Physician leadership can take many forms. As noted in a recent issue of PLJ, physicians are increasingly assuming top positions in healthcare and need additional skills to succeed and thrive. Many of these required skills exist outside of what is traditionally taught in medical school.(1)
One leadership paradigm, the use of high-reliability organization (HRO) principles, is increasingly applied in several areas of medicine.(2-5) The leadership of Navy Medicine found applying the principles and practices of an HRO to be of particular value in responding to the challenges of the current viral crisis.
Explicated by Karl Weick and Kathleen Sutcliffe in their organizational study Managing the Unexpected, an HRO functions well in a complex environment with a significantly lower rate of mishap and error than expected.(6) Critical to the understanding of an HRO is that it is not error-free, but that errors do not disable it. An HRO demonstrates resilience and improvement by moving past errors and learning from both previous failures and suboptimal performance.
Using examples of HROs in the areas of naval aviation and the nuclear power industry, the authors identified several significant characteristics defining these organizations and divided these characteristics into principles of anticipation and containment. Table 1 provides the tenets of high-reliability organizations as well as a brief description of the tenets. Together, these five principles lead members of an HRO to a greater level of mindfulness.
As the following case study demonstrates, the effort to instill HRO principles in Navy Medicine that began in 2014 paid dividends as the organization sought to defend the fleet against the virulence of the SARS-CoV-2 virus. Employing high-reliability practices has been critical to our ability to navigate this global health emergency and keep the fleet underway and out forward defending our country while also contributing to the body of knowledge regarding this relentless adversary.
USS Theodore Roosevelt Outbreak
In the early days of the COVID-19 pandemic, little was known about the virulence and transmissibility of SARS-CoV-2. It was a coronavirus, but as a new strain, it had different characteristics from other coronaviruses, and the lack of transparency in the early response from the People’s Republic of China led to a tendency to discount its severity.
As it began to spread beyond the borders of China, cruise ships proved to be a platform especially susceptible to transmission of the virus. While a cruise ship is much different from a warship, there are enough similarities that it warranted investigation and monitoring. As an organization that is always on the lookout for disease threats that can affect the health of our sailors and Marines, Navy Medicine sent three teams of preventive medicine physicians and technicians from Naval Medicine Research Units to the Navy’s three largest ships in the western Pacific to conduct population surveillance testing using a research-use-only CDC SARS-CoV-2 assay.
The effort proved prescient aboard the aircraft carrier USS Theodore Roosevelt when on March 22, 2020, a sailor tested positive for a SARS-CoV-2. Though the individual was quarantined and subsequently flown off the ship, shipboard medical personnel identified additional infected crew members in quick succession, and the ship was ordered to Guam.
While many positive actions were taken in response to the outbreak and a great many medical personnel worked tirelessly to ensure the well-being of the crew and return the ship to sea, the ship did not leave Guam to continue on its mission until June 4, a little more than two months after the first case; nearly a quarter of the ship’s personnel had contracted COVID-19.
Navy Medicine focused on containing the outbreak and caring for the crew in Guam as well as all sailors and Marines at the broader strategic level. Immediate, onsite containment included a commitment to resilience by bringing in additional medical personnel both in person and through telemedicine. The additional personnel support ensured the crew could be safely screened, treated, and returned to health.
Deference to expertise was also demonstrated by bringing in public health professionals with the Navy and Marine Corps Public Health Center to work with the crew and the various Navy entities to determine which cleaning solutions worked best aboard the ship, how to reconfigure duty sections to reduce cross-contamination, and establish ways to reduce other disease vectors that could lead to reinfection of the crew based on available information at the time.
Additionally, an outbreak investigation was conducted in coordination with the Centers for Disease Control and Prevention (CDC) to better understand transmission and characteristics of the disease.(7) This study, published in the CDC Morbidity and Mortality Weekly Report, was one of the first scientific studies to identify the role that asymptomatic and pre-symptomatic cases played in disease transmission as well as the loss of taste and smell as additional symptoms not previously described.
While these efforts to contain the outbreak were productive, one sailor unfortunately died from COVID-19. The ship was able to return to sea after almost two months in Guam. Most importantly, this event was appreciated as a sentinel event that required the development of protocols and procedures for the entire Navy fleet, approximately one-third of which is underway at sea at any given time.
Preoccupation with Failure and Its Causes
The lessons learned from the Roosevelt were distributed through knowledge-sharing networks created before the pandemic to ensure rapid bi-directional communication up, down, and across the Navy Medicine enterprise. These networks include the Chief Medical Officer Network made up of the senior medical officers of every command, both operational and shore-based, and the Public Health Emergency Officer (PHEO) Network, which includes all Navy Medicine PHEOs at bases around the world.
