When famed aviator Charles Lindbergh was told of his sister in-law’s impending death due to a failing cardiac valve caused by rheumatic fever, his response was characteristic of an engineer’s: Why not just replace the valve?(1)
In the 1930s, medical care was not sufficiently advanced to develop cardio-pulmonary bypass and valve replacement technologies. Despite this, the forward-thinking Lindbergh saw fit to request an introduction to the Nobel prize-winning vascular surgeon Alexis Carrel. This began a fascinating partnership between the aviator and surgeon that would lead to innovations in organ reperfusion that are still relevant today. One such innovation concerns kidneys harvested for transplant, which are kept viable during transport by a modern version of the Carrel/Lindbergh perfusion pump design.(2)
Such feats take time, and while Lindbergh was unable to save his sister-in-law, many thousands of patients have been saved by the miracle of organ transplantation. This accomplishment, one might argue, came from a sense of intellectual curiosity, coupled with the courage to place one’s own personhood, be it reputational or physical, at risk to find out. In the case of Lindbergh, his foray into medicine illustrates the former and his experience designing and testing aircraft in flight illustrates the latter.
The COVID-19 pandemic year 2020 gave us the miracle of multiple effective vaccines. This space-age feat of vaccine research and large-scale production with distribution was somewhat thwarted by the prevalence of anti-science and vaccine misinformation. Ideas became ideologies and were amplified through social media and politically weaponized.
As citizens’ mistrust in government agencies, journalism, and science grew, simple truths were called into question, including requiring healthcare workers to be vaccinated from communicable diseases in an effort to reduce the possibility of infecting patients — something supported by decades of practice and precedent. Perhaps because of this mistrust, healthcare systems around the United States seemed hesitant to move forward with a COVID-19 vaccine mandate for healthcare workers.
The first healthcare system in America to publicly decree its intent for a vaccine mandate was the Houston Methodist hospital system in Texas, comprised of an academic medical center, six community hospitals, and a long-term acute care hospital in the greater Houston area.
If one were to use the metaphor of reason being akin to an aircraft, the leadership at Houston Methodist completed all the pre-flight safety checks then deliberately chose to take to the skies. Despite their aircraft being buffeted by storms, its landing reminded the rest of the world what it meant to fly. This article investigates the process and the principles that guided this decision.
Three Foundations of Reason
There are approximately 637 healthcare systems in the United States with 6,000 hospitals, many of which are internationally renowned. The authors sought to understand how, in this crowded field of healthcare systems, Houston Methodist chose to set its historic precedent. Such a decision would have been remarkable anywhere in the nation but especially so in the Lone Star State, known for its strong libertarian values.
The CEO and president of the Houston Methodist system, Marc Boom, MD, MBA, FACP, FACHE, a practicing physician who continues to see patients on Tuesday afternoons, shared in a series of interviews, his insights and observations on working with his executive teams.
It seemed plausible, even probable, to assume that the decision to mandate came from a chief executive with a larger-than-life personality of Lindbergh-like proportions. Such an assumption would be incorrect.
The reality of Houston Methodist’s decision to mandate vaccines is that there was no movie-worthy moment of courage, no individual act of heroism. Through our conversations, it became apparent that the mandate decision was the result of the careful development of a decision-making system over years and even decades at Houston Methodist. Boom said the only hard decision was when to “pull the trigger.” “It was never if,” he explained.(3)
In truth, the foundations of the decision to mandate can be found at any local bookstore. Boom and his team practice well-known and well-established leadership concepts. In researching this article, the authors identified three primary principles that enabled Houston Methodist to plan in the midst of such turmoil: adherence to a clear understanding of purpose, deliberate team building, and deliberate action and communication.
Adherence to a Clear Understanding of Purpose
In his book The Culture Code, author Daniel Coyle describes the Johnson & Johnson (J&J) board room during the Tylenol poisonings that occurred in Chicago in the fall of 1982. With seven deaths traced to the poisoning, J&J faced an extremely challenging scenario: major financial risk, uncertain legal implications, and significant political pressure.
