Abstract
Effective administration of healthcare in an emergency setting, especially in field-hospital deployment where order must be established, needs assessed and limited resources allocated effectively, is considerably more complex than the regular patient–doctor interactions characteristic of routine times. Due to the complexity and uncertainty typical of such an environment, leadership is required not only by the field hospital staff but also by the affected public, which seeks leadership in those who are perceived to be the center of clinical service delivery.
This type of leadership demands organized command and control and practice of more than just basic leadership processes, and therefore requires, alongside the mission leader, a structured management and task-orientated chain of command.
For the hospital to operate effectively and independently, it is necessary to also define the organizational structure. The organizational structure discussed in this chapter is a model tested over the past three decades by the IDF Medical Corps hospital in numerous missions. This structure is generally similar to the basic structure of a small- to medium-scale hospital in routine times. At the same time, it allows more focused and simple managing processes required in non-routine scenarios such as emergencies or disasters.
Introduction
Due to the complexity and uncertainty of health care in an emergency-setting environment, effective field-hospital leadership is essential. This type of leadership demands a structured management and task-orientated chain of command. This chapter will describe a comprehensive conceptual model for effective field hospital leadership and the organizational structure and operational system supporting the hospital leadership, and will propose a basic framework for field hospital leadership development.
Command and Control
The lines of command and control in the field hospital include the hospital leadership group (HLG), the hospital operation and organizational structure, and the leadership functions and processes. These are described in more detail below.
The Hospital Leadership Group (HLG)
The HLG is the operational staff of the mission leader. The HLG comprises several professionals and its main role is to enhance the leadership capabilities and functions, and to augment the medical outcome and team performance.
The main objectives of the HLG are to:
guarantee mission accomplishment
integrate the work of the different hospital units
enable maximal security for the staff and patients
analyze the internal and external environment and adjust accordingly
be responsible for the needs of the staff and patients
implement logistic support
execute strategic and tactical planning
allocate resources in a sapient manner
establish local and international collaboration
Figure 8.1 shows a generic structure of the leadership group for a complex mission. However, it is important to remember that this is a basic structure, which can be adjusted to specific types of missions by adding or removing staff members.
Figure 8.1 Example structure of the HLG
Designated Roles and Responsibilities
The following describes the various roles, along with their responsibilities, of each member of the HLG:
Deputy/Chief of Staff
acts as a stand-in and replacement for the hospital leader, in his or her absence
is responsible for the output of the HLG and for synchronizing the various elements within the medical mission’s management
coordinates and synchronizes all elements of the mission, including logistics and auxiliary services
ensures the daily routines are carried out and maintains them
communicates with rescue mission, in the event there is one
sets up the hospital and ensures it is dismantled at the end of the mission
responsible for the process of “lessons learned” and “conclusions reached” during and following a mission, regarding his or her area of responsibility
Chief Medical Officer
reports directly to the hospital leader on all medical issues within the hospital compound
serves as the most senior medical authority and, as such, is the primary authority in the medical decision-making process and in determining treatment policies
ensures the medical personnel have certifications and ensures their professional fitness to accomplish the medical tasks, prior to deployment
coordinates all the activities of the hospital’s ethics committee
organizes knowledge management and on-the-job learning
holds medical staff meetings to discuss medical issues, dilemmas, and treatment policies
records and organizes lessons learned from investigations and meetings
Chief Operations Officer
coordinates patient flow to and from the hospital, as well as the patient evacuation process
ensures operational continuity
manages and organizes the activity of the hospital headquarters
responsible for the security of hospital personnel and equipment
organizes and prioritizes planned and unplanned activities
coordinates the various teams’ activities outside of the hospital
gathers and records all operational data pertaining to the hospital
reports to the hospital leader on all ongoing operational aspects
Chief Informatics Officer
distributes informatics infrastructure and communications equipment
responsible for all medical data collected and accumulated throughout the mission, including data recording and storage
formats medical data for reporting to local authorities and the dispatching organization
manages informatics personnel
responsible for operating and maintaining all equipment pertaining to informatics infrastructure and communications
reports to the hospital leader
Chief of Human Resources
responsible for utilization of personnel
distributes personnel between the various hospital departments, including task shifting as needed
manages personnel shortages and replenishments
manages the logistical care of personnel casualties
looks after the personal needs and welfare of personnel
ensures personnel rest and recreation
reports to the hospital leader on all functions and processes related to the human resource component of the mission
Chief of Logistics
Chief of Public Communications
answers directly to the hospital leader on all issues and tasks pertaining to outreach and communications to the local public population
acts as a spokesperson to, and coordinates communications with, the mass media and social media.
coordinates all activity connected with communications and the local population pertaining to their medical treatment
Chief of Coordination
maximizes capabilities by collaboration
responsible for all contact and coordination with the authorities in the host country
responsible for all contact and coordination with international governmental and nongovernmental organizations (NGOs)
briefs local health authorities, the Emergency Medical Team Coordination Cell (EMTCC), and the health cluster
establishes contact and coordination with adjacent local and international medical teams and search-and-rescue teams
Organizational Structure
Hospital Structure
To allow the hospital to operate effectively and independently, it is necessary to define, alongside the HLG, the organizational structure that enables effective operation of the hospital. The organizational structure illustrated in Figure 8.2 is a model tested over three decades by the Israel Defense Forces (IDF) Medical Corps field hospital in numerous missions. This structure is generally similar to the basic structure of a small- to medium-scale hospital during routine times. At the same time, it allows for the more focused and simple management processes that are required in nonroutine scenarios, such as emergencies or disasters.
