COVID-19 management at one of the largest hospitals in Germany: Concept,evaluation and adaptation

After action review workshop series

The LMU University Hospital’s disaster management team conducted an After Action Review (AAR). The AAR was implemented following the working group AAR format developed by the WHO. ¹² The workshop participants corresponded to the different pillars of the pandemic management at LMU University Hospital during the first pandemic wave. The list of participants was based on the role of the represented departments as the main points of interaction between all stakeholders, which placed the essential focus of the workshops on intra- and inter-organizational interdependence.

The individual workshops were conducted as plenary discussions with the following main topics

(1) Management structure and decision-making processes – identification of elements in need of optimization, challenges, and good practices arising from the originally adopted management structure (Figure 1);

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Figure 1

. [Originally adopted pandemic management structure of LMU University Hospital during the first pandemic wave of COVID-19 in Munich, Germany (approx. 03.-07.2020)].

The workshop series, as well as the processing of the outcomes, were further informed by the relevant guidelines of the Federal Office of Civil Protection and Disaster Assistance and the European Centre for Disease Prevention and Control.^7,6

Employee survey

The LMU University Hospital disaster management team conducted an anonymous and voluntary survey to determine the satisfaction of employees with the adopted COVID-19 measures (Appendix 1). The questionnaire’s design was tailored specifically to the concerns and needs raised by the executive board and aimed at informing the further development of the pandemic management at the university hospital. During the designing process, no analogous employee surveys were identified, hence a reference could not be applied. The questionnaire underwent several rounds of revision by the team as well as pretesting by representatives of the Institute of the Emergency Medicine and Management in Medicine and the Department of communication, who were not directly involved in the topic.

The questionnaire was divided into five chapters: information and awareness (10 questions), LMU University Hospital measures (4 questions), professional environment (4 questions), personal environment (5 questions), and general and demographic data (8 questions).

The questionnaire was created using LimeSurvey (Version 4.3.3 + 200,707). All employees received an e-mail invitation to participate in the survey and received regular reminders through the intranet page and the COVID-19 newsletter. For employees without access to a workplace computer, a printed version was created using the program Zensus direkt (Blubbsoft GmbH). The ethics committee of the medical faculty of the University of Munich approved the study (Project-No 20-614 KB).

The online version was available to all employees from 16.07.2020 until 06.08.2020. The printed questionnaires were delivered to the respective departments on 23.07.2020. The completed and sealed questionnaires were collected on 04.09.2020. The analysis was carried out with IBM SPSS Statistics Version 26 software package. We tested the interaction between participants’ characteristic and their satisfaction with the adopted measures using Spearman-Rho and Phi coefficients. A subgroup analyses was conducted using the Mann-Whitney-U-Test as well as the Jonckheere Trend-Test depending on the data format.

After action review

Three face-to-face workshops were conducted between 10.07.2020 and 09.09.2020. The number of participants varied between nine and 12 people at each workshop. All participants received a detailed results report. Since the documentation was designated for internal use only, we provide a brief summary of the key outcomes in the following section. Two main aspects requiring optimization emerged from the discussions.

The first workshop (10.07.2020) was focused on compiling an overview of the participants’ impressions of the management structure and decision-making processes during the first wave. The participation was purposefully limited to the disaster management team and one representative each of the executive board, of the department of project management and of the department of organizational development as to strategically inform the topical organization of the further workshops (N = 7). The main problematic area identified within the workshop was the need for a more precise definition of the tasks, the teams, and the individuals responsible for those. Participants identified this as a cause of inadequate communication between departments and the stakeholders within and between the executive and operational levels of the COVID-19 response. Participants acknowledged that the suboptimal delegation of responsibility originated from uncertainties regarding the virological, medical, and epidemiological properties of SARS-CoV-2. The problem was reflected in the lack of description of the scope of duties expected to be covered by the working groups in the first wave.

