Guidance for Health Care Leaders During the Recovery Stage of the COVID-19 Pandemic: A Consensus Statement | Global Health | JAMA Network Open | JAMA Network
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Figure.  Health Leadership Imperatives During the Recovery Stage of a Crisis
Health Leadership Imperatives During the Recovery Stage of a Crisis
Table.  Leadership Imperatives During the Recovery Stage of a Crisis, Required Capabilities, and Reflection Questions
Leadership Imperatives During the Recovery Stage of a Crisis, Required Capabilities, and Reflection Questions
1.
Editors.  Dying in a leadership vacuum.   N Engl J Med. 2020;383(15):1479-1480. doi:10.1056/NEJMe2029812PubMedGoogle ScholarCrossref
2.
Tedros  AG, Bainimarama  JV, Chan-o-cha  P,  et al.  COVID-19 shows why united action is needed for more robust international health architecture.  World Health Organization. Published online March 30, 2021. Accessed March 30, 2021. https://www.who.int/news-room/commentaries/detail/op-ed---covid-19-shows-why-united-action-is-needed-for-more-robust-international-health-architecture
3.
Peeri  NC, Shrestha  N, Rahman  MS,  et al.  The SARS, MERS and novel coronavirus (COVID-19) epidemics, the newest and biggest global health threats: what lessons have we learned?   Int J Epidemiol. 2020;49(3):717-726. doi:10.1093/ije/dyaa033PubMedGoogle ScholarCrossref
4.
PLOS Medicine Editors.  Pandemic responses: planning to neutralize SARS-CoV-2 and prepare for future outbreaks.   PLoS Med. 2020;17(4):e1003123. doi:10.1371/journal.pmed.1003123PubMedGoogle Scholar
5.
AlKnawy  B.  Leadership in times of crisis.   BMJ Leader. 2019;3(1):1-5. doi:10.1136/leader-2018-000100Google ScholarCrossref
6.
Sachs  JD, Karim  SA, Aknin  L,  et al; Lancet COVID-19 Commissioners, Task Force Chairs, and Commission Secretariat.  Lancet COVID-19 commission statement on the occasion of the 75th session of the UN General Assembly.   Lancet. 2020;396(10257):1102-1124. doi:10.1016/S0140-6736(20)31927-9PubMedGoogle ScholarCrossref
7.
Shukman  D.  Coronavirus: world reaches dangerous new phase.  BBC News. Published June 29, 2020. Accessed July 15, 2020. https://www.bbc.com/news/health-53210553
8.
Narayan  KMV, Curran  JW, Foege  WH.  The COVID-19 pandemic as an opportunity to ensure a more successful future for science and public health.   JAMA. 2021;325(6):525-526. doi:10.1001/jama.2020.23479PubMedGoogle ScholarCrossref
9.
Lancefield  D.  How to reinvent your organization in the middle of a crisis.  Harv Bus Rev. Published online February 15, 2021. Accessed March 19, 2021. https://hbr.org/2021/02/how-to-reinvent-your-organization-in-the-middle-of-a-crisis
10.
Chiriboga  D, Garay  J, Buss  P, Madrigal  RS, Rispel  LC.  Health inequity during the COVID-19 pandemic: a cry for ethical global leadership.   Lancet. 2020;395(10238):1690-1691. doi:10.1016/S0140-6736(20)31145-4PubMedGoogle ScholarCrossref
11.
 Coronavirus will be with us forever, Sage scientist warns.  BBC News. Published August 22, 2020. Accessed August 26, 2020. https://www.bbc.com/news/uk-53875189
12.
Murray  CJL, Piot  P.  The potential future of the COVID-19 pandemic will SARS-CoV-2 become a recurrent seasonal infection?   JAMA. 2021;325(13):1249-1250. doi:10.1001/jama.2021.2828PubMedGoogle ScholarCrossref
13.
Del Rio  C, Malani  P.  COVID-19 in 2021 — continuing uncertainty.   JAMA. 2021;325(14):1389-1390. doi:10.1001/jama.2021.3760PubMedGoogle ScholarCrossref
14.
 WHO warns Covid-19 pandemic is “not necessarily the big one.”  The Guardian. Published December 29, 2020. Accessed January 19, 2021. https://www.theguardian.com/world/2020/dec/29/who-warns-covid-19-pandemic-is-not-necessarily-the-big-one
15.
Tourish  D.  Introduction to the special issue: why the coronavirus crisis is also a crisis of leadership.   Leadership. 2020;16(3):261-272. doi:10.1177/1742715020929242Google ScholarCrossref
16.
Geerts  JM.  Our approach to COVID-19 won’t work as well for a second wave.  Globe and Mail. Published May 25, 2020. Accessed June 11, 2021. https://www.theglobeandmail.com/opinion/article-our-current-approach-to-covid-19-wont-work-as-well-for-a-second-wave/
17.
Barber  HF.  Developing strategic leadership: the US Army War College experience.   J Manag Dev. 1992;11(6):4-12. doi:10.1108/02621719210018208Google ScholarCrossref
18.
Empson  L, Howard-Grenville  J. How has the past year changed you and your organization? Harv Bus Rev. Published online March 10, 2021. Accessed March 19, 2021. https://hbr.org/2021/03/how-has-the-past-year-changed-you-and-your-organization
19.
Uhl-Bien  M, Arena  M.  Leadership for organizational adaptability: a theoretical synthesis and integrative framework.   Leadersh Q. 2018;29(1):89-104. doi:10.1016/j.leaqua.2017.12.009Google ScholarCrossref
20.
Child  J, McGrath  RG.  Organizations unfettered: organizational form in an information-intensive economy.   Acad Manage J. 2001;44(6):1135-1148. doi:10.2307/3069393Google Scholar
21.
Standiford  TC, Davuluri  K, Trupiano  N, Portney  D, Gruppen  L, Vinson  AH.  Physician leadership during the COVID-19 pandemic: an emphasis on the team, well-being and leadership reasoning.   BMJ Lead. Published online December 23, 2020. Accessed June 11, 2021. doi:10.1136/leader-2020-000344Google Scholar
22.
Esser  J.  The secret of adaptable organizations is trust.  Harv Bus Rev. Published online March 15, 2021. Accessed March 19, 2021. https://hbr.org/2021/03/the-secret-of-adaptable-organizations-is-trust
23.
Rokkas  P, Cornell  V, Steenkamp  M.  Disaster preparedness and response: challenges for Australian public health nurses - a literature review.   Nurs Health Sci. 2014;16(1):60-66. doi:10.1111/nhs.12134PubMedGoogle ScholarCrossref
24.
Gamble  MS, Hanners  RB, Lackey  C, Beaudin  CL.  Leadership and hospital preparedness: disaster management and emergency services in pediatrics.   J Trauma. 2009;67(2)(suppl):S79-S83. doi:10.1097/TA.0b013e3181af069fPubMedGoogle Scholar
25.
Kunzle  B, Kolbe  M, Grote  G.  Ensuring patient safety through effective leadership behaviour: a literature review.   Saf Sci. 2010;48:1-17. doi:10.1016/j.ssci.2009.06.004Google ScholarCrossref
26.
Hannah  ST, Uhl-Bien  M, Avolio  BJ, Cavarretta  FL.  A framework for examining leadership in extreme contexts.   Leadersh Q. 2009;20(6):897-919. doi:10.1016/j.leaqua.2009.09.006Google ScholarCrossref
27.
Kolditz  TA.  In Extremis Leadership. Jossey-Bass; 2007.
28.
Scoblic  JP.  Learning from the future.  Harv Bus Rev. 2020;98(4):38-47.
29.
Olson  CM.  Consensus statements: applying structure.   JAMA. 1995;273(1):72-73. doi:10.1001/jama.1995.03520250088040PubMedGoogle ScholarCrossref
30.
Helmer  O, Rescher  N.  On the epistemology of the inexact sciences.   Manag Sci. 1959;6(1):25-52. doi:10.1287/mnsc.6.1.25Google ScholarCrossref
31.
Franklin  KK, Hart  JK.  Idea generation and exploration: benefits and limitations of the policy Delphi research method.   Innov High Educ. 2007;31(4):237-246. doi:10.1007/s10755-006-9022-8Google ScholarCrossref
32.
Zonneveld  N, Raab  J, Minkman  MMN.  Towards a values framework for integrated health services: an international Delphi study.   BMC Health Serv Res. 2020;20(1):224. doi:10.1186/s12913-020-5008-yPubMedGoogle ScholarCrossref
33.
Mitroff  I, Turoff  M. Philosophical and methodological foundations of Delphi. In: Linstone  H, Turoff  M, eds.  The Delphi Method: Techniques and Applications. Addison-Wesley; 1975:17-35.
34.
Jones  J, Hunter  D.  Consensus methods for medical and health services research.   BMJ. 1995;311(7001):376-380. doi:10.1136/bmj.311.7001.376PubMedGoogle ScholarCrossref
35.
de Loë  RC, Melnychuk  N, Murray  D, Plummer  R.  Advancing the state of policy Delphi practice: a systematic review evaluating methodological evolution, innovation, and opportunities.   Technol Forecast Soc Change. 2016;104:78-88. doi:10.1016/j.techfore.2015.12.009Google ScholarCrossref
36.
Kezar  A, Maxey  D.  The Delphi technique: an untapped approach of participatory research.   Int J Soc Res Methodol. 2016;19(2):143-160. doi:10.1080/13645579.2014.936737Google ScholarCrossref
37.
Koehn  N. Real leaders are forged in crisis. Harv Bus Rev. Published online April 3, 2020. Accessed August 26, 2020. https://hbr.org/2020/04/real-leaders-are-forged-in-crisis
38.
Robbins  M. Why employees need both recognition and appreciation. Harv Bus Rev. Published online November 12, 2019. Accessed August 8, 2020. https://hbr.org/2019/11/why-employees-need-both-recognition-and-appreciation
39.
Stajkovic  AD, Lee  D, Nyberg  AJ.  Collective efficacy, group potency, and group performance: meta-analyses of their relationships, and test of a mediation model.   J Appl Psychol. 2009;94(3):814-828. doi:10.1037/a0015659PubMedGoogle ScholarCrossref
40.
