Weathering and Weaving

Pitt County Memorial Hospital: Greenville N. C.

Weathering and Weaving: Lessons from the Trenches

By Birute Regine and Roger Lewin

Weathering: bearing up against and coming safely through

The Storm

“The awful shadow of some unseen Power/Floats though unseen among us...” - Percy Bysshe Shelley

Not since Hazel in 1954 was Greenville, N.C. a target of a major hurricane. Pitt County Memorial Hospital (PCMH), part of a five hospital system called University Health Systems of Eastern Carolina (UHS)–the nexus of care for the eastern North Carolina region of 29 counties–was well prepared for Hurricane Floyd’s anticipated hit on Thursday, Sept 16,1999. Running an academic medical center is a daily challenge, and being prepared for disaster is no minor event considering that PCMH is a 731-bed hospital, with 500 medical staff, 1,375 nurses and a total of 4,300 employees. To be ready on this scale requires a “philosophy,” says John Meredith, disaster chief for University Health Systems. “Once you take the philosophy that your hospital itself is a community that you are managing, your perspective changes. Do you have ample generator capability to run a hospital for an extended period of time? What happens when you lose water?” When a hospital is a like a community having extra water then translates into importing five 10,000-gallon tankers. Extra medications ultimately translated into a quarter of a million dollars spent. Redundancies, it is clear, is a key strategy to weathering disasters and crises.

Fortunately the staff at PCMH were an experienced crew. Just the week earlier, they had weathered Hurricane Dennis, which dumped seven inches of rain on the region. But Floyd was in a league of its own–a category five–which required extra precautions, such as boarding up windows, something they had never done before. Regardless of scale, PCMH’s mission was clear: to sustain critical operations of the hospital no matter how strong the wind or rain was.

On Wednesday, the day before the storm, the Hospital Command Center, headed jointly by John Meredith, PCMH’s “disaster chief,” and Sharon Bradley, VP of Patient Care Services, and staffed by medical, safety, and administration personnel, was set up near the Emergency Department, with eight-hour, around the clock shifts. Banks of phones were installed, which channeled questions and demands from the public, from within PCMH, and with the other hospitals in University Health Systems, and also a direct line to the county’s emergency control center. Every morning Hospital Command Center people would hold briefing meetings for PCMH managers in the Hickory Room, an opportunity for everyone to catch up with what was happening in other areas of the hospital, an opportunity to share ideas, and, often, to share laughter as well as concern.

They hunkered down, expecting to face the worst that night. The storm made landfall on September 16, 1999 at 6:45 AM at Topsail Island, along the North Carolina coast at which point they heard it had diminished to a category two storm. A collective sigh of relief and a burst of applause filled the Hospital Command Center. It wasn’t going to be a big deal after all. By 8 AM it was sweeping through Greenville with wind gusts up to 100 mph and sustained winds over 60 mph and torrential rain. By noon time, everyone was feeling like the worst was over. By two o’clock, they were disbanding the emergency management. Most went home as usual. That night the rain stopped.

Friday morning was a bright and beautiful day, refreshed as it often can be after a storm. There were trees down and some creeks flooding, but hospital staff went to work expecting to be debriefed about the storm. What they heard was that it was not over yet; that it wasn’t just something that would be gone in twenty-four hours, that some flooding was expected, that it may go on through the weekend.

On such a glorious fall day, it was impossible to imagine that a crisis was quietly and insidiously building–unseen, silent, unexpected, that five miles away tragic, life-threatening dramas would develop. They never anticipated that they would be watching the river rise daily, the sandbags piling high in response, until it finally crested, a foot short of the last electrical line, the last source of electricity for the city. They never expected how long they would be gripped by this drama, for it would be more than a week before the river crested. They never realized how devastating water can be, how it can wipe out a home, a life, many lives.

In experiencing the worst natural disaster to hit North Carolina in living memory, they would soon see a magnitude of despair they had not previously witnessed. At half a dozen hastily assembled, make-shift shelters around the county, elderly would sit with dazed eyes, their possessions destroyed; these precious links, lifelines to the past, gone forever, left now only with memories. People would cling to their meager belongings stuffed in a garbage bag, and carrying them where ever they went–to the toilet, to eat–never letting go. Teenagers would sleep all day and all night, deeply depressed. Convicts with testy tempers would intermingle in shelters with others, among a tube fed paraplegic, among the destitute and the despairing. They never imagined that the crisis would last not the anticipated three days but rather twelve, and for the devastated areas where entire communities were wiped out, indefinitely. On that beautiful Friday after the storm, it was hard for the staff at PCMH to believe a disaster lay around them. Surrealistic, like entering the Twilight Zone.

By noon on Friday, PCMH was rapidly becoming an island. Although the rain had stopped, Floyd’s fourteen inches of rain, hitting ground already saturated by Hurricane Dennis’s seven inches, a total of twenty-two, was harbinger to a rapidly-rising flood of Biblical proportions. The creeks and rivers quickly began to swell and soon there were no roads out of Greenville. Within a few days of the storm, surrealism would enter another depth–PCMH would look like something right out of M.A.S.H. “What we saw was unbelievable,” remembers chief of staff Paul Bolin. “I have never seen so much heavy equipment land in one place in my life. There was a three helicopter landing zones over the surgical center, a double LZ over the county building. It was like these battle scenes with all these helicopters.” In addition to choppers, there were heavy trucks and HMV’s for traversing the deep waters. Their appearance was terrifying, awe-filling, and exciting, as Tom Irons, president of Health East, recounts: “You can imagine the excitement of getting to go in the big Black-Hawk helicopter, the urgency and thrill of rescue.”

The Crisis

Crisis, taken from the Greek “krisis” literally means decision. Generally it means a turning point where things can go for better or worse, and in Greenville crisis was fractal–at the community level, in the hospital, and individually. For individuals, whose lives were radically changed, the crisis was emotional trauma. Within the University Health Systems headquarters, where one in eight people of Greenville work, blurring the line between UHS and the community, 10 percent of the 6,000 employees either completely lost their home or a majority of their home. One nurse, recently divorced, moved into a trailer with her parents. Like many trailer homes, hers was completely washed out. She, like others, continued to work in spite of her own dire situation, and because she had lost everything, she even had to resort to buying uniforms for work. Then there was the secretary who lost two homes since she was in the process of moving from one home to another when the storm hit. Both were in the same location, both flooded. And she had no flood insurance. And she had three children. Many staff stayed in the hospital for five, six days straight. They slept where ever they could find space for a makeshift cot, and then worked because, often, they had nowhere else to go. Paul Bolin describes an instance in his dialysis unit: “We had a nurse here who lost everything. I mean she was here working, taking care of patients. She and others would help their patients and then go in the back room and just start crying. And they’d come back and help patients, and go back in the back room and cry again.”