The second workshop (03.08.2020) targeted a more implementation-oriented aspect of improving the communication between stakeholders by streamlining the documentation management. Participants included representatives the department of communication, human resources, project management and organizational development (N = 7). The participants underscored the need for a project management platform that categorizes, regularly updates, and communicates all documents related to the hospital’s pandemic response management. A special need was identified in updating or removing outdated regulations that have changed due to improved knowledge or to changes in legal measures by the public health policy-makers and institutions. Another advantage of having a platform over the method of individually uploading individual documents to the designated intranet site used at the time was seen in the consistent availability and convenience of communication to staff. In addition, participants suggested that for the platform to act as the point of access for all administrative documentation of executive meetings, including agendas, protocols, and presentations.

The third and final workshop focused on compiling and discussing the thus far collected input into a strategically laid-out management structure for the new Pandemic Board. Participants included all previously involved stakeholders (N = 11). The workshop served as a final feedback round prior to the first meeting of the Pandemic Board on 10.09.2020. All outcomes are presented in Adaptation of pandemic management structure section.

Employee survey results

Out of 11 070 employees of the LMU University Hospital, 3139 participated in the online survey, and 2182 questionnaires were completed. Only completed questionnaires were analyzed (Table 2). The majority of questions were designed with a 5-point Likert scale with options ranging between “strongly disagree” at item one and “strongly agree” at item 5.

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Table 2.

Demographic and occupational data of surveyed employees.

	N	%	Coefficient*	p-value
Age
<20 years	9	0.40	0.100**	.001
20-30 years	385	17.60	—	—
30-40 years	519	23.80	—	—
40-50 years	462	21.20	—	—
50-60 years	586	26.90	—	—
>60 years	169	7.70	—	—
No answer	52	2.30	—	—
Occupation
Nonmedical staff	1062	48.70	0.100***	.000
Medical staff	1120	51.30	—	—
Regular home office
Yes	415	19.00	0.119***	.000
No	864	39.60	—	—
Home office not possible	807	37.00	—	—
No answer	96	4.40	—	—
Work with COVID-19 patients
Yes	197	9.00	0.106***	.001
Mean number of weeks = 8.20 (SD = 5.60)
No	1985	91.00	—	—
Rotation to a different unit
Yes	131	6.00	0.064***	.073
No	1967	90.10	—	—
No answer	84	3.80	—	—
All	2182	—	—	—

Overall, the participants felt well informed by the hospital management during the first wave (8 items; α = 0.875). Access to the relevant information on the intranet (mean = 4.19; SD = 1.02) and in the IT portal (mean = 4.03; SD = 1.04) was perceived positively. The information provided by the LMU University Hospital on the current situation (mean = 4.03; SD = 1.03) and the measures taken (mean = 4.01; SD = 1.04) on various platforms was generally rated as good: newsletter “News from the Executive Board Task Force” (mean = 4.38; SD = 0.84), information on the intranet (mean = 4.00; SD = 1.02), and on the IT portal (mean = 3.92; SD = 1.02), information from superiors (mean = 3.52; SD = 1.34). In terms of additionally desired communication channels, posters (mean = 2.06; SD = 1.15), flyers (mean = 2.00; SD = 1.13) and videos (mean = 2.08; SD = 1.12) were not required (4 items; α = 0.699). The development of an employee app was perceived as a good idea by the majority of participants (mean = 3.60; SD = 1.45).

Subgroup analyses

Based on the effects presented by the variables in Table 2, we executed subgroup analyses for the satisfaction with the measures adopted by the hospital (Table 3).

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Table 3.

Subgroup analyses for the satisfaction of employees with the general information provision of the LMU University Hospital.

Satisfaction with the measures adopted by the LMU university hospital	Median	Mean ± St.Dev	τb	p
Regular home office*			−0.087	.000
Yes (n = 415)	4.00	4.15 ± 0.958	—	—
No (n = 864)	4.00	4.02 ± 1070	—	—
Home office not possible (n = 807)	4.00	3.83 ± 1176	—	—
Age**			0.081	.000
<20 years (n = 9)	5.00	4.33 ± 0.866	—	—
20–30 years (n = 385)	4.00	3.85 ± 1146	—	—
30–40 years (n = 519)	4.00	3.98 ± 1082	—	—
40–50 years (n = 462)	4.00	3.96 ± 1141	—	—
50–60 years (n = 586)	4.00	4.14 ± 1023	—	—
>60 years (n = 169)	4.00	4.08 ± 1069	—	—
Satisfaction with the measures adopted by the LMU university hospital			r	p
Work with COVID-19 patients***			0.069	.001
Yes (n = 197)	4.00	3.70 ± 1276	—	—
No (n = 1985)	4.00	4.02 ± 1072	—	—
Occupation***			0.098	.000
Nonmedical staff (n = 1062)	4.00	4.11 ± 1043	—	—
Medical staff (n = 1120)	4.00	3.89 ± 1134	—	—

