Table 1 Theme 1, Building the plane while flying it

1. Building the plane while flying it

The organisations existing pandemic plan was not fit for purpose

Q1 “we obviously had a pandemic plan at the beginning of 2020, which was developed for pandemic influenza, but there was an abstractness to that plan, because it had not been developed to specifically combat this pathogen” [….] “the plan had been developed through the lens of this might happen at some point, rather than oh my goodness this is happening” [….] “The other major problem was trying to reconcile whether any of the planning that had been done, from an infection control pandemic management perspective, was going to be relevant and appropriate” (P3)

Q2 “At the time WHO was announcing there was a pandemic, there was essentially no pandemic plan, so that’s the starting point”[….] “I remember sitting at a leadership meeting in about March 2020, and you’re asked to develop a pandemic plan” [….]“At that point being advised we were in stage 1, and I said we might as well forget about stage 1 and 2 cause we are already in stage 3 by the time we actually publish a plan” [….] “Various layers of planning were required from a strategic level, running a big health service as part of a big state-wide health system, to what you do at an individual emergency department, ICU, ward level, there was a complete absence of any planning” (P2)

Q3 “The original pandemic plan just lacked that granular detail, and some of the discussions we've had over the last two years are just extraordinary in terms of granular details that you just don't think of until you're in the middle of it” (P3)

Q4 “I think our preparation for a real contagious virus was well underdone, there hadn’t really been anything since Ebola and not everybody was affected by that” [….] “we based it [the pandemic plan] on sort of flu outbreaks and a few other things that hadn't realistically being reviewed for a while. I don't think people really thought it was a priority until suddenly we were faced with it all, and of course obviously the pandemic sort of snowballed of its own accord” (P11)

Q5 “Early on I looked at the pandemic plan that had been written and I just went well that was never gonna cut the mustard was it. We had a very high-level plan of what would happen, and you know that's not what played out, that’s not what happened in a tabletop exercise” (P5)

Lack of command-and-control verses egalitarianism

Q6 “So again we had and very much still had today, what’s the hospital down the road doing, are we consistent, we don’t want to be the front runners in case we make a mistake, whereas people working in other jurisdictions the ministry has said you will do this, and that’s what happens. And it creates a different sort of psyche and I think an element of inefficiency which has been significant” (P2)

Q7 “it’s easy to run a pandemic you only have to do one thing and that’s run a pandemic, but it’s all the business as business-as-usual stuff which is a lot harder” (P8)

Q8 “The history is different too, New South Wales didn't all of a sudden turn on command control, it’s how they operate, it is an aggressive jurisdiction, it’s an aggressive culture up there. And in a pandemic, it absolutely was command and control” [….] “They’ve (NSW) got a centralized model of some of these big pillars, they've got the CEC and ACI, so a lot of the guidelines, a lot of the directions were coming out of the CEC, absolutely. Victoria’s governance in that space isn't command and control. They don’t have the pillars to support a command-and-control approach” [….] “In the beginning everyone was scrambling for procurement and consumables and New South Wales was as well, but it got centralized a lot quicker, and that gave the organization's confidence that that wasn't going to be an ongoing issue” (P8)

Q9 “I have never worked in new South Wales, but it sounds like they have a far more streamlined process, they have a far more well developed health system in the sense of different parts talking to each other, and they appear to have managed things at times better than we have in Victoria” [….] “ And I know unhappy people from some of those States who prior to the pandemic bemoaned the dictatorial nature of some people within their health problems and outside of an emergency you could argue that Victoria’s system is better than a more dictatorial top-down approach, but in a crisis you just leaders, you need people running the show so that you have some consistency and you have some stuff in plan and like there's a balance there right, like obviously it gets to dictatorial. I think that de-centralization in Victoria has led to a huge volume of redundant work, I think it has led to a lot of conflict, I think it's led to a lot of inequality in terms of how many people support each aspect and each health service, and I think it's created some problems, but you know we'll see if we learn for next time” (P3)

Q10 “it's an interesting thing, whose responsibility is things, is it the health departments, is it the society of infectious diseases, is it the hospitals themselves, you know we've had so much conflict throughout this pandemic between all of those groups as to who should be doing what, it's been difficult to get any kind of coordinated response” (P3)

Q11 “I think that command and control and just that focus on making sure that we had one meeting you know, and it could go forever and it's not compulsory, I did say to the team come if you want to come it’s not compulsory and yesterday we had 25 people still on the zoom. You can get the answers, you can ask the questions and then we can all move on with a decision” (P8)

Q12 “So I just make a decision and you know I’ve got to back myself, and I get advice if I don’t know things, I’m not that precious that I can ask the question. But to be able to get the information, make the decision and move on, so everyone else can move on, and to have confidence that we know that I am with them if it all turns to shit you know” (P8)