Figure 1. Broad Overview of Communication Channels for COVID Information Distribution; a)The Chief Medical Officer (CMO) works out of Navy Medicine HQ (BUMED); b)Embedded Medical Personnel work for the commanders and support those medical personnel below them in the chain of command.
The most up-to-date understanding of the virus, its protean manifestations, stealthy behavior, and the means of containing it were communicated via these networks in virtual conferences, phone calls, and emails to every ship underway, in addition to all other naval units ashore and pierside. Using multiple methods of communication ensured at least one communications channel would successfully pass the information along to all units.
On all submarines and many of the Navy’s smaller ships, the only medical provider aboard is a highly trained senior hospital corpsman. These independent duty corpsmen function as the primary medical advisors to the captain of the ship and are responsible for the well-being of the crew. Though they operate independently, they are still connected to Navy Medicine through the Navy Medicine Chief Medical Officer (CMO), fleet surgeons, and tele-medicine when internet connectivity is available.
On the USS Kidd, a Navy destroyer with approximately 300 personnel operating off the coast of Central America, Chief Hospital Corpsman Clint Barton was the primary medical provider for the crew with two junior corpsman assistants. Updated lessons learned from the Roosevelt outbreak reached the ship through the CMO network. These directed Navy Medicine personnel to be more sensitive to their daily operations (i.e., clinical cases) by looking more closely at influenza-like illnesses in patients in order to identify any patterns that might indicate COVID-19 among the daily minor illnesses reported by crew members.
Barton recognized that one sailor had presented with some symptoms that were not at the time associated with COVID-19 but had continued to show signs of illness that aligned with this new information. The ship was able to send the sailor ashore by helicopter for COVID testing and follow-on care. Results came back quickly that the sailor was indeed COVID-19 positive.
Barton took action using the updated guidance from headquarters, but as a small ship operating at sea, Kidd’s personnel had many close contacts, and creating physical distance between crew members, given the tight confines of the ship, was not a viable option. Barton called for additional support to bolster the ship’s resilience.
Navy Medicine was able to deploy an ad-hoc, seven-person team of doctors, corpsmen, and one of the few available Abbott diagnostic machines to the ship. With support from the operational side of the Navy, the team was assembled and flown out to the ship off the coast of Costa Rica within 12 hours of the request for assistance. The combined team tested the entire crew, separated the infected from those not carrying an active infection, and cared for other ill crew members.
As the second ship to have an outbreak, it was ordered to San Diego for additional assistance. By the time the ship arrived in San Diego, four days after the COVID outbreak was identified, the entire crew had been tested at least once and isolated as appropriate.
Once the ship was pierside in San Diego, a round of PCR testing was conducted by personnel from several Navy Medicine teams to confirm the Abbott device test results. Additionally, blood samples were taken from volunteers for antibody testing, as had been done on the USS Theodore Roosevelt. The crew was isolated or quarantined, based on infection and close contact, and returned to sea approximately one month after arriving in San Diego.(8)
The lessons learned from the Roosevelt had been quickly distributed across Navy Medicine and allowed Barton to readily identify the relevant perturbations from the baseline health of the crew as an early indication of the outbreak then act quickly to contain it and support resilience among the crew.
Kidd was the second ship sidelined by the virus, and as of October 2021, it was the last. Preoccupation with the failures aboard Roosevelt led to not only rapid identification of the outbreak aboard Kidd, but responses that contained the outbreak and allowed the ship to return to full duty in half the time it took to get Roosevelt back to sea.
Further efforts, using additional characteristics of HROs discussed below, cultivated a level of mindfulness across Navy Medicine that prevented additional outbreaks from sidelining operational ships.
Reluctance to Simplify
Because SARS-CoV-2 was a novel coronavirus, Navy Medicine, operating as an HRO, recognized that with so many unknowns, the virus needed to be examined in all its complexity, and that its behavior, particularly with regard to how and when it could be transmitted, should not be simplified or minimized.
Navy Medicine capitalized on opportunities to examine the virus and its effects whenever possible and push the information out to others. In addition to the MMWR publication on the serology results from the crew of the Roosevelt, a comprehensive analysis was performed on data compiled from the Roosevelt outbreak investigation and published in the New England Journal of Medicine in order to share the key findings.(9)
These two papers were among the first to provide rigorous scientific data on asymptomatic COVID-19 cases as well as identification of the previously unrecognized symptoms of altered sense of taste or smell. This research, an example of the reluctance to simplify the understanding of the illness, offered critical insight into how to prevent transmission among a young, generally healthy population of adults.
Further research was conducted in cooperation with the U.S. Marine Corps Recruiting Depot, Parris Island, regarding the efficacy of non-pharmaceutical interventions to control the transmission of SARS-CoV-2 among a congregate population of young adults.