Shanafelt  TD, Wang  H, Leonard  M,  et al.  Assessment of the association of leadership behaviors of supervising physicians with personal-organizational values alignment among staff physicians.   JAMA Netw Open. 2021;4(2):e2035622. doi:10.1001/jamanetworkopen.2020.35622PubMedGoogle Scholar
41.
Pfefferbaum  B, North  CS.  Mental health and the Covid-19 pandemic.   N Engl J Med. 2020;383(6):510-512. doi:10.1056/NEJMp2008017PubMedGoogle ScholarCrossref
42.
Stapleton  FB, Opipari  VP.  The current health care crisis-inspirational leadership (or lack thereof) is contagious.   JAMA Netw Open. 2020;3(6):e208024. doi:10.1001/jamanetworkopen.2020.8024PubMedGoogle Scholar
43.
Whelehan  DF, Algeo  N, Brown  DA.  Leadership through crisis: fighting the fatigue pandemic in healthcare during COVID-19.   BMJ Lead. Published online February 22, 2021. doi:10.1136/leader-2020-000419Google Scholar
44.
Maunder  RG, Lancee  WJ, Balderson  KE,  et al.  Long-term psychological and occupational effects of providing hospital healthcare during SARS outbreak.   Emerg Infect Dis. 2006;12(12):1924-1932. doi:10.3201/eid1212.060584PubMedGoogle ScholarCrossref
45.
Wiens  K, McKee  A.  Why some people get burned out and others don’t.  Harv Bus Rev. Published online November 23, 2016. Accessed September 1, 2020. https://hbr.org/2016/11/why-some-people-get-burned-out-and-others-dont
46.
Heifetz  RA.  Leadership without Easy Answers. Harvard University Press; 1994.
47.
Linzer  M, Poplau  S, Prasad  K,  et al; Healthy Work Place Investigators.  Characteristics of health care organizations associated with clinician trust.   JAMA Netw Open. 2019;2(6):e196201. doi:10.1001/jamanetworkopen.2019.6201PubMedGoogle Scholar
48.
Frazier  ML, Fainshmidt  S, Klinger  RL, Pezeshkan  A, Vracheva  V.  Psychological safety: a meta-analytic review and extension.   Pers Psychol. 2017;70(1):113-165. doi:10.1111/peps.12183Google ScholarCrossref
49.
Stoller  JK.  Reflections on leadership in the time of COVID-19.   BMJ Lead. 2020;4(2). doi:10.1136/leader-2020-000244Google Scholar
50.
Smallwood  J, Schooler  JW.  The restless mind.   Psychol Bull. 2006;132(6):946-958. doi:10.1037/0033-2909.132.6.946PubMedGoogle ScholarCrossref
51.
Shearer  FM, Moss  R, McVernon  J, Ross  JV, McCaw  JM.  Infectious disease pandemic planning and response: Incorporating decision analysis.   PLoS Med. 2020;17(1):e1003018. doi:10.1371/journal.pmed.1003018PubMedGoogle Scholar
52.
Snowden  DJ, Boone  ME.  A leader’s framework for decision making.   Harv Bus Rev. 2007;85(11):68-76, 149.PubMedGoogle Scholar
53.
Kanter  RM.  Leading your team past the peak of a crisis.  Harv Bus Rev. Published online April 30, 2020. Accessed August 26, 2020. https://hbr.org/2020/04/leading-your-team-past-the-peak-of-a-crisis
54.
Grint  K.  Leadership, management and command in the time of the Coronavirus.   Leadership. 2020;16(3):314-319. doi:10.1177/1742715020922445Google ScholarCrossref
55.
Alliger  GM, Cerasoli  CP, Tannenbaum  SI, Vessey  WB.  Team resilience: How teams flourish under pressure.   Organ Dyn. 2015;44(3):176-184. doi:10.1016/j.orgdyn.2015.05.003Google ScholarCrossref
56.
Tannenbaum  SI, Traylor  AM, Thomas  EJ, Salas  E.  Managing teamwork in the face of pandemic: evidence-based tips.   BMJ Qual Saf. 2021;30(1):59-63. doi:10.1136/bmjqs-2020-011447PubMedGoogle ScholarCrossref
57.
Shanafelt  TD, Makowski  MS, Wang  H,  et al.  Association of burnout, professional fulfillment, and self-care practices of physician leaders with their independently rated leadership effectiveness.   JAMA Netw Open. 2020;3(6):e207961. doi:10.1001/jamanetworkopen.2020.7961PubMedGoogle Scholar
58.
Kuehn  BM.  Africa succeeded against COVID-19’s first wave, but the second wave brings new challenges.   JAMA. 2021;325(4):327-328. doi:10.1001/jama.2020.24288PubMedGoogle ScholarCrossref
59.
 The plight of essential workers during the COVID-19 pandemic.  Editorial.  Lancet. 2020;395(10237):1587. doi:10.1016/S0140-6736(20)31200-9PubMedGoogle ScholarCrossref
60.
Marion  R, Uhl-Bien  M.  Leadership in complex organizations.   Leadersh Q. 2001;12(4):389-418. doi:10.1016/S1048-9843(01)00092-3Google ScholarCrossref
61.
Geerts  JM, Goodall  AH, Agius  S.  Evidence-based leadership development for physicians: a systematic literature review.   Soc Sci Med. 2020;246:112709. doi:10.1016/j.socscimed.2019.112709PubMedGoogle Scholar
62.
Lyons  O, George  R, Galante  JR,  et al.  Evidence-based medical leadership development: a systematic review.   BMJ Lead. Published online November 16, 2020. Accessed June 11, 2021. doi:10.1136/leader-2020-000360Google Scholar
63.
Teece  DJ, Pisano  G, Shuen  A.  Dynamic capabilities and strategic management.   Strateg Manag J. 1997;18(7):509-533. doi:10.1002/(SICI)1097-0266(199708)18:7<509::AID-SMJ882>3.0.CO;2-ZGoogle ScholarCrossref
64.
Dixon  S, Meyer  K, Day  M.  Building dynamic capabilities of adaptation and innovation: a study of micro-foundations in a transition economy.   Long Range Plann. 2014;47(4):186-205. doi:10.1016/j.lrp.2013.08.011Google ScholarCrossref
65.
Jain  SH, Lucey  C, Crosson  FJ.  The enduring importance of trust in the leadership of health care organizations.   JAMA. 2020;324(23):2363-2364. doi:10.1001/jama.2020.18555PubMedGoogle ScholarCrossref
66.
Suarez  FF, Montes  JS.  Building organizational resilience.  Harv Bus Rev. 2020;98(6):47-52.
67.
Levinthal  DA, March  JG.  The myopia of learning.   Strateg Manag J. 1993;14(S2):95-112. doi:10.1002/smj.4250141009Google ScholarCrossref
68.
Angus  DC.  Optimizing the trade-off between learning and doing in a pandemic.   JAMA. 2020;323(19):1895-1896. doi:10.1001/jama.2020.4984PubMedGoogle ScholarCrossref
69.
O’Reilly  CA  III, Tushman  ML.  The ambidextrous organization.   Harv Bus Rev. 2004;82(4):74-81, 140.PubMedGoogle Scholar
70.
de Wit  M, Cooper  C, Reginster  J-Y; WHO-ESCEO Working Group.  Practical guidance for patient-centred health research.   Lancet. 2019;393(10176):1095-1096. doi:10.1016/S0140-6736(19)30034-0PubMedGoogle ScholarCrossref
71.
Roger  VL.  Outcomes research and epidemiology: the synergy between public health and clinical practice.   Circ Cardiovasc Qual Outcomes. 2011;4(3):257-259. doi:10.1161/CIRCOUTCOMES.111.961524PubMedGoogle ScholarCrossref
72.
Appleby  J.  Covid-19: a V shaped recovery for the NHS?   BMJ. 2020;370:m3694. doi:10.1136/bmj.m3694PubMedGoogle Scholar
73.
Born  K, Kool  T, Levinson  W.  Reducing overuse in healthcare: advancing Choosing Wisely.   BMJ. 2019;367:l6317. doi:10.1136/bmj.l6317PubMedGoogle Scholar
74.
Zahra  SA, George  G.  Absorptive capacity: a review, reconceptualization, and extension.   Acad Manage Rev. 2002;27(2):185-203. doi:10.5465/amr.2002.6587995Google ScholarCrossref
75.
Leonard-Barton  D.  Core capabilities and core rigidities: A paradox in managing new product development.   Strateg Manag J. 1992;13(S1):111-125. doi:10.1002/smj.4250131009Google ScholarCrossref
76.
Birkinshaw  J, Gibson  C.  Building ambidexterity into an organization.   MIT Sloan Manag Rev. 2004;45(4):47. Accessed June 11, 2021. https://sloanreview.mit.edu/article/building-ambidexterity-into-an-organization/Google Scholar
77.
Holland  JH.  Emergence: From Chaos to Order. Oxford University Press; 1998.
78.
Herington  MJ, Fliert  E van de.  Positive deviance in theory and practice: a conceptual review.   Deviant Behav. 2018;39(5):664-678. doi:10.1080/01639625.2017.1286194Google ScholarCrossref
79.
Lee  TH, McGlynn  EA, Safran  DG.  A framework for increasing trust between patients and the organizations that care for them.   JAMA. 2019;321(6):539-540. doi:10.1001/jama.2018.19186PubMedGoogle ScholarCrossref
80.
Managing the COVID-19 infodemic: promoting healthy behaviours and mitigating the harm from misinformation and disinformation. Joint statement from World Health Organization, United Nations, UNICEF, United Nations Development Programme, UNESCO, UN Programme on HIV/AIDS, International Telecommunication Union, UN Global Pulse, and International Federation of Red Cross and Red Crescent. World Health Organization website. Published September 23, 2020. Accessed February 9, 2021. https://www.who.int/news/item/23-09-2020-managing-the-covid-19-infodemic-promoting-healthy-behaviours-and-mitigating-the-harm-from-misinformation-and-disinformation
81.
Gates  B.  Responding to Covid-19 - a once-in-a-century pandemic?   N Engl J Med. 2020;382(18):1677-1679. doi:10.1056/NEJMp2003762PubMedGoogle ScholarCrossref
82.
Scally  G, Jacobson  B, Abbasi  K.  The UK’s public health response to Covid-19.   BMJ. 2020;369:m1932. doi:10.1136/bmj.m1932PubMedGoogle Scholar
83.
Rittel  HWJ, Webber  MM.  Dilemmas in a general theory of planning.   Policy Sci. 1973;4(2):155-169. doi:10.1007/BF01405730Google ScholarCrossref
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    Consensus Statement
    Global Health
    July 8, 2021