Lack of guidance from the health department

Q13 “The Victorian information was probably the better of all the States and the Commonwealth”[….] “the Commonwealth information and the Victorian information would often conflict, so we would try to look at what was the best information we thought we had at the time” (P1)

Q14 “some of what we were being given is very difficult to operationalise, and probably at times was given to us in a way that almost makes it impossible to operationalise” [….] “it's such a challenge, getting that balance right between giving people instructions with enough detail that they can follow them, but not so little that they can follow them without necessarily knowing how they can operationalize them. At times there appeared to be some internal contradictions” [….] “They were giving people instructions that lack some of that granular detail, but then it's very difficult to operationalize cause you are trying to think what do you actually want me to do” (P3)

Q15 “The information coming from the Department was sporadic, it was haphazard at times, it was unclear, It was duplicating, I found it really reactive and not proactive” (P11)

Q16 “In the first several months there was a plethora of documentation and I guess one of the principles that the health leadership group had to stick with was, if there is a document from the department we should stick with it because we have got a defendable position, but the absence of documentation was a real challenge and the void was being filled by people in management roles and by clinicians however they saw fit” [….] “We still have elements now, well beyond those sorts of days where different elements of government and the department issue documentation which sometimes are not consistent with each other, or in fact in straight conflict with each other in terms of some of the detail that needs to be applied in the workplace” (P2)

Q17 “The department was not on the front foot about communicating things in a pragmatic and clear way to those they send out directions of what to do” [….] “The department information would make no sense when you try to translate it into an operational environment, they send out all this kind of principle-based information without thinking about who's going to be doing the work” (P9)

Q18 “We were given a set of principles and we were going away to actually interpret what we thought those principles were” [….]“I think in terms of guidance we would have preferred perhaps more explicit guidance” (P10)

Q19 “I know a lot of staff got very confused at times with what are they asking us to do. And if the instruction was relatively clear, it was well how's that going to impact our health service, because you know each health service can I guess interpret as you like, like so does that mean we have to do A or do we have to do B” (P11)

Volume, velocity, and source of information

Q20 “And depending on where we were in the process, the advice was changing if not weekly, daily, on what you could and what you couldn't do, what was on what was off” (P4)

Q21 “In terms of the actual advice and the guidance itself, the volume of information coming out was very chaotic and it was hard to keep across, and to then be able to disseminate to my team in a timely manner” [….] “there were days where you would get up to 2, 3, maybe even 4 separate bulletins come out from government that all could be about the same thing and providing up to date different advice, so the one in the morning would have different advice by the evening” (P12)

Q22 “I also understand that obviously there was a velocity to this, the changes that I think was always going to be challenging and difficult to go through” [….] “The timing of a lot of that communication was less to be desired. It was quite often a Friday afternoon at 5 pm and there were circulars that were provided to us, which we had to essentially try to communicate to the rest of the health service before packing up to go home on the weekend” (P10)

Q23 “And just the level of information coming out was really high volume and trying to filter that to what was relevant and what people could actually absorb in one hit was really challenging” [….] “It was such a new disease, they really didn't understand it, nobody in the world really did, so we were really just sort of rolling with whatever information we were provided, and a lot of the information that came from the Department was really late on a Friday, with directions of what health services had to respond to, or implement and we were constantly doing it” (P11)

Q24 “At that stage by then we actually we counted that we had 13 different agencies come into the home over that period of time and would tell the staff something different” (P1)

Q25 “One of the major challenges was around information coming through thick and fast from a lot of different avenues, including the media, we had to develop fairly quickly a communication structure that was going to mean that we could get managers and leaders the information that they needed, in order to perform their roles in the safest possible way (P9)

Q26 “Initially a huge variety of information was being distributed by multiple people across the organization, so people were distributing information as a come out of Europe, from other hospitals, from professional bodies, and it wasn't the same information, there were a lot of discrepancies in it. It was creating a panic, and that was the first sense of we didn't have any control over the information going around the entire organization, and the volume of it” (P1)

Craft groups implemented independent plans and practices

Q27 “The absence of documentation was a real challenge, and the void was being filled by people in management roles and by clinicians however they saw fit” [….] “Working with a workforce what we found as one of the major challenges was the various craft groups would come up with their own professional document from just about anywhere in the world to answer a clinical issue that had arisen in relation to what sort of PPE should we be using, under what sort of circumstances” (P2)

Q28 “We then had to explain to us why we were making some of the decisions we were, trying to provide that reassurance that that the information we were providing was based on best practice, based on trying to balance demand was in agreeance with guidance coming out of the department, so that that period was very challenging because obviously from an individual staff member perspective, there was a lot of differences of opinion from individual staff as to why some of the decisions were being made” (P3)