In the COVID-19 Health Action Response for Marines, or CHARM study,(10) Naval Medical Research Command scientists dove further into the question of the effectiveness of recommended public health practices. The study identified that asymptomatic transmission is still possible in highly controlled environments even when recommended public health practices are observed.
A follow-up study, published in The Lancet(11) showed that although infection with COVID-19 provides some subsequent protection against reinfection, it does not preclude reinfection, and, in fact, roughly one-fifth of young adults in the study were re-infected.
The profound impact these studies had on modifying our force health protection guidelines emphasizes the importance of not oversimplifying explanations when faced with novel situations. Our public health teams made no assumptions about the behavior of the virus and performed an objective assessment of the data at hand. The health and well-being of the entire fleet benefited directly from their reluctance to simplify.
Sensitivity to Operations
The third anticipatory characteristic of HROs is sensitivity to operations. During Navy Medicine’s response to the COVID-19 pandemic, two types of operations required close attention.
First, Navy Medicine’s primary mission is to ensure the medical readiness of the Fleet and Fleet Marine Force. Force health protection guidance was modified to ensure sailors and Marines could operate safely around the world despite the challenges of the pandemic. Navy Medicine experts and operational leaders worked together to develop Standard Operating Guidance (SOG) for operating the fleet in a COVID environment.
The first SOG was issued in May 2020 and used the most current information available about SARS-CoV-2 and COVID-19 to minimize the risk of infection and prevent shipboard outbreaks. The guidance addressed fundamentals of public health adapted to the realities of operating a warship at sea 24 hours a day, seven days a week for months on end. It also covered pre-deployment screening, testing, and quarantine in an attempt to create COVID-free bubbles aboard ship. Underway surveillance testing and the steps to be taken in the event a crewman became ill with COVID while underway were also codified.(12)
Following HRO principles, this guidance was continually evaluated to ensure that it was based on the best available evidence, that outcomes were as intended, and that the guidance was serving the objectives of the organization. During the year following the initial SOG, the guidance underwent three major and two minor rewrites. Ever sensitive to operations, the guidance will continue to be adjusted as warranted by enhanced understanding of the virus and lessons learned on the deck plates of our ships.
Commitment to Resilience
On multiple occasions, Navy Medicine has found a focus on resilience to be a key success factor in continuing operations and functioning as a high-reliability organization. Navy Medicine and the Navy suffered a setback with the USS Theodore Roosevelt in the early days of the pandemic. The lessons learned from that experience halved the time required to get the second ship that suffered an outbreak back to sea. Since that time, the SOG and continuous efforts by our public health professionals has enabled U.S. Navy sailors to operate safely in a COVID environment.
Navy Medicine has also learned that a commitment to resilience has strengthened our organization. With each encounter with this adversary, the insights gained by Navy scientists, public health experts, and medical teams have made the response more agile, responsive, and ultimately stronger. That strength has made us more powerful, and we’re using that power for the benefit of those that we have the privilege of protecting. High-reliability organizations thrive on the opportunity to grow, adapt, and gain strength in the process.
Deference to Expertise
Throughout the pandemic, Navy Medicine has relied on expertise in many ways, from our public health experts collaborating with the CDC on the Roosevelt outbreak investigation, to deploying teams of ICU personnel to support rural hospitals across the country. Many experts, in many fields, of all ranks and specialties, have stepped up to find solutions and create a path to keep the Navy and Marine Corps healthy.
One specific group that assembled in the early days of the pandemic was the Navy Medicine Scientific Advisory Panel. The Surgeon General of the Navy brought together experts from multiple fields to help sift through the volumes of data being produced, everything from best public health practices to treatments for COVID-19 and eventually evaluation of the vaccines and how best to distribute them across the force.
The Scientific Advisory Panel collected newly released research from online journals, state and federal agencies and news media, and our own laboratories, among other sources, to identify information that might be useful to the Navy and Marine Corps. Short summaries of each piece of information were combined into a weekly report sent to senior Department of the Navy leadership through the CMO and PHEO networks and directly to the fleet and Marine Corps operational channels.
The report brought useful information to the fore and helping address rumors and bad science before misperceptions could take hold. The insights from the panel were used to develop the SOG as well as identify best practices for commanders across the force.
Discussion
Karl Weick has described safety as “a dynamic non-event — what produces the stable outcome is constant change rather than continuous repetition. To achieve this stability, a change in one system parameter must be compensated for by change in other parameters.”(13) In a similar way, public health and force readiness can be seen as a dynamic non-event.
