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July 29, 2021

Fostering Hospital Resilience—Lessons From COVID-19

Author Affiliations
  • 1University of Pittsburgh, Pittsburgh, Pennsylvania
  • 2Department of Critical Care, University of Pittsburgh, Pittsburgh, Pennsylvania
JAMA. 2021;326(8):693-694. doi:10.1001/jama.2021.12484

The COVID-19 pandemic created an unprecedented number of patients who required admission to hospitals and intensive care units (ICUs). According to recently released federal data,1 nearly half of hospitals in the US (2199 of 4587) operated at more than 85% capacity at some point during the height of the pandemic, between August 2020 and April 2021. Many hospitals struggled to maintain standards of care under this strain, with critically ill patients treated outside of ICUs and clinicians unable to keep pace with delivering needed care because of increased patient-to-staff ratios.2 Yet these problems were not universal. Some hospitals reportedly seemed to accommodate the sudden increase in demand, maintained care standards, and delivered high-quality patient care even during times of rapidly surging COVID-19 cases.3

As the pandemic begins to ebb in terms of the numbers of patients who are hospitalized and who require critical care, and yet recognizing the possibility of additional surges, hospitals should examine why some centers were able to sustain effective operations while others struggled. Traditional approaches to understanding hospital pandemic responses focus on the “4S” framework of preparedness: staff, stuff, space, and systems.4 These are the health care professionals needed to deliver care, the medications and other supplies required for treatment, the physical rooms and settings in which patients receive care, and the systems required to integrate these resources.4 A great many hospitals struggled with COVID-19 surges despite plenty of lead time and extensive resources to implement the 4S framework.5 It is now clear that attention to these factors was necessary but not sufficient.

A complementary approach is to understand the pandemic response through the lens of organizational resilience. In the management domain, organizational resilience characterizes firms that rapidly adapt in response to an existential challenge, enabling both an attenuated effect from the challenge and a more rapid recovery. For instance, after the September 11, 2001, terrorist attacks, empirical work revealed that airlines with more efficient business models and more stable finances imposed fewer immediate layoffs and regained revenues more quickly compared with other airlines.6 Although the time scales of the post-9/11 recovery and the COVID-19 pandemic differ, the idea that resilience matters, and that studying variation in past resilience can inform policy that promotes future resilience, is a promising way to examine hospitals’ responses to the pandemic.

What would organizational resilience look like in the context of COVID-19? First, resilient hospitals would respond to a surge in COVID-19 cases in ways that ensure the delivery of high-quality care for patients with the disease. Patients with COVID-19 would be admitted to well-staffed specific units with physicians and other health care personnel who have the skills and experience necessary to provide appropriate, guideline-concordant care. If such units were not available, resilient hospitals would coordinate with regional hospitals and transport services to rapidly and safely transfer these patients to capable centers. Second, resilient hospitals would respond to COVID-19 surges in ways that preserve standards of care for patients without COVID-19, such as those needing cancer care, emergency cardiac care, and trauma surgery. Hospital leaders would acknowledge that although trade-offs exist, mitigating the unintended effects of surge responses by accommodating urgent needs of non–COVID-19 patients is as important as addressing the needs of patients with COVID-19. Third, resilient hospitals would preserve access to care for the entire community of patients they serve, continuing elective surgeries and mitigating the exacerbation of health disparities during the pandemic. These hospitals would anticipate and mitigate ways in which changes to care delivery (such as the rapid move to telemedicine) might differentially affect vulnerable individuals in surrounding communities.7 Fourth, resilient hospitals would do all of this while also protecting the well-being of frontline staff, not just by ensuring adequate personal protective equipment but also through clear communication from leaders that make staff feel valued and connected to the organizational mission.

Several factors might foster resilience at the hospital level. Well-developed, scalable clinical protocols, such as those that guide the management of patients who require mechanical ventilation, could enable evidence-based care under different staffing models or in unfamiliar care locations. Flexible electronic health records could allow hospitals to quickly implement and iterate on new care pathways in the face of novel diseases with evolving best practices. A supportive, interdisciplinary working environment in which all team members feel safe to raise concerns and share new ideas (a concept known as psychological safety) could have several benefits. Psychological safety might simultaneously support the rapid trust and flexibility needed for successful implementation of innovative care models like team nursing while empowering team members to raise concerns about overly exploratory models that could put patients at risk. An overarching theme is that effective and transparent leaders at multiple levels are essential to promote organizational alignment during a rapidly changing clinical and administrative landscape.