And then there were the stories of crisis outside the hospital. As Joan Wynn, director of Care Management recalls, “Being isolated in the hospital, we would watch TV to see what was going on outside. I remember one family that was at a shelter telling their story about how they had lost their child during the waters rising. He had been down at the corner store while they were at home. His parents eventually got rescued off their roof. But they didn’t know where their son was. Their son was with them in the interview, so we knew it turned out all right, but it was still so heart wrenching.”

Barbara Lawson, director of University Home Care, a UHS subsidiary, like many others, came in personal contact with these tragedies as people came to the physical therapy gym, which had become a holding place with beds for people with special needs without needing to be admitted. “Because these patients in the hospital shelter weren’t admitted,” said Barbara Lawson, “they had to bring a care giver. On several occasions, it wasn’t just one care giver. It was whole families that had just been rescued from their rooftops. One elderly woman came in with her neighbor. They had just been rescued from a tree which they had been in for several hours with her two grandchildren. They were rescued by a boat, but then the boat tipped over, and the woman’s two little grandchildren drowned. She came to the hospital shelter having just lost her grandchildren, not knowing where her family was, and her home gone. Even though she didn’t have a special need per se, we certainly weren’t going to turn her away. So we made her the care giver of her neighbor who did have special needs, and she stayed with him.”

(A detailed chronology of crisis events is given at the end of this story.)

The Challenges

We never know how high we are/Till we are asked to rise/And then if we are true plan/Our statures touch the skies– Emily Dickinson

Since crisis lingers at the edge of chaos, an unstable time when a critical phase has been reached, these circumstances require a form of management that is adaptable and flexible, so that a system can respond quickly and effectively to a rapidly changing environment. The Hospital Command Center, with its bank of constantly ringing phones, its cacophony of voices shouting questions, suggesting solutions, became the central nervous system for the hospital; where information was received, dispersed, and adaptive measures taken. As Sharon Bradley said, “You’re dealing with an array of issues. You deal with resources in terms of staffing and supplies, and not only supplies for here, but for each of the five hospitals in our system. Then there’s supplies for shelters. Our job is to try to understand people’s needs and prioritize and organize a response.” The many challenges that the hospital would face funneled through the Hospital Command Center. And there were many.

Mobilizing medical relief to thousands of people in shelters in addition to caring for those already in the hospital was, needless to say, a daunting task. Doctors and nurses voluntarily got together and assembled medical kits, such as, anti-hypertensives, diuretics, cold and ear infections remedies for people in the shelters who had no medicines, and were then airlifted to the shelters. “Even more than medicines,” said VP for Community Based Services Diane Poole, “we had to put together hygiene kits. Volunteers from community health centers and non-clinical people went to Wal-Mart and bought out all the little things–toothbrushes, combs, small bars of soap, shampoo. We were down to basics. People needed underwear. People needed baby formulas.” And in the midst of addressing these external crises, the hospital faced many internal crises. Following are two of many stories of creative adaptations that occurred at PCMH as its staff successfully weathered the challenges before them. They are testimonies to the power that can be engaged when people collectively organize, that is, organizing around issues rather than job titles.

The Transportation Challenge: something new emerges

With much of Pitt County under water at the height of the flood, PCMH was virtually unreachable by road for more than a week, and for one day was completely cut off. The task of getting patients to and from the hospital, of sending medical teams and supplies to the half dozen shelters in the area, and even getting staff in and out of the facility therefore was a major problem. And the failure of much of the county’s Emergency Medical Services system made matters even worse. “We’d get calls from people saying, ‘I called 911, and they say they can’t help me’,” recalls John Meredith. “They’d ask, ‘Can you help me?’ These were people who either needed to get to the hospital or required medicines or oxygen.” Of all the challenges faced in the first few days of the disaster, transport was one of the biggest. And, as it happened, the solution that emerged was one of the most powerful demonstrations of creativity and ingenuity in the face of urgency.

Transportation was one of the three major functions of the command center, the other two being communications and logistics. By the weekend after the hurricane, road transport was too dangerous–or impossible–to even attempt. If anything or anyone was to be moved, it would have to be by air, and PCMH’s single helicopter would not be up to the task. Dozens of military helicopters had been made available to the county emergency services, which initially were used mainly for rescuing people from rooftops and trees. A request by PCMH to the county for the use of at least one, preferably more, helicopters, was refused, mainly because all were needed in the initially frantic rescue effort, plucking people off roofs, from tree tops, and so on.

The response of the hospital’s CEO, Dave McRae was to give the crisis management team the authority to get helicopters by whatever means was necessary. Money no object. He joined in the effort, too, and in the end three were obtained, including, for a short time, a military Black-Hawk , which can carry up to fourteen passengers. At the height of the crisis there were as many as thirty helicopter missions each day, more than ten times the rate in normal times. “It felt like being in a war zone,” comments Joan Wynn, who was part of the emerging transportation effort.

On the Friday after the hurricane, Wynn, whose normal job has nothing to do with transport, volunteered to help compile lists of names and contact phone numbers of nurses, as part of the task of finding who could come in and what people needed. She left that evening thinking that that was the end of her participation. The next morning, Sharon Bradley called her and said, “We need that list you were working on yesterday, because we need to start calling people.” Wynn was to do the calling. “Calling them and telling them what?” she asked. “We’re getting some trucks that are going to be able to transport people here,” was the explanation. Many people at PCMH had been on the go since Wednesday; they were tired and needed to be replaced. Wynn’s job was to figure out where people could gather to be picked up by trucks. She was joined in the effort by Joy Perry. By the end of the day, however, it was already obvious that road transport wasn’t going to work. If people were going anywhere, it would have to be by helicopter. John Tolson, of PCMH’s EastCare division, which operates the hospital’s lone helicopter, was to be in charge of communications.

Trying to arrange for people to gather and be picked up by helicopter initially proved to be something of a nightmare, because it was impossible to be precise about the time when helicopters would be available. There were some frayed tempers among people who found themselves waiting for hours to be picked up, not knowing what was going on. The atmosphere in the Hospital Command Center was hectic, as people tried to cope with a stream of demands. By the next morning, Sunday, those demands increased further, when Cynthia Manning asked for helicopter time for transporting patients, in addition to ferrying staff and supplies. “Coordinating the transport needs got to be pretty chaotic,” says Bradley, “and we knew it wasn’t working as well as we needed it to.” So she and Meredith decided to take a time and, gather everyone together around 1:00 PM, and figure out what should be done.

