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Crises and Turnaround Management: Lessons Learned from Recovery of New Orleans and Tulane University Following Hurricane Katrina

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  • University of Nevada, Las Vegas School of Medicine

Abstract and Figures

By their very nature both man-made and natural disasters are unpredictable, and so we recommend that all health-care institutions be prepared. In this paper, the authors describe and make a number of recommendations, regarding the importance of crisis and turnaround management using as a model the New Orleans public health system and Tulane University Medical School post-Hurricane Katrina. Leadership skills, articulation of vision, nimble decision making, and teamwork are all crucial elements of a successful recovery from disaster. The leadership team demonstrated courage, integrity, entrepreneurship, and vision. As a result, it led to a different approach to public health and the introduction of new and innovative medical education and research programs.
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RAMBAM GRAND ROUNDS
Open Access Rambam Maimonides Medical Journal
Abbreviations: FEMA, Federal Emergency Management Administration; FQHC, Federally Qualified Health Center;
NIH, National Institutes of Health; TUHC, Tulane University Hospital and Clinic; TUSOM, Tulane University School of
Medicine.
Citation: Kahn MJ, Sachs BP. Crises and Turnaround Management: Lessons Learned from Recovery of New Orleans and
Tulane University Following Hurricane Katrina. Rambam Maimonides Med J 2018;9 (4):e0031. Review.
doi:10.5041/RMMJ.10354
Copyright: © 2018 Kahn and Sachs. This is an open-access article. All its content, except where otherwise noted, is
distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.
Conflict of interest: No potential conflict of interest relevant to this article was reported.
* To whom correspondence should be addressed. E-mail: bsachs@strategyimplemented.com
Rambam Maimonides Med J | www.rmmj.org.il 1 October 2018 Volume 9 Issue 4 e0031
Special Issue Celebrating the 80th Anniversary of Rambam Health Care
Campus
Crises and Turnaround Management:
Lessons Learned from Recovery of New
Orleans and Tulane University
Following Hurricane Katrina
Marc J. Kahn, M.D., M.B.A., M.A.C.P.1,2,3,4 and Benjamin P. Sachs, M.B., B.S.,
D.P.H.5,6*
1The Peterman-Prosser Professor and Senior Associate Dean at Tulane University School of Medicine,
New Orleans, LA, USA; 2Department of Pharmacology, Tulane University School of Medicine, New
Orleans, LA, USA; 3The AB Freeman School of Business, Tulane University, New Orleans, LA, USA;
4Department of Medicine and Office of Admissions & Student Affairs, Tulane University School of
Medicine, New Orleans, LA, USA; 5Visiting Professor of Obstetrics and Gynecology, The Ruth & Bruce
Rappaport Faculty of Medicine, TechnionIsrael Institute of Technology, Haifa, Israel; and 6Sackler
Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
ABSTRACT
By their very nature both man-made and natural disasters are unpredictable, and so we recommend that all
health-care institutions be prepared. In this paper, the authors describe and make a number of recommen-
dations, regarding the importance of crisis and turnaround management using as a model the New Orleans
Crisis Management Following Hurricane Katrina
Rambam Maimonides Medical Journal 2 October 2018 Volume 9 Issue 4 e0031
public health system and Tulane University Medical School post-Hurricane Katrina. Leadership skills,
articulation of vision, nimble decision making, and teamwork are all crucial elements of a successful
recovery from disaster. The leadership team demonstrated courage, integrity, entrepreneurship, and vision.
As a result, it led to a different approach to public health and the introduction of new and innovative medi-
cal education and research programs.
KEY WORDS: Crisis management, education, health-care reform
INTRODUCTION
On Monday August 29, 2005, Hurricane Katrina
came ashore on the Mississippi Gulf Coast as a cate-
gory 3 storm (on the SaffirSimpson Hurricane
Scale). The storm stretched across some 645 km and
had sustained winds of 160225 km per hour. The
following morning, August 30, the levees, engin-
eered to protect the city of New Orleans, failed.
