Imperatives of Leadership: A Pandemic Response

“We few, we happy few, we band of brothers…”

The name of this website was inspired by an article on leadership based on two books by Sandhurst military historian John Keegan. The Face of Battle was his 1976 analysis of major battles in history including Agincourt (October 27, 1415). His 1987 book The Mask of Command highlighted styles of military leadership through history and concluded with five of what Keegan considered to be the “Imperatives of Leadership:” kinship, prescription, sanction, action, and example. The 1998 article examined Shakespeare’s speech by Henry at Agincourt (Henry V, Act 4, Scene 3) as an example of Keegan’s leadership imperatives.

In the early spring of 2020 as the COVID pandemic gained momentum, US Army Colonel (Retired) Dr. Jim Ficke and I were asked at the behest of the Governor to stand up a field hospital in the Baltimore Convention Center with a number of leaders from Johns Hopkins Medicine, the University of Maryland Medical Center and the Maryland Department of Health.

Fifteen months later the team concluded inpatient operations after providing care for 1,495 inpatients with COVID. Along the way (and often with short notice) we added missions including a mass COVID testing capability and later numerous community sites that have performed more than 110,000 tests to date. Monoclonal antibody infusions were added in the autumn of 2020 and more than 2,300 have been provided since. And finally, when vaccines became available,  a large-scale vaccination center was opened that has provided more than 122,000 vaccinations since February 2021. The Baltimore Convention Center Field Hospital (BCCFH) is almost certainly the longest continually operating convention center COVID hospital in the nation, and probably the only one where the same team also provided ambulatory infusion treatment, large scale COVID testing and vaccination.

In retrospect, Keegan’s imperatives of leadership were the standard as we established and operated the hospital. In many ways, they were key elements of its success.

Kinship. (“Blood” relationships.) Henry declared his force at Agincourt to be a band of brothers. With the expert assistance of Johns Hopkins Medicine (recruited and hired provider staff) and the University of Maryland Medical System (recruited and hired nursing and support staff) a team came together that over time numbered more than 3,000 professionals. These women and men courageously signed up to care for patients with COVID at a time when little was known about the disease and its potential risks. The staff, executive team, contract security, environmental services and logistics personnel were on a first name basis from the beginning and shared duties, meals (socially distanced) and common spaces. Recently the team conducted a white coat ceremony for a college graduate who worked with us. She had emerged as one of our key site leaders and was leaving for medical school. The ceremony was the idea of staff and mid-level leaders. We have become family to one another.

Prescription. (Directive with authority.) On a cold autumn morning, Henry laid out expectations for his weary, outnumbered troops near a castle named Agincourt. The BCCFH is a unit created from scratch: it had no name, no heraldry, no reputation. Working with the Governor’s office within weeks the team established the organization’s formal name (“Baltimore Convention Center Field Hospital,” the “BCCFH”) and logo (the visible sign of an organization’s identity and brand). With the Maryland National Guard and architectural support through the Maryland Department of Health, an inter-agency group assembled the 250-bed “FEMA field station” hospital in 128,000 square feet of convention center exhibit hall and we were ready for inpatient care in less than a month. (Care was delayed a week or two while all the necessary personal protective equipment was secured. To assure staff safety in the face of national shortages, we wanted two weeks’ supply on hand before we began treating patients.) As missions were added to the hospital our identity was forged by rapidly evolving expertise in COVID-care and the brand was embodied by the adage, “Yes we can. What’s the question?” This message was reinforced with “elevator speeches” at daily huddle, at informal and formal gatherings of staff and by regular all-staff emails. Staff embraced the field hospital’s motto (borrowed from shared military experience) displayed in large letters on a convention center wall: “One Team. One Fight.”

Sanction. (Permission, penalty or reward.) Henry’s warriors knew what was at stake in terms of risk and return. In Maryland, the COVID surge of the spring of 2020 was followed by three additional surges in late summer, late fall and mid-winter to spring that stretched state health care systems to their limits. The fifth surge of cases began this month. With every mission, the team has understood the field hospital’s responsibility to the City and State. This is a relentless, evolving crisis that has disproportionately affected the underserved populations of our city (and our nation). Our BCCFH teammates speak openly of their commitment to these individuals in all of our treatment and testing settings. As an example, where the monoclonal antibody infusion emergency use authorization (EUA) required a provider referral, the infusion and care coordination teams developed a system of telemedicine consults to support patients who didn’t have a primary care physician to refer them for treatment. A healthy leadership climate is demonstrated by shared risk, shared respect and shared reason. The most significant medical crisis of our lifetimes provided a singular, focused reason and the BCCFH has been consistently fortunate to have more staff members interested in working than there are shifts available to work.

Action. (The act of doing; a thing done.) Henry scouted the enemy troops himself and then personally lead them into battle. There was an enormous amount of operational planning to stand up a hospital from scratch, and to establish standard of care for all components; addressing each of what Dr. Paul Farmer calls the “staff, stuff, systems and space” of a health care setting. Jim had commanded a hospital in Iraq while he was in the Army and I had helped run a health system in the combat theater as well as a number of military hospitals in the states. The BCCFH is fortunate to have an executive team, advisory group, governing body and quality team of accomplished leaders from Hopkins, University of Maryland and the Maryland Department of Health, as well as a number of contracted nursing, logistic and security professionals. Leaders had to balance time on the ground rounding in the inpatient and ambulatory infusion “hot zone,” assisting with testing at community sites and weekend mass vaccination with planning and operating at the strategic level. The team was well prepared from shared civilian and military experience and well supported by a cast of talented professionals and leaders. It was and is “One Team.”

Example. (Follow me.) “He today who sheds his blood with me shall be my brother,” Henry declared. And then he fought alongside his men and shared the same risks. Keegan says that the most important imperative of leadership is example: the leader must be present. At the height of our busiest days testing (up to 1,500 patients a day) or vaccination (nearly 3,000 a day) members of the exec team worked alongside their colleagues wiping down tables and chairs, talking to queues of waiting patients, handling patient concerns and more often, receiving patient compliments. They helped with community site set up and tear down. Leaders have tested and vaccinated. In the hot zone, we inspected bathrooms, tidied nursing stations, rounded and met with patients and staff. Recently when nurses were unavailable to care for our infusion patients, the nurse and clinician managers stepped in and provided direct patient care. The leadership team didn’t want anyone to think “That’s not my job.” Everyone embraced the mindset: “It’s my house.” It started with us.

Recently a social worker who has been a part of the team since our earliest days said, “This has been the most rewarding experience of my professional career.” It is a theme we have heard countless times. And frankly I think the leaders agree. In June as we closed inpatient operations, we distributed unit patches – purchased by the executive team – to every team member. It is an Army tradition that an individual who serves in combat can wear that unit’s patch for the remainder of their career.

This team has earned the right. Certainly it has not all been perfect. We were practicing medicine and public health in a convention center exhibit hall, in streets and on parking lots. But as the BCCFH transitions its ongoing missions this autumn and becomes a State COVID task force, it continues to be an honor to lead this team – this band of brothers and sisters – in what will likely be the fight of our lives.

Chuck Callahan Henry V 4.3 – Lead from the Front   https://henryv43.com/