“It took just ten minutes to come up with a solution,” recalls Sharon Bradley. “We decided to put all the transport issues together, helicopters and trucks, and everything they had to do, and establish a Transport Center that would be separate from the Command Center.” Tolson was to be in charge, with Wynn, Perry, and Manning being the rest of the team. Bradley’s charge to the team was simply stated, if not simple in itself: “Go into that room. Figure out how to get it done. Staff it twenty-four hours a day. Give me a schedule. Period.” Apart from Tolson, none of the Transport Center staff had any experience in working with transport issues. Wynn describes their situation this way: “Had we ever done anything like this before? No. Did we really know what we were doing when we got started? No. We just got into the process of it, figuring things out as we went along.”

Everyone proved to be very fast learners, bringing organization and strategy skills learned in other circumstances to the new challenges. Wynn had once worked as an ICU nurse, for instance, so she was used to pressure, but she wasn’t used to the degree of chaos she and her colleagues were plunged into. “We had absolutely no control at first,” she recalls. “Zero. Things got better as we got more helicopters, but we often felt helpless having to tell people ‘I’m really sorry you’ve been waiting two hours to be picked up, but I really can’t tell you when a helicopter will be available. But it will come, trust me.’”

At first, the transport team felt as if some people in the Hospital Command Center were breathing down their necks a little too much, no doubt because of a genuine concern as to whether this experiment would work. But work it did, as the transport team came to grips with trying to organize what was essentially a free-flowing, fluctuating, unpredictable confection of demands and solutions. The team’s members devised novel methods of operating and assigned responsibilities day by day. Transport priorities shifted during the crisis, going from the initial need to get PCMH staff to the hospital, and then including taking patients home and bringing in emergency cases, shipping supplies to other UHS hospitals, and supplies and staff to shelters across the county. Out of the initial chaos, a complex, important job got done with tremendous efficiency. And amid an intense atmosphere of emergent creativity, laced sometimes with laughter at the exhilaration of it all, sometimes with tears at the recognition of personal tragedies all around, the transport team found themselves forming tight bonds, both in their collective effort as a team, and as people who had come to know each other deeply under extraordinary circumstances.

The notion of a separate Transport Center had not been part of emergency preparedness plans that have been developed over the years at PCMH. But, says Meredith, it will be in the future. He notes that the Center worked more efficiently as a single unit during crisis than the normally separate hospital air services and motor pool usually do during routine times. A perfect example of the ingenuity of people facing novel challenges, and the power of emergent creativity.

The Water Challenge: “Water, water, everywhere, nor any drop to drink.” Samuel Coleridge

The call came in the early morning of Tuesday, 21^st, around 6:00 o’clock, remembers Mike Elks, administrator for plant operations: Malcolm Greene, general manager of Greenville Utilities Commission (GUC), was on the line, telling Elks that the town’s water supply might, just might, go down within the day, because the flood had prevented normal maintenance of pumping and filtering equipment. It would be for just a couple of hours, Greene said. “I wasn’t particularly worried,” remembers the unflappable Elks. “We thought we had half a day to get our back-systems ready.”

The Tar River was just a few hours away from cresting at 29.72 feet above flood level. At this point, Pitt had already weathered in less than a week what most medical facilities might face in a year; probably longer. Along with much of the town of Greenville, the hospital had lost primary power on the night of Friday 17^th, when one of the utility’s relay stations was engulfed in the rising flood waters. No problem: Pitt’s quartet of primary back-up generators kicked into life, and, with the help of a trio of smaller machines turned on for specific tasks, the hospital’s considerable thirst for electricity was fully sated, apart from power for air conditioning. Fortunately, the weather was being kind, temperature-wise at any rate. This particular emergency had therefore passed without too much threat to the smooth running of the facility, despite one of the generators having some required running repair of a coolant leak.

The same evening that the primary power went out, flood waters seeped into Greenville Utilities’ water treatment plant on Old River Road, potentially bringing with them the first traces of noxious mix of chemicals, hog-farm waste, and the detritus of thousands of animal corpses. As a precaution, GUC customers had been advised to boil water before drinking it or using it for cooking. At Pitt, the solution was the daily delivery of thousands of bottles of potable water for drinking, and the use of non-water-based hand wash by doctors and nurses, instead of water, for sterilizing their hands.

Elks’ calm at the prospect of the loss of primary water was in part due to his thinking that he had time to act, but also due to precautions that had been put into place after previous shortages. In 1997, for instance, during building work at the facility, external connections to the internal water system were installed, rather like sprinkler system hook ups, one not far from the hospital’s on-site well, the second at the other end of the building. The notion was that, were the mains supply to break down, pumper trucks would be able to supply at least part of the hospital’s demand for up to 300 gallons of water a minute, drawn from temporary tanks. Without this foresight, it’s unlikely that PCMH could have come through the crisis as it did.

As it turned out, the loss of primary water, and the context in which it happened, brought Dave McRae closer than any other confluence of events did to having him make the decision to close down what many had come to see as an island of succor and care in a sea of devastation. “I actually called the CEO of UNC, (University of North Carolina), our peer hospital, and a good friend, and I said, ‘Eric, I need for you to be prepared to get some helicopters down here and get patients out of here if I can’t take care of them,’” McRae, recalls. Although the power was back on at this time, it was still intermittent and obviously not reliable. More of a threat was the fact that the mains water pressure was falling faster and much sooner than Elks had been told it would. “I knew that if we were without water pressure for any length of time, we wouldn’t be able to operate as we needed to,” says McRae, “and it would be irresponsible to try to remain open.”

Paul Bolin recalls this time as the emotional nadir of the whole Floyd experience. In the few days running up to that Tuesday, Bolin had been discretely urging medical staff to identify which patients could be evacuated and which could not, if the worst case occurred. “We did this very quietly,” he now says. “We didn’t want people panicking. In the end, everyone had a plan.” But, to have put these plans into action would have represented failure; not just a technical failure, but a failure of faith, too.

McRae told his senior staff of his concerns that morning, and his likely impending action, his burden and responsibility as CEO. The response? “I had Ernie Larkin, Paul Bolin, Jim Ross, and Sharon Bradley saying to me, ‘Dave, don’t make that decision!’” Nevertheless, something dramatic would have to change within 30 minutes, or “that decision” was going to have to be implemented.