There were an estimated 53 breeches of the levees,
flooding over 80% of the city. Approximately 1,836
deaths were directly attributed to the storm, although
it is not known how many people subsequently died
or suffered because of a lack of health care, stress, or
hurricane-related injuries.1 The damage to property
exceeded US$150 billion, and parts of the Missis-
sippi Gulf coast disappeared. Over 1 million people
from Louisiana, Mississippi, and Alabama fled the
storm, with the US Census estimating a nearly 50%
decrease in New Orleans’s population between 2000
and 2006, the year following the hurricane. Although
the storm hit on Monday August 29, 2005, it took
until the following Friday for the US federal govern-
ment to come in force to save the residents of New
Orleans.2 During these five days the physicians and
nurses at Charity Hospital and surrounding health-
care facilities in New Orleans had to work under
unbelievable conditions, with no electricity or water,
in buildings reaching 35 degrees Celsius and 100%
humidity. According to the Federal Emergency Man-
agement Agency (FEMA), Katrina was “the single
most catastrophic natural disaster in US history.”3
The first author (M.J.K.) is the Peterman-Prosser
Professor and Dean of Students at Tulane Medical
School (New Orleans) who experienced Hurricane
Katrina as a faculty member and administrator; the
second author (B.P.S.) was recruited, in November
2007, as the Senior Vice President, Dean and Doty
Distinguished Professor of Tulane Medical School.
He had worked at Harvard Medical school for 29
years, and at the time he was recruited he had been
the Rosenfield Professor at Harvard Medical School
& Harvard School of Public Health (19972007),
Chair of the Department of Obstetrics, Gynecology,
and Reproductive Biology at Beth Israel Deaconess
and Harvard Medical School (19892007), and the
President of the Beth Israel Deaconess Physician
Organization (19992007).
The following are lessons learned from the recov-
ery of Tulane and the New Orleans’s public health
system, and, from our perspective, what worked and
did not work. These lessons learned are shared
because catastrophes can occur in other places and
times, and the lessons themselves are generalizable
to many other circumstances. Specifically, Israel is
at risk of both a major war and natural disasters
such as an earthquake with or without a tsunami.
Israel sits on the boundary of two tectonic plates:
to the west the African Plate (Golan Heights and
Jordan) and to the east the Arabian Plate (Galilee,
West Bank, Coastal Plain, Negev, and the Sinai Pen-
insula). The region has a long history of lethal earth-
quakes. The historian, Josephus Flavius, reported
that an earthquake in 31 BCE killed 30,000 people
in the Jordan Valley. In 1927, approximately 500
people died in the “Jericho Earthquake” affecting
Jerusalem, Jericho, Ramle, Tiberias, and Nablus,
and both the Church of the Holy Sepulcher and the
al-Aqsa Mosque experienced major damage. Be-
cause of politics and location, Israel’s vulnerability
to war and its aftermath goes without saying.
PRE-KATRINA NEW ORLEANS
Tulane University School of Medicine (TUSOM) was
established as the Medical College of Louisiana in
1834. Located in downtown New Orleans, TUSOM is
one of the oldest medical schools in the deep south
of the United States and was mentioned in the 1910
Flexner Report as one of only a few schools in the
southern USA as being educationally sound in its
academic programs.4 Since its inception, TUSOM
has been closely affiliated with Charity Hospital,
which was founded in 1736 as a New Orleans
hospital for the poor. Prior to Hurricane Katrina, in
August 2005, TUSOM had close clinical affiliations
Crisis Management Following Hurricane Katrina
Rambam Maimonides Medical Journal 3 October 2018 Volume 9 Issue 4 e0031
with the Veteran’s Administration Hospital New Or-
leans (VAHNO) and Tulane University Hospital and
Clinic (TUHC). In 1996, TUHC was purchased by
the for-profit entity Columbia HCA, now known as
Hospital Corporation of America (HCA). It is run as
a joint venture between Tulane and HCA. Prior to
Hurricane Katrina, TUSOM had its challenges:
TUSOM was undercapitalized and was threatened
with probation by the Liaison Committee on Medi-
cal Education (LCME). Several of its graduate medi-
cal education (GME) programs were in jeopardy of
losing accreditation.
Pre-Katrina, New Orleans had a population ap-
proaching half a million people. Over half of the
population was African-American. Louisiana had
the highest homicide and incarceration rates in the
USA and was ranked 49th out of 50 US states in
respect to health outcomes.5 Upwards of 30% of the
New Orleans population lived below the poverty
level, the public-school system was failing, and near-
ly 30% of the population was medically uninsured so
that the majority of their care, including primary
care, was provided through the Emergency Depart-
ment at Charity Hospital. Louisiana had the highest
cost per capita of federally funded Medicare and the
worst health outcomes of any state in the USA.5,6
This is not surprising, given that so many residents
had poor care for most of their lives and that once
people became eligible for Medicare at age 65 it was
too late to reverse their chronic diseases. To make
matters worse, Louisiana had one of the strictest
criteria for state and federal health-care assistance
(Medicaid). Medicaid is a health-care program that
assists low-income families or individuals in paying
for doctor visits, hospital stays, long-term medical
custodial care costs, and more. Louisiana required a
family of four to have an income below $4,500 to
qualify for Medicaid and had the provision that
adults without children were completely ineligible
for financial assistance regardless of income.7
HURRICANE KATRINA
From a public health perspective, five hospitals in
New Orleans were destroyed by Hurricane Katrina,
including the 550-bed Charity Hospital and the 400-
bed Veteran’s Administration Hospital. The TUHC
and the Tulane University sustained over US$900
million in damage.8 Tulane University declared
financial exigency and borrowed US$100 million to
stay solvent. The School of Medicine lost one-third
of its faculty due to attrition or dismissal. Research
facilities, including records and specimens, were
destroyed. As a temporary measure, TUSOM moved
its educational programs to Houston, Texas, 350
miles from home for the entire 20052006 academ-
ic year.9 Morale was low, post-traumatic stress
disorder was rampant, and teaching beds were in
short supply.10
Following the hurricane and its resultant loss
and destruction, the question was often asked: “Why
save New Orleans?”11 From an economic perspec-
tive, the answer was simple. The Port of New Or-
leans and the Port of South Louisiana in the nearby
town of Laplace combine to form the largest port
system in the world based on annual tonnage.
Additionally, Louisiana ranks in the top three states
in the USA for oil and natural gas production, re-
sponsible for 30% of total US production, and leads
the country in offshore oil production. From a
cultural perspective, New Orleans is unique, blend-
ing French, Spanish, Creole, Native American, and
Anglo roots. As a result, New Orleans has its own
cuisine and music that rivals any in the world. In
many ways New Orleans represents the best in
America: economic opportunity, a unique culture,
and a diverse population. It is in many ways the
quintessential American city.
POST-KATRINA RECOVERY
In planning for recovery, we recognized that the
faculty, residents, and students who returned and
remained in New Orleans after Katrina were people
of immense courage who, despite enormous person-
al challenges, were determined to save New Orleans,
its community, and Tulane University. Many if not
most professionals had the choice of leaving the city.
Yet, they bravely decided to stay and help build a
safer and better New Orleans.
The Dean and Senior Vice President of TUSOM
(B.P.S.) officially took on this new role in November
2007. However, strategy planning began three
months beforehand, with commutes from Boston to
New Orleans and Washington DC. Following the
storm, Tulane University had hired three consulting
firms and had been through a number of strategic
planning processes with little to show for the efforts.
The new Dean recognized that there would be no
tolerance among the faculty for more strategic plan-
ning. What was needed was definitive action. A
major concern was that unless decisive actions were
taken, faculty would leave. During the three months
prior to his official start date, the new Dean com-
muted from Boston, spending a significant amount
Crisis Management Following Hurricane Katrina
Rambam Maimonides Medical Journal 4 October 2018 Volume 9 Issue 4 e0031
of time listening, learning, and taking notes about
the social, political, economic, and health-care situa-
tion in New Orleans, TUHC, and Tulane University.
Furthermore, the new Dean built a network of
contacts in New Orleans with the help of friends and
colleagues, including business and civic leaders from
around the country. The Dean recognized that if he
were to make a difference in New Orleans, he would
need to have strong relationships with business
leaders and local community leaders, including
religious figures, politicians, the African-American,
Vietnamese, and Hispanic Communities, and above
all the Federal Government.
In the Dean’s initial message to the Tulane com-
munity, he wanted to give a sense of purpose and
pride and to encourage entrepreneurship. The key
points he made were:
We will help to build a different health-care sys-
tem, not rebuild.
The time to act is now. No more consultants or
“strategic planning.”
Turn adversity into opportunity.
The door to the Dean’s office is always open. All
are welcome to come to discuss problems with
their recommended solutions.
All medical schools have the tripartite mission of
education, research, and clinical care. The Tulane
faculty developed a new vision/mission statement in
the form of a logo with the motto “We Heal Com-
munities” as the fourth mission (Figure 1). The Dean
believed that this message would allow the Tulane
community to move forward to take care of patients,
to do research, to educate trainees, and to better the
city of New Orleans. This new vision provided the
rallying cry to recruit students and faculty to the
School of Medicine. Faculty and students were
drawn to Tulane, motivated to help build a new New
Orleans. In fact, under the leadership of the new
Dean, the faculty numbers grew by over 100%,
applications to the School of Medicine increased by
25%, and the average grade point average and
Medical College Admissions Test scores of incoming
medical students increased.12 Healing communities
was the vision for the future.
