key: cord-0053409-5m0o5jem authors: Dowling, Michael J.; Carrington, Maxine; Moscola, Joseph; Davidson, Karina W. title: Covid-19 Crisis Response: First, Address the Safety and Well-Being of Your Team date: 2020-12-02 journal: NEJM Catal Innov Care Deliv DOI: 10.1056/cat.20.0544 sha: 78086dd4dacc736f7543fddcd71621369ff1a515 doc_id: 53409 cord_uid: 5m0o5jem Health care workers are driven to put their patients first, but in the case of an unprecedented and deadly disaster — with the associated economic recession and long-term disruption of daily routines — leaders need to establish confidence and stability among the workforce so that they can focus on their mission: caring for their patients and community. The coronavirus disease 2019 (Covid-19) pandemic shocked health care systems worldwide. What do you do when suddenly faced with a tsunami of patients with a new and deadly virus? How do you transform and cannibalize all systems and procedures to ensure the safety and well-being of your personnel and patients? And how do you prepare, after the initial wave of infections, to adjust the pace and prepare for ongoing challenges while staying alert and ready for subsequent surges? At Northwell Health, we became an epicenter of the global pandemic in March 2020 and saw the nation's highest volume of Covid-19 cases for two months. Northwell is an integrated health system in New York State with a prominent clinical, academic, and research enterprise. The system comprises 23 hospitals and more than 800 outpatient facilities. Before the pandemic, Northwell supported approximately 3,000 hospital beds (624 in the intensive care unit) and 72,000 employees, consisting of approximately 25% nurses, 9% physicians, 11% clinical professionals, and 9% non-clinical professionals. Northwell's 5,000 hospital volunteers also play an important role by visiting patients and providing caring support. Overall, Northwell has a service area that includes approximately 11 million people in the greater New York City area, including the surrounding counties ( Figure 1 ). Our challenge started on January 13, 2020, when our supply chain for personal protective equipment (PPE) was suddenly disrupted, and we had to manage a massive recall from one of our largest suppliers in China. 1 Then, a few weeks later, the first patient to contract the virus through community spread in the New York City region tested positive for Covid-19 at a hospital in New Rochelle.2 On March 7, we hospitalized our first patient with Covid-19. On April 7, we had 3,425 hospitalized patients with Covid-19 among 5,044 total hospitalized patients ( Figure 2 ). By the end of June 2020, we had treated 71,181 unique patients who tested positive for Covid-19. Of those patients, 15,101 were treated in a hospital, 28,865 in ambulatory settings, and 12,006 in urgent care centers; another 10,274 were treated and released from emergency departments; and 4,935 resided in long-term care facilities. In those 16 weeks, we added more than 2,000 hospital beds, including 1,200 intensive care unit (ICU) beds. 3 We added beds in lobbies, conference rooms, research facilities, and outpatient facilities. We erected tents in parking lots. But our biggest challenge was keeping our team members safe while caring for patients. We established an initiative, Keeping Our Team Members Safe, to better protect the health, safety, and well-being of our team members. Plans and procedures to successfully execute this goal were developed and refined while patients flooded into our system. Thus, as we sought to achieve a difficult goal, we determined: sprint first, then adjust the pace to complete a marathon. At Northwell, we started preparing for emergency events in 1998,4 when we were warned by the head of a Joint Terrorism Task Force about a possible attack on New York City. Over the last two decades, we hosted several conferences to enhance our organizational culture and capabilities to proactively prepare for emergencies and build a robust emergency preparedness infrastructure within our health system. Our basic philosophy was that we must prepare for the unpredictable. We did not have plans ready to be enacted. Instead, we had a capable leadership team ready to create needed plans as unpredictable events arose and immediately enact them. Over the last two decades, we hosted several conferences to enhance our organizational culture and capabilities to proactively prepare for emergencies and build a robust emergency preparedness infrastructure within our health system." We hired and promoted experts in emergency management, invested millions of dollars in equipment, and trained thousands of staff members during simulations of various emergencies or disasters. These efforts were unusual for a health care system in part because they required a major financial investment with no anticipated return on investment. Typically, disaster preparation is considered the responsibility of federal, state, or local governments -and rarely that of private health systems. Given the critical role of hospitals and other providers in responding