Elks didn’t know why the city’s water pressure plummeted the way it did; even GUC didn’t have a good idea at the time. But one thing was certain: “It was scary,” recalls Elks. His people were in the middle of hooking up a supply from the on-site well, which would be pumped into the hospital’s system by a fire truck, via three 2000-gallon dump pools, which essentially are like small, portable swimming pools. Some people were alarmed when the flow from the well first began, because it flowed brown. It looked as if the well had been contaminated and would be useless. These fears were allayed when those familiar with wells pointed out that the initial flow is always sludgy when a well is tapped. Meanwhile, plans were being made for having fire trucks pump water into the second external connector.

Suddenly, however, it was no longer a matter of measured preparations for a modest, temporary lowering of water pressure. The pressure dropped so dramatically that, no matter how fast Elks and his people pumped water into the internal system, they realized that they would never be able to get the pressure up. Because in 700 toilets around the facility, the flush valves would be hanging open, essentially draining the system as fast as it was being fed.

“We had anyone and everyone running around the hospital turning the valves off and posting notices that said, ‘Don’t Flush,’” recalls Elks. And forty portable toilets were set up around the medical center, for the use of the staff. “Yes, we had bottled water for drinking, and ways of sterilizing for nurses and doctors, but you can’t run a hospital for long when you can’t do something as basic as flushing toilets in the usual way.” Getting the system filled, the pressure up, was therefore urgent, otherwise McRae’s worst fears would be unavoidable. It wasn’t just the utilities’ people from plant operations who were running around shutting down valves, posting notices. That’s their job in such a situation. It was everyone: maintenance, carpenters, everyone who was available.

One of Elks’ people had close contacts with a local volunteer fire department, and so PCMH was able rapidly to recruit its help in delivering water from a neighboring water source, Bell Arthur Water Corporation, that was still operating. But, because the hospital’s water system had lost so much pressure, there was the very real possibility that pumping water into it via dump pools wouldn’t be adequate. After all, their capacity was only 2000 gallons each. Then, in one of those brainstorming experiences where, later, it is impossible to attribute this or that bright idea to any particular individual, the solution emerged: use the rehab pool as an initial major source of water, and a continuing mega-storage site. The pool, as good fortune would have it, was just 150 feet from the second external water connector; and it held 80,000 gallons.

Very soon, three 2000-gallon dump pools were set up in the rehab parking lot, and four pump trucks were variously pumping water from the on-site well into one external connector, pumping water from the rehab pool into the second external connector, refilling the rehab pool from dump pools in the parking lot, or delivering water from a fire plug five miles distant, serviced by Bell Arthur, into the dump pools. Two 10,000-gallon, 18-wheel water tankers from the North Carolina Forestry Service also became part of the effort to deliver sufficient water to Pitt.

This massive, free-flowing, collective effort eventually prevailed, but not before Elks and his people watched, horrified, as the rehab pool initially drained lower and lower, down to less than 20 percent capacity, with no strong signal that internal pressure was returning. “We felt sure pressure should have started building before this,” says Elks. “But it didn’t, and we had no idea why.” Maybe some underground pipes had burst, as often happens when the ground becomes water-logged and then dries, someone speculated. Another possibility was that, unbeknownst to anyone, the water was being pumped unwittingly into the Greenville water system. Yes, all the known connections to the system had been shut down, but maybe, just maybe, someone some time had hooked up a bootleg connection to the system? Bolin made a hasty call to a previous chief of nephrology to ask if he knew of anything of the sort. He didn’t.

Just when it seemed that the collective heroic effort had been foiled by some hidden yet powerful glitch, the pressure started to build. And build. And build. And it was within the 30 minute deadline that McRae had set himself. “You can imagine the relief we all felt,” says Elks. “There was cheering at that point.” Overcoming this potentially calamitous challenge was a tremendous morale booster. “I felt profoundly confident at that point that nothing could take us out now,” remembers Bolin. “We had stared into the abyss, and we had won.”

PCMH’s water supply was delivered in this manner for four days, until GUC could be certain that its system was secure again. The only hitch–which actually had the potential for being devastating–during this time was when a 1500-gallon gasoline tanker truck, that was servicing the pumpers caught fire during a refueling operation, but fortunately did not explode, at about 8:30 in the evening of Wednesday, 22^nd. “I don’t know how it happened,” comments Elks. “No one does. But the fire department was right there on the spot, and so they were able to deal with it before anything really bad happened.”

Plant operations prevailed, and Pitt remained open, through a combination of previous planning, and, as Elks puts it, “finding solutions on the fly.”

The Interconnected Web of Relationships

Weaknesses Uncovered

Freud wrote, “If we throw a crystal to the floor, it breaks; but not into haphazard pieces. It comes apart along its lines of cleavage into fragments whose boundaries, though they were invisible were predetermined by the crystal’s structure.” In other words, times of crisis, when the status quo falls apart, reveal the strengths and weaknesses in a system and makes these often invisible structures of connection and disconnection accessible for viewing. In this way, the crisis created by Hurricane Floyd created an opportunity to see the weaknesses and strengths within University Health Systems. The previous stories revealed the strengths; the following two examples reveal weaker connections.

Relationship to other services

There was some difficulty in coordinating with other services, such as the National Guard, the county, Red Cross, and other service agencies. Consequently Janet Mullaney, CEO of Heritage Hospital in Tarboro, part of the University Health Systems, sees the need to revise the existing disaster plan. “Instead of the Edgecombe County government having a disaster plan and all other agencies having their own plans and standards, what we’re trying to do is coordinate our work so that there is one plan for the entire county.” In an interconnected web, crisis shows that if your neighbors aren’t prepared, neither are you; too much diversity in plans is like no plan; and paradoxically, if there is room for only one way of doing things, that can undermine adaptability.

The latter point can be exemplified with the Red Cross situation as told by Tom Irons. “The shelter that the Red Cross said was the best managed because they followed every single Red Cross rule was by far the worst according to anyone who entered that shelter. Things weren’t going smoothly. There wasn’t a sense of shared responsibility. People were doing a wonderful job there, but everyone was at each other’s throat; there was a lot of tension. And that’s because the Red Cross managed it with extreme rigidity. They have a number of rules which are primarily geared to protect the shelter clients. But often they fly in the face of good sense. For example, if you want to find out if a relative is in a shelter, you have to fax a document showing your relationship, which takes a lot of time. And then the shelter has to give it to someone else who then calls the family. The problem is that it’s all about control and imposing order onto things which undermines opportunities for producing creative solutions.