CLINICAL “REVOLUTION”
Following Katrina, in 2006, Dr Karen DeSalvo
(Tulane faculty) started one of the first new primary
care clinics with funding from the Government of
Qatar. In Boston, community health centers form
the basis of primary care services for the under-
served; this was in stark contrast to pre-Katrina New
Orleans, that depended on the emergency depart-
ment of Charity Hospital for “primary care.” The
Dean saw the tremendous opportunity to rebuild
health care in the region using this approach.13 To
help facilitate Tulane’s mission and to have a role
model in the post-Katrina environment, Dr Karen
DeSalvo was appointed as a Professor and Vice Dean
for Community Affairs and Outreach. By February
2018, Tulane had developed a business plan (known
as the Tulane University Plan to Advance the Devel-
opment of Community-based Health Centers in New
Orleans) to demonstrate the economic viability of
the neighborhood health center concept. Much to
our surprise, civic and political leaders showed little
interest in this concept. All they wanted was to
reopen Charity Hospital, as this was their reference
point. We realized that their only experience was
with the old Charity Hospital concept of a hospital
for the poor that provided both inpatient and out-
patient services in a single inner-city location. They
had never seen a network of successful community-
based primary care clinics such as the Federally
Qualified Health Centers (FQHCs) that exist
throughout the USA. The FQHCs are not-for-profit,
consumer-directed health-care organizations that
provide access to high-quality, affordable, and com-
prehensive primary and preventive medical, dental,
and mental health care.14 Thus, FQHCs have a
unique mission of ensuring access for underserved,
underinsured, and uninsured patients and are
provided with federal subsidies for their operations.
Figure 1. Post-Katrina Logo for Tulane University
School of Medicine Emphasizing the Tripartite Mission
of Education, Clinical Care, and Research in the
Context of Healing the Community of New Orleans.
Crisis Management Following Hurricane Katrina
Rambam Maimonides Medical Journal 5 October 2018 Volume 9 Issue 4 e0031
The leadership under the Dean decided to change
perceptions in 2008 by arranging for a group of
civic, community, and religious leaders and the
newly appointed Vice Dean to visit Boston to see
how these neighborhood health centers functioned.
This trip was accompanied by significant media
coverage to publicize our notion of a new model of
primary health-care in post-Katrina New Orleans.
Additionally, having politicians and business leaders
witness first-hand the value of neighborhood health
centers greatly assisted our achieving local buy-in
for this plan. A turning point in our efforts was when
a black pastor who was on the Boston trip said that
it was the first time that he had ever seen anyone
like himself treated with respect in a health-care
facility.
At that time, the US Secretary of The Department
of Health and Human Services (DHHS) in the Presi-
dent Bush administration was Secretary Michael
Leavitt. He was deeply committed to helping New
Orleans recover after the storm. His administration,
together with the State Government, arranged for a
Medicaid waiver where state and federal funds could
be used to help fund the growth of primary care
clinics. Thus, with funding and the political will, our
vision became a reality. By 2010, there were 25
organizations operating in 93 sites providing care
for 220,000 people, representing 20% of the popu-
lation. As further evidence of Tulane’s success in
rebuilding the community, in 2010, Tulane Univer-
sity School of Medicine was awarded the Spencer
Foreman Award for Outstanding Community Ser-
vice by the Association of American Medical Col-
leges. This award singles out institutions that serve
as examples of social responsibility through their
outreach to their communities.
In September 2010, New Orleans Mayor Mitch
Landrieu and the new Secretary of DHHS Kathleen
Sebelius (President Obama administration) wrote in
an article under the heading “City’s network of
clinics a model for national health reform”: “It
seems fitting that New Orleans and its people, who
have shown the nation how to survive unthinkable
tragedy, can now set an example for strengthening
the nation’s health care system into the future.”15
Looking forward, the state and federal govern-
ment began to arrange funding for the rebuilding of
Charity Hospital under the new name, “University
Medical Center.” Ground was broken in April 2011.
The US$1.1 billion new hospital opened in August
2015 as a 213,677 sq. meter hospital with 446 acute
care beds, 19 operating rooms, and 56 emergency
department exam rooms. The new facility was situ-
ated 6.4 meters above flood elevation and was
constructed with emergency power backup and the
ability to withstand the impact of a category 3 major
hurricane.16 In a similar fashion, the Southeast
Louisiana Veterans Health Care System was rebuilt
in New Orleans and reopened in the summer of
2017. The new 160,000 sq. meter 440-bed facility
was built at a cost of US$1 billion.17
EDUCATION
From an educational perspective, it was clear that
conventional strategies were not going to be enough.
The two new teaching hospitals were only opened in
2015 and 2017. As a result, the patients and beds
that were needed to support the undergraduate and
graduate medical education enterprise were scarce
in New Orleans. The first innovation was the
establishment of a clinical campus in Baton Rouge,
75 miles from New Orleans. Following the storm,
New Orleans was no longer the most populated city
in Louisiana due to the exodus of its residents.
