Teamwork Culture Facilitated the Mass General Cardiac Surgery Response to COVID-19

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On March 11, 2020, the Incident Command System at Massachusetts General Hospital directed the Division of Cardiac Surgery to defer non-emergent cases, and some staff and resources were diverted to expanded ICUs. In ramping down from about eight cases per day to approximately one to three, the division functioned as a coherent unit, applying uniform ground rules to all surgeons' practices.

There were no complaints about favoritism or inequity because of the sense of cohesion, mutual trust and teamwork that had been established over the course of previous years. Arminder S. Jassar, MBBS, cardiac surgeon, and Thoralf M. Sundt III, MD, chief of the Division of Cardiac Surgery and director of the Corrigan Minehan Heart Center, explain the particulars in the Journal of Cardiovascular Surgery.

A "Unit," Not a "Division"

Some cardiac surgery departments celebrate the team over the individual; in others, surgeons essentially run independent practices, often competing with each other overtly or subtly. The Cardiac Surgery Division at Mass General explicitly aims to combine the best of both paradigms through practices such as:

• Strategically hiring individuals who have specific skill sets and diverse clinical and academic interests, that complement rather than compete with the interests of other team members
• Having both outpatient and inpatient referrals received by a central referral coordinator who has access to the clinic schedule andoperating room (OR) availability for all surgeons, and can help direct patients based on acuity and patient or referring physician's preference
• Sharing OR block time equally among all surgeons from the newest hire to the most senior
• Weekly division meetings about matters of concern (e.g., division finances, resident education, ICU protocols, upcoming clinical trials)
• Promoting a shared sense of responsibility for outcomes via an unblinded review of mortality and morbidity data
• Basing the surgeon compensation plan on relative value units to neutralize the impact of differences in payor mix
• Basing annual bonuses on the overall margin generated by the group rather than each surgeon

Good Teams Beat Great Players

Because of the "bank account" of trust built over preceding years, in March 2020, the division pivoted to a new pandemic-driven workflow without major conflict.

Centralized control—Individual allocation of OR slots was abolished, and inpatients requiring urgent care were centrally referred to surgeons on a largely rotating basis.

A weekly videoconference was instituted to discuss outpatient cases listed for the OR the following week, with leaders from cardiac anesthesia, OR nursing, perfusion and critical care included. Each surgeon presented patients from their practice that they felt could not be deferred, and the whole team prioritized the cases collectively.

Deferral lists—As ORs and ICU beds became available again, a single waitlist of pending outpatients (comprising of all surgeon practices) was assembled, from which patients were prioritized for surgery based on clinical urgency.

Backlogs varied among surgeons (e.g., patients with critical aortic stenosis had been prioritized over those needing elective mitral valve repair). Surgeons with long waitlists volunteered to defer accepting new consults until they could clear their queue, which allowed surgeons with shorter waitlists to take a greater proportion of new referrals, again allowing equalization of workload between surgeons, while minimizing wait times for the patients.

Strengthened by the Crisis

Certain changes to workflow proved so helpful that they have been preserved:

• The weekly videoconference has become a brief daily huddle at 6:45 am where surgeons, anesthesiologists, perfusionists and nurses review the anticipated flow of the day—surgeons describe their cases in one sentence and all can offer (or solicit) suggestions about particularly challenging or high-risk patients. Anesthesia and nursing logistics are discussed. Surgeons with less busy schedules for the day may offer to assist in ways in which we were all previously would have been unaware of
• Monthly multidisciplinary team meetings to discuss patients with endocarditis have been supplemented with ad hoc videoconferences, expediting decision-making for these complex patients
• Clinics have become "smart": many initial and postoperative visits with the surgeon are performed by video or telephone conference, a welcome change for the many patients who previously needed to travel a significant distance to our tertiary referral center

Shaping Organizational Culture

Organizational culture is expressed as values, behaviors and processes. The Mass General Division of Cardiac Surgery values collective success and has established processes that promote transparency, shared responsibility for shared resources and collective reward. This culture of teamwork allowed all staff to better accommodate the stresses of the COVID-19 crisis, which actually made the unit stronger.

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Learn more about the Division of Cardiac Surgery

Refer a patient to the Corrigan Minehan Heart Center