“Gum Swamp shelter that was marvelously run had virtually no Red Cross support for days because it was on the other side of the river where people couldn’t get to. So the local people set the whole shelter up themselves. The school cafeteria cook did the cooking; she knows how to feed a cast of thousands. The doctor who lived down the street and his wife, who was a nurse, simply moved into the shelter. The local fire and rescue people handled the transportation of water and those things. They were clicking. Then the Red Cross came in and said, ‘you can’t do this, you can’t do that’ to the point that the local fire and rescue people walked out en masse.”

Complexity thinking shows that when you have a fluid system and you impose rules and structures onto systems without engaging the system itself, without allowing those in the system to participate, it breaks the system apart.

Relationship to the poor

As is often the case, the hardest hit in disasters are the already down trodden, the poor, and so it was with Hurricane Floyd. As Clyde Brooks, Associate Medical Director for Clinical Information, said, “The flood is making explicit what a lot of us have known in this region for a long time. That we have a population here that is very needy, around 25 counties. We have a stroke belt, a diabetes belt, a dialysis belt. How can we take care of these populations to improve the health status in this region? How, in other words, do we get ourselves and our infrastructure out to where people need us?”

These concerns were actively being pursued prior to the storm, driven largely by doctors who wanted more involvement in the system, an interesting innovation in that most doctors, usually more entrepreneurial in attitude, keep themselves apart from the system. As Ernie Larkin, Medical Affairs Health Officer for PCMH said, “There is an increasingly widespread feeling that we can affect more patients than we do. We can have a positive affect on the health of the population here as well as doing one on one care. How can this system be facilitated to care for people by making heath services, not just health care, more accessible? And how can the community be involved in developing that plan? The flood made these issues clear--we saw the need that existed and the difficulties involved in providing care to people who needed it.”

In a sense, the disaster uncovered another disaster–the health plight of the poor and uninsured. As Tom Irons observes, “The poor communities of this region are barely hanging together in terms of available health services. These people are on the edge. They make very modest incomes. It’s extremely difficult to manage in an environment where you never know who the payer is. The disaster created a significantly larger pool of uninsured people. Many of them were paying something on their doctor visits, and now they can pay nothing. That alone is enough to push most of the health centers over the edge. When you consider the long term effects on the frail elderly, who were able to sustain themselves, but barely, and now are unable to, the profound effect on the economy where farm workers’ jobs have been seriously compromised with the devastation of fields, you see how fragile this thing is. What the disaster did was to take off the very thin covering. What I learned about in the shelters I visited was the existence of a population of chronically ill, elderly, and poor people who didn’t have any medicine, and the method for getting that medicine was not well established.

“No one feels responsible for the uninsured, except those that actually deliver the care. There appears to be no way of funding it. We’ve got to all get together. We want public health people and others to come to the table and share resources instead of trying to operate independently. The disaster gives us a chance to catapult and change the system.”

And again, PCMH staff are reminded of the urgency of this situation and the need to collectively address decentralization. On January 27, 2000, Greenville was hit by a major snow storm, and the issue of reaching the poor at the outer reaches resurfaced, and again a reminder that this is not just a crisis issue but a daily concern. PCMH has been working on an overall strategic plan for about two years, and yet in spite of the good intent of many, there have been few breakthroughs and many break downs and inertia. Generally there has been a feeling of being stuck and getting no where fast–lots of frustration in the face of urgency. As Harvard Business School professor John Kotter has observed, energy and time expended on long-term strategic planning is often a way of obscuring a lack of direction and an inability to adapt to changing circumstances.

Obviously, being more responsive to community health needs is a complex issue leaving no realm untouched–economic, political, social–realms that are interconnected rather than separate with every element having a vital role in meeting needs for creating a healthy whole. Because of this, including a diversity of people is a wise strategy, both external agencies and also internally, that is, people from all levels of the UHS.

In trying to resolve this issue, there exists a tension between proposed strategies, between revolution or evolution. The former seeks to put the whole system into a form of chaos in order to make radical change. This has been a successful strategy in organizations embedded in old and sufficiently successful ways of doing things. Systems such as these can have all the pieces fitting well together, albeit they may be dysfunctional. In these cases, change requires a holistic approach that puts the whole system in chaos for a period of time so that new structures can emerge.

On the other hand, we also know small changes can have a big effect in complex systems, especially when a critical mass is building. It could be argued that a critical mass whose source is frustration is building. A sense of motion, in any direction, a learn-as-you-go strategy may break the impasse created by trying to agree on one clearly defined strategy. And even if one strategy were agreed upon, in the currently fast paced environment, it often becomes outdated by the time it is ready for implementation. Joan Wynn may have a way to open the door. “We don’t need to have every single thing in place before we start doing something. If we have a vision and the minimum things we need to do them, then we can move on and do it.” Evolution and revolution might meet.

A Strength Recovered

There’s an old saying that goes, “It’s an ill wind that blows no one any good.” Hurricane Floyd certainly counts as an ill wind in many ways, but it did blow University Health Systems some good, in two ways. First, it brought people together in ways that crises often can, as everyone struggled together to meet the challenges of Floyd. Secondly, the very obvious determination–and ultimate success–of the staff, collectively, to keep the facilities open and ready to meet every need of the community helped heal a painful breach between the system and the community it serves. It helped the community see what had been lost sight of when, in 1998, the system went from being a public, not-for-profit organization to being a private not-for-profit entity: namely, that the heart and soul of PCMH and its associated hospitals were deeply committed to caring for the people of Pitt County and beyond, regardless of the corporate structure.

Four years ago, the system’s administrators had realized that, if it was going to survive in the rapidly changing health-care environment, it could no longer operate under the restrictions imposed by being a public agency. “When you are a governmental entity, it makes you very, very cumbersome in your decision making,” explains Jim Ross, Chief Operating officer of University Health Systems and President of PCMH. “And when you are competing with for-profit entities that are moving into your area, who are very much more sophisticated in decision-making styles, it’s hard to successfully fight against that. We knew we couldn’t outspend them, but we also knew that we could be a little more nimble in our decision making.” Privatization was proposed as the answer. “If we were going to fulfill our mission in eastern North Carolina as a major teaching hospital, improving health care for the whole region, not just this county, we had to have a corporate structure that would allow us to invest money in other counties and to do other things we needed to do,” says Dave McRae.

Uproar is not too strong a characterization of the reaction in much of the community to this proposal change, and among some of the system’s staff, too. The reasons for this response are complex, and include local power politics. But they are also rooted in what the hospital symbolized to the community. When, in 1923, Pitt Community Hospital was opened, it was the only medical facility in the county. Over the years it grew, changed its name, first to Pitt General, then, in 1949, to PCMH in recognition of the county’s fallen heroes of two World Wars, and became a valued and revered haven of care in a community that, being among the poorest in the nation, desperately needed someone to care for them. And care it did, genuinely, deeply.