    Guidance for Health Care Leaders During the Recovery Stage of the COVID-19 Pandemic: A Consensus Statement

    Author Affiliations
    • 1Research and Leadership Development, Canadian College of Health Leaders, Ottawa, Ontario, Canada
    • 2Bayes Business School, University of London, London, United Kingdom
    • 3Royal College of Nursing, Marylebone, London, United Kingdom
    • 4Yale School of Medicine, New Haven, Connecticut
    • 5Barts Health NHS Trust, Royal Hospital, London, United Kingdom
    • 6Staff College: Leadership in Healthcare, London, United Kingdom
    • 7Department of Public Administration, Korea University, Seoul, Republic of Korea
    • 8Global Health Systems, Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts
    • 9Department of Political Science, University of São Paulo, São Paulo, Brazil
    • 10Solidarity Research Network for Public Policies and Society, Observatorio COVID-19 Brazil
    • 11United Nations Mission in South Sudan, UN House, Juba, South Sudan
    • 12Public Health Foundation of India, Gurugram, India
    • 13Department of Health Metrics Sciences, Institute for Health Metrics and Evaluation, University of Washington, Seattle
    • 14Royal Infirmary Hospital Edinburgh, Edinburgh, United Kingdom
    • 15Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
    • 16Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
    • 17Vårdcentralen Värmlands Nysäter and Centre for Clinical Research, County Council of Värmland, Värmland, Sweden
    • 18Medicine and Health, Örebro University, Örebro, Sweden
    • 19University of Lincoln, Brayford Pool, Lincoln, United Kingdom
    • 20Chief Executive Officer, Health PEI, Charlottetown, Canada
    • 21Department of Medicine, University of Toronto, Toronto, Ontario, Canada
    • 22Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
    • 23Nigeria Centre for Disease Control, Jabi, Abuja, Nigeria
    • 24School of Public Health, University of Alberta, Edmonton, Alberta, Canada
    • 25World Health Organization Patients for Patient Safety, Geneva, Switzerland
    • 26Patients for Patient Safety Canada, Edmonton, Alberta, Canada
    • 27Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, Alberta, Canada
    • 28Canadian Medical Association, First Nations Health Authority, Indigenous Physicians Association of Canada, West Vancouver, British Columbia, Canada
    • 29Institute for Travel and Tropical Medicine, Sheba Medical Center, Tel HaShomer, Ramat Gan, Israel
    • 30School of Medicine, Tel Aviv University, Tel Aviv, Israel
    • 31Indigenous Primary Health Care Council, Toronto, Ontario, Canada
    • 32Monash Centre for Health Research and Implementation, Monash University, Clayton, Australia
    • 33St Vincent’s Health Australia, East Melbourne, Australia
    • 34Nuffield Department of Surgical Sciences, Medical Sciences Division, University of Oxford, John Radcliffe Hospital, Headington, Oxford, United Kingdom
    • 35College of medicine, King Saud University, Riyadh, Saudi Arabia
    • 36Division of Epidemiology & Biostatistics, Department of Global Health, Faculty of Medicine & Health Sciences, Stellenbosch University, Cape Town, South Africa
    • 37School of Public Health, Bielefeld University, Bielefeld, Germany
    • 38Canadian Association of Occupational Therapists, Nepean, Ontario, Canada
    • 39Organizations for Health Action, Ottawa, Ontario, Canada
    • 40London Health Sciences Centre, London, Ontario, Canada
    • 41Department of Physical Therapy, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
    • 42HIV/STI Surveillance Research Center and WHO Collaborating Center for HIV Surveillance, Institute for Future Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
    • 43Centre for Addiction and Mental Health, Toronto, Ontario, Canada
    • 44Department of Psychiatry and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
    • 45Department of Health, Melbourne, Victoria, Australia
    • 46Monash University School of Public Health and Preventive Medicine, Melbourne, Australia
    • 47China Center for Disease Control and Prevention, Beijing, China
    • 48Division of HIV Prevention, National Center for AIDS/STD Control and Prevention, Beijing, China
    • 49Department of Epidemiology, UCLA Fielding School of Public Health, University of California, Los Angeles
    • 50Surgeon General, Canadian Armed Forces, Ottawa, Ontario, Canada
    JAMA Netw Open. 2021;4(7):e2120295. doi:10.1001/jamanetworkopen.2021.20295
    Key Points

    Question  What leadership imperatives are most essential for health leaders following the emergency stages of the COVID-19 pandemic?

    Findings  In this consensus statement, 32 coauthors from 17 countries with expertise in various aspects of health leadership, health care, public health, and related fields outline 10 imperatives to guide leaders through recovery from the emergency stages of the pandemic. Key leadership capabilities and reflection questions are presented to guide leaders and to structure performance reviews.

    Meaning  Leaders who most effectively implement this framework are ideally positioned to address urgent needs and inequalities in health systems and to cocreate a culture within their organizations that best serves its people.

    Abstract

    Importance  The COVID-19 pandemic is the greatest global test of health leadership of our generation. There is an urgent need to provide guidance for leaders at all levels during the unprecedented preresolution recovery stage.

    Objective  To create an evidence- and expertise-informed framework of leadership imperatives to serve as a resource to guide health and public health leaders during the postemergency stage of the pandemic.

    Evidence Review  A literature search in PubMed, MEDLINE, and Embase revealed 10 910 articles published between 2000 and 2021 that included the terms leadership and variations of emergency, crisis, disaster, pandemic, COVID-19, or public health. Using the Standards for Quality Improvement Reporting Excellence reporting guideline for consensus statement development, this assessment adopted a 6-round modified Delphi approach involving 32 expert coauthors from 17 countries who participated in creating and validating a framework outlining essential leadership imperatives.

    Findings  The 10 imperatives in the framework are: (1) acknowledge staff and celebrate successes; (2) provide support for staff well-being; (3) develop a clear understanding of the current local and global context, along with informed projections; (4) prepare for future emergencies (personnel, resources, protocols, contingency plans, coalitions, and training); (5) reassess priorities explicitly and regularly and provide purpose, meaning, and direction; (6) maximize team, organizational, and system performance and discuss enhancements; (7) manage the backlog of paused services and consider improvements while avoiding burnout and moral distress; (8) sustain learning, innovations, and collaborations, and imagine future possibilities; (9) provide regular communication and engender trust; and (10) in consultation with public health and fellow leaders, provide safety information and recommendations to government, other organizations, staff, and the community to improve equitable and integrated care and emergency preparedness systemwide.

    Conclusions and Relevance  Leaders who most effectively implement these imperatives are ideally positioned to address urgent needs and inequalities in health systems and to cocreate with their organizations a future that best serves stakeholders and communities.

    Introduction

    The COVID-19 pandemic is the greatest global test of health leadership of our generation.1,2 Although some lessons of epidemics are available from severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS) experiences, few jurisdictions were prepared to manage this crisis effectively.3-5 COVID-19 has highlighted worldwide interdependency,2,4,6 and consequently Dr Tedros Adhanom Ghebreyesus, the director-general of the World Health Organization (WHO), stated, “The greatest threat we face now is not the virus itself, it’s the lack of global solidarity and global leadership.”7

    The pandemic has laid bare and exacerbated gaps and wide inequalities in health systems,5,8,9 including underlying structural, societal, political, and economic problems in an undeniably graphic way.6 Accordingly, there have been calls for systemic social change and pressure on governments to address these issues and to ensure that the needs of at-risk and priority populations are met.10

    Even with the widespread distribution of vaccines, the projected timelines for achieving international herd immunity have been lengthening11 and some experts suggest that there is a critical need to prepare for the endemic potential of persistent and seasonal resurgences of the virus.12,13 Furthermore, a letter by Dr Tedros and 26 heads of state asserted that “the question is not if, but when” future pandemics will arise,2 which Dr Mike Ryan, executive director of the WHO Health Emergencies Programme, suggests may be even more lethal.14

    The unprecedented and high stakes nature of this global phenomenon highlights an urgent need for clear guidance to support leaders at all levels in navigating the course of this crisis and in preparing for those to come.2,15

    The Context: 4 Stages of a Crisis

    The COVID-19 pandemic and other global crises can be understood in a novel model of 4 overlapping progressive stages: 1) escalation, 2) emergency, 3) recovery, and 4) resolution.16 The escalation stage (stage 1) is predominantly characterized by an increasing realization, often based on limited, erratic, or unsubstantiated information, that an external threat is encroaching, and by the need for rapid preparations. The emergency stage (stage 2) focuses on leadership at the onset of a threat, when it is direct and local. The recovery stage (stage 3) is highly capricious because although it is less acute than the previous phase, there may be widespread staff and community fatigue or burnout, along with a prolonged looming potential threat of reverting to an emergency state at any point in reaction to a resurgence. The resolution stage (stage 4) involves addressing the repercussions of the crisis and subsequently setting priorities, ideally alongside a collective creative discussion of postcrisis opportunities and strategies to achieve a new (and hopefully) better reality.

    Advancement through these stages may not be linear given the volatile nature of crises, and overlap is inevitable, especially as resurgences arise and abate. Globally, the threat from COVID-19 is far from over, since although several jurisdictions have withstood initial waves of the pandemic and are now in the recovery stage, others remain in the throes of the storm or may soon return to it before transitioning to recovery.

    The Recovery Stage: Stage 3

    This report focuses on leadership imperatives during the recovery stage, which requires the greatest spectrum of capabilities at any stage of a crisis and compared with noncrisis situations. The unique leadership challenge during stage 3 is balancing competing priorities, maintaining staff engagement and motivation, and avoiding burnout within a postemergency environment that remains volatile, uncertain, complex, and ambiguous (known in management theory as VUCA).4,17 The longer each installment of the recovery stage persists and the more frequently one must reevaluate priorities, reschedule, and reorganize logistics as the situation shifts, the more challenging leadership in this context becomes.18 Stage 3 also offers unprecedented opportunities at all levels to capitalize on improvisations, innovations, collaborations, and lessons learned during the emergency stages to improve performance and care and to address the needs of, and inequalities in, communities.9

    The recovery stage demands a versatility beyond the capacity of any individual leader. In contrast to a directive, top-down approach, which is commonly applied in emergencies, the hallmark of effectiveness in the recovery stage is an enhanced systemwide distribution of leadership, beyond the immediate “org chart.” In this context, an evolving, experimental, adaptive, coordinated, and collaborative approach is essential. To succeed, alignment around a shared purpose and common objectives is required, as well as leaders releasing some control and establishing and maintaining high levels of trust among key stakeholders.5,19-22

    Purpose of the Framework

    The purpose of creating an evidence- and expertise-informed leadership framework for the recovery stage of the COVID-19 pandemic was for it to potentially serve as a resource to guide health and public health leaders, including those in positional or informal leadership roles at all levels and in organizations of any size. The framework could also provide a structure for reviews of individual leader, team, and organizational performance, which could be used to increase organizational resilience, capacity, innovation, and emergency preparedness.

    Although there is an established body of knowledge that is relevant for the emergency stage, including scholarship on disaster preparedness,23,24 crisis resource management,25 and leadership in crises,26,27 to the best of our knowledge there is no comparable framework in the literature for the recovery stage. The need for credible guidance is urgent, especially if the expert predictions are correct and this pandemic becomes endemic, in which case variations of stage 3 may become the new reality.12 Furthermore, the extent to which leaders effectively implement the imperatives in the recovery stage is directly linked to success in subsequent iterations of the emergency stage (stage 2), as well as during the resolution stage (stage 4).4,9,28

    Methods

    To create the framework for this report, we assembled a team of 32 coauthors from 17 countries who were selected based on their relevant professional and/or academic expertise29-32 in various aspects of health leadership, health care, public health, and related fields. These fields and professions included: leadership research, public health, patient advocacy, patient safety, aged and long-term care, mental health, Indigenous health, infectious diseases, epidemiology, nursing, physicians, regulated health professionals, the military, peacekeeping, academic health care centers, community hospitals, primary care, national health leadership organizations, and a national chief health officer.

    Rather than by soliciting the feedback of subject matter experts as external contributors through surveys or focus groups, our contention was that including them as coauthors could enhance their involvement and investment in creating the framework. Their diverse range of perspectives and collective consensus validation of the final framework could also potentially augment its quality, reliability, and validity,29,33,34 thus increasing its potential to resonate with and be most useful to leaders. To achieve this, we followed Standards for Quality Improvement Reporting Excellence (SQUIRE) reporting guideline for consensus statement development and applied the core characteristics of a modified Delphi method.35,36

    The first author (J.G.) conducted a literature search for peer-reviewed, English-language articles published between 2000 and 2021 using PubMed, MEDLINE, and Embase. The search terms were, leadership and emergenc* or cris* or pandemic* or disaster* or COVID-19 or public health. The initial search yielded 10 910 articles, the titles and abstracts of which were scanned for relevance. Second, the first author drafted an initial set of evidence-based imperatives and the team of coauthors engaged in a structured dialogue on a critical question,29 which was: leadership imperatives are required during the recovery stage of the COVID-19 pandemic?

    Third, we completed 6 rounds of feedback, revisions, and synthesis before reaching consensus.35,36 Delphi round 1 was completed by 7 authors (A.A., M.B., M.G., J.G., W.G., E. Loh, P.T.). Rounds 2 and 3 involved the original 7 authors and 6 more (D.K., S.J., A.K., A.L., H.S., V.S.). Round 4 was completed by an additional 28 authors (J.A., R.A., L.B., A.D., R.D., L.E., C.I., E. Leshem, O.L., K.N., O.R., H.S., B.S., Z.W.), and the final 2 rounds were completed by all 32 authors (N.B., J.F., C.L.J., J.S.T.). No coauthors who agreed to participate dropped out. For a complete account of the process, see eAppendix in the Supplement.

    For each round, coauthors provided written feedback on the manuscript, to which the first author responded point-for-point, revised the manuscript accordingly, and then circulated an updated working version to all coauthors for reconsideration.35,36 This process was supervised by 3 senior coauthors (M.B., M.G., W.G.). All coauthors provided feedback during the final 2 (of 6) rounds of the process and had equal verification of the final version of the manuscript.29,35,36 Here, we present the consensus framework.

    Results
    An Evidence- and Expertise-Informed Framework: 10 Imperatives for Health Leaders During the Recovery Stage of a Crisis

    After 6 rounds of revisions, our team reached consensus on 10 leadership imperatives for the recovery stage of the COVID-19 crisis, with corresponding capabilities for each and reflection questions for leaders to self-assess their leadership and organizational capacity (Table). The imperatives are presented in 6 groups (Figure): people focus (1 and 2); environmental scan (present and future focus) (3); learning and preparation (past and future focus) (4); recalibrating, optimizing, organizing (present focus) (5, 6, and 7); envisioning (future focus) (8); and crisis communication (9 and 10).

    People Focus
    Acknowledge Staff and Celebrate Successes

    Following the emergency stage, to increase and maintain morale, there is an essential need to acknowledge and celebrate the dedication, resilience, and achievements of staff.5,9,37,38 Recognition can reenergize and inspire individuals, teams, organizations, and communities, as well as increasing their performance.39,40 This is also an opportunity to reinforce through praise the behaviors that are considered vital to improving patient outcomes in the future, including that successful crisis response relies on leadership and contributions, large and small, from everyone in the organization.

    Provide Support for Staff Well-being

    Burnout and mental health issues have risen during the pandemic, particularly among health professionals, since many have been traumatized by firsthand experiences or by sustained uncertainty, health risk, and exhaustion.21,41-43 In addition to their professional work, many have also had to care for elderly relatives and/or manage children at home because of daycare and school closures, as boundaries between work and home lives have blurred deleteriously.18 The longer the pandemic persists, the more the likelihood of identified and latent effects of the crisis on people will manifest.21,43,44 Leaders must demonstrate emotional intelligence,42 empathy,45 care and compassion,9 and the initiative to engage frontline staff in their work environment.5,21,46 There, leaders can gauge their stress level, understand their challenges, solicit their feedback based on unit-level data and/or their experiences, and foster their well-being and resilience.5,47 Visiting the frontlines also enables leaders to see the impact of their decisions at point of care. Engaging with staff in the field requires leaders to be confident that their colleagues can substitute for them effectively and will report anything urgent immediately.

    To perform effectively, as well as to recover and to heal, staff need access to psychologically safe spaces where they can voice confusion, express frank concerns, and admit mistakes without fear of undue negative repercussions.9,18,21,48,49 Being mindful of the frustration, guilt, and anxiety experienced by those whose work, research, or learning/training have been inevitably interrupted by the crisis is also indispensable.5 Where appropriate, leaders should identify and address the nonwork concerns of staff (eg, family or financial worries) that can adversely affect their performance.50 It is essential for leaders to recognize the importance of traditional forms of healing—humor and laughter—and to realize that, as Empson and Howard-Grenville state, “Emerging from a profoundly disruptive experience takes time.”18

    Changing directions too frequently, unnecessarily, or without a clearly communicated strategy can also contribute to staff fatigue and burnout.9 Staff need essential breaks to rest and recuperate and to sustain organizational capacity, as well as formal burnout prevention strategies based on their input regarding which components will be most meaningful.9,43 It is essential to communicate the volatility of the situation to staff while instilling confidence that they are in it for the long haul and will be ready and supported to overcome adversity, even when leaders themselves are experiencing uncertainty.5,49 Leaders must also promote and model self-care themselves.37 This includes taking time to reflect on and appropriately communicate their own struggles, whether to colleagues or to a trusted confidant, and considering sharing the workload more widely.9,21 Those experiencing burnout or who are feeling overwhelmed should be afforded rest, receive support, or be allowed to transition to other roles with grateful acknowledgment of their contributions.43 Outstanding performers should be prioritized for promotion and succession planning that is rooted in equity, diversity, and inclusivity that reflects the local communities being served.

    Environmental Scan
    Develop a Clear Understanding of the Current Local and Global Context, Along With Informed Projections

    Understanding the current local and global context of this crisis includes appreciating its VUCA nature, with a resultant humility and acceptance that no one has all the answers.21,37,51 Leadership in complex and chaotic situations involves experimenting based on imperfect and conflicting information, including from experts, and preparing people to expect setbacks, failures, and adaptations in response to real-time results.8,49,52

    To keep updated, leaders must identify reliable sources of information and key experts to help guide decisions and policy making.5,6,53,54 This pandemic has highlighted explicitly the crucial role that experts should play, as well as the consequences when they are ignored.8 When facing “wicked problems”—a term used in planning theory to describe complex, interrelated sets of issues for which there are no clear solutions83—rather than show an overreliance on clear answers from individual experts, the role of the leader is to ask the right questions of diverse colleagues with relevant expertise, challenge assumptions, encourage debate and innovative approaches, and draw from their collective intelligence to determine priorities and next steps.54

    Leaders must also analyze the pandemic using systems thinking to recognize the interconnectivity of events and potential ripple effects of how developments in other jurisdictions might ultimately impact their organizations and communities, which Heifetz has described as taking a strategic viewpoint “from the balcony.”46 This also involves understanding which changes in the landscape are likely to be temporary and pandemic- or stage-specific vs those that may be permanent.9,21

    This process involves monitoring surveillance and case reporting data about how the virus spreads and affects citizens, directly and indirectly. It is important to focus too on which populations are being disproportionately affected and to incorporate timely mitigation strategies to counter impacts. Conducting regular risk assessments and modeling scenarios to project the consequences of possible future events and responses, including the benefits and the costs of each, is vital to situational awareness and to organizational and system resilience by anticipating and preparing for future possibilities.9,51,55,56 Similarly, strategic foresight exercises, which involve imagining future scenarios, clarifying assumptions, and developing response strategies, enhance the ability to sense, shape, and adapt to future events, as well as to make progressively better and more timely decisions in the present.9,28 The ongoing results of these processes should drive action and resourcing.49

    Learning and Preparation
    Prepare for Future Emergencies (Personnel, Resources, Protocols, Contingency Plans, Coalitions, and Training)

    Actively preparing for future emergencies in the recovery stage is vital2,5,12 and it begins with introspective analyses and debriefs of individual, departmental, organizational, and interorganizational performance during the earlier stages of the pandemic.9,21,49,57 The lessons learned should derive from systematically assessing: what worked well; what strengths can be leveraged; and what did not work well, why, and what is needed to augment infrastructure and to manifest organizational values. The framework presented in this article can be used to structure this process, which should be informed by operational and clinical outcome data and by multisource anonymous feedback from key stakeholders, including frontline staff, external stakeholders, patients, families, and others who have been highly critical and/or disproportionately impacted by the crisis. This process should involve considering in what ways emergency operational protocols, structures, policies, and contingency plans should be improved and updated based on stakeholder input,5 as well as leadership best practices.49 Leaders should commit to actioning and resourcing these suggestions because implementing lessons from past pandemic experiences has been shown to improve the effectiveness of subsequent emergency response and current operations.5,9,58 It is also important to identify teams and individuals who have performed admirably9 and those who should be supported with further training or reallocated. It is also valuable to discern collaboratively whether certain capabilities, conditions, or prior training contributed significantly to differences in performance, since this can help identify how to select the best leaders and prepare them to perform under pressure.

    Following this review, the next step is ensuring that the required human, technological, and material resources are in place, which includes a reliable supply chain that is responsive to the urgency of the crisis.49 This may involve sourcing creatively when supply is thin; however, operating without the requisite resources causes tremendous anxiety among staff and can jeopardize their safety and effectiveness.5,21,43,59

    Complex, high pressure situations often foster the formation of new coalitions as diverse groups unite for a shared goal to produce an adaptive response.21,60 These symbiotic coalitions across silos and with partner organizations should be sustained to provide a higher quality continuum of care and to increase system capacity.53

    Training of staff should focus on the process of clarifying roles and accountabilities, coherent decision-making in complex situations, productive resource allocation, crisis communication skills, and adaptability to tailor responses to fluctuating circumstances, imperfect information, and to the diverse needs and roles of staff.37 Evidence shows that leadership development interventions can contribute effectively to successfully improved outcomes at the individual, organizational, and benefit-to-patients levels.61,62 Leaders need to be able to trust their staff to execute under pressure and to improvise with ad hoc problem solving and creative workarounds5; staff should be reassured that they will be supported in their decisions53 and that successful practices can lead to new procedural norms.9

    Properly debriefing pandemic performance and outcomes, particularly during the recovery stage, is a developmental and investment opportunity that should not be missed, particularly in terms of individual and system adaptability, resilience, emergency preparedness, and future viability.5,55,56,63

    Recalibrating, Optimizing, and Organizing
    Reassess Priorities Explicitly and Regularly and Provide Purpose, Meaning, and Direction

    It is vital to renew priorities and to provide direction regularly as the situation evolves,64 especially given the tendency for crises to derail organizational strategic plans.37 The recovery stage creates unparalleled opportunities to check underlying assumptions and to reassess with key stakeholders what matters most to the organization, including what should be prioritized and which services should be discharged, parked, or managed elsewhere.9,18 The iterative cycle of regularly assessing priorities should consider how to address the needs of population groups that have been overlooked or underserved5 and how to balance the potential benefits of proposed improvements and the anticipated toll of change fatigue on people’s energy levels and stamina. Frequent communication can help reduce confusion.37,53

    Especially as uncertainty heightens, leaders must inspire people with meaning and purpose37 by explicitly communicating the constants—what is not changing, despite the volatility—such as the commitments to core values and priorities, to keeping the best interests of people at the forefront of decision-making, and to overcoming adversity.5,40,65 This is vital to avoid succumbing to what has been called the “waiting it out” (until final resolution) syndrome.16 This syndrome is characterized by a prolonged limbo-like state of existence—merely plodding along with listlessness and depleted joy, passion, productivity, and ambition—which is marked solely by the passage of time. Distinctly separating the defining constants from the transposable (ie, structures, programs, processes, procedures) is a key leadership imperative and challenge, especially when the latter have become entrenched so deeply in the culture that they are treated as constants and impede optimization and innovation.66 Crises present a unique opportunity to illuminate this distinction.

    Lastly, it is essential to avoid focusing exclusively on managing short-term priorities. Being ambidextrous, that is, simultaneously considering future possibilities (“exploring”) and present obligations and opportunities (“exploiting”), is crucial for future-proofing, increasing organizational and system adaptability, and improving timely decision-making.19,67-69

    Maximize Team, Organizational, and System Performance and Discuss Enhancements

    Within each evolving context of the crisis, leaders need to critically reexamine conditions for top team, organizational, and system performance in collaboration with staff.9 This reexamination includes interorganizational collaboration, management structures, staffing, scheduling, costing, and achieving the optimal balance between in-person vs flex time for virtual care, work, education, and training. This process is an opportunity to break free from the default of “the way we’ve always done it” and should be based on the experiences, outcomes, and lessons of planned and improvised adaptations in earlier stages of the crisis.5,9,18 Without sacrificing organizational or system alignment and coordination, as much as possible, these decisions should be entrusted to leaders who are closest to the work and informed by the input of top performers and teams. This can include enabling high-performing teams to maintain some of the autonomy granted to them during the emergency stage. It is also important to agree on indicators of success for the proposed enhancements. The goal of discussing optimal approaches is to enhance effective and efficient care provision,70 staff engagement, and organizational and system capacity and resilience, as well as motivating and unifying people under a shared purpose.53

    Manage the Backlog of Paused Services and Consider Improvements While Avoiding Burnout and Moral Distress

    Managing the reintegration of services that were paused or that people avoided because of fear during the emergency stage, including surgeries, procedures, and diagnostic testing and screening, should be done in a strategic manner, rather than simply resuming previous operations. Reintegration decisions should be aligned with the evidence provided by outcomes research71 and contingent on organizational capacity and public health directives.72 Staff resilience, burnout, and the guilt and moral distress caused by the impact of service delays on patients and families should also be top considerations.43 Public trust in the health system may need to be regained through an effective communications strategy. Despite the logistical challenges, reintegration discussions present opportunities for optimization through process and service improvements, such as greater access to consultations with specialists and improved triaging in a “choosing wisely” approach,73 as well as for considering which services should be deprioritized, discontinued, or could be managed by collegiate organizations.

    Envisioning
    Sustain Learning, Innovations, and Collaborations, and Imagine Future Possibilities

    Looking forward, it is vital during the recovery stage to discuss how to capitalize on and commit to sustaining lessons learned, successful innovations, collaborations, and coalitions. The urgency of crises can ignite unparalleled innovation,5,9,28 which can circumvent traditional individual and organizational barriers to change. These barriers include entrenched resistance to change, rigid adherence to traditional mental and operational models, routines, and processes, excessive bureaucracy, and skepticism regarding the plausibility of introducing ideas from outside sources or organizations.5,74,75 Leaders should leverage the creative momentum and successes from the previous stages and secure space to reimagine possible improvements and future opportunities, rather than delaying this process until the pandemic is over.5,16,22,53 It is crucial to ensure that people understand that there is no returning to the former status quo or to “business as [previously] usual.”9,11 Instead, discussions should begin from a premise of abiding uncertainty and with a focus on thriving in an evolving context while imagining, inventing, and communicating the benefits of various better futures in the endemic world.8,9,28

    The concept of learning organizations provides a helpful model for a culture that can facilitate the requisite system improvements for ongoing resilience and sustainability. In this environment, people at all levels are enabled, within appropriate boundaries, to propose new ideas and to innovate spontaneously without seeking permission, while remaining coordinated and aligned with strategy.76 This approach combines centralized purpose and trust with judiciously decentralized power.20 Strategic foresight, adaptability, innovation, collaboration (across silos, organizations, communities, and disciplines), and the continuous reappraisal of optimal work conditions should become institutionalized and embedded in the organizational culture.18,22,28 This kind of culture increases organizational capacity and future viability,67 enhances team and organizational effectiveness complementarily in the present,28 and contributes to functioning as a complex adaptive system that evolves with the changing environment.77 Although this should ideally be embedded systemwide, it can be implemented at the team and unit level in alignment with overall strategy.78

    Crisis Communication
    Provide Regular Communication and Engender Trust

    Underpinning all the imperatives is the essential need for leaders to provide and engage in regular, clear, and unambiguous communication with their staff and stakeholders in a way that engenders trust and confidence.5,8,21,79 Cultivating a culture of trust requires instilling certainty that leaders are making decisions based on the best available evidence and always putting the health and wellness of their people and communities at the forefront.65 This also involves anchoring messaging in realism, being transparent when there is little evidence, and clarifying the process and criteria by which decisions are being made and their corresponding timelines.5,49,65 It is also important to selectively and consistently debunk false information,6,58 including messaging broadcast on social media, which is part of the “infodemic.”5,8,80

    Building trust may mean sharing detailed and even sensitive or controversial information with the community. It is also critical for leaders to create environments where constructive challenges are welcome, to acknowledge their own mistakes, to be explicit about what might have gone wrong, why, and what they have learned in the process.5,9 Finally, it is important to highlight achievements9 and to inspire confidence and hope that the commitment of the people, organization, and community to thriving in and emerging from the crisis will ultimately be successful.49

    In Consultation With Public Health and Fellow Leaders, Provide Safety Information and Recommendations to Government, Other Organizations, Staff, and the Community to Improve Equitable and Integrated Care and Emergency Preparedness Systemwide

    Health leaders have a unique opportunity and responsibility to influence long-term structural changes that are required for health care systems to address the needs of all people, including social determinants of health.6,8 Historically, international crises have ignited what Narayan et al8 have described as “a tipping point for proactive [altruistic] collective action.” Regional and international cooperation is paramount to effectively preventing disease movement, bolstering global leadership, and effectively addressing priority needs.2,4,5,8,58 Health and public health leaders should collate their expertise and experiential learning to advise government, in consultation with social and behavioral scientists and leaders from professional societies, other sectors, and community organizations on what is needed to address immediate and anticipated needs, as well as to strengthen future coordinated emergency response capacity.5,8,58,81 This also involves highlighting gaps, priority areas, and required resources, and making policy recommendations that are informed by input from the community.82 Frontline leaders have an equal responsibility to make recommendations for improvements to senior leaders in their own organizations based on their experience and requirements.

    Health and public health leaders have an additional role of informing and engaging staff and the community as part of a formal, coordinated, nonpartisan public health strategy.4,5 Serving as safety standard bearers is additionally important in jurisdictions where messaging from government officials, experts, and health leaders is not aligned.1

    Limitations

    This framework has several limitations. It is focused on an unprecedented phenomenon, the nature of which is evolving constantly. We also acknowledge that despite the diverse nature of our team of authors in terms of expertise and geographical location, it would be beneficial to validate our framework in other contexts globally. Third, we have deviated from the traditional Delphi method of including the input of international subject matter experts on the topic as respondents by elevating them to the role of coauthors, which has implications on the process and outcomes. Our view is that coauthorship enhances the level of responsibility that subject matter experts assume for the final framework, which augments its quality and credibility.

    Conclusions

    To our knowledge, the literature has neglected the crucial recovery stage of crisis response. The framework of 10 imperatives that we present provides support for health and public health leaders as they navigate the interweaving challenges and opportunities during the most dynamic phase of the daunting leadership test that is COVID-19.

    The organizations, communities, jurisdictions, and nations whose leaders most effectively distribute leadership and implement the imperatives are ideally positioned to address urgent needs and inequalities in health systems and to thrive with purpose, meaning, and the cocreation of a future that best serves its people. This cocreation must start now. Institutionalizing the imperatives and embedding them in organizational and systemwide culture and policies will ensure that the adaptability, capacity, and innovation needed for formidable responsiveness, resilience, and better health care equity are sustained long after this pandemic is over.

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    Article Information

    Accepted for Publication: June 2, 2021.

    Published: July 8, 2021. doi:10.1001/jamanetworkopen.2021.20295

    Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Geerts JM et al. JAMA Network Open.

    Corresponding Author: Jaason M. Geerts, PhD, The Canadian College of Health Leaders, 150 Isabella St, Ste 1102, Ottawa, K1S 1V7, Canada (jaasongeerts@cantab.net).

    Author Contributions: Dr J. Geerts had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: J. Geerts, Taheri, Abraham, Ahn, Best, Gardam, Ihekweazu, Johnson, Kooijman, Lafontaine, Loh, Stergiopoulos, Sutton, Wu.

    Acquisition, analysis, or interpretation of data: J. Geerts, Kinnair, Atun, Barberia, Dandona, Dhahri, Emilsson, Free, W. Geerts, Johnson, Leshem, Lidstone-Jones, Lyons, Neel, Nyasulu, Razum, Sabourin, Schleifer Taylor, Sharifi, Wu, Bilodeau.

    Drafting of the manuscript: J. Geerts, Abraham, Best, Dhahri, Razum.

    Critical revision of the manuscript for important intellectual content: J. Geerts, Kinnair, Taheri, Abraham, Ahn, Atun, Barberia, Dandona, Dhahri, Emilsson, Free, Gardam, W. Geerts, Ihekweazu, Johnson, Kooijman, Lafontaine, Leshem, Lidstone-Jones, Loh, Lyons, Neel, Nyasulu, Razum, Sabourin, Schleifer Taylor, Sharifi, Stergiopoulos, Sutton, Wu, Bilodeau.

    Statistical analysis: Wu.

    Administrative, technical, or material support: Gardam, Johnson, Lafontaine, Neel, Nyasulu, Sharifi, Sutton, Wu.

    Supervision: Taheri, Ahn, W. Geerts, Ihekweazu, Leshem, Loh, Bilodeau.

    Conflict of Interest Disclosures: None reported.

    Additional Contributions: We would like to thank Dr Isser Dubinsky, Institute of Health Policy, Management, and Evaluation, Miranda R. Ferrier, Canadian Support Workers Association, Major-General (Ret) Kristin Lund, Peace Research Institute Oslo, Ariane Séguin Massie, York University, Dr Kaveh Shojania, University of Toronto, and Dr Jamie Stoller, Cleveland Clinic, for their helpful feedback. Jerry Hacker, Carleton University, designed and created our graphic.

    References
    1.
    Editors.  Dying in a leadership vacuum.   N Engl J Med. 2020;383(15):1479-1480. doi:10.1056/NEJMe2029812PubMedGoogle ScholarCrossref
    2.
    Tedros  AG, Bainimarama  JV, Chan-o-cha  P,  et al.  COVID-19 shows why united action is needed for more robust international health architecture.  World Health Organization. Published online March 30, 2021. Accessed March 30, 2021. https://www.who.int/news-room/commentaries/detail/op-ed---covid-19-shows-why-united-action-is-needed-for-more-robust-international-health-architecture
    3.
    Peeri  NC, Shrestha  N, Rahman  MS,  et al.  The SARS, MERS and novel coronavirus (COVID-19) epidemics, the newest and biggest global health threats: what lessons have we learned?   Int J Epidemiol. 2020;49(3):717-726. doi:10.1093/ije/dyaa033PubMedGoogle ScholarCrossref
    4.
    PLOS Medicine Editors.  Pandemic responses: planning to neutralize SARS-CoV-2 and prepare for future outbreaks.   PLoS Med. 2020;17(4):e1003123. doi:10.1371/journal.pmed.1003123PubMedGoogle Scholar
    5.
    AlKnawy  B.  Leadership in times of crisis.   BMJ Leader. 2019;3(1):1-5. doi:10.1136/leader-2018-000100Google ScholarCrossref
    6.
    Sachs  JD, Karim  SA, Aknin  L,  et al; Lancet COVID-19 Commissioners, Task Force Chairs, and Commission Secretariat.  Lancet COVID-19 commission statement on the occasion of the 75th session of the UN General Assembly.   Lancet. 2020;396(10257):1102-1124. doi:10.1016/S0140-6736(20)31927-9PubMedGoogle ScholarCrossref
    7.
    Shukman  D.  Coronavirus: world reaches dangerous new phase.  BBC News. Published June 29, 2020. Accessed July 15, 2020. https://www.bbc.com/news/health-53210553
    8.
    Narayan  KMV, Curran  JW, Foege  WH.  The COVID-19 pandemic as an opportunity to ensure a more successful future for science and public health.   JAMA. 2021;325(6):525-526. doi:10.1001/jama.2020.23479PubMedGoogle ScholarCrossref
    9.
    Lancefield  D.  How to reinvent your organization in the middle of a crisis.  Harv Bus Rev. Published online February 15, 2021. Accessed March 19, 2021. https://hbr.org/2021/02/how-to-reinvent-your-organization-in-the-middle-of-a-crisis
    10.
    Chiriboga  D, Garay  J, Buss  P, Madrigal  RS, Rispel  LC.  Health inequity during the COVID-19 pandemic: a cry for ethical global leadership.   Lancet. 2020;395(10238):1690-1691. doi:10.1016/S0140-6736(20)31145-4PubMedGoogle ScholarCrossref
    11.
     Coronavirus will be with us forever, Sage scientist warns.  BBC News. Published August 22, 2020. Accessed August 26, 2020. https://www.bbc.com/news/uk-53875189
    12.
    Murray  CJL, Piot  P.  The potential future of the COVID-19 pandemic will SARS-CoV-2 become a recurrent seasonal infection?   JAMA. 2021;325(13):1249-1250. doi:10.1001/jama.2021.2828PubMedGoogle ScholarCrossref
    13.
    Del Rio  C, Malani  P.  COVID-19 in 2021 — continuing uncertainty.   JAMA. 2021;325(14):1389-1390. doi:10.1001/jama.2021.3760PubMedGoogle ScholarCrossref
    14.
     WHO warns Covid-19 pandemic is “not necessarily the big one.”  The Guardian. Published December 29, 2020. Accessed January 19, 2021. https://www.theguardian.com/world/2020/dec/29/who-warns-covid-19-pandemic-is-not-necessarily-the-big-one
    15.
    Tourish  D.  Introduction to the special issue: why the coronavirus crisis is also a crisis of leadership.   Leadership. 2020;16(3):261-272. doi:10.1177/1742715020929242Google ScholarCrossref
    16.
    Geerts  JM.  Our approach to COVID-19 won’t work as well for a second wave.  Globe and Mail. Published May 25, 2020. Accessed June 11, 2021. https://www.theglobeandmail.com/opinion/article-our-current-approach-to-covid-19-wont-work-as-well-for-a-second-wave/
    17.
    Barber  HF.  Developing strategic leadership: the US Army War College experience.   J Manag Dev. 1992;11(6):4-12. doi:10.1108/02621719210018208Google ScholarCrossref
    18.
    Empson  L, Howard-Grenville  J. How has the past year changed you and your organization? Harv Bus Rev. Published online March 10, 2021. Accessed March 19, 2021. https://hbr.org/2021/03/how-has-the-past-year-changed-you-and-your-organization
    19.
    Uhl-Bien  M, Arena  M.  Leadership for organizational adaptability: a theoretical synthesis and integrative framework.   Leadersh Q. 2018;29(1):89-104. doi:10.1016/j.leaqua.2017.12.009Google ScholarCrossref
    20.
    Child  J, McGrath  RG.  Organizations unfettered: organizational form in an information-intensive economy.   Acad Manage J. 2001;44(6):1135-1148. doi:10.2307/3069393Google Scholar
    21.
    Standiford  TC, Davuluri  K, Trupiano  N, Portney  D, Gruppen  L, Vinson  AH.  Physician leadership during the COVID-19 pandemic: an emphasis on the team, well-being and leadership reasoning.   BMJ Lead. Published online December 23, 2020. Accessed June 11, 2021. doi:10.1136/leader-2020-000344Google Scholar
    22.
    Esser  J.  The secret of adaptable organizations is trust.  Harv Bus Rev. Published online March 15, 2021. Accessed March 19, 2021. https://hbr.org/2021/03/the-secret-of-adaptable-organizations-is-trust
    23.
    Rokkas  P, Cornell  V, Steenkamp  M.  Disaster preparedness and response: challenges for Australian public health nurses - a literature review.   Nurs Health Sci. 2014;16(1):60-66. doi:10.1111/nhs.12134PubMedGoogle ScholarCrossref
    24.
    Gamble  MS, Hanners  RB, Lackey  C, Beaudin  CL.  Leadership and hospital preparedness: disaster management and emergency services in pediatrics.   J Trauma. 2009;67(2)(suppl):S79-S83. doi:10.1097/TA.0b013e3181af069fPubMedGoogle Scholar
    25.
    Kunzle  B, Kolbe  M, Grote  G.  Ensuring patient safety through effective leadership behaviour: a literature review.   Saf Sci. 2010;48:1-17. doi:10.1016/j.ssci.2009.06.004Google ScholarCrossref
    26.
    Hannah  ST, Uhl-Bien  M, Avolio  BJ, Cavarretta  FL.  A framework for examining leadership in extreme contexts.   Leadersh Q. 2009;20(6):897-919. doi:10.1016/j.leaqua.2009.09.006Google ScholarCrossref
    27.
    Kolditz  TA.  In Extremis Leadership. Jossey-Bass; 2007.
    28.
    Scoblic  JP.  Learning from the future.  Harv Bus Rev. 2020;98(4):38-47.
    29.
    Olson  CM.  Consensus statements: applying structure.   JAMA. 1995;273(1):72-73. doi:10.1001/jama.1995.03520250088040PubMedGoogle ScholarCrossref
    30.
    Helmer  O, Rescher  N.  On the epistemology of the inexact sciences.   Manag Sci. 1959;6(1):25-52. doi:10.1287/mnsc.6.1.25Google ScholarCrossref
    31.
    Franklin  KK, Hart  JK.  Idea generation and exploration: benefits and limitations of the policy Delphi research method.   Innov High Educ. 2007;31(4):237-246. doi:10.1007/s10755-006-9022-8Google ScholarCrossref
    32.
    Zonneveld  N, Raab  J, Minkman  MMN.  Towards a values framework for integrated health services: an international Delphi study.   BMC Health Serv Res. 2020;20(1):224. doi:10.1186/s12913-020-5008-yPubMedGoogle ScholarCrossref
    33.
    Mitroff  I, Turoff  M. Philosophical and methodological foundations of Delphi. In: Linstone  H, Turoff  M, eds.  The Delphi Method: Techniques and Applications. Addison-Wesley; 1975:17-35.
    34.
    Jones  J, Hunter  D.  Consensus methods for medical and health services research.   BMJ. 1995;311(7001):376-380. doi:10.1136/bmj.311.7001.376PubMedGoogle ScholarCrossref
    35.
    de Loë  RC, Melnychuk  N, Murray  D, Plummer  R.  Advancing the state of policy Delphi practice: a systematic review evaluating methodological evolution, innovation, and opportunities.   Technol Forecast Soc Change. 2016;104:78-88. doi:10.1016/j.techfore.2015.12.009Google ScholarCrossref
    36.
    Kezar  A, Maxey  D.  The Delphi technique: an untapped approach of participatory research.   Int J Soc Res Methodol. 2016;19(2):143-160. doi:10.1080/13645579.2014.936737Google ScholarCrossref
    37.
    Koehn  N. Real leaders are forged in crisis. Harv Bus Rev. Published online April 3, 2020. Accessed August 26, 2020. https://hbr.org/2020/04/real-leaders-are-forged-in-crisis
    38.
    Robbins  M. Why employees need both recognition and appreciation. Harv Bus Rev. Published online November 12, 2019. Accessed August 8, 2020. https://hbr.org/2019/11/why-employees-need-both-recognition-and-appreciation
    39.
    Stajkovic  AD, Lee  D, Nyberg  AJ.  Collective efficacy, group potency, and group performance: meta-analyses of their relationships, and test of a mediation model.   J Appl Psychol. 2009;94(3):814-828. doi:10.1037/a0015659PubMedGoogle ScholarCrossref
    40.
    Shanafelt  TD, Wang  H, Leonard  M,  et al.  Assessment of the association of leadership behaviors of supervising physicians with personal-organizational values alignment among staff physicians.   JAMA Netw Open. 2021;4(2):e2035622. doi:10.1001/jamanetworkopen.2020.35622PubMedGoogle Scholar
    41.
