 800 speakers to Chicago, April 13th through the 16th. This year's event includes keynote conversations with Dallas Cowboys legend Troy Aikman and former President George W. Bush. For the agenda and event details, visit Beckershospitalreview.com and click on the events tab in the upper right, click. We're looking forward to hosting you in Chicago. Hello, everyone, and welcome to a very special Becker's Healthcare podcast. I'm Scott King, thrilled today to be joined by two very special guests. Ben Toombs, the Director of Emergency Programs with UW Health, and Nick Bell, Manager of Safety and Emergency Management with UW Health. And we're going to have a really interesting, unique conversation today. We're going to work with the title Beyond Checklist, Readiness versus Reality Leading MCI change. Going to cover a lot with a mass casualty incidents and how to prevent them and some really great in depth stuff. And Ben and Nick, thank you guys so much for doing this. I appreciate it.
- [01:09]
B
Yeah, thank you, Scott.
- [01:11]
A
Of course. And then, you know, we'll just jump right in here. You know, the first thing I wanted to ask you and Ben, if you don't mind taking this one. What's the biggest misconception leaders have about what MCI readiness really requires today?
- [01:27]
C
Yeah, absolutely. Great question. So with mci, when you're dealing with MCI preparedness, there are a lot of little traps out there that sometimes create pitfalls for MCI readiness and being prepared for it. Some of them can be as simple as saying that you have an MCI plan. The issue with sometimes saying you have an MCI plan can be that you have this false sense of security where you say, well, we've got this binder, we have these policies and we have this annual drill. So therefore we're ready for an mci. But actually, most failures when it comes to an MCI isn't on the clinical side. It's actually looking at the organizational logistics side of how to deal with an mci. The reality of an MCI and how to handle it, it's like an operational muscle. You have to constantly be using it and testing it to really make it stronger and more robust. So with that, you also have to be comfortable with working with what you have and not becoming distracted or again, creating that false narrative of saying, well, okay, if this happens, we're going to do this. Well, are you sure? Have you tested that? Are you aware that's actually what's going to happen. And sometimes we fall into this other trap, which is believing something is going to happen, but actually that isn't. What is the reality when an MCI occurs? So beyond capability and logistics, what you really want to be looking at is having conversations around, well, what is an mci? What is, we're very lucky. We're a level one trauma center for both pediatrics and adults. We're also a pediatric adult burn centre. So that means we can handle a lot of different things coming through our doors. But when you talk about an mci, is it a gunshot penetrating wound? Is it blunt trauma from a vehicle accident? Is it burns from kids throwing petrol on a bonfire? But also when we look at mci, we're talking about an organization that has reached its limit of capability with a mass surge of patients coming in and how it can handle that. And so organizations need to be really honest with themselves about what their logistical challenges are and what their supply chains are and how that is going to interact with their MCI plan. A powerful word we talk about a lot is what does that mean? So when we talk about our MCI planning, we always say, well, what does that mean? And we really dig deep into that conversation, whether it's talking about burn patients that can take multiple days and months to care for or penetrating gunshot wounds and saying, well, what does that mean and how does that look like? Or when we talk about supply chains, well, what does it mean for a supply truck to arrive on a Monday versus a Saturday night during winter? And those are the conversations you really need to be having.
- [04:41]
A
Ben, you have really, really interesting stuff. I just want to ask you a quick follow up. You mentioned dealing with MCIs is, I mean, safe to say, this day and age, there's just a lot more kind of distractions across the board. I'm curious which ones you may want to emphasize there.
- [05:00]
C
Yeah, so for us, we have really robust clinical skills here. And what we're really looking into now is, you know, what does the next day look like, what does tomorrow look like? Because we can handle the MCI when it comes through our door, but if we use all our resources, then, so what does tomorrow like for our next patients? But also, we're looking at, if there is an mci, then how do we handle our stroke patients, our STEMI patients, How do we continue our normal care as well? At the same time, burn patients is a really interesting one because with a penetrating gunshot wound, I'm going to simplify it, they come into the ed, they get stabilized, they go to the or, they go to inpatient that should be, they might go back to the OR for another review or some more surgery. But with a burn patient, what you end up having there is if it's a real deep burn, they're going to be in the OR multiple, multiple times over a number of months for, for skin grafts or debridements or cleaning. And so now what you thought with your MCI plan was, well, okay, we can handle this within a couple of days, is now an MCI plan that could take months with a huge supply chain requirement behind it.
- [06:18]
A
And Nick, what has fundamentally changed about MCI planning in the last five years and what hasn't changed nearly enough or as much as it should?