Figure 8.2 Organizational structure model
We have chosen to place the mental health-care professionals under auxiliary services due to the basic intention that their main task is to treat the medical team. Having said that, and as mentioned, this is a basic workforce configuration, which can be adjusted and, of course, the mental health-care professionals can be called on to treat those patients or the affected population in need of help and assistance.
Leadership Functions and Processes
The operation of a field hospital requires a wide range of functions and processes. This section focuses on the central functions and processes, which are key for the effective leadership of a field hospital in any scenario, and methods for adapting them for extreme situations.
Setting and Operating with Clear Vision and Organizational Values
This is important for every leader in any situation, and requires modifying the mindset to strategic thinking, consolidating organizational thought, developing a vision, aligning viewpoints, and setting goals. The importance of these skills greatly increases during emergency field-hospital scenarios when uncertainty and time pressure emphasize the need for an almost automatic response.
Hospital leaders are expected to keep mission and organizational values in mind in the decision-making process and stay true to their values, even when it may be tempting to back out[1]. A clear vision based on well-established values guides leaders and individuals to act properly, sometimes against instincts or even under life-threatening situations, as in extreme disasters such as the earthquake in Haiti[2], the 9/11 attack in New York City[3], or the genocide in Rwanda[4,5]. This is essential not only for the leaders but also for medical professionals who should be educated to understand they have a responsibility to contribute to the effective operation of the hospital in which they work and to its direction and objectives.
Clear vision is also the major driving force to move individuals and teams in light of the “drop-in-the-sea” phenomenon. In an environment of a massive number of victims in which there are only limited resources by definition, leaders may face frustration, which may have a negative impact on hospital function. In such cases, the clearer the vision is, the stronger the values are, and the more they are shared, the more it will be understood that numbers are not the only thing that counts, but rather the value of saving lives and the role of bringing hope.
Planning: Strategic and Tactical
Field-hospital emergency missions are usually characterized by a highly demanding environment with multiple constraints mandating continuous environment analysis, effective resource allocation, and rapid operation, especially in the early-response phase. Therefore, planning is crucial as a key factor for preparedness, readiness, rapid response, and, subsequently, effective decision-making[2,6]. This process is composed of planning at both the strategic level and the tactical level.
The strategic level is concerned with defining goals and determining the missions and resources to achieve them, such as the type of hospital to deploy, the potential length of deployment, the type of environment at the deployment area, and resource considerations. It should be continuous, beginning before the mission, through day-to-day operations, to the planning of an exit strategy, and, just as importantly, with a view beyond the scope of the crisis, on the day after and during the recovery phase. The planning process must be adaptable to the rapidly changing environment and integrative, combining all the elements essential for effective decision-making, including political, social, demographic, logistic, and medical aspects.
However, strategic-level planning alone is not enough in times of emergency or crisis. The HLG should also be able to create short-term planning at the tactical level, which includes role rotation of medical personnel, flexibility in team structure, and creative solutions. The HLG should design the outcome-oriented planning process framework by choosing a destination, evaluating alternative routes, and deciding the specific course of the plan[7]. Moreover, due to the unpredictability of the situation, hospital leaders should be able to shift from the strategic level of planning to the tactical level and switch between them according to the changing environment, the needs and the required adjustments[2,8]. For example, during the Haiti mission, after the earthquake in 2010, the IDF field-hospital leadership needed to decide on the optimal type of field hospital to erect in response to this earthquake[2]. The options included a “light” hospital, which would provide primary treatment to many patients, or a more sophisticated hospital with advanced capabilities from a wide variety of specialties, which would limit the number of potentially treatable victims. The IDF leadership’s choice of the latter option was based on prior experience with disasters in general and earthquakes in particular where local hospital infrastructure is often destroyed and many victims who need hospital-level care require evacuation either to facilities lying outside the affected region or to mobile hospitals deployed locally with capabilities to treat such injuries. We understood that expected delegations would mostly be bringing “light” hospitals and clinical facilities, and so we decided to transport a sophisticated field hospital capable of providing advanced care. This decision proved to be appropriate in Haiti, but we soon faced having to cope with changes in the medical requirements of an earthquake zone over time. In the first few days, we had to concentrate our efforts on treating earthquake-related injuries, and so we transformed one orthopedic treatment station into a surgical unit with full anesthetic and monitoring capabilities, thus doubling our surgical capacity. We also shifted medical staff members, especially nurses, from nonsurgical units to general and orthopedic surgery units. A few days later, when patients presented with less urgent medical needs, we again readjusted staff assignments, organization of the units, and the indications for hospitalization. Such intramission adaptability, as we have learned, is possible when there is maximal versatility in staff training and capabilities, and in utilization of equipment and adjustment of organizational structure. Most importantly, it requires a clear understanding of commitment to the goal at the individual level, as well as continuous, adaptive, and integrative planning processes at the leadership level.
Related posts:
Chapter 6 – Training and Accreditation
Chapter 3 – Definitions, Needs, Scenarios, Functional Concept, and Modes of Deployment
Chapter 11 – Auxiliary Medical Services in a Field Hospital
Chapter 7 – Personnel
Chapter 18 – Orthopedics in a Field Hospital
Chapter 25 – Infectious Diseases and Public Health in a Field Hospital
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