Baton Rouge, the state capital, was the new
population center. Creating a new program located
in the state capital allowed for a thematic approach
to undergraduate medical education. The campus
was created along the theme of leadership: Lead,
Educate, Advocate, Discover. In addition to typical
clinical rotations (internal medicine, surgery,
obstetrics and gynecology, etc.) specific
opportunities to explore community development,
entrepreneurship, involvement in the political
process, organized medicine, and practical experi-
ences in the Governor’s Office and Department of
Health were created.
In addition, recognizing the high cost of training
a physician and the amount of time necessary, the
School of Medicine created an accelerated under-
graduate-to-MD program that uniquely included a
mandatory year of public service with AmeriCorps
VISTA. Consistent with the mission of healing com-
munities, allowing highly motivated undergraduates
the path to an MD in six years plus a year of service
was mission-consistent and was expected to lead to
bright young physicians with an emotional attach-
ment to the city.
Building on the reputation of the city as a culin-
ary capital and recognizing the poor state of health
of the New Orleans residents, the school, under the
leadership of Dr Timothy Harlan (Associate Dean
Crisis Management Following Hurricane Katrina
Rambam Maimonides Medical Journal 6 October 2018 Volume 9 Issue 4 e0031
for Clinical Services) developed The Goldring Center
for Culinary Medicine at Tulane University. This is
the first dedicated teaching kitchen to be imple-
mented at a medical school. The center provides
hands-on training for medical students through
culinary medicine classes in the form of electives
and seminars as well as continuing education for the
health-care and foodservice industries. Of note, as of
2018, the nutrition curriculum developed by the
center is being used in approximately one-third of
all medical schools in the USA.18
Finally, under the direction of Dr Kevin Krane,
Vice Dean for Academic Affairs, new methods of
teaching were put into the curriculum. It is esti-
mated that the doubling time of medical knowledge
has gone from 50 years in 1950 to 3.5 years in 2010.
By 2020, the doubling time is estimated to be only
73 days (Figure 2).19 As a result, medical students of
the future need to be “adaptive learners,” able to
apply existent knowledge to new situations.20 Recog-
nizing this concept, new modalities of instruction as
alternatives to classroom lectures were developed.
These included Just in Time Teaching, Team-based
Learning, and other flipped classroom techniques
that provided instruction using pedagogy more
consistent with adult learning theory. As an im-
mediate result, student pass rates on national board
exams were higher than the national average for the
first time in many years.
The rapid expansion of medical knowledge, as
described, will fundamentally change the role of a
physician in ways that are hard to predict today. One
possible solution, advanced by Tulane, was the devel-
opment of unique dual degree programs. The physi-
cian of the future needs to be more than just a good
diagnostician. As such, the School of Medicine con-
structed a four-year combined MD/MBA program.
The school had a five-year program for several years
prior to Katrina, but recognizing the value of time a
four-year program with an emphasis on health care
was developed. This program was one of only a few
of its kind in the USA and was used as a recruitment
tool by the School of Medicine to attract students
who were not only academically talented but also in-
terested in management and being part of the crea-
tion of a new infrastructure for health-care delivery.
RESEARCH
As with their clinical and education programs,
Tulane University School of Medicine was forced to
readdress the focus of their research programs fol-
lowing Hurricane Katrina. As a result of the storm,
the school lost significant research assets due to
failure of refrigeration and power, as well as losing
research faculty due to layoffs and resignations. The
Dean decided to expand research by focusing on
research programs that were interdisciplinary,
involving investigators not only from the School of
Medicine but also from the schools of science and
engineering, law, and business. Through funding
available from the National Institutes of Health as
part of the post-recession (2008) recovery stimulus,
the school was able to build modular laboratory
space that was flexible and open. Rather than a
scientist working alone in an individual laboratory,
this new space encouraged groups of scientists,
across disciplines, to work together in a collabora-
tive fashion. Synergies in research interests and
geographical proximity were hoped to create novel
research programs designed to address the needs of
both the New Orleans and Tulane community.
Tulane also focused recruitment of new faculty and
Department Chairs to individuals whose funding
and research interests dovetailed with Tulane’s
strengths in research that included infectious
diseases, heart disease, and cancer biology. Through
these efforts, Tulane realized its best years in secur-
ing extramural NIH funding since inception, with
steady growth of 10%20% in NIH research dollars
per year following the new vision.
LESSONS LEARNED
Sometimes it takes a disaster to remove silos and
create a new vision. Based on our experience, the
following are our key recommendations:
Figure 2. Estimated Doubling Time of Medical Knowl-
edge by Year.