“Many people thought that by becoming private that we were somehow deserting them,” says McRae. “People were saying in effect, ‘It’s my hospital. I don’t want to lose it!’ They didn’t understand the kind of legal and corporate structures that were going to be necessary if we were going to continue and expand the care of the community in the way we wanted to.” People against the change conjured up images of executives driving around in Mercedes with thoughts only of their own future and fortune. There was a fear that UHS would change its sight, its vision, as a privately run system. “We tried to tell people that we were not Wall Street bound,” says Ross. “We tried to explain that we didn’t want to be multi-state, we don’t want to be international, that we’re about eastern North Carolina, that this was and would continue to be our mission.” But many people did not, or would not, listen.

In the struggle to persuade the county commissioners of the wisdom of privatization, McRae and his supporters were subjected to much public abuse and anger, and the effect was devastating, both on the reputation of the hospital in general and to McRae personally. In the end, the commissioners voted by the narrowest of margins to approve privatization, but, at a terrible price. “A relationship with the community that had been nurtured for more than 20 years was virtually wiped out over night,” says McRae. “I felt personally responsible for that, because I’ve committed myself all these years to building that relationship.” Trust and respect for the hospital had evaporated. All the efforts over the years to provide quality care, the involvement with community groups, investing money and services in the community, of which McRae nursed justifiable pride, counted for naught. “After privatization, nothing we had done previously counted for anything. We had to start over from scratch.”

The bad press surrounding privatization was compounded by a business downturn. Patient flow ebbed and margins diminished, so much so that expected staff bonuses could not be met. This exacerbated ill feeling within the system. Nevertheless, those UHS staff members who had been against privatization gradually came to see that changing the legal status of the system did not change its mission. But negative community sentiment barely budged, despite considerable efforts, such as greater support for community health care centers. Then came Hurricane Floyd, and the flood. And the heroic efforts of UHS people.

The fact that all the UHS hospitals remained open, not only for providing health care services but for shelter and sources of meals when there were no others; the fact the UHS personnel committed themselves so fully to doing whatever was necessary to help people, despite many of them having suffered personal losses, too; the fact that these same people took care of people in shelters across the county; the fact that PCMH came to look like a scene from Vietnam, with scores of helicopter flights daily ferrying patients–and sometimes domestic animals, too–back and forth; the fact that UHS came to be a source of succor and care to any one who needed it; all this was a reminder to people, either through direct personal experience, word of mouth, or reports in the press, of what UHS really was in the community, a demonstration of what was most important to UHS people: namely, the community and the health and welfare of its people.

“The flood reminded people in the community of who we really are and why we are here,” says McRae. “It catapulted us back more or less to where we had been in their eyes two years ago. We are now ready to move forward.”

Weaving: create by intertwining threads

The range of what we think and do is limited by what we fail to notice. And because we fail to notice, there is little we can to do change; until we notice how failing to notice shapes our thoughts and deeds.” Ronald Laing

Times of crisis can destroy an organization or pull it together. At PCMH there was a strong foundation of care and commitment that allowed people to come together better than ever in crisis. The right systems and structures for disasters were in place, and they worked. The staff had done their homework and had a clarity of how things were to be done; they had rehearsed disaster drills and, when it was show time, they performed brilliantly. And with clear directions in place, administration could turn the system loose. This paradox of direction without directives enabled PCMH to be highly responsive and adaptive, and like Noah’s Ark, were able to keep afloat.

Unlike most crises which last just a few days, the staff at PCMH had engaged in another way of working together and being with each other for 12 days, long enough that it became familiar, and many discovered that they liked. With the chain of command lifted, most people felt a new sense of accountability, commitment, freedom, individual expression. They had tasted the power of independent decision making, felt an ease unperturbed by bureaucratic red tape, and experienced a sense of comradery by having direct access to people they did not have before. And they loved it. They loved not having to go to their VP to get a decision made. They could take on a problem, deal with it, and get things done. They felt fully engaged and focused.

Although hard to admit without a twinge of guilt, a tragic situation had created circumstances in which work had become fun. Feeling productive is fun. Feeling opportunities open rather than bumping into barriers is fun. Seeing a common purpose is fun. A can-do attitude is fun. And this in turn, made for a robust system–adaptive, responsive, and agile. And so it’s not surprising that, with the ending of crisis mode of operation, most people felt a certain let down, a loss. They wondered how long it would take before people went back to their old ways.

Dave McRae would argue that this way of working is not reality for all the time. “You have to have check and balances and controls and sign off. We can’t afford to forever say you can spend all the resources without thinking about budget and the chain of command for authorization.” Granted costs were high; it took days to see what the economic fallout was, something to the tune of six million lost in revenues and two to four million in costs. But there was insurance for revenue loss and other things in place so in the end the costs were not that damaging. But the crisis exposed a more subtle reality; that the chain of command that controls money inadvertently also has an inhibiting effect on what people feel they can bring to the table–their ingenuity, creativity, resourcefulness. The question then is, is there a way to engage people in normal times as they were in crisis times? Are there behaviors and dynamics that can be recognized and nourished toward these ends?

Principles of relational dynamics

In an article for AHA News called “Lessons Learned in Carolina from the great flood of ‘99," written by Dave McRae and Tom Fortner, one of the lessons learned was “crisis brings out the best in people,” and that “there is something about being in the crucible together that melts the barriers that can exist between individuals and groups both inside and outside your hospital.” In this section, we will be addressing what those “somethings” are that melt down barriers as a way of identifying what can be cultivated in normal times that engages the human spirit and people at their best.

The perspective that gives a deeper insight into understanding the workings of complex systems is relational dynamics, that is, the observation of the quality of behaviors between people that can generate new connections, create disconnection, or provide paths for reconnection. The relevance of this perspective to organizations is that organizations are complex systems, and the source of what emerges in the organization–culture, creativity, productivity–stems from a deep simplicity, that is how people interact with each other and the kind of relationships they form. This dimension of organizations is often not noticed, or minimized. Paying attention to relational dynamics gives access to a deeper understanding of what makes a system more connected and fluid, exposing an overlooked nexus of influence and a source of change.

Relational dynamics is informed by relational psychology; that is, we know ourselves only to the extent that we can be in relationship to others, and we can only be in relationship to others to the extent that we know and can be ourselves. In other words, the more authentic we can be with others and open to being influenced by others, the more dynamic the interchange, which can lead to feeling connected to others, to learning opportunities, to greater participation, to innovative ideas and solutions.