- [06:28]
B
Yeah, thanks. I think thinking from an industry perspective, I think over time, despite the complexity of the topic, we've increasingly got a better understanding of how to do MCI preparedness well. And I think there's many useful resources out there for healthcare organizations to use to do this well. And I think also kind of hand in hand with that over time we've increasingly seen improved technologies and communication tools that are at our disposal that we can incorporate into our response strategies. And I think another thing that's changed, a positive, positive thing today is that there's been an increased focus on staff mental health and well being and recognizing that these situations can be traumatic and staff need to receive the support that they need as part of our crisis response. But I think another thing to talk about with this sort of like the shifting landscape of hazards with respect to MCI and kind of what keeps us up at, obviously that's shifted over the last 25 years, maybe a little bit less so over the last five years. But I think with the story with MCI preparedness, it's been kind of an increasingly broad scope lens when it comes to those hazards. Right. Like I think 25 years ago after 9 11, the focus was on terrorism and bioterrorism. After Hurricane Katrina, there came a more broad all hazards view of preparedness generally. And obviously we're living in a post Covid world and infectious disease, these surges are probably part of your planning process, if they weren't already. Even though there's maybe not necessarily full overlap with your MCI plans and trainings and exercises with infectious disease surge. But maybe one of the newer things that we think about more today than ever before is cybersecurity and cybersecurity incidents, which you may not think of something that's related to mci, but we think about the possibility of A cyber attack or cybersecurity breach of a public or large infrastructure system that could have some really significant impacts that leads to a patient surge event. So like Ben was talking about previously, you know, MCIs can be caused by many different hazards, right? There's be severe weather or natural disaster, could be civil unrest, a crowd crush, a vehicle accident, hazardous material incident. And the injuries from that can be blunt or penetrating or burn or chemical, radiological. And we really need to be ready for all of those things. I think, having said that though, I think while MCIs can be caused by a lot of different things, the one that, when, you know, you discuss this topic with people today, the one that has them worried, and I think rightfully so, is a large scale active shooter incident like a Las Vegas style mass shooting or an Orlando style mass shooting, school shootings that you see that occur across our country, things like that. And in particular, that sort of potential situation where your resources are truly rapidly overwhelmed in the face of a massive surge of patients like 50, 100 or more. That's the big one that people think about and talk about when we do MCI planning. And at UW Health, obviously we experienced a mass casualty incident in December 2024 when the abundant Life Christian school shooting took place. And of course we're really proud of the care that our patients received during that incident. But at UW Health and I think in emergency management generally, it's all about continuous improvement, right? So how could we do this better? And so that was really a catalyzing incident for us. We took that really seriously. And shortly after the incident, we formed an MCI preparedness steering committee and said, okay, we're going to make sure that we're really prepared. And that process that we've gone through over the past year has involved many different leaders across our organization, both physician leaders and operational leaders. And it involved creating this open, no fault learning environment. And have some. We had some very frank, open and honest conversations. And I think it involved tearing down our assumptions about our readiness. You know, Ben was touching about on this really what would happen if we had an mci? You know, we have assumptions about that, really question them. And we just took our plans, we took our assumptions and we churned it all up. And the outcome of that was a completely revamped MCI surge plan for us, as well as a revamped labor pool and traffic control and family reunification plan.
- [11:00]
A
Yeah, thanks, Nick. You know, I think it's the focus on paying attention to and helping with a team member's mental health Dealing with mcis, I just, I think that's so important. Is there any way you can kind of just dive into a little more maybe some things that UW Health does or is planning to do along those lines?
- [11:21]
B
Yeah, absolutely. So we have an employee assistance program. We have resources that are in place that we can link our employees to to make sure that they get that mental health support that they need. And a big part of that, too, is just, you know, when that sort of thing needs to be activated, that's going to be something that's activated through our hospital incident command system. So it's also about ensuring that the designated leaders at our organization who are going to fill those roles are aware of those resources and to activate them to get those. Get staff, those resources as quickly as possible.
- [12:00]
A
Wonderful. And Ben, how do you balance detailed clinical protocols with execution under, you know, extreme stress in these situations?