James Burke, president of J&J at the time of the crisis, said of the actions of the organization, “We had to make hundreds of decisions on the fly; hundreds of people made thousands of decisions…. Those thousands of decisions all had a splendid consistency about them.”(4)
J&J chose to act decisively, ordering an immediate national recall of all Tylenol products, providing public comments about grief and regret, and inventing new, tamper-proof packaging. Many of these actions were opposed by government and legal advisors, but J&J chose to act. Six weeks later, their products were on shelves in tamper-proof packaging. Through frequent communication with the public, J&J regained the public trust and recaptured then surpassed their pre-recall market share.
Most organizations struggle to achieve clarity even during times of prosperity. How did J&J manage this in the middle of the organization’s worst crisis? Burke believed this success was rooted in J&J’s deep belief in the company’s founding principles, which were outlined in a one-page document called “The Credo.”(4)
Robert Wood Johnson, the company’s former chairman, drafted The Credo in 1943. But in 1975, seven years before the crisis, Burke feared The Credo had lost its meaning. Burke led J&J through a deliberate process to validate The Credo. He invited J&J’s managers to openly challenge these principles, arguing that if the organization could not live by them, it would be better to “tear it off the walls.”(4)
J&J’s leaders engaged in lengthy debate, eventually agreeing to keep The Credo intact. Burke repeated this process often, continually challenging the organization’s principles. This process brought The Credo to life and cemented the principles in the day-to-day actions of the organization.
It was The Credo that guided J&J’s response to the Tylenol crisis. The Credo stated: “We believe our first responsibility is to doctors, nurses and patients, to mothers and fathers and all others who use our products and services.”(4)
Houston Methodist drafted its own version of the J&J Credo in 2012. Intentionally designed to be short, simple, and actionable, it is called “The Vision for the Second Century.” It is six simple words: “Unparalleled safety, quality, service, and innovation.” Echoing James Burke, Boom shared the purpose of this document: “It’s about aligning people; alignment on the broad concepts, the framework, to help guide decisions going forward.”(1)
Most organizations have a vision statement. What makes the Houston Methodist example noteworthy? The authors believe that this may come down to how the vision is implemented. Is it a statement on the wall without connection to the daily work? Or does it live in the decisions and actions of the organization and its leaders?
As was the case with J&J, Houston Methodist regularly tests and reaffirms the vision to ensure continued relevance and importance. The vision was at the center of the decision to mandate, serving as a north star and emphasizing the organizational priority of unparalleled safety. It is worth mentioning that in 2001, after a devastating flood that practically shut down the flagship hospital, the organization chose five core values. These shared values of integrity, compassion, accountability, respect, and excellence made the choice and implementation of the six words possible.
According to Boom, by establishing organizational clarity, key decisions, even potentially difficult ones like the decision to mandate vaccines, are “actually, really easy in terms of should you do it.”(1)
Deliberate Team Building
“First, get the right people on the bus” is one of the memorable quotes from Jim Collins, author of Good to Great.(5) Collins asserts that it is more important to have the right people than the right strategy. The right people will be able to respond to any situation and develop effective strategies. The wrong people will be ineffective in facing challenges, regardless of the strength of their over-arching strategy.
The team at Houston Methodist followed this lesson and took deliberate steps to ensure that they had the right people in the executive room. The authors found three specific examples that were particularly intriguing, in part because of the unique nature of the roles, but also for the importance each played in Houston Methodist’s response to the COVID-19 pandemic.
First was the chief of strategy and legal. In our experience, these two functions are generally separated into respective positions and on different ends of the organizational spectrum. Strategy roles often function as the organization’s flight throttle, seeking new opportunities and pushing the organization forward. Legal roles often function as the organization’s air brakes, avoiding liability and cautioning against unnecessary risks. Not so at Houston Methodist, where both functions fall to one individual.
This choice seemed to inform the organization’s approach to the decision to mandate the vaccine. In line with the organization’s purpose, the decision to mandate was clear to the executive team, but that did not mean it was without risk. The legal team could have simply stated that such a decision was risky and would certainly result in legal challenge. Rather, the legal team functioned as the organization’s flight yoke, guiding it through the legal issues, articulating the risks, conveying the applicable laws, and helping the organization reach a reasonable decision rooted in purpose.
This approach withstood the impending legal challenges and served as permission-to-act to hundreds of other healthcare organizations that would soon follow with their own version of a vaccine mandate.
