Quality work is the psychological safety and wellbeing of our workforce. The original first tenet of our quality transformation plan centered on building a culture of safety to encourage transparency, trust, and wellness in frontline staff. As COVID-19 plundered our communities, addressing emotional distress and psychological safety remained at the forefront of our efforts.

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Healthcare Quality in a Post-COVID-19 World
By.Dr.Mahboob Khan
Covid-19 started in Wuhan in early January with 44 cases in
just 12 months the cases jumped to 105 million infected and 2
million deaths globally.
Priority 1: Focus on Psychological Safety.
Quality work is the psychological safety and wellbeing of our
workforce. The original first tenet of our quality transformation plan
centered on building a culture of safety to encourage transparency,
trust, and wellness in frontline staff. As COVID-19 plundered our
communities, addressing emotional distress and psychological safety
remained at the forefront of our efforts.
Like many healthcare workers across the globe caring for COVID-19
patients, our staff members experienced insurmountable grief, anxiety,
and stress from the burden and uncertainty brought on by the pandemic.
Consequently, we are aware of a “parallel pandemic” caused by the
emotional toll and second victimization of staff. To best support our
workforce, we are committed to truly understanding and responding to
their needs.
Therefore, prioritizing psychological safety will be a key aspect
integrated into QI projects. To underscore this, a system chief wellness
officer position has been created, which integrates psychological
safety, care experience, and QI roles.

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Priority 2: Reprioritize QI Activities for COVID-19
Foundational to all QI activities across hospitals are the
system's 5 strategic pillars: quality and outcomes, care
experience, financial sustainability, access to care, and
culture of safety. Specifically, improvement projects
conducted throughout facilities and services within the
system align with at least 1 of these pillars. While the
strategic pillars continue to be essential in prioritizing
quality activities post-COVID-19, we must also consider
the effects of the pandemic on the workforce.
It is important to also note that many changes were rapidly
implemented during the COVID-19 surge. We must review these
changes and formalize ways to sustain and reimplement useful
processes in consideration of another surge, especially those that
expanded access to care. For example, we quickly implemented a
centralized telehealth palliative care program with 5 hospitals during
the surge, as critically ill COVID-19 patients and their families faced
challenging end-of-life decisions. Disaster credentialing and
onboarding of 64 palliative care physician volunteers from less-
affected areas across the country supported local palliative care
telehealth efforts in the system, and over a 2-week period, volunteers
completed 109 palliative care video or phone consults with patients and
families needing to discuss end-of-life care. Despite not having a strong
telehealth infrastructure within the system prior to the pandemic,
volunteers and hospital site leads noted substantial benefits of the
program. Resilience of the system in consideration of COVID-19
depends on learning from rapidly tested programs like this, and the
ability to quickly develop similar efforts will allow us to be more
flexible and expand healthcare services remotely.
Lastly, protecting our staff from unnecessary exposure to COVID-19
is a priority. An early report from the Centers for Disease Control and
Prevention reported that between February 12 and April 9, 2020,
approximately 10% of US healthcare staff who acquired COVID-19

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during the pandemic required hospitalization. International efforts,
such as Choosing Wisely, have now expanded focus in consideration
of COVID-19, and our clinical workflows and QI must be streamlined
to reduce overuse, now more than ever, to protect patients and frontline
staff.
Priority 3: Modify Quality Reporting and Management
Activities
The hospitals consistently prioritized quality and engaged with facility
leadership to understand goals for improvement. Through quarterly,
facility-based QAPI committees reporting to the Board, we
incorporated discussions about COVID-19 execution and response at
each facility's meetings. This not only gives QAPI board members an
opportunity to inquire about the response, but it also affords facility
leadership, clinicians, and staff a chance to share their successes and
challenges as they continue to treat and learn about COVID-19 in the
communities they serve. This transparent dialogue with QAPI
committees reporting to the Board about the monumental efforts
combatting COVID-19 will evolve as we continue to understand the
ways in which we can improve quality as it relates to COVID-19
response.
Priority 4: Resume QI Capacity Building
Quality cannot advance without building internal QI capacity across all
staff and without the involvement of frontline workers. Outlined in our
transformation plan is a focus on developing skills, understanding, and
expertise at all levels of the workforce so we can effectively drive
change and make sustainable improvements. To optimize staff roles in
QI, we constructed a 4-tiered approach: Tier 1 – develop a shared,
baseline understanding of quality in all hospitals employees; Tier 2 –
develop the next generation of QI leaders, targeted to both clinical and
nonclinical staff; Tier 3 – build managers and supervisors' ability to
empower those leading QI efforts in Tier 2; and Tier 4 – build
executives' capacities to sponsor QI efforts and align with the hospitals
mission and vision. Over the past year, most activities and trainings to
support this transformation had been in-person meetings until the pause

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due to the COVID-19 response. However, the post-COVID-19 world
in lieu of new social distancing guidelines and restrictions on in-person
meetings will necessitate innovation to continue QI capacity building
programs.
We also must consider education for medical students and residents.
Because of the immediate response to COVID-19, medical education
was shortened, and hospitals were forced to cancel residents'
educational conferences, electives, and off-service rotations so they
could solely focus on the crisis. For medical students, all lecture-based
learnings were moved to online platforms, a method not uncommon to
students, especially those at schools where attendance is not
mandatory.11 The crux of any medical education is apprenticeship
training, with students in clinical settings obtaining hands-on training
from experienced physicians; interruptions in clinical rotations may
have a dramatic effect on a medical student's career trajectory. This
raises a potential issue: What impact, if any, will such an interruption
of clinical training have on the future for healthcare and the medical
profession?

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Conclusion and Implications for the Future
The pandemic has forced us to reassess and think
creatively about quality in the post-COVID-19 world.
We all yearn to get back to normalcy, but we are cautious
of the potential harm “normal” quality and safety
activities could cause healthcare workers who are still
reeling from their experiences through the COVID-19
surge. Workforce emotional support and wellbeing has
been and continues to be at the center of all quality
activities as we balance system learning and
improvement in preparation for the next wave and
continue to build a culture of trust and transparency.
Another key priority is to sustain beneficial new
processes operationalized during the surge, which may
contribute to future resiliency. Quality management and
reporting remain crucial to driving change that improves
care, even during a pandemic. Identifying specific
COVID-19-related quality measures and developing
process improvements are important to enhance our
response to a possible future surge. Continuing education
through our QI capacity building structure, with COVID-
19 considerations in mind, will also build staff resiliency.
We, like everyone else, are grappling with the question,
“What is quality in the post-COVID-19 world?”
Learning as we go and sharing lessons broadly across the
organization and beyond within each of the 4 priorities
articulated will help foster a culture of continuous
improvement in the post-COVID-19 world.