- [12:10]
C
Yeah, so, you know, we don't. We don't really purely rely on just protocols when you're under stress. You really rely on training patterns. You know, how many times, I mean, when you really think about it, how many times during the day do you do something out of habit rather than thought? And so when you're in a stressful situation, you tend to go back to that safe, known pattern. And so, you know, the way we're working, that is people revert back to habits, not policies, in some respects. And so what we're doing is where, you know, we've got great clinical staff and we're allowing our clinical staff to be the strong providers and nurses support staff that they are. We're not messing with those relationships unnecessarily, but what we are doing is we're nudging habits down into the right pathway. So when those stressful episodes do happen, those patterns are already ingrained into what needs to be done. Part of that is developing on what we call job action sheets, setting role identification, so that when people have a crisis, an MCI moment, then their normal reaction is to go to focus on clinical. Because that's what we all do as nurses and doctors. We focus on what we know, but what we want to do is nudge the leaders in those groups to say, okay, let the clinical people do the clinical, and you are now going to be doing the operational stuff and the command and control stuff in there. And interesting that we were talking about mental health a second ago, because part of that journey with mental health is allowing people, giving people those roles and saying, this is what you're responsible for, making a unsafe, unknown environment to A safe, unknown environment. And what does that truly mean? It really means that by training people, by having definitive roles set out, by letting people do their jobs well, by giving them the tools and supplies, it allows people to function in that unknown environment in a safe manner. And that really helps providers achieve that high level of care in those environments.
- [14:21]
A
Nick, where does MCI planning most often break down? Is it governance, communication, training or execution?
- [14:29]
B
Yeah, gosh, that's a really difficult question. And like, you know, my initial reaction, I want to say all of the above, but I think if I had to, if I had to pick one or two, I'm inclined to say, you know, governance or communication. I think that's where we've had some issues in the past where we've needed to make some of our biggest improvements at UW Health. I think those things, governance and communication fail before execution can really even begin. So, you know, execution is downstream from those things. So governance. Right. I take that to mean like, who has the authority to make decisions during an incident? Who has the ability to declare that your NCI plan has been activated? Who can make these decisions before, like, you know, if you've got administrators on call before they're notified. So, you know, once your, once your command center is activated, you know, staffed by those leaders, you know, decision making, authority and governance and who's responsible for managing the incident is probably super clear at that point. But there's, there's a more uncertain period prior to that where delegation of authority and clarity of authority is really, really important. In our, our county, Dane county in Wisconsin, define, they define an MCI as in any incident that involves five or more patients. And so we get notified anytime an incident like that takes place. But we don't necessarily want to activate our full surge response plan anytime that happens. It's not necessary, result in alarm, fatigue. See, so you need that decision making process that you initiate when, when you're notified of an MCI happening in the community where somebody looks at the incident, you look at how many patients there are, whether they're adults or pediatrics or mics or there's their triage status, the type of injuries they have. You look at your internal census, your staffing levels and you make a call to say, yes, we are going to activate our response plan. So having that person or group of people that have that authority and know they have that authority and the responsibility and having them feel empowered, like Ben talked about earlier, to do what they feel is necessary is super important for everything else after that to work. And I just that's governance. But I think I'd be remiss if I didn't mention communication. It's so important and so difficult to get right during mcis. I think really mcis can be chaotic situations. Time is full of uncertainty, information's flying around or misinformation is flying around. And, and you know, execution can't happen unless you both make the decision that you're going to activate your plan, but then also get that updated information to the people who need it in your organization in a timely manner. And, you know, I think there's, there's. With that, there's a couple of different things that we've grappled with. One's about like how to get that critical information in the hands of people who need it quickly. You know, because MTIs are incidents that progress, they evolve, they change over time really rapidly sometimes. So when you first huddle and make a decision one way, you think there's a certain number of patients coming at one minute, a minute later, it could be completely different. So you need to build mechanisms in your communications plan to quickly send timely updates out to everyone. And you need to build flexibility in your response plans to ensure you can, you can quickly escalate the level of response up or down when you need to. And then I think just lastly, at the same time, there needs to be a balance struck between over communication and under communication. You know, similar to what I said before, you don't necessarily want or need to notify everyone every time an MCI occurs in the community or in your region. So one of the things we've developed was an escalating communication flow that had a number of concentric circles. You know, the number of people informed would grow as the situation escalated. So, you know, the first it's our ed care team, team leader, then it's the huddle group, and it's all those who have a role in the plan, and then it's all staff, and you do that when you need to.
- [18:47]
A
And also for you, Nick, how should systems integrate MCI planning across hospitals, ems, public health, and regional partners?