The other two key members of the vaccine mandate decision team were the vice president of spiritual care and values integration and an ethicist. The spiritual care and values integration position, mandated by the organization’s bylaws, reports directly to Boom. One of the primary functions of this role is to make sure the organization’s actions and decisions align with the faith-based roots of the Methodist Church and the vision and values of the organization. In other words, Houston Methodist believes living its purpose and values is so important that it has a senior leader whose job is to ensure that it happens.
The ethicist at Houston Methodist reports to the vice president of spiritual care and values integration. Rather than dealing piecemeal with issues of ethics, Houston Methodist chose to infuse ethics into the entire decision-making process. Inviting the ethicist to join the conversation from the beginning sent a clear message about the importance of that role and function in every aspect of the mandate decision.
When a team gets the right people on the bus, it unlocks the potential for superior performance. Any team, whether on the aviation field or in the board room, must practice and work hard to produce the best results.
One of the key elements behind the Houston Methodist decision to mandate was the ability of the senior team to engage in dialogue, debate to reach clear and effective decisions, and strive to function as a cohesive unit.
Boom defines cohesive as, “when we leave the room, we’re all on the same page.” He does not mean consensus; in fact, he explicitly encourages that the team engage in debate over opposing views. When he meets with newly positioned leaders, he tells them, “If you have a disagreement, I want to hear it. I want to hear it so that we can have a discussion about it.”
This process can be uncomfortable and it can be messy. The focus should not be on the comfort of the leadership team, but rather on the quality and clarity of the decisions. The more a team can engage in dialogue and debate, the better decisions they can make. Having the right people on the bus is key; however, giving them the freedom to navigate conflict organically also appears essential.
It would seem challenging to engage in this process with the wrong people. The Houston Methodist case provides an example of a team completing both necessary elements — getting the right people around the decision-making table and creating an environment that welcomes, even demands, debate. This aligns with Charles Lindbergh’s decision to seek out Alexis Carrel’s expertise in vascular surgery to match his mastery of fluid dynamics and engineering principles. The right team can undertake transformational work.
Deliberate Action and Communication
One might assume that Boom and his leadership team first began discussing a potential vaccine mandate at the onset of the COVID-19 pandemic, taking steps to implement it around the time vaccine development was making positive end roads in late 2020. In reality, the groundwork for the decision to mandate began almost a decade earlier.
In the spring of 2009, the leadership at Houston Methodist began to contemplate mandatory influenza or “flu” vaccines for their healthcare workers — an idea that, at the time, was a novel concept in American healthcare. Later that year, Houston Methodist became an early adopter of mandatory flu vaccines for its healthcare workers, now a standard practice in the healthcare industry.
The organization weighed many factors in its decision to mandate the flu vaccine: positive impact on patient health, legal constructs, impact on operations, and ethical issues to name a few. Placing patient safety at the heart of its decision making, the leadership at Houston Methodist decided that mandating the flu vaccine was a necessary action. Hence, before they led with COVID-19 vaccination mandates, they led with flu vaccination mandates. This is analogous to how J&J laid the ethical groundwork of The Credo prior to relying on it to help the organization navigate the myriad issues of legal, public opinion risk, and patient safety drivers during their moment of crisis.
Houston Methodist spent the next decade building on this work. The team further defined core values, outlined the “Vision for the Second Century,” and acted consistently and repeatedly to entrench those concepts into the heart and mind of the organization.
Because of this dedicated focus, the decision to mandate the COVID-19 vaccine was “culturally obvious for us,” Boom said. “Quite honestly, we never had a discussion of should we ever mandate. The discussion was always: When will we mandate?” This clarity allowed Houston Methodist to begin a series of actions more than a year before the mandate went into effect.
As early as May 2020, Boom and his leadership team began implementing what may have been the most important aspect of the entire effort: communicating to the hospital system’s staff. Boom and his leadership team needed to make sure the staff knew that this issue was important.
As Patrick Lencioni shares in his book The Advantage, one of the best ways to reinforce the importance of a message “is to repeat [the message] over a prolonged period of time.”(6) Boom and his team began by communicating regular updates from the vaccine trials and sharing leadership’s hopes for what these vaccines might mean. The updates were shared by different leaders in a variety of manners throughout the summer.