    Pfefferbaum  B, North  CS.  Mental health and the Covid-19 pandemic.   N Engl J Med. 2020;383(6):510-512. doi:10.1056/NEJMp2008017PubMedGoogle ScholarCrossref
    42.
    Stapleton  FB, Opipari  VP.  The current health care crisis-inspirational leadership (or lack thereof) is contagious.   JAMA Netw Open. 2020;3(6):e208024. doi:10.1001/jamanetworkopen.2020.8024PubMedGoogle Scholar
    43.
    Whelehan  DF, Algeo  N, Brown  DA.  Leadership through crisis: fighting the fatigue pandemic in healthcare during COVID-19.   BMJ Lead. Published online February 22, 2021. doi:10.1136/leader-2020-000419Google Scholar
    44.
    Maunder  RG, Lancee  WJ, Balderson  KE,  et al.  Long-term psychological and occupational effects of providing hospital healthcare during SARS outbreak.   Emerg Infect Dis. 2006;12(12):1924-1932. doi:10.3201/eid1212.060584PubMedGoogle ScholarCrossref
    45.
    Wiens  K, McKee  A.  Why some people get burned out and others don’t.  Harv Bus Rev. Published online November 23, 2016. Accessed September 1, 2020. https://hbr.org/2016/11/why-some-people-get-burned-out-and-others-dont
    46.
    Heifetz  RA.  Leadership without Easy Answers. Harvard University Press; 1994.
    47.
    Linzer  M, Poplau  S, Prasad  K,  et al; Healthy Work Place Investigators.  Characteristics of health care organizations associated with clinician trust.   JAMA Netw Open. 2019;2(6):e196201. doi:10.1001/jamanetworkopen.2019.6201PubMedGoogle Scholar
    48.
    Frazier  ML, Fainshmidt  S, Klinger  RL, Pezeshkan  A, Vracheva  V.  Psychological safety: a meta-analytic review and extension.   Pers Psychol. 2017;70(1):113-165. doi:10.1111/peps.12183Google ScholarCrossref
    49.
    Stoller  JK.  Reflections on leadership in the time of COVID-19.   BMJ Lead. 2020;4(2). doi:10.1136/leader-2020-000244Google Scholar
    50.
    Smallwood  J, Schooler  JW.  The restless mind.   Psychol Bull. 2006;132(6):946-958. doi:10.1037/0033-2909.132.6.946PubMedGoogle ScholarCrossref
    51.
    Shearer  FM, Moss  R, McVernon  J, Ross  JV, McCaw  JM.  Infectious disease pandemic planning and response: Incorporating decision analysis.   PLoS Med. 2020;17(1):e1003018. doi:10.1371/journal.pmed.1003018PubMedGoogle Scholar
    52.
    Snowden  DJ, Boone  ME.  A leader’s framework for decision making.   Harv Bus Rev. 2007;85(11):68-76, 149.PubMedGoogle Scholar
    53.
    Kanter  RM.  Leading your team past the peak of a crisis.  Harv Bus Rev. Published online April 30, 2020. Accessed August 26, 2020. https://hbr.org/2020/04/leading-your-team-past-the-peak-of-a-crisis
    54.
    Grint  K.  Leadership, management and command in the time of the Coronavirus.   Leadership. 2020;16(3):314-319. doi:10.1177/1742715020922445Google ScholarCrossref
    55.
    Alliger  GM, Cerasoli  CP, Tannenbaum  SI, Vessey  WB.  Team resilience: How teams flourish under pressure.   Organ Dyn. 2015;44(3):176-184. doi:10.1016/j.orgdyn.2015.05.003Google ScholarCrossref
    56.
    Tannenbaum  SI, Traylor  AM, Thomas  EJ, Salas  E.  Managing teamwork in the face of pandemic: evidence-based tips.   BMJ Qual Saf. 2021;30(1):59-63. doi:10.1136/bmjqs-2020-011447PubMedGoogle ScholarCrossref
    57.
    Shanafelt  TD, Makowski  MS, Wang  H,  et al.  Association of burnout, professional fulfillment, and self-care practices of physician leaders with their independently rated leadership effectiveness.   JAMA Netw Open. 2020;3(6):e207961. doi:10.1001/jamanetworkopen.2020.7961PubMedGoogle Scholar
    58.
    Kuehn  BM.  Africa succeeded against COVID-19’s first wave, but the second wave brings new challenges.   JAMA. 2021;325(4):327-328. doi:10.1001/jama.2020.24288PubMedGoogle ScholarCrossref
    59.
     The plight of essential workers during the COVID-19 pandemic.  Editorial.  Lancet. 2020;395(10237):1587. doi:10.1016/S0140-6736(20)31200-9PubMedGoogle ScholarCrossref
    60.
    Marion  R, Uhl-Bien  M.  Leadership in complex organizations.   Leadersh Q. 2001;12(4):389-418. doi:10.1016/S1048-9843(01)00092-3Google ScholarCrossref
    61.
    Geerts  JM, Goodall  AH, Agius  S.  Evidence-based leadership development for physicians: a systematic literature review.   Soc Sci Med. 2020;246:112709. doi:10.1016/j.socscimed.2019.112709PubMedGoogle Scholar
    62.
    Lyons  O, George  R, Galante  JR,  et al.  Evidence-based medical leadership development: a systematic review.   BMJ Lead. Published online November 16, 2020. Accessed June 11, 2021. doi:10.1136/leader-2020-000360Google Scholar
    63.
    Teece  DJ, Pisano  G, Shuen  A.  Dynamic capabilities and strategic management.   Strateg Manag J. 1997;18(7):509-533. doi:10.1002/(SICI)1097-0266(199708)18:7<509::AID-SMJ882>3.0.CO;2-ZGoogle ScholarCrossref
    64.
    Dixon  S, Meyer  K, Day  M.  Building dynamic capabilities of adaptation and innovation: a study of micro-foundations in a transition economy.   Long Range Plann. 2014;47(4):186-205. doi:10.1016/j.lrp.2013.08.011Google ScholarCrossref
    65.
    Jain  SH, Lucey  C, Crosson  FJ.  The enduring importance of trust in the leadership of health care organizations.   JAMA. 2020;324(23):2363-2364. doi:10.1001/jama.2020.18555PubMedGoogle ScholarCrossref
    66.
    Suarez  FF, Montes  JS.  Building organizational resilience.  Harv Bus Rev. 2020;98(6):47-52.
    67.
    Levinthal  DA, March  JG.  The myopia of learning.   Strateg Manag J. 1993;14(S2):95-112. doi:10.1002/smj.4250141009Google ScholarCrossref
    68.
    Angus  DC.  Optimizing the trade-off between learning and doing in a pandemic.   JAMA. 2020;323(19):1895-1896. doi:10.1001/jama.2020.4984PubMedGoogle ScholarCrossref
    69.
    O’Reilly  CA  III, Tushman  ML.  The ambidextrous organization.   Harv Bus Rev. 2004;82(4):74-81, 140.PubMedGoogle Scholar
    70.
    de Wit  M, Cooper  C, Reginster  J-Y; WHO-ESCEO Working Group.  Practical guidance for patient-centred health research.   Lancet. 2019;393(10176):1095-1096. doi:10.1016/S0140-6736(19)30034-0PubMedGoogle ScholarCrossref
    71.
    Roger  VL.  Outcomes research and epidemiology: the synergy between public health and clinical practice.   Circ Cardiovasc Qual Outcomes. 2011;4(3):257-259. doi:10.1161/CIRCOUTCOMES.111.961524PubMedGoogle ScholarCrossref
    72.
    Appleby  J.  Covid-19: a V shaped recovery for the NHS?   BMJ. 2020;370:m3694. doi:10.1136/bmj.m3694PubMedGoogle Scholar
    73.
    Born  K, Kool  T, Levinson  W.  Reducing overuse in healthcare: advancing Choosing Wisely.   BMJ. 2019;367:l6317. doi:10.1136/bmj.l6317PubMedGoogle Scholar
    74.
    Zahra  SA, George  G.  Absorptive capacity: a review, reconceptualization, and extension.   Acad Manage Rev. 2002;27(2):185-203. doi:10.5465/amr.2002.6587995Google ScholarCrossref
    75.
    Leonard-Barton  D.  Core capabilities and core rigidities: A paradox in managing new product development.   Strateg Manag J. 1992;13(S1):111-125. doi:10.1002/smj.4250131009Google ScholarCrossref
    76.
    Birkinshaw  J, Gibson  C.  Building ambidexterity into an organization.   MIT Sloan Manag Rev. 2004;45(4):47. Accessed June 11, 2021. https://sloanreview.mit.edu/article/building-ambidexterity-into-an-organization/Google Scholar
    77.
    Holland  JH.  Emergence: From Chaos to Order. Oxford University Press; 1998.
    78.
    Herington  MJ, Fliert  E van de.  Positive deviance in theory and practice: a conceptual review.   Deviant Behav. 2018;39(5):664-678. doi:10.1080/01639625.2017.1286194Google ScholarCrossref
    79.
    Lee  TH, McGlynn  EA, Safran  DG.  A framework for increasing trust between patients and the organizations that care for them.   JAMA. 2019;321(6):539-540. doi:10.1001/jama.2018.19186PubMedGoogle ScholarCrossref
    80.
    Managing the COVID-19 infodemic: promoting healthy behaviours and mitigating the harm from misinformation and disinformation. Joint statement from World Health Organization, United Nations, UNICEF, United Nations Development Programme, UNESCO, UN Programme on HIV/AIDS, International Telecommunication Union, UN Global Pulse, and International Federation of Red Cross and Red Crescent. World Health Organization website. Published September 23, 2020. Accessed February 9, 2021. https://www.who.int/news/item/23-09-2020-managing-the-covid-19-infodemic-promoting-healthy-behaviours-and-mitigating-the-harm-from-misinformation-and-disinformation
    81.
    Gates  B.  Responding to Covid-19 - a once-in-a-century pandemic?   N Engl J Med. 2020;382(18):1677-1679. doi:10.1056/NEJMp2003762PubMedGoogle ScholarCrossref
    82.
    Scally  G, Jacobson  B, Abbasi  K.  The UK’s public health response to Covid-19.   BMJ. 2020;369:m1932. doi:10.1136/bmj.m1932PubMedGoogle Scholar
    83.
    Rittel  HWJ, Webber  MM.  Dilemmas in a general theory of planning.   Policy Sci. 1973;4(2):155-169. doi:10.1007/BF01405730Google ScholarCrossref
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