Q29 “Certain craft groups were very active in developing their own guidelines, there was obviously positive aspects to that, the people were looking at their own workflows and situations and trying to develop appropriate guidelines, but at the same time that created a lot of conflict because certain groups were mandating certain things and others weren't, and there was a lot of conflict there. We had one situation where a craft group was manufacturing their own PPE and we had to try and deal with the concept of you can't do that, like you know this is not safe” (P3)

Q30 “And there were concerns across the different craft groups, say anaesthetics for example who had undertaken measures which I think were probably decisions made by individual departments without the right governance” [….] “And I think professional craft groups felt that some groups were perhaps more equal than others. So again there was that tension as well, and it was difficult because even though the department had a particular view about that, it wasn't necessarily accepted that that was the correct view” [….] “You know if it was good enough for the anaesthetists, it was good enough for the intensivists, it was good enough for the emergency physicians” (P10)

Q31 “There was some challenges in terms of managing individual personalities, as well as craft groups who again had a view that perhaps they should have been vaccinated earlier, or they should have been actually in that first group” (P10)

Q32 “People would come up and I could hear them chatting outside my office, and we're going to do this we're going to do that, I kept saying we’re not doing anything that's not approved through the governance committee. I mean, I can make decisions on the run, but I’m not doing it” (P8)

Q33 “All the maternity tertiary hospitals put together an expert working group and got together every week and really all trying to make decisions at the same time, so we were trying to really move together as a group, which was not that easy to do. Like it sounds like it would be something that we would make a decision and then all go with it, but then we also had our executives that we have to go back to” (P6)

Q34 “I was advocating ahead of the rest of the state to say actually I think my team should probably be wearing a higher level of PPE than what the Health Service was recommending. We did manage to convince them of those needs on each occasion when we needed it, sometimes there was tension saying all you know that's going to increase the usage, and I would say well that increases the usage at least I've got staff” (P9)

Tolerance for risk

Q35 “As an infectious diseases physician I not infrequently have to treat people who have diseases that I could contract, so you cognitively get an opportunity to get past that, whereas for a lot of doctors it's very uncommon for them to ever come into direct contact with a patient who has a medical condition that they might contract and might actually cause them some harm” [….] “When I started as an infectious diseases registrar I started at a point where we had a measles outbreak, and so I am vaccinated against measles but it's not a disease you are used to seeing, I had to go into rooms with a highly infectious pathogen. And I know for me it was a process, particularly with little kids at home, it was a process of being like okay, I'm doing this, the PPE works, I follow the rules and I follow the instructions I'm going to be okay. And then I was okay. Then COVID comes along and you're already used to that, follow the instructions do the process right, wash your hands, blah blah blah and you'll be fine, I think for a lot of other staff that wasn't something they necessarily really confronted a number of times before, and obviously your mind wanders in those situations and we saw a lot of that, what about my wife, what about my kids, what about my whatever whatever, and that side of things certainly made things very difficult” (P3)

Q36 “I will note as a clinician, that having been around long enough and grew up effectively as an early consultant in the HIV era, I have long held the view that health care might kill me, and maybe its just me but there were some contextual issues around how you’ve developed your philosophy around what you do as a health care provider. I think people who haven’t had that previous exposure have grown up with a degree of ignorance of the fact that health care is potentially a dangerous environment, not just a ticket to earning big dollars speaking from a medical staff point of view. And as we have seen things like mandatory competencies for hand hygiene, or donning and doffing, use of PPE, some of the anaesthetic group kind of would be the last group, absolutely refused to wear masks, yet I’ve been in meetings 18 months ago where I have been personally threatened for potentially killing anaesthetists by not providing them with masks” (P2)

Q37 “These are the things I've noticed the most, is how much different craft groups tolerance for uncertainty and their tolerance for risk are totally different. You feel like you've got your head around something and then you'll go and try and deal with another craft group and they’ll be totally not on board with it because their tolerance of risk of their tolerance and uncertainty is totally different and that's been a huge challenge” [….] “At the medical level ED and anaesthetics are the two most opposite extremes, anaesthetists are very risk averse and don't like uncertainty, whereas emergency doctors tend to be far more just give us a bit of instruction and we'll just run with it, because you know our lives are fairly chaotic and that's how it is. And it's been a really interesting aspect of all of this” (P3)

Q38 “Many people around us quoted whoever it was within the WHO in response to pandemics, or response to disaster situations, where you have to be agile, you have to actually come up with decisions quickly rather than go through 15 committees and have bureaucracies” [….] “At exactly the same time we are going through hospital accreditation which is almost the antithesis of this, where you have every nut and bolt in place and you have every clinical guideline reviewed and up to date and sits on an electronic register, and yet here we were creating guidelines that were just literally being churned out of, in some cases, one individual persons notebook, without going through those checks and balances that we sort of take for granted, so that was quite challenging” [….] “We were used to having that sense of security around us in terms of, they can come up with a plan, consult with people, go through a committee if it needs a bit of fine tuning does it really matