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On August 25, 2017, Hurricane Harvey made landfall 180 miles south of Houston, our nation’s fourth largest city. Over 4 days, 50 inches of rain and 20 trillion gallons of water fell throughout greater-Houston and Southeast Texas, causing over 75 deaths. Weather forecasting enabled hospitals to prepare several days before the storm, but flooding occurred a day earlier than predicted, complicating the response.
Harvey is among the worst natural disasters in United States history, surpassing Tropical Storm Allison in 2001, which dumped 30 inches of rain, caused 23 deaths in Texas, and paralyzed the Texas Medical Center (TMC) with over $2 billion of damage.
The TMC is the largest medical center in the world and serves as an umbrella organization, home to over 50 member institutions, situated in a 2.1-square-mile area of Houston. Due to the TMC’s learnings from Allison, TMC hospitals remained fully operational, despite Harvey’s great severity (with the exception of Ben Taub Hospital, which evacuated three patients and had compromised pharmacy operations). Throughout Harvey, the Houston Methodist system operated each of its eight hospitals, including Houston Methodist Hospital, a 907-bed teaching hospital located in the TMC. Four business days post-storm, the Houston Methodist physician organization delivered care to its usual daily 4,000 ambulatory patients.
This occurred despite many challenges to staff, including the inability to travel, home evacuations, challenges with potable water, and electricity outages. Over 15% of the Houston Methodist workforce was affected by loss of home, car, or family member. Five success factors — disaster infrastructure, resilient culture, technological developments enabling constant communication, operations and preparedness of staff, and care coordination — made bracing the storm, and returning to business as usual afterward, possible.
Disaster Infrastructure: During Allison, infrastructure was insufficient to prevent hospital flooding. Furthermore, redundancies were uncommon, leading to critical failures in generators and other building infrastructure. Following Allison, improved flood gates were installed in TMC hospitals, and backup generators and transformers were relocated from basements to higher floors, avoiding power failure. Additionally, a co-generator plant was built to provide consistent power throughout disasters.
Resilient Culture: Organizational culture is not specific to emergency preparation and response; however, it is an important underlying success factor. Each facility in the TMC has a unique culture that manifested during Harvey. Houston Methodist has a value-based culture grounded in integrity, compassion, accountability, respect, and excellence (“I CARE values”).
Living these values leads to a workforce that makes well-intentioned decisions in both routine and challenging situations. This not only empowers staff, but it also provides a reliable foundation in which leadership can trust. One example of living these values arose in meeting unmet needs related to the disaster for staff and providers. Furthermore, recognition of staff for dedication and personal sacrifice may improve morale and align leadership and staff.
Technological Developments Enabling Constant Communication: Technological developments, often driven by Meaningful Use, provided the foundation for tailored communication with patients during Harvey. At Houston Methodist, this included patient portals to electronic health records and a sophisticated call center that allowed for quick and effective triage and direction of patients. Portals were leveraged for mass communication and diversion of patients to operational ambulatory facilities, as well as individualized communication (such as e-prescriptions and routine questions). Constant communication with and between staff is essential during a disaster for maintaining their situational awareness and the continuity of operations.
During Allison, email was not robustly used to communicate; furthermore, this challenge was compounded with the power outages and generator failures. But 16 years later, Houston Methodist could utilize email, text messaging, and social media to communicate with staff and to enable staff and providers to communicate with one another. Communication with staff was also performed four times daily regarding hospital preparations, routes to and from clinics and hospitals, availability of staff support, and more; there was also an open conference line for staff to call with unit-level operational groups. One remarkable development was the amplification of communication over social media — updates were published to the patient portal about clinic and hospital availability, which was leveraged through social media for the general public’s use. Furthermore, peer-to-peer assistance was made possible through an online portal, where employees could post personal needs, such as supplies or housing.
Operations and Preparedness of Staff: To empower quick and effective action, emergency policies and procedures were developed and drilled between Allison and Harvey. These included: clearly defined roles and responsibilities, with manageable span of control; procedures to ensure continuity of operations; advanced planning for labor needs, including ride-out and recovery phases; and policies to guide appropriate response.
At Houston Methodist, these were drilled annually as part of required employee education and training. Partially due to short notice of Allison, only routine levels of supplies were available. Part of these new policies and procedures included advanced stockpiling of food, medications, and supplies. These improvements enabled efficient decision-making and direction of staff.
Care Coordination: Population health management infrastructure and relationships fostered over the past 4 years between Houston Methodist and community partners were leveraged during the disaster. During Harvey, when local care was the safest option, we directed patients to affiliated retail and urgent care clinics. The health information exchange enabled sharing of records between facilities.
Challenges and Gaps
Nevertheless, despite major improvements to ensure continuity of operations, challenges remained during Harvey. One challenge was a lack of advanced planning for dialysis patients, whose usual facilities became inoperable during and immediately following the storm. Another challenge arose with social media. While this form of communication was generally helpful, such as postings about availability of facilities, at times it rapidly propagated misinformation. For example, social media reported that the Houston Methodist Hospital in the TMC had flooded, when in fact it remained operational throughout the storm. Conversely, social media was utilized quickly to correct the misinformation. One gap in coordination of care surfaced with retail pharmacies, with many unable to maintain operations during and following the storm. A possible solution may include integrating continuity of operation planning and personnel resourcing between hospital facilities and pharmacy locations.
The pursuit of high reliability demands that health care institutions continue to learn from failures and commit to resilience. Preparation, planning, and response of the TMC and Houston Methodist to Allison and the subsequent outcome of Harvey is an expression of this commitment.
Acknowledgements: We would like to acknowledge all of our staff and physicians for their remarkable display of compassion and teamwork throughout the devastating events that took place during Hurricane Harvey. Our success in overcoming these challenges is a true reflection of our dedication to our patients and communities.