Along with this perspective is different moral code; rather than morality being based on equality and justice, which addresses the individual self, in the relational domain care and responsibility are the values that guide behaviors. Care and responsibility were abundantly evident at PCMH during the crisis with a few exceptions. As Paul Bolin noted, “Crisis doesn’t change people; it amplifies who you really are, for better or worse.” There were, of course, people who tried to take advantage of the storm for their own personal gains, others self-aggrandized what they did, still others remained clueless about the big picture, self-absorbed in their own interests. But these were minuscule events compared to the outpouring of a caring human spirit, that for some was reaffirming, for others a surprise. In many ways, the crisis magnified the caring and responsible relationships that already existed. But it did more than that as well–it opened paths to new connections between people and to themselves

Following are behaviors to notice, ways of doing and being, that melted down the barriers which in turn created an atmosphere for the best to come forth. All these behaviors were already present at PMCH; the crisis just enhanced them. Seeing, valuing, and weaving these five threads of behaviors into daily life, strengthens the fabric of relationships and the organization. These threads, as demonstrated during the crisis, are ways to tap into often unrealized resources and a deeper level of commitment and involvement in normal times.

Five threads to weave on Monday morning

1. Let up on the reins

The role of administration and executives changed in crisis–rather than following the usual command style of leadership, administrators became more servant as leader–they let up on the reins and supported people, which proved to be highly effective. As Dave McRae said, “The executives go down to the command station, and we’re not there to be bosses but rather we’re there to say, ‘When you need something you can’t get, you let us know, and we’ll get the resources.’ It’s mostly to be there for people when they can’t get things moving or working. We help break those logjams.” In other words, as Janet Mullaney said, “You take care of the people you work with, they’ll take care of the people they work with, and then the patients will get taken care of. If you’re going to nurture an environment where everybody can be stars, you don’t need to control them.”

For Paul Bolin it boiled down to two words: “letting go.” “When you let go,” he said, “you find out how good a person is. You let them form their own opinions and then come back and talk about it rather than telling them how to solve it. You get a better decision if you hear everybody out on how to solve a problem. People prove themselves. I realized my staff could take the ball and run with it probably better than I could. I’m much more relaxed about leaving things in people’s hands. The downside is that people make mistakes, or to rephrase that, they solve the problem differently than you would. So it’s learning to not grab the reins and then seeing how it goes.” Letting up on the reins allows for distributed control which, from the principles of complexity science, we know creates conditions for greater efficiency and adaptability, important qualities for success in the current economic milieu as well as times of crisis. As John Meredith noted, “One thing about distributed leadership is it empowers people, motivates them; they become invigorated and excited about what they are doing.”

Although it sounds simple, it’s not. It’s very difficult to learn to let go of control and let people find their way, but this thread weaves into another strength–faith in people.

Lesson: People can and want to handle more than you think; have faith.

2. Step back and focus

Administrators found that one of the most powerful abilities they had to offer in the heat of crisis was perspective. As Dave McRae said, “The role Jim and I played was partly to stand back with some oversight. So I spent much time looking at how people were doing, who was losing their cool, who was thinking clearly, who was in conflict. Are they supporting each other? I try to help and touch and remind people of what we’re trying to do. And if the people I work with do that in turn, you get a ripple effect down through the system, and you create a very good environment for people to get things done. As long as you keep focused on the value and culture. There’s a value that says support employees; they are not assembly lines. They are human beings with their own issues and their own need to excel. Give them a chance to do that.”

In crisis, the necessity to step back is more apparent because of the pace and urgency of things. But in normal times, this is a powerful leadership skill as well. When you step back you see things; you see the strain on people’s faces, you see people as people which informs your direction. Stepping back allows you to recognize what Clyde Brooks calls “visceral leadership.” “It’s a kind of unspoken communication,” he said, “seeing attitudinal distinctions that differentiate people based on initiative, attitude, and hopefulness. You can just feel them.” Stepping back lets others come to the table. As John Meredith stated, “True leadership is a community function.”

Times of crisis have a way of clarifying what is important in life because in many ways people are forced to step back. For many at PCMH, the crisis raised a whole new set of questions about their jobs. What am I doing and why am I doing it? Is it important? Does it make a difference? These are very important questions because they are a way of sustaining the sense of self-actualization that occurred for people like Joan Wynn who said, “One thing I learned is that I can do pretty much anything anybody wants me to do.” But they are also important for tapping into an enormous pool of unrealized and unknown talents and resources in the organization and a way for the organization to structure itself around those talents.

Lesson: Listen, listen, listen to see how you can help

3. Get out there

During the crisis everyone got out of their offices. That created a lot of interaction, lots of diversity, which creates energy and fuels creative outcomes. Doctors became involved in the system and could be seen talking to janitors for opinions; the same with executives and other administrators. As Janet Mullaney said, ‘What got reinforced for me was the importance of walking the halls. It’s so easy to get into the day-to-day meetings, reports, analyzing numbers. But that’s not what’s going to make this organization click.”

Getting out there creates a sense of mutuality that fosters a sense of comradery–people see their leaders not just as a job title but as people. It is often felt by staff people in hierarchical organizations that it is difficult if not impossible to have access to people at the top. This creates a two-sided problem. For executives, they become shut out of many realities in their organization, which impedes them having an accurate reading of the pulse of the organization. For staff people, it generates cynicism–they think top people don’t really understand what is going on, so that when mandates come down, the response is often, “Come into the real world and see what things are really like.”

The impact when administrators are more accessible is apparent. For instance, pharmacist Pam Payne, who became the medicine distributor for all the shelters during the crisis, said, “I met administrators whose names I’ve heard for six years and never saw them. Now I recognize them as people, not just titles or the perception of their role. Seeing them as people makes me more willing to play along with whatever needs to be done. Like Dave McRae, he was just an administrator to me. Now I know he’s a nice person and that he really cares. I really saw a lot about him.”

It was also how administrators got out there that made a difference; that is, being in the buzz of things, and dressed in a more relaxed fashion. That, too, melts away barriers. A less strict dress code softens the difference between levels–it kindles a sense of everyone mutually working together, with each person, no matter their title, having a unique and valuable contribution. And people feel easier about talking to others when the clothing is more relaxed. This is not to say there isn’t a place for more formal attire; it’s to say there are benefits to different forms of dress and trusting people to make appropriate choices.