Resilience might also be fostered in the interactions among hospitals. For example, regional transfer networks could enable hospitals to notify regional systems that they are overwhelmed and rapidly identify hospitals with available beds to which they could transfer patients. For instance, Arizona implemented a “surge line” during the pandemic to coordinate patient care across more than 100 hospitals and multiple health systems.8 This system also included an option for bedside physicians to obtain specialty telemedicine consultation, enabling high-quality care without transfer in appropriate cases. During the initial surge in New York City, the pandemic catalyzed the rapid deployment and scaling of larger telemedicine programs to project expertise across systems and states.9 Despite the potential in these approaches, there remain limited data on their effectiveness, making empirical research an essential component of efforts to develop evidence-based policy based on hospital resilience.

Hospital resilience, in this context, differs from traditional conceptions of disaster preparedness. In disaster preparedness, hospitals plan for a relatively narrow set of operational challenges, such as flooding, structural damage, communication system failure, and disruption of the power grid. Responses are often algorithmic: if a specific event occurs, there is a specific response. But it is impossible for a hospital to preplan a response for every potential operational challenge, and algorithms do little good when the threats evolve in unpredictable ways. For example, a hospital that was well prepared only for an Ebola virus outbreak would not have been prepared for COVID-19. Preparations for Ebola virus focused on relatively small, high-level containment units for treating patients with a disease transmitted primarily by direct contact,10 whereas COVID-19 presented hospitals with hundreds of critically ill patients with respiratory failure from an airborne pathogen. Likewise, preparedness for COVID-19, such as having a large stockpile of ventilators and N95 masks, is unlikely to translate into an effective response to the next emergent pathogen.

Rather, the hallmark of organizational resilience is the flexibility to pivot as new and unexpected challenges arise, and to absorb unexpected shocks that cannot be avoided even with proper planning. Resilient hospitals have more degrees of freedom, allowing them to consider a range of solutions to each problem and quickly pivot when a preplanned strategy is not working. The hospitals could then rapidly and effectively implement novel solutions instead of simply relying on preplanned solutions that might not fit the current problem. Hospitals can be resilient even if they are unprepared, and can be prepared but not resilient. Unlike preparedness, which is useful only in the event of disasters and pandemics, the factors that lead to resilience are likely to support high-quality care during routine operations.

In this context, hospitals should resist the temptation to simply prepare for the next pandemic only by creating the infrastructure and procedures they lacked during COVID-19. Efforts to stockpile supplies and increase ICU bed capacity will be useful if the next pandemic is similar to COVID-19 but would also be redundant and inefficient, increasing health care costs without improving day-to-day quality.

Instead, hospitals should implement changes that will be of value no matter the challenges they may encounter and that will be useful even during normal times. Among these changes may be more robust supply chains, cultures of excellence and collaboration, and systems for coordinating operations within and across hospitals. At the same time, the health services research enterprise should conduct rigorous studies investigating which organizational elements are most important for fostering hospital resilience. The factors that create resilient hospitals remain poorly understood, and a more nuanced understanding of what it means to be a resilient hospital will provide novel strategies to create resiliency ahead of the next pandemic.

COVID-19 will not be the last large-scale public health threat of the 21st century. In addition to infectious diseases, hospitals and health systems will confront climate-mediated extreme weather events, cyberterrorism disruptions, and other threats in the decades to come. Hospitals can never be truly prepared for these events. But if hospitals understand and build sustainable resilience, they will be ready.

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Article Information

Corresponding Author: Ian J. Barbash, MD, MS, University of Pittsburgh, Montefiore Hospital 628 NW, 3459 Fifth Ave, Pittsburgh, PA 15213 (barbashij@upmc.edu).

Published Online: July 29, 2021. doi:10.1001/jama.2021.12484

Conflict of Interest Disclosures: Dr Barbash reported being employed by the University of Pittsburgh Medical Center (UPMC) Health System. Dr Kahn reported receipt of personal fees from UPMC.

Funding/Support: This work was funded in part by Agency for Healthcare Research and Quality grant K08HS025455 to Dr Barbash.

Role of the Funder/Sponsor: The Agency for Healthcare Research and Quality had no role in the preparation, review, or approval of the manuscript or decision to submit the manuscript for publication.

Additional Contributions: We thank Rachel Sackrowitz, MD, MBA, and Don Yealy, MD, both of the University of Pittsburgh School of Medicine and the UPMC Health System, for their discussion of the concepts involved in this article. They were not compensated for their contributions.

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1 Comment for this article
Excellent paper with lesson for all healthcare
Wayne Maksylewich, MSc., MEng | Retired Engineer

The authors have provided an excellent discussion of the need for resilience in healthcare and not only for COVID-19.

Leveson, Holnagel, and others have written extensively on resilient systems (1-3).


1. Nancy Leveson. Engineering a Safer and More Secure World (MIT free download)

2. Erik Hollnagel, Jeffrey Braithwaite - Resilient Health Care (2019) CRC Press

3. Blanchet et al. Governance and Capacity to Manage Resilience of Health Systems: Towards a New Conceptual Framework. Int J Health Policy Manag. 2017 Aug; 6(8): 431–435.