to public health crises, we believed that we needed this capability. In our emergency preparedness system, we routinely monitor infectious disease outbreaks worldwide and their prevalence systemwide. Northwell's proximity to three large international airports -John F. Kennedy, LaGuardia, and Newark Liberty -are major points of entry to the United States and are within minutes of Northwell hospitals. We knew that we needed an emergency response that could be enacted within hours to successfully manage patients who presented at any of our hospitals or outpatient settings with a potentially deadly infectious disease. Our emergency operations center and network incident command structure were activated during the 2001 World Trade Center terrorist attack, the 2003 Northeast blackout, the 2003 severe acute respiratory syndrome (SARS) surge, the 2012 Hurricane Sandy, and the 2014 Ebola outbreak. As we monitored the spread of Covid-19 across China, we activated this emergency operations team in January 2020. We were determined to " focus on how we could (1) best support our team members and the tsunami of patients during this infectious disease outbreak and (2) address the concerns and stressors post-surge as we realized that Covid-19 would not run its course for several weeks, if not months or even years. Our emergency operations team is led by an incident commander (Chief Operating Officer) and deputy incident commander (Chief Administrative Officer). Both have extensive experience in emergency preparedness, as they started their careers as emergency medical technicians. The structure of the team is similar to that used by other emergency organizations (e.g., police, fire departments, the Federal Emergency Management Agency [FEMA], the military), making lines of command and responsibilities clear so that we could make the well-informed, rapid decisions. The structure of the team is divided into five categories: operations, clinical operations, finance and administration, logistics, and planning ( Figure 3a ). For our Keeping Our Team Members Safe initiative, we established councils that were mandated to identify issues and concerns in their specific areas of expertise, resolve those that could be addressed, and escalate other important issues and pressing problems to their parallel emergency operations team for a system response ( Figure 3b ). This structure worked well because every functional area was represented on the emergency operation team. Furthermore, everyone understood that when the team was called, we needed to work rapidly and collaboratively to create a single plan that the incident commander would implement. This process removed bureaucracy and enabled the team to work more efficiently and quickly to address issues. As part of Northwell's key learnings in 2020, we focused on team members' personal concerns and trying to make the workplace as safe and supportive as possible. Staffing, supplies, and logistics would be a major focus, but paramount was our Keeping Our Team Members Safe initiative. To determine the best ways to support team members, and understand their concerns, we started by surveying them on how they were managing during the crisis. This survey was conducted between May 4 and May 11, 2020, for approximately 70,000 team members. More than 24,708 team members completed the survey within one week (35% response rate). The highest number of responses came from team members in the following areas: 4,700 clerical staff, 4,219 nurses, and 4,115 management personnel. We had 8,767 (35%) of responding team members request resources for managing stress or psychological well-being -the greatest need across almost all job functions. Team members also requested resources for caring for their overall well-being (7,749; 31%), physical well-being (7,250; 29%), financial well-being (6,008; 24%), and caretaking responsibilities (5,597; 23%). The sum of request responses (35,371) exceeded the sum of those responding to the survey (24,708) because team members could select more than one need. Physicians specifically reported needing support with the navigation of Northwell processes and procedures as well as support for managing stress and well-being. The Keeping Our Team Members Safe initiative means ensuring that team members have the tools and resources they need. The greatest needs identified through our councils and our survey results and span five tactical areas: physical safety, financial security, familial safety, psychosocial safety and well-being, and overall safety and well-being ( Figure 4 ). The five domains were driven by the five goals of the Keeping Our Team Members Safe Council. Mandate Masks and PPE. By March 13, 2020, we required all team members to wear a procedural mask in all hospital and ambulatory locations, regardless of their contact with patients. We also implemented physical distancing guidelines for team members and visitors. At the peak of the pandemic, our daily use rate of N95 masks was 25,000. Last year, ourmonthly use rate was 15,000 (approximately 500 per day). Comparing to the same period last year, we increased our daily use of surgical masks (11,000 pre-Covid-19 versus 125,000 during Covid-19), gloves (1 million versus 1.5 million), isolation gowns (11,000 versus 100,000), and face shields and goggles (125 versus 7,000). Overall, PPE use was up by approximately 60%. Support Remote Work. In early March, we directed nearly 10,000 non-patient-facing team members to work from home. This included personnel from billing, legal, information technology, ambulatory services, and other support staff. This shift also increased PPE availability for team members with direct patient contact. From March through June 2020, for example, our remote workers logged more than 4.5 million hours. To fully appreciate the dedication of the team, consider this: In April 2020, the first full month of required remote working, total hours worked by the same non-patient-facing team nearly doubled to 1,242,632 hours from the previous month's 666,577 hours. The sharp increase stabilized by June, when we recorded 850,256 hours of remote work. These increased work hours showed us that team members contributed when needed to meet the demands of the pandemic and that they could work remotely. Supply Free, Convenient Testing. To determine who had Covid-19, we collaborated with Northwell Health Laboratories to develop and validate tests forsevere acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We set up 52 convenient testing locations, including drive-through facilities, that supported physical distancing for team members and patients. By early March 2020, we provided free polymerase chain reaction (PCR) testing to team members with symptoms of Covid-19 or suspected exposure to SARS-CoV-2. From May 1 to June 23, we also provided them with free antibody testing regardless of symptoms.5 To determine who had Covid-19, we collaborated with Northwell Health Laboratories to develop and validate tests for SARS-CoV-2. We set up 52 convenient testing locations, including drive-through facilities, that supported physical distancing for team members and patients." Offer Compensation During Self-Quarantine. When any team member self-quarantined after exposure to SARS-CoV-2, we provided them with full salary and benefits while they recovered away from work. For example, between late February and late April 2020, this benefit supported full-time and part-time nursing staff diagnosed with Covid-19, approximately 9% of all of our nursing staff. If self-quarantined team members were able to work remotely and felt well enough to do so, they were expected to work during the quarantine period. Request Team Member Reassignment. As we expanded our capacity, we asked team members to take on other roles within the health system. If they declined, they could take personal time or unpaid leave (with full benefits). More than 3,000 of our team members worked where needed " at any one time. For example, of 831 physicians who were redeployed to work in critical care, hospital medicine, and emergency medicine, 248 (30%) were originally in medicine, 179 (22%) in cardiology, 196 (24%) in surgery, and 208 (25%) in other specialties. Also redeployed were 2,750 other staff, including 791 nurses, 429 nurse practitioners/physician assistants, 236 other clinical professionals, and 324 other health professionals. Additional staff that were redeployed included 587 service and maintenance professionals, 294 clerical professionals, and 89 nonclinical professionals. When necessary, we would conduct competency reviews and training for team members who were coming back to the bedside from procedural areas such as interventional radiology, cardiac catheterization, and perioperative services.4 Enhanced Health and Welfare Benefits. We waived copayments on virtual medical visits for team members enrolled in our system's benefit plans. We also gave part-time and full-time new nonunion hires immediate eligibility for benefits. In addition, we supported free, convenient exercise programs, a virtual fitness challenge, and many other fitness initiatives. Commit to Maximum Job Security. We started the pandemic by setting aside financial concerns and focusing on the health and wellbeing of our patients and team members. We committed to retaining our team members and providing salary support to the best of our ability, regardless of whether job functions were considered essential. Between March and June 2020, we did not have any Covid-19-related layoffs. Create New Financial Systems and Processes. We implemented special provisions for paid time off and gave team members increased flexibility to use that time after the surge. The flexibility included paid time off to make up for extra hours worked during the surge and extending the expiration date of unused paid time off. We also developed services -supported by government loans/grants (e.g., CARES Act Relief funding), the operating budget, rainy day fund, and volunteer contributions from staff and the community -to provide financial assistance, advice, and support to team members in need. In addition, we established caregiver support and memorial funds for the families of team members who died from Covid-19 and created a process for local businesses and community groups to donate food, supplies, or money to team members. We received more than $3.5 million in-kind donations, including shoes, children activity kits, technology, and food. One organization provided money to support tranquility tents and other spaces provided to team members. Local restaurants and community volunteers helped to feed our staff when hospital cafeterias were closed at night and on weekends. Pay for Hotel Rooms for Patient-Interacting Team Members. Many team members expressed concern about exposing their families to SARS-CoV-2. We provided free accommodations to these team members, as well as those who worked extra shifts or traveled from out of town to care for patients. These accommodations included hotel rooms from national hotel chains and alternative housing, such as the Ronald McDonald House, Adelphi University, and other places. Approximately 350 team members used these accommodations on a regular basis. Create Educational Information. Team members requested educational materials to help their children cope with fears about the pandemic. With support from our pediatric behavioral health specialists, we created free resources for children of all ages, including instructional videos and online interactive programs. Provide Dependent-Care Resources. For all non-union team members scheduled to work at least half-time (0.5 full-time equivalent), we expanded our back-up child/elder care program to provide additional center-based and in-home care. Through a partnership with Bright Horizons, we created a program that offered 10 center-based and in-home visits within a calendar year at low copays to team members whose regular caregiver or care routine fell through (for example, as a consequence of school closings, caregiver vacation or illness, or an unexpected shift coverage). We later implemented a crisis-care reimbursement model, giving these team members up to $1,000 per month ($100 per day for 10 days) to fund dependent care through their personal network. Approximately 13,000 team members were helped by this program. We are also offering these team members subsidized in-person childcare for the 2020-2021 school year. Set Up Tranquility Spaces. We set up tranquility spaces where team members could reflect, meditate, or pray before, during, or after shifts. More than 69,000 team members visited these spaces by the end of August 2020. Normalize Mental Health Services. Our Employee Assistance Program for team members and their families offered free, confidential therapy as well as app-based interventions and referrals to help those struggling with substance use. They also partnered with a 24/7 emotional support call center to listen, offer counsel, and provide referrals as needed, in recognition of the high psychological impact of the pandemic on health care personnel.6 Further, we waived copays for behavioral telehealth visits and fast-tracked appointments at our behavioral health locations. Our Center for Traumatic Stress Resilience and Recovery and our Physician Partners leadership proactively reached out to team members including physicians in vulnerable and hard-hit facilities to ask how they were coping. For example, based on data from China indicating that critical care nurses are most vulnerable,7 our Center called all 242 critical care nurses at one of our hardest-hit hospitals. Of those nurses, 41% of 200 nurses wished to speak with the caller (42 did not answer the call). The Center also created a Stress First Aid program that, by the end of August 2020, reached 1,892 team members by telephone and created other methods of contact, such as home mailers, text messages, and emails, to ensure that if a team member wanted help, they knew it was available. Finally, we expanded our Team Lavender program, which provides staff with timely emotional and spiritual support, such as grief counseling following the death of a team member or patient. Team Lavender also provides physical support, such as offering safe places to sleep and eat, providing PPE, and restructuring facilities to make physical distancing possible. Team Lavender responded to 440 calls by the end of August 2020. Provide Leader Toolkits and Training. To ensure that team members felt valued and recognized that their safety was Northwell's highest priority, leaders were provided with materials such as PowerPoint slide decks, text messages, and training materials so that they could, in turn, effectively communicate with team members. Communications from leaders to team members was distributed regularly to share updated or new clinical guidelines, safety protocols, information about hospital accomplishments, and ongoing challenges. Communicate Directly with Team Members. We set up daily communication channels so that team members on any shift and at any time knew what was happening, how we were preparing, and how we were responding to their requests. We created a central virtual destination, the Coronavirus Employee Resource Center, which was housed on a website outside a firewall so that team members could access information easily and quickly and from any location. This homepage included a quick guide to the latest information as well as stories and pictures from frontline workers. As part of this Coronavirus Employee Resource Center, we also launched our virtual wellbeing resource center. This center was a destination for all our well-being resources and programs, including the emotional support, stress management and resilience, substance use prevention, spiritual well-being, and physical well-being initiatives described above. Between the beginning of March and the end of June, the website received more than 600,000 visits, and it has become a valuable resource for team members. We also launched a text messaging service through which team members could opt in to receive real-time news alerts via text that led them to the Coronavirus Employee Resource Center. More than 30,000 team members opted in for this service, which was particularly useful given that protocols and guidelines were constantly changing -sometimes within a single day -during the spring surge. Celebrate Victories, Large and Small. We celebrated and recognized our team members. At daily rounds, leaders profusely thanked them. We organized "clap outs" to recognize team members at shift changes and to celebrate when ICU patients were discharged from our hospitals. Songs celebrating patient success stories, such as the Beatles' "Here Comes the Sun," were played on hospital speakers when patients were extubated and discharged. And thousands of thank-you notes and letters lined every corridor, hall, and elevator. Recognize Team Members. We wanted to recognize the sacrifices of our team members and their exemplary contributions to our patients' care. To this end, Northwell awarded more than 55,000 team members (90% patient-facing) with up to $2,500 bonuses and five days of paid time off to support their well-being. While in the sprint phase of the Keeping Our Team Members Safe initiative, we faced four major hurdles: cost, time, political will, and evaluation. First, we could calculate the cost of some programs, such as providing PPE for all staff, but we could not easily estimate the cost of such offerings as flexible use of personal time off, subsidized child/elder care, or immediate access to health care coverage for new employees. Estimating costs was a challenge because we did not know what the utilization rate would be, and if the utilization rate during the sprint would be generalizable to a marathon phase of the initiative in the event such a marathon was needed. From January 1 to June 30, 2020, our Covid-19-specific efforts to support the pandemic had a dramatic financial impact of approximately $1.16 billion on our health system. To put this loss in context, our 2019 operating budget was approximately $12.5 billion. The Covid-19-related costs to our health care system were partially offset by $754 million in Coronavirus Aid, Relief, and Economic Security (CARES) Act relief grants and funding for a net overall negative impact of approximately $400 million. Second, developing, communicating, and implementing these programs took many hours of time each week from leadership, management, and other staff. Hundreds of team members were involved in planning, communicating, and delivering each program, potentially delaying other tasks during this emergency. These time opportunities had to be weighed carefully and judged to be worthwhile even in the absence of known benefit or any possibility of a return on investment. Evaluating each program's success is difficult during emergencies. They were created quickly in immediate response to team member requests, iterated as councils provided qualitative feedback, and co-existed with several other new programs. While we evaluated the cost of the overall initiative, we could not easily discern which individual program was most successful, particularly as we temporarily halted most team member surveys (see below). Third, each of these new components required enormous political will from the health system's corporate leadership, and support from all departments in the health care system. Organizations need to clearly coordinate their emergency response to ensure they listen to different opinions, consider all aspects of issues rapidly, and then issue a single directive to ensure that fragmented or competing initiatives do not unfold. Any leader (legal, financial, regulatory, quality, medical, human resources, or other) who is not fully committed and practiced at this accelerated way of making and implementing rapid decisions can interfere and disrupt the process. If organizations do not hold simulated disaster training, these differences in political will can fester and cause conflict during an actual emergency. Regular training exercises reinforce the need for everyone to accept one solution rather than ongoing debate. For example, some leaders advocated for frequent employee surveys to immediately understand the impact of each of