Lesson: Be in the buzz

4. Make work personal

Under dire circumstances people get to know more about each other in a personal way. Across the board, one of the things said they liked the most during those twelve days was getting to know more people and getting to know them better. In terms of the system, personal relationships strengthen connections, because if you know a person, you care more, you feel more accountable, you trust more, and trust in organizations is vital for the health of the organization. As Barbara Lawson said, “Personally I felt like I came into contact with a lot of people that I didn’t know well. I’ve been in the system a long time and you start to make quick judgments about people. I have new perspectives on a lot of different people and it’s changed our relationship, it’s just warmer, an easier conversation.”

When people know each other on a more personal level, they said they found it lubricated the work relationship–people are more honest, forth right because they have a better sense of where people stand. Take Janet Mullaney: “I’d been at the hospital for days, and the day I was finally going home, Dr. Gil Alligood, a physician on staff, saw me and said, ‘You haven’t been home yet!’ I told him every time I went home the neighbors were ringing the door bell so I couldn’t get any sleep, so I would just go back to the hospital. He pulled out a Valium and said, ‘Here. We learned this in the Army. When you need to get a bit of rest, just go home, lock your doors and take this. You’ll be better after this.’ I’m not much of a medication person, but I took that Valium and I did rest. But it was how he gave it to me that was different. It was like he was personally helping me. Now when I sit down with him we really have a good conversation. I have some trepidation handling certain issues with physicians. I find it hard to give bad news or bring up difficult problems. Now I feel a lot more comfortable doing that, because I feel there’s more mutual respect there.”

Or Pam Payne: “My relationship to people in my department has changed. That surprises me. I usually keep to myself in my office. Now there’s a lot of comradery and pulling together kind of attitude that wasn’t there before. What I think helped to get that feeling was getting to know the people I work with in a personal way. For instance, the secretary and I used to just interact minimally, whatever was required to do the job. She lost everything in the disaster. Now I have some insight into her personal life and what she is really about and I view her in a whole different way and we interact in a different way.” For Ernie Larkin, getting to know people in a deeper way was a revelation. “I discovered there were plenty of like-minded people working together here, and now I don’t feel so alone. I knew that they were there; they just weren’t accessible.”

The benefits of continuing to develop relationships that were galvanized by the crisis is best said by Diane Poole: “So much of getting things accomplished in a big system like this is facilitated by relationship. I mean effective relationships that are based on more than formal lines. Those who can create more personal relationships are the creative and innovative ones, because so much of leading is persuading people to do things a little differently or take a little risk, to think a little out of the box. When people can relate to their manager or supervisor, I think they work harder and want to perform better. To find effectiveness in an organization, you have to find ways to enhance those relationships. That means take care of each other.”

Lesson: Learn about each other’s stories–their life, their work passion, what they care about.

5. Make Someone’s Day

During and after the crisis, there was an outpouring of appreciation from administration to the staff: from helicoptered Starbucks coffee, to written and verbal thanks, to ice cream, money, and mugs. These small actions had a huge affect on the morale of personnel during the crisis, but also no less in normal times. As Nurse Marge Gerber said, “It was sad to see that appreciation diminish. I’d like it to stay strong. And I’m not talking about gifts or money. Just being acknowledged. Just knowing that they’re concerned about you running around and having no lunch or not stopping for twelve hours. Nursing is fast paced and hard work, and it means a lot to just be appreciated.”

The omission of seeing what people do and expressing appreciation on a daily basis is implicit when Mike Elks, whose department was heralded for its heroic work during the crisis because of their water solution, said, “Personally, I don’t think we were heroes. It was just another problem we dealt with. And we deal with problems every week.” In other words, crisis made what they normally do more visible.

Appreciation–thankfulness, admiration, approval, gratitude–as a consistent thread in an organization doesn’t cost anything, doesn’t take much time, and the benefits are far bigger than the act itself. In the financial world, something that “appreciates” grows in value. When the power tool of genuine appreciation becomes a consistent behavior among people in an organization lives grow in value. When done consistently, mentoring becomes a natural extension of appreciation. As Joan Wynn says, “I’m really working on trying to give people opportunities to be at the front of the room, have them tell me what their plans are and how I can help them. I don’t think people really think enough about who am I mentoring? We can promote people in a different way, and it’s important to recognize that we don’t do that enough now. How do we lift people or put people in situations where their abilities come to the top and are really used? Like, who should be going to graduate school?” In other words, how can we appreciate people so they grow in value, for themselves and for the organization?

Lesson: Appreciate someone everyday, for your sake as well as theirs.

These five threads of relational dynamics, when not simply espoused but genuinely embraced can strengthen the fabric of the organization by creating an environment that encourages people to explore and discover what they can do that they didn’t know they could do or develop what they do know. These threads were amplified during the crisis and, when woven together, made the organization responsive, adaptable, and successful. Paying attention to people as people, and caring how we relate to each other and the quality of our relationship, is that edge needed for organizational success.

Restoring the Soul

“Character cannot be developed in ease and quiet. Only through experience of trial and suffering can the soul be strengthened, ambition inspired, and success achieved.” -Helen Keller

The crisis was over, the Hospital Command Center was disbanding. It was Friday at noon and two hundred hospital managers had gathered . Dave McRae was there, dressed in casual clothes, talking to people, walking around. He stood in front of the group of doctors, nurses, managers. Everyone was tired; everyone had gone through stressful times, tough times, but there they were together, listening. McRae said, “We all need to go home now, finally, and rest and come back next week, ready to go. And I plan to go home and restore my soul this weekend.”

At this point, physically and emotionally exhausted, his voice cracked and he could not contain the depth of feeling in him. He wept. And with him, so did two hundred people. For McRae it was partly an embarrassment, partly a revelation. And certainly a moment he will never forget, a moment no one in the room will forget. For everyone present it was a powerful moment of spiritual connection, a deeply emotional bond. Even when people recounted this moment months later, they became teary in their recollection. An indelible mark had been made.

For the staff at PCMH, Dave McRae has a special gift–to communicate on a personal level, be it five or five hundred people. But with all the distractions of building the health system, the stress of dealing with political sentiment, getting mired down with a burden of feeling ultimately responsible as a leader, he had gotten too far away from what he did and loved best: interacting with people. In that teary moment, he recovered his ability to inspire, to move people, to help them see themselves as part of, and contributing to, a greater good. He, like many in the course of those intense emotion-ridden days, had during the crisis unexpectedly recovered something not lost over the past two years, but perhaps forgotten. In that moment of closure, everyone had come to a place of clarity, and they remembered what was important to them: the meaning of their work, a faith in each other, and a community spirit of being in it together. In that moment, bone weary and bleary eyed, their souls were joined and thus restored. A legacy.