The non-event, in this case fleet wellness during the pandemic, requires dynamic engagement by all parties to support the health of a crew. As we learn more, our plans and policies change and adapt to incorporate the best available information. The efforts of Navy Medicine combined with Navy leadership and operational sailors to support a continuous series of dynamic non-events across the fleet meant that only two ships, both early in the pandemic, have been tied pierside and unavailable for mission assignment for a significant period.
USS Theodore Roosevelt had a second minor outbreak in February 2021, but through the fast action of the medical department and the crew, now attuned to the minor deviations that indicated infection, the outbreak was limited to three individuals. When compared to the 1,271, individuals infected 11 months prior, it was indeed a non-event regarding operations of the ship.
In fact, as of the end of May 2021, there have only been two ships of the hundreds operating around the world, made operationally unavailable due to a COVID-19 outbreak. The efforts of the Navy’s preventive medicine teams, working in concert with operational leadership and the support of sailors at every level over the last 15 months, was indeed a dynamic non-event.
Though this has been a case study of how Navy Medicine uses HRO tenets to provide quality healthcare to the Navy and Marine Corps, the same HRO principles are applicable in healthcare systems across the United States. Table 6 lists several questions physician leaders can use to determine how HRO principles and tenets can contribute to success in the civilian sector as well.
Conclusion and Way Forward
HRO behaviors applied system-wide support the development of a mindful organization, one that is continually working to ensure their dynamic efforts generate the non-event of force health protection. Techniques such as the patient safety program TeamSTEPPS and other team-oriented processes support HRO principles and reinforce organizational mindfulness.
It is important that physician leaders understand the potential of HRO principles and practices to serve as the framework for organizational improvement and sustained high performance. The principles of HROs are as readily applicable to civilian healthcare systems as they are to the Navy’s healthcare system. Organizations that train-to and practice mindfulness through the tenets of HROs create the conditions for sustained superior performance.
Author Disclaimer: The views expressed in this journal article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, nor the U.S. Government.
References
Boothman, RC, Hickson, GB. Time to Rethink Physician Leadership Training? Physician Leadership Journal. 2021; 8(2):41–46.
Sutcliffe K. High Reliability Organizations (HROs). Best Practices in Residential Clinical Anesthesiology. 2011;25:133–144. doi:10.1016/j.bpa.2011.03.001
Van Stralen D, McKay SD, Mercer TA. Flight Decks and Isolettes: High-Reliability Organizing (HRO) as Pragmatic Leadership Principles during Pandemic COVID-19. Neonatology Today. 2020;July:113–121. DOI: 10.51362/neonatology.today/20207157113121
Carroll JS, Rudolph JW. Safety by Design: Design of High Reliability Organizations in Health Care. Qual Saf Health Care. 2006;15(Suppl I):i4–i9. doi: 10.1136/qshc.2005.015867
Stichler J. Exploring the Interface Between Healthcare Design and High-reliability Organization Initiatives. Health Environments Research & Design Journal. 2017:10(4)17–21. https://journals.sagepub.com/doi/10.1177/1937586717707839
Weick K, Sutcliffe K. Managing the Unexpected: Assuring High Performance in an Age of Complexity. San Francisco: Jossey-Bass; 2001.
Payne DC, Smith-Jeffcoat SE, Nowak G, et al. SARS-CoV-2 Infections and Serologic Responses from a Sample of U.S. Navy Service Members – USS Theodore Roosevelt, April 2020. CDC Morbidity and Mortality Weekly Report. 2020:69(23)714–721.
Sobocinski, A. The Saga of USS Kidd: A Look Back at the Historic Deployment of Jacksonville’s Rapid Response Team. Defense Visual Information Distribution Service. www.dvidshub.net/news/394264/saga-uss-kidd-look-back-historic-deployment-jacksonvilles-rapid-response-team .
Kasper MR, Geibe JR, Sears CL, et al. An Outbreak of COVID-19 on an Aircraft Carrier. N Engl J Med 2020; 383:2417–2426. doi: 10.1056/NEJMoa2019375
Letizia AG, Ramos I, Obla A, et al. SARS-CoV-2 Transmission among Marine Recruits during Quarantine. N Engl J Med. 2020; 383:2407–2416 doi: 10.1056/NEJMoa2029717
Letizia A, Ge Y, Vangeti S, et al. SARS-CoV-2 Seropositivity and Subsequent Risk of Healthy Young Adults: A Prospective Cohort Study. Lancet Respir Med. Published Online April 15, 2021, https://doi.org/10.1016/S2213-2600(21)0015
US Navy. US Navy COVID-19 Standardized Operational Guidance. Naval Administrative Message. 262253Z May 20. https://www.mynavyhr.navy.mil/Portals/55/Messages/NAVADMIN/NAV2020/NAV20155.txt
Weick KE. Organizational Culture as a Source of High Reliability. California Management Review. 1987:29(2):112–127. Doi:10.2307/41165243