the Keeping Our Team Members Safe initiative programs. Others were concerned about the pandemic, anxiety, and increased workloads, and they wanted to temporarily stop all nonessential employee surveys. We chose to stop all surveys. In this specific example, delays in surveys and polls sacrificed immediate feedback from team members but ensured that essential work duties were prioritized. We also delayed several important plans that were in progress before the pandemic, including a key human resources initiative to restructure and enhance job descriptions and career growth opportunities across Northwell Health. Instead, we immediately implemented the Keeping Our Team Members Safe programs during the pandemic delaying this other human resource initiative until we were out of the spring part of the pandemic. Finances and human resource statistics were the main metrics monitored during the sprint phase of this initiative (January 1, 2020-July 1, 2020). Our Northwell workforce retention rates improved by 18% between March and July 2020, compared to the same period in 2019. We continue to track those rates and see year-over-year improvements, but do not know how much of this improvement is attributable to our multi-program initiative, our corporate culture, or other factors such as the unpredictability of the future job economy. Spending on salaries and employee benefits increased by $429 million, an 11.2% increase compared to the same period in 2019. This increase was primarily due to staffing needs related to the Covid-19 pandemic, payment of crisis bonuses to frontline team members ($124 million) and staffing investments to expand the physician and ambulatory network and support population health initiatives. Spending on supplies increased by $114.6 million, a 6.3% increase over the same period in 2019. This increase was due to PPE, lab supplies, pharmaceuticals, and other costs, such as investments in safety, quality and patient experience initiatives, information technology, and new physician practices. Additionally, we spent approximately $500,000 on housing accommodations and approximately $40 million on the crisis-care reimbursement programs for childcare. We have recently restarted our surveys after the "sprint" ended and we transitioned into the pandemic marathon. We typically survey Northwell team members three times each year: a full survey of all team members and physicians, a pulse survey to a subset of team members (30%), and an award application survey to 5,000 team members. Instead, as part of our key learnings, we will administer targeted micro-pulse surveys that each focus on one key area (decided at the time, and as needed) going forward. Additionally, we will maintain the Keeping Our Team Members Safe councils that we established during the height of the pandemic to obtain qualitative feedback from team members. We will also leverage social media as an input into team members' impressions about the work environment, including the remote work environment. This type of feedback was vital for quickly iterating the components of our initiative during the sprint and will be used during the predicted pandemic marathon. As part of our key learnings, we will administer targeted micro-pulse surveys that each focus on one key area (decided at the time, and as needed) going forward. Additionally, we will maintain the Keeping Our Team Members Safe councils that we established during the height of the pandemic to obtain qualitative feedback from team members." Over a week in late July 2020, we did conduct a survey of team members working remotely during the pandemic, requesting anonymous answers provided to our usual third-party survey vendor. Before the pandemic, Northwell expected team members to work face-to-face in an office setting and join meetings held in large conference rooms with hundreds of attendees. We had 9,319 " (65%) of our 14,420 remote team members respond. Of those, 87% thought that Northwell cared about their well-being during the pandemic, and 95% believed that Northwell transparently communicated information regarding Covid-19. However, the survey indicated that 59% of team members missed the social aspects of in-person work. We now turn to the plans for phase two of Keeping Our Team Members Safe -that is, the marathon phase. 1. Plan for Leading During the Unpredictable. Emergencies are inevitable. We all must continually assess our capabilities to create plans that can be created and executed on demand.8 At Northwell, we update our emergency management practice multiple times each year. We conduct preparation activities, such as table-top exercises; activation events, such as infectious disease emergence spatial cluster detection (or "disease hotspotting")9; and preparation for weather-related events such as tropical storms, hurricanes, and snowstorms. We persevered through major emergencies (e.g., 9/11 and Hurricane Sandy) from which we learned how to evolve our emergency management programs and processes -it is not a matter of having a playbook at the ready but, instead, having a team that can assess