*Kruskal-Wallis p-value = 0.000; the post-hoc test was executed using Jonckheere Trend-Test at p = 0.000; the correlation effect was calculated with Kendall-Tau-b. **The option “No answer” was excluded from this analysis, as it does not provide any insights into the correlation. Kruskal-Wallis p-value = 0.001. ***The analysis was executed with a Mann-Whitney-U-Test as the variable is binary.

On the scale of 1 to 5 where “strongly disagree” is placed at item one and “strongly agree” at item 5.

There were significant yet very weak differences based on the ability to work from home during the pandemic with those who do not or are not able to do so evaluating the adopted measures as less sufficient than those who do work from home (τb = −0.087; p = 0.000). The opposite effect was observed with age, where the older the participants were the better they perceived the measures adopted by the hospital (τb = 0.081; p = 0.000). The effects of working with COVID-19 patients and of the occupational area of participants were similarly very weak (r = 0.069, p = 0.001; respectively r = 0.098, p = 0.000).

Adaptation of pandemic management structure

All first wave measures were de-escalated, re-escalated, and qualitatively adjusted depending on the current pandemic and the hospital activity in Munich and Bavaria. Changes to the applied measures were communicated via the newsletter as well as the designated intranet page “Update Coronavirus”. A detailed report with the results of the employee survey and management recommendations derived from it were made available to all employees.

A number of specific aspects of pandemic management at the LMU University Hospital requiring optimization were derived from the results of the workshop series as well as of the employee survey. The adjustments adopted prior to the second pandemic wave in Munich, between September 2020 and February 2021, are described below.

Management structure

In preparation for an expected second wave in the fall of 2020, adjustments in the management structures were adopted (Figure 2). A new management level, represented by the Pandemic Board, was implemented in order to address the main topics of concern highlighted through the workshops. The Pandemic Board was primarily tasked with improving the communication between stakeholders as well as towards employees by

• Coordinating the information flow between the executive and operational levels;

• Handling pandemic related inquiries from internal and external stakeholders including questions from employees;

• Conducting regular meetings with executive and operational level representatives during periods of lower pandemic activity (during less acute phases of incidence rates when Executive Board Task Force meetings are not necessarily required on a regular basis).

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Figure 2

. [Pandemic management structure of LMU University Hospital during the second pandemic wave of COVID-19 in Munich, Germany (approx. 09.2020-02.2021)].

Additionally, the thematic focus of the working groups was laid out in detail to better reflect the interdisciplinary nature of the teams needed to effectively manage the intra-hospital response. In order to ensure the effective delegation and tracing of tasks, the Pandemic Board compiled a profile for each working group reflecting the spectrum of responsibilities that the group is expected to manage. (Appendix 2)The adjustment also resulted in a reduction in the number of working groups, facilitating communication among all stakeholders. Furthermore, the Pandemic Board compiled a Pandemic Response Plan incorporating an exhaustive task assignment covering the complete organizational structure of the hospital (including individual departments outside of the Boards’s jurisdiction).

The Task Force Corona operating during the first wave was dissolved in its role as an expert committee. The experts involved were accordingly included in the adapted structure of the working groups and were regularly invited as expert advisors to the meetings of the Executive Board Task Force.