Students starting medical school in 2010 will master 6%
of the knowledge available in 2020. Adapted from
Denson, 2010.17
0
10
20
30
40
50
60
1950 1980 2010 2020
50
73.5 73 Days
Years
Years
Crisis Management Following Hurricane Katrina
Rambam Maimonides Medical Journal 7 October 2018 Volume 9 Issue 4 e0031
1. Understand the culture: For an outsider coming
in to help the recovery after a major disaster, it is
essential to understand, appreciate, and show re-
spect for the local culture. Build a broad coalition
of local leaders: No matter how wonderful the
plan/vision for recovery, without obtaining local
“buy-in” and support, change is very unlikely.
2. Build a strong leadership team: The road to
recovery will be long and hard, and recovery will
never be achieved by a micro-managing single
leader. It is important, from the outset, to build a
management team and to delegate decision
making but at the same time to hold the team
responsible. As part of this approach, consider
empowering entrepreneurship and encourage
managers to take risks.
3. Have a recovery plan, but be prepared to adapt
based on local conditions: The frequent approach
following a disaster is to hire consultants, organ-
ize retreats, and develop strategic plans. We
believe this is the wrong approach, because it is
too time-consuming. In a crisis, there is a signifi-
cant risk of the loss of key personnel and for the
community to lose confidence. A vibrant vision
will give people a sense of hope. In preparing for
the position, the new Dean interviewed a wide
group including the Tulane community and civic
leaders. As a result, when B.P.S. presented his
vision, the community felt they had input.
4. Vision alone is insufficient: When the vision in-
cludes a radical new approach, words alone
cannot build support. Our goal was to build a
network of neighborhood clinics to replace the
use of Charity Hospital’s emergency room for
primary care. To build broad support for this
approach, we took key community leaders to
Boston to show them the value of neighborhood
health clinics. We learned that explanation is no
substitute for first-hand experience.
5. Manage post-traumatic stress disorder (PTSD):
Following disaster, expect widespread psycho-
logical problems among adults and children that
have survived the crisis. It is vital for the leader-
ship to show compassion and recognize the needs
of everyone involved. This will require the careful
allocation of scarce resources.
6. Lead by example.
LONG-TERM CHALLENGES
Despite the many successes in the transformation of
Tulane University School of Medicine and the
health-care system in New Orleans following
Katrina, several long-term challenges remained. The
first was maintaining a system to care for the poor
and indigent population with limited financial
resources. The Affordable Care Act (ACA) was enact-
ed in the USA in March of 2010 and provided for
expanded coverage for the poor through expansion
of state and federal funding through Medicaid. How-
ever, state challenges to the legality of provisions of
the ACA resulted in a Supreme Court majority
decision that allowed individual states to choose to
not participate in federally supported Medicaid
expansion. Louisiana was such a state that did not
expand Medicaid, with an estimated loss of over
US$1 billion of federal subsidy and an estimated
human cost of over 1,000 lost lives per year.21 It was
not until January 2016 that a new governor, John
Bel Edwards, agreed to Medicaid expansion in
Louisiana.
A second challenge, “Katrina fatigue,” required a
constant reinforcement of the vision and mission to
a community that was still experiencing the post-
traumatic effects of the storm.
As health-care facilities were rebuilt, maintaining
bed occupancy remained a challenge as the city was
over-bedded prior to the storm. This resulted in
intense competition for insured patients. To main-
tain market share, hospitals made plans for consoli-
dation and reorganization that increased feelings of
uncertainty among health-care providers and insti-
tutions. In fact, the replacement hospital for the old
Charity Hospital, in order to remain financially sol-
vent, sought to compete with other hospitals in New
Orleans for insured patients, resulting in mission
drift.22 Additionally, due to political forces the LEAD
program was discontinued in Baton Rouge, and
Tulane decreased its medical school class size in
2015.
Finally, external factors such as increased risk of
major hurricanes due to global warming, the loss of
Louisiana wetlands that provide some protection
from hurricane tidal surges, and rising sea levels
continue to leave the city of New Orleans vulnerable
to significant weather-related damage. Although the
levees that protect the city were rebuilt, they are far
Crisis Management Following Hurricane Katrina
Rambam Maimonides Medical Journal 8 October 2018 Volume 9 Issue 4 e0031
from perfect. In addition to the risk of flooding,
Louisiana continues to face annual budget deficits
such that the New York Times has called Louisiana a
“Failed State.”23 Louisiana state law allows for re-
ducing a budget shortfall only by reducing expendi-
tures in two areas: education or health care.
CONCLUSIONS
Although it is impossible to completely plan for dis-
asters, it is clear that political instability, the risk of
war, climate change, and geography make disrup-
tion a potential reality for any health-care system.