In September of that year, Boom and his team communicated to staff that a COVID-19 vaccine mandate was an eventuality. The messaging stated that “when we deem [the vaccines] to be safe and effective and they’re widely available, we will mandate these just as we mandated the flu vaccine.”(3)
Houston Methodist implemented a phased approach to the vaccine mandate. In December 2020, as the Pfizer and Moderna vaccines became available, Boom and his team introduced a bonus program for staff who became fully vaccinated. In announcing the bonus program, Houston Methodist again stated that the vaccines would ultimately become mandatory, and repeatedly shared data proving vaccine safety and efficacy to employees and physicians.
This focused effort early in the process made the final steps leading to the mandate much easier to accomplish operationally. Because of the consistent messaging and thoughtful approach, by the time Houston Methodist announced the vaccine mandate and set a date for compliance, 85% of the workforce had already been vaccinated.
The team knew the mandate would result in the departure and/or termination of some employees — a tough issue to entertain during a global pandemic where every single individual was needed. In the end, 158 employees (out of 27,000) refused to get vaccinated and subsequently departed the organization. A small but vocal group of employed dissenters proceeded to enter into a class-action lawsuit against the health system, resulting in a substantial amount of national and international media coverage.(7) During this time, the leadership at Houston Methodist steadfastly maintained its stance on supporting science and educating both the public and its own staff on the merits of mandatory vaccination as a patient safety measure in the healthcare setting.(8)
On June 12, 2021, U.S. District Judge Lynn N. Hughes ruled that Houston Methodist did not violate state or federal law or public policy with the vaccine mandate. The five-page ruling appeared as a triumph of common sense. Here is an excerpt:
“Methodist is trying to do their business of saving lives without giving them the COVID-19 virus. It is a choice made to keep staff, patients, and their families safer.” (9)
In mandating and subsequently defending their decision successfully, Houston Methodist became the first healthcare system in the United States to do so.(8) Shortly thereafter, many healthcare systems came out in support of vaccination mandates.(10,11) In the following months and years, however, mandatory vaccines for healthcare workers were and continue to be a divisive political issue.(12–15)
Conclusions
In the field of aviation, one might define three roles. There are the pilots, who learn the subtleties of flight so that they can ferry themselves and their passengers safely to and from their respective destinations. Second are aeronautical engineers, who look to science and mathematics to help engineer what is possible in terms of launching aircraft into the skies. The third role is the aviators, who it would seem are a blend of the two, taking on the challenge of not only defining what may be possible in terms of aircraft design, but assuming the task of piloting and testing these designs, often at great risk to themselves.
When the executive team at Houston Methodist formulated their plan to mandate vaccination (and now, boosters) for their employees, they turned to their guiding principles, mission, and vision. They were purposeful in building a team to engineer their rationale, guided by science, ethics, legal precedent, and their values.
Critically, they also assessed the risk of such an undertaking during the uncertainties of how the public might respond during the pandemic. Amplified by organized disinformation campaigns on social media, the winds of anti-science took on unprecedented levels of ferocity. And yet, Houston Methodist still took flight with its healthcare worker vaccine mandate and were the first to do so in the nation. Their preparation and planning helped them skillfully navigate a torrent of anticipated legal challenges.
Shortly after judgments had passed in their favor, many of the country’s notable healthcare systems followed suit albeit in varying degrees.(15) They may have reminded the rest of us in healthcare what it was to steel one’s self and take flight.
Amelia Earhart, notable for her accomplishments in aviation and shattering gender norms, once remarked, “The most difficult thing is the decision to act. The rest is merely tenacity. The fears are paper tigers. You can do anything you decide to do. You can act to change and control your life and the procedure. The process is its own reward.”(16)
The time and space between the decision to be the first healthcare system with mandatory healthcare worker vaccination and the final legal validation of this approach must have seemed both immense and lonely. The media barrage that followed the mandate would have been enough for some less tenacious hospital systems to do an about-face. History now shows the Houston Methodist team had both the intellectual courage to act and the tenacity to persevere through the winds of uncertainty and into the pages of history.
Acknowledgment: The authors wish to thank the following individuals for their contributions and review of this paper: Marc Boom, MD; Saad H. Chaudhry, Roxanne O’Brien, and Rebecca Harrington.
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