The adaptations of the management structure were further informed by the Nationales Netzwerk Universitätsmedizin (NUM; National Network University Medicine). NUM was established in March 2020 with the aim of facilitating a coordinated COVID-19 response among all German university hospitals. ¹³

Limitations

Beyond February 2021, LMU University Hospital’s overall pandemic management and individual measures continue to be a subject of regular evaluation. The evaluation process of the LMU University Hospital response and management after the first COVID-19 wave in Munich remains limited due to several factors. While the AAR implemented working group format allowed for open and honest discussion of optimization needs, planning and executing this format presented a great organizational challenge especially under the circumstances limiting in-person meetings. Consequently, the disaster management team was required to organize the review during a response that was still technically underway even though it was in a relatively moderate phase compared to period of incidence peak in April of 2020. ¹⁰ The suboptimal timing could have potentially led to misperceptions of the relevance, key findings, or functionality of various elements of the management structure. It is essential to note that the questionnaire contents were mainly driven by the necessity for internal evaluation commissioned by the executive board, hence there are no direct references to the presented outcomes. Furthermore, the employee survey reached approx. 1/3 of LMU University Hospital employees, which limits the internal and external generalizability of the results. Nevertheless, the outcomes of the evaluation process provide a general overview of the main topics, concerns, and challenges of establishing and coordinating a COVID-19 response in a large hospital.

The decision-making processes were and still are dependent on the latest knowledge of SARS-CoV-2 as well as on the incidence rates and their development within and beyond administrative and geographical borders. Nevertheless, it is evident that the internal hospital pandemic management and continuous optimization efforts adopted by LMU University Hospital are consistent with nationally recommended best practice models and leadership strategies for COVID-19 management as well as with the existing evidence on constructing a people-centered approach in the healthcare workforce governance.^18,19

Beyond February 2021, LMU University Hospital aims to further improve its internal COVID-19 management by increasing efforts in the regular evaluation of adopted measures. Highlighting employee appreciation and enhancing employee wellbeing through improving the workplace atmosphere outline the frame of the hospital’s priorities for 2021.

Implications for research and practice

The presented analysis differs in purpose and execution from previously published and standardized methods of analysis of employee satisfaction as it addresses a bottoms-up need for assessment of an acute situation rather than of the general working context and satisfaction. Nonetheless, it provides insight into how to approach several of the aspects previously identified as particularly influential on employee satisfaction: managerial structures and participation in decision-making processes. ²⁰ Despite the narrow scope of the evaluation, the results correspond to previously identified challenges to hospital management especially in the realm of value streaming processes. ²¹

Our analysis highlights the requirements for implementing a structured, agile and people-centered pandemic management in a hospital setting. The implementation process calls for responsive decision-making generating an exhaustive spectrum of measures that take into account the personal challenges of stakeholders, especially employees, beyond the realm of the workplace. The results provide empirical evidence for the evaluation of internal organizational dimensions in maturity models in a hospital context (structure, management, decision-making, people management). ²² Furthermore, the specific constraints of the topical scope and timeline of the this paper add insights into the evaluation of medical care provision in times of crisis beyond the implementation of field hospitals and within the framework of an already existent and functioning healthcare organization and system.^23,24

The broad range of involved entities in this context requires the adoption of a continuous, self-critical, and flexible evaluation process. As the COVID-19 pandemic meets the definition of a wicked problem, investigative and systematic approaches towards its solving have been increasingly diverging from the design of classical emergency management systems.^25,26 Instead, pandemic management approaches and interventions observed since March 2020 in diverse contexts worldwide are rather informed by the concepts of co-production and inclusion.^27–29 The short and long-term consequences of co-production initiatives in healthcare systems and stakeholders remain to be explored beyond COVID-19.

The successful implementation of preventative measures in a hospital setting assumes open and honest communication between all stakeholders. This inevitably highlights any intra- and inter-organizational interdependences within the healthcare facility as well as within the area of regional healthcare services. The process calls for the full disclosure of uncertainties and of the characteristics and issues of the decision-making processes leading to the adoption of measures. While there is a large body of theoretical and empirical evidence on inter-organizational collaboration in a hospital context, thus supporting the planning and execution of efforts, more research is needed on hospital intra-organizational partnerships and networks. ³⁰ Our analysis serves as an exploratory case study of intra-organizational collaboration, yet further systematically obtained evidence is required.