Articulation of vision, nimble decision making,
maintenance of mission, and focus on results are all
essential features of successful recovery from disas-
ter. Following Hurricane Katrina, Tulane University
School of Medicine and the New Orleans public
health system were able to rebuild as well as reform
education, research, and clinical care. Remaining
challenges include budgetary and funding issues and
the possibility of another Katrina-like storm. Des-
pite these challenges, the reforms have proven, in
most cases, to be sustainable and better adapted to
the challenges facing the health-care profession.
REFERENCES
1. CNN. Hurricane Katrina statistics fast facts. August
28, 2017. Available at: https://cnn.it/2xnKHrK
(accessed July 5, 2018).
2. Taylor IL, Krane NK, Amedee RG, Kahn MJ. Rebuild-
ing institutional programs in the aftermath of Hurri-
cane Katrina: the Tulane experience. Am J Med Sci
2006;332:2648. Crossref
3. The Federal Emergency Management Agency (FEMA).
FEMA 549, Hurricane Katrina in the Gulf Coast:
Mitigation Assessment Team Report, Building Per-
formance Observations, Recommendations, and Tech-
nical Guidance (Cover page, Executive Summary, and
Table of Contents). July 2006. Available at:
http://bit.ly/2pepOvb (accessed July 5, 2018).
4. Flexner A. Medical education in the United States
and Canada; a report to the Carnegie Foundation for
the advancement of teaching. New York, NY: The
Carnegie Foundation for the Advancement of
Teaching; 1910.
5. Morial JC. Katrina: health care system recovery,
reform and renaissance. Perm J 2007;11:6670.
Crossref
6. Henry J. Kaiser Family Foundation website. Medi-
care spending per enrollee, by state. 2018. Available
at: https://kaiserf.am/2LB3IvU (accessed July 5,
2018).
7. Rudowitz R, Rowland D, Shartzer A. Healthcare in
New Orleans before and after Hurricane Katrina.
Health Affairs 2006;25(5):Biotech drugs come of age.
Available at: Crossref (accessed July 5, 2018).
8. Taylor IL. Hurricane Katrina’s impact of Tulane’s
teaching hospitals. Trans Am Clin Climatol Assoc
2007;118:6978.
9. Krane NK, Kahn MJ, Markert RJ, Whelton PK,
Traber PG, Taylor IL. Surviving Hurricane Katrina:
reconstructing the educational enterprise of Tulane
University School of Medicine. Acad Med 2007;82:
75762. Crossref
10. Kahn MJ, Markert RJ, Johnson JE, Owens D, Krane
NK. Psychiatric issues and answers following
Hurricane Katrina. Acad Psychiatry 2007;31:2004.
Crossref
11. Sachs BP, Krane NK, Kahn MJ. Medical school dean
as a turnaround agent. Am J Med Sci 2008;336:142
6. Crossref
12. Krane NK, DiCarlo RP, Kahn MJ. Medical education
in post-Katrina New Orleans: a story of survival and
renewal. JAMA 2007;298:10525. Crossref
13. DeSalvo KB, Sachs BP, Hamm LL. Health care
infrastructure in post-Katrina New Orleans; a status
report. Am J Med Sci 2008;336:197200. Crossref
14. Health Resources & Services Administration (HRSA).
Federally qualified health centers. May 2018.
Available at: http://bit.ly/2pdj4h6 (accessed July 5,
2018).
15. Landrieu M, Sebelius K. City’s network of clinics a
model for national health reform: a guest column by
Mitch Landrieu and Kathleen Sebelius. The Times-
Picayune, September 22, 2010. Available at:
http://bit.ly/2MAcc6R (accessed July 5, 2018).
16. The Times-Picayune. Look inside the new $1.1 billion
University Medical Center, opening Aug. 1. The
Times-Picayune, June 17, 2015. Available at:
http://bit.ly/2NMnI3P (accessed July 5, 2018).
17. Litten K. Long awaited, long delayed: New Orleans
VA hospital finally opens. The Times-Picayune,
NOLA.com, November 18, 2016. Available at:
http://bit.ly/2pdjGmU (accessed July 5, 2018).
18. CulinaryMedicine.org, Where Health Meets Food
website. 2018. Available at: https://culinarymedicine.
org (accessed July 5, 2018).
19. Densen P. Challenges and opportunities facing medi-
cal education. Trans Am Clin Climatol Assoc 2011;
122:4858.
Crisis Management Following Hurricane Katrina
Rambam Maimonides Medical Journal 9 October 2018 Volume 9 Issue 4 e0031
20. Kahn MJ, Maurer R, Wartman SA, Sachs BP. A case
for change: disruption in academic medicine. Acad
Med 2014;89:121619. Crossref
21. Fowler A. The facts about Medicaid expansion in
Louisiana. Louisiana Budget Project, Baton Rouge,
LA. April, 2013. Available at: http://bit.ly/2pcZmCp
(accessed July 5, 2018).
22. Barrow B. University Medical Center’s success hinges
on web of financial unknowns. The Times-Picayune,
September 12, 2011. Available at: http://bit.ly/
2xnO2a7 (accessed July 5, 2018).
23. Leonhardt D. Louisiana, “a failed state.” The New
York Times, March 8, 2018. Available at: https://
nyti.ms/2paPBEH (accessed July 5, 2018).
... All of this has forced the sense of a global crisis to services whatever their locality. Today, the use of scientific methods as a way for dealing with crises has become more important and a necessity not only for achieving positive results, but also because the use of un-scientific alternatives can deliver results which may be greatly destructive (Kahn & Sachs, 2018). As a result of the importance and risk associated with the crises, their management and treatment with advanced managerial thinking is key. ...
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... The experiences published described instances in which residency programs were able to sustain procedural exposure by redistributing residents to other areas of the state. 1 Overall, the need for strong educational leadership and the presence of comprehensive recovery plans were the greatest lessons that emerged from the Katrina natural disaster. 2 The COVID-19 pandemic has been inherently unique in that it affected our entire country and the global community. It impacted nearly all facets of daily life and work, including the need to drastically adjust healthcare systems, patient care, and healthcare delivery, 3 as well as health sciences education. ...
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Background: The COVID-19 pandemic disrupted the delivery of surgical services. The purpose of this communication is to report the impact of the pandemic on surgical training and learner wellbeing and to document adaptations made by surgery departments. Study design: A 37-item survey was distributed to educational leaders in general surgery and other surgical specialty training programs. It included both closed- and open-ended questions and the self-reported stages of GME during the COVID-19 pandemic as defined by the Accreditation Council for Graduate Medical Education (ACGME). Statistical associations for items with Stage were assessed using categorical analysis. Results: The response rate was 21% (472/2,196). U.S. Stage distribution (n=447) was Stage 1 22%, Stage 2 48%, Stage 3 30%. Impact on clinical education significantly increased by Stage with severe reductions in non-emergency operations (73%and 86% vs.98%) and emergency operations (8% and 16% vs. 34%). Variable effects were reported on minimal expected case numbers across all stages. Reductions were reported in outpatient experience (83%), in-hospital experience (70%), and outside rotations (57%). Increases in ICU rotations were reported with advancing stage (7%and 13%vs.37%). Severity of impact on didactic education increased with stage (14%and 30% vs.46%). Virtual conferences were adopted by 97% across all stages. Severity of impact on learner wellbeing increased by Stage: physical safety (6%and 9%vs.31%), physical health (0% and 7%vs.17%), emotional health (11% and 24%vs.42%). Regardless of stage most, but not all, made adaptations to support trainees' wellbeing. Conclusion: The pandemic adversely impacted surgical training and wellbeing of learners across all surgical specialties proportional to increasing ACGME Stage. There is a need to develop education disaster plans, to support technical competency, and learner wellbeing. Careful assessment for program advancement will also be necessary. The experience during this pandemic shows that virtual learning and telemedicine will have significant impact on the future of surgical education.
... Nevertheless, some lessons learned from responses to natural disasters have been applicable to the pandemic situation. Following Hurricane Katrina, the interruption in medical education necessitated some acceleration of the educational process, with a reevaluation of what requirements were necessary to graduate with an MD degree [5]. The pandemic situation is forcing educators to take a hard look at what the minimum requirements should be to complete a field of medical study. ...
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For a long time, organizational turnaround was a subject of interest; literature on the financial turnaround of hospitals that faced decline after a major disaster like death due to fire is scarce. An Indian hospital group incurred losses for years after death due to a fire in one of its units and earned an operational surplus for the last few years. This case study explores the strategies for its financial turnaround; hospital documents and interviews with managers provided data for it. The purpose of the study is to investigate the interventions taken by the organization for its financial turnaround. The theoretical framework of the study relied on the turnaround model of Maheshwari (2000), Khandwalla (2001), Chowdhury (2002), Jacobs et al. (2013), and Sylkin et al. (2019). The pragmatism theories advocated by Kahneman and Klein (2009), Ansell and Boin (2019), and Boin and Lodge (2021) were also relied upon.This study contributes to the organizational change literature by highlighting that though the theories of turnaround serve as a foundation, managerial intuition and continuous evaluation are strong driving forces for a financial turnaround.
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