the immediate crisis and design the programs tailored to succeed in a sprint or in a longer-term, unpredictable crisis. We urge other health systems to invest in proactive planning practices for the unpredictable emergency. Eventually, every organization will have one. However, emergencies that last weeks, months, or even years are black swan events in health care. A pandemic of this speed and scale may have been unprecedented, but our emergency procedures provided an excellent foundation. As an organization, we activated our emergency operations center and, within Human Resources, we activated a similar emergency team to implement this initiative. We were able to rapidly innovate within every area of our institution to address the short-term and long-term consequences of the pandemic only because we were well prepared and able to leverage existing processes and protocols. However, one overarching decision was made -to focus on Keeping Our Team Members Safe -so that departmental or other divisional conflicts were minimized while we acted together to implement it. Crises, whether long or short, demand this. Though your health system may have a different core priority, you ought to identify, proclaim, and organize your emergency response around it. This type of emergency leadership structure is a must for the upcoming marathon that many health systems will undergo as they battle Covid-19 surges in the coming weeks and months. We also encourage other health care organizations to involve their team members in providing input on what is needed; they are at the frontlines of these emergencies, and they know better than anybody what they need to address the crisis your health care system may be facing. We surveyed ours, offered them many of the resources they requested, and then learned by utilization which ones seemed to be helpful. We chose not to conduct numerous surveys to determine usefulness of each program. If you have finished your sprint, make sure your team members rest if possible. As the longer-term marathon of this pandemic unfolds, decisional fatigue, work burnout, and depression are all concerns for caregivers. 10 We not only offered more flexible use of existing paid time off but provided five additional days of paid time off, and we encouraged supervisors to ensure team members used this time off when our Covid cases started to decline. We end by stating our plans for 2021. We will continue to have our emergency operations team in both Human Resources and our health system. Highest-utilized programs of this initiative were teleworking, investment in childcare, continued access to free and convenient Covid-19 testing, and convenient symptom monitoring (available online rather than at facility entrances prior to entry). We will continue these programs, as well as others requested by our team members as we enter the marathon phase of this pandemic. Highest-utilized programs of this initiative were teleworking, investment in childcare, continued access to free and convenient Covid-19 testing, and convenient symptom monitoring (available online rather than at facility entrances prior to entry). We will continue these programs, as well as others requested by our team members as we enter the marathon phase of this pandemic." Over 2021, we will continue to survey our team members about their concerns and needs and will continue to offer them new programs as these are requested. We will keep monitoring the evolving surrealistic situation in which we all find ourselves and always put our team members first. As they have shown us, when the organization puts its workers first, the team will be better equipped to provide excellent care for patients. final metrics. We acknowledge the role of the Northwell Covid-19 Research Consortium, which was instrumental in aiding with planning, data collection, editing, meetings, and other support. We acknowledge and honor all our Northwell team members who consistently put themselves in harm's way during the Covid-19 pandemic. We dedicate this article to them, as their sacrifices on the behalf of patients made it possible. Health Care Supply Chains: COVID-19 Challenges and Pressing Actions For 4 Days, the Hospital Thought He Had Just Pneumonia. It Was Coronavirus. The New York Times Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area Leading through a pandemic: The Inside Story of Humanity, Innovation, and Lessons Learned During the COVID-19 Crisis Prevalence of SARS-CoV-2 Antibodies in Health Care Personnel in the New York City Area The Psychological Impact of Epidemic and Pandemic Outbreaks on Healthcare Workers: Rapid Review of the Evidence Factors Associated With Mental Health Outcomes Among Health Care Workers Exposed to Coronavirus Disease Responding to Covid-19: Lessons from Management Research What is a Hotspot Anyway? To care is human-collectively confronting the clinician-burnout crisis We would like to thank Crystal R. Herron, Jennifer C. Johnson, and Andrew Dominello for editorial support as well as Howard Tuchman for coordinating the team who gathered and verified the "