- [18:56]
B
Yeah, that's a good question. I think. So maybe thinking about this first and foremost internally, like within a system of hospitals, that to me, it's somewhat depends. For us at UW Health, we have University Hospital in downtown Madison. American Family Children's Hospital is a children's hospital attached to University Hospital. And then on the east side of Madison, there's East Madison Hospital. And because of their proximity to each other and because of how we operate as a System of hospitals in Madison. When we activate our MCI surgery plan, we activate at all three of our hospitals. It's not a building by building thing though. You know, our response within each building may look a bit different depending on the incident. But then also as an organization, we, you know, we have several hospitals in northern Illinois, quite a distance away, and we might align on how we do things as much as possible with northern Illinois. You know, we might use the same terminology between regions and use the same definitions, but I think our plans just out of necessity are they're going to have to be different, there's going to have to be differences and it's not going to be exactly the same playbook. There's just different capabilities, different realities across the state lines. And then externally, I'd say, you know, if you have a local, ideally multi agency, multi organizational emergency preparedness committee or council that you can participate in and collaborate with those other entities at the local or municipal or county level, you know, that's fantastic. You should be involved in that. I think, of course, you know, there's your regional healthcare readiness coalition as well. And I think both of those are potentially really critical venues through, through which you can, you know, conduct that collaboration and coordination and integrated planning can take place with those entities. And then, you know, part of that collaboration, what that might look like, there could be just sharing of information. Everyone understands, you know, what everyone else is doing. You develop that common operating picture, you share assumptions, maybe share some language. One thing I want to share that I think, I want to really highlight something I think we, we do well in Dane county is the concept of base hospital or area or regional medical coordination centers. The way it works, you know, for us at least I'm sure there's, there's, it works differently where this is implemented elsewhere. But when an MCI occurs in our community responding ems, they communicate with the base hospital emergency department. For us, that's a university hospital emergency department and they request activation of base hospital. And then base hospital, what they do, they send out an alert to all the area hospitals requesting information on capacity. What's your capability of taking triaged red patients or yellow patients or green patients? How many can you take? And then base hospital, they receive that information, they relay it back to EMS in the field, and then they can make informed decisions on where best to distribute patients. And I think that like pre hospital collaboration with area hospitals and EMS is really, really critical for us to make it less likely that any one hospital in the area is surge during that MCI incident or if, you know, if that's not possible because of the size of the incident, it can really help to flatten the curve of incoming patients at each facility. And ultimately that helps us reduce the impact in our hospitals and improves the likelihood that we avoid unnecessary loss of life during emergency.
- [22:27]
A
So thanks so much, Nick and Ben. If you can, please help us close out, close out our conversation here. How do you keep MCI preparedness from becoming a check the box exercise? You know, like something a system has to do. How do you keep it top of mind?
- [22:41]
C
Yeah, don't put it on the shelf. It's really easy for it to become a checkbox exercise and to say, yes, we've got an MCI plan, thank you very much, put it away till we need it. Or maybe that annual review, you know, a thought exercise we sometimes play with each other and we talk about. Within our steering committee is the, as I said, was the. What does that mean? So everyone listening, I want you to kind of think about, okay, so you have an MCI and you say to yourself, okay, we need some more bed sheets. Well, in our plan, our policy says, supply chain will bring more bed sheets. Well, what does that mean? Because what if your supply chain is two people and one of them is currently getting blood products and the other one is trying to find IV kits for other people? So who is getting the bed sheets? And bedsheets are a really small, low level thing that we're talking about. But those can be, those are the kind of things that layer up every other time. When you think of it just as a checkbox exercise, you really need to go into minutiae and really look at every single aspect and say, okay, so I, our policy says this, well, who's actually going to be doing that role and do we have someone doing that and where's it overlapping? And so one of the joys of the process is, you know, I come from a nursing background. Nick comes from an operational emergency management background. But our steering committee has providers and nurses and emergency management group and operational leaders. And we all have that safe environment to poke holes at everything, question everything. And you know, we say to ourselves, if we're making everybody feel uncomfortable during a drill, we're doing it right. Because that uncomfortable feeling is you questioning and you taking part of that continuous improvement culture and asking, what does that mean? Which is part of creating a robust MCI drill roadmap. You know, it really comes down to looking at logistics and operations and then self validating. And again, Nick and I always say that if the answer at the end of a drill or the answer at the end of anything is it went really well. We always want to hear a. But we want to it really well. It went well, but we could have done this, this, this, and this. Because there's always something that could be learned from anything, and that's something that we want everyone to walk away with is ask yourselves, what does that mean?
- [25:06]
A
Yeah, I think it's a great point. You do want to hear a button there for something important, because then, you know, there's something you, you have to work on to make it go seamlessly. Ben, Nick, thank you both so much for just a great conversation on MCI readiness, and it was wonderful to hear how UW Health is leading a much needed change with nci. So thank you both so much.
- [25:27]
B
Thank you very much.