Health worker well-being and resilience: A Red Ball issue for the COVID-19 response

In the US Air Force, a “red ball” is a maintenance issue that comes up before aircraft launch or during flight. If the issue is not resolved quickly and properly, the mission could suffer as the aircraft might crash or not be able to fly. ¹ The term may date back further to the early 1900s, to a system used to indicate priority handling on the Santa Fe Railroad. Fast trains with priority over other trains on the track displayed a placard marked with a red disc and were referred to as “red ball” trains. ²

The term has not generally been used in medicine, except when it is used in the context of emergency management. At Johns Hopkins Medicine, which established a COVID-19 Unified Incident Command Center (UCC) in March 2020, top priorities were referred to as red ball issues.

The incident command structure was intended to control all of the critical functions needed to deliver care during the coronavirus pandemic. It enabled staff from every corner of the organization to work together rapidly, effectively and efficiently, short cutting the prevailing red tape and siloed decision-making processes. Leaders from operations, finance, planning, logistics, communications, infection control, supply chain, human resources, and others were coordinated to move forward rapidly and decisively.

A large conference room and auditorium were taken over to provide a physical location for the Command Center, which was to remain open 24 hours a day for the next 80 days. The room was staffed by appropriately masked and physically-distanced representatives from each of the mission-critical functional areas, who manned their posts for up to 15 hours a day. Three times a day, system wide calls were held that pulled in leaders from the respective areas at all of the affiliated inpatient and ambulatory clinical entities. At times, there were several hundred participants on the line.

It is a credit to the institution that from the very beginning of the pandemic, the UCC commanders and top leaders of the health system were concerned about the well-being of the staff, including both care providers and non-professional workers. The existing programs designed to support hospital workers also began to meet early in March. For the first time in the history of the institution, leaders from the Office of Well-being, Employee Assistance Program, Department of Spiritual Care and Chaplaincy, Psychiatry, and RISE peer support program began to meet regularly. These services were dubbed Mental, Emotional, and Spiritual Help, or MESH. These meetings rapidly coalesced into a daily meeting to develop and coordinate a continuum of helping services, ranging from health promotion to psychiatric care. Command center leaders invited representatives from the MESH group to attend UCC briefings, present relevant information, and provide advice. Top leaders including the Medical School Dean and Health System President routinely mentioned MESH services and encouraged their use.

Thereafter, patient safety and staff well-being were featured prominently at UCC briefings. At the main briefing of the day, Patient Safety gave the first report, which summarized COVID-19 related incidents submitted to the institution’s electronic event reporting system. The safety officer of the day flagged problems that called for rapid resolution, such as breaches in infection prevention measures. ³

The safety officer also reported on the number of calls to the RISE (Resilience in Stressful Events) peer support program, and the number of staff supported by the respondents who deliver psychological first aid.^4,5 One of co-directors of RISE was generally present and on a weekly basis summarized the principal concerns and themes from support encounters. For example, early in the pandemic, staff were afraid of exposure, and worried most about rapid changes in policy and appropriate use of personal protective equipment. It is not surprising that staff working in the UCC itself were stressed, in particular in Infection Control, which had begun working around the clock weeks earlier. Later, other issues become more prominent, like burnout, distress about visitor restrictions, and worries about potential furloughs.

At the close of the daily briefing, lead commanders summarized the Red Ball issues for the next 24-hour period. As might be expected, maintaining adequate supplies of personal protective equipment was often mentioned, as was increasing COVID testing capacity. But maintaining staff well-being and resilience was the number one red ball issue nearly every day. Leadership astutely recognized that workers were the institution’s most important asset. Distress can be disabling. If health care workers were not supported, it could lead to absenteeism and turnover at a time when those workers were in high demand and short supply. It could also lead to reduced performance, compassion fatigue and an increase in medical errors. All of these could pose a threat to institutional resilience and the COVID response. Those leaders were happy to listen to and provide resources to ensure a net of support for workers.

An encouraging sign during the many weeks was that when human resources gave their report, there was never an increase in the number of call outs among both staff members and providers. There were never any staffing shortages. The tantalizing suggestion was that the focus on health worker wellbeing and resilience was paying off.

In this issue of the Journal, Sir Liam Donaldson, patient safety envoy for WHO, and Neelam Dhingra, WHO coordinator for patient safety and risk management, underlined that the theme for World Patient Safety Day 2020 is Health Worker Safety: A Priority for Patient Safety. ⁶ They paid tribute to the courage of compassion of health workers in every country, and the obligation to ensure their physical safety and mental health.

In her graphic account, Milesky provided a forensic description of the burden of caring for patients during the pandemic. ⁶ She documented personal experience with unacceptable variations between different hospitals in responding to the pandemic. Robust hospital systems mobilized quickly to provide a safe work environment, adequate staffing and emotional support for frontline staff. In weaker systems, there was inadequate protection, unsustainable expectations, misplaced focus, and little support.

Morris and colleagues described the tragic inequity in deaths among Black, Asian and ethnic minority health care workers in the UK. They proposed several strategies that could improve workplace safety. ⁸

In summary, in disasters and other crises, lack of attention to the well-being and resilience of health workers could make the wings fall off of health care. Red ball issues critical to maintaining operations are not restricted to infection control measures and supply chain. To support the resilience of the enterprise and its ability to deliver high quality care, the well-being and personal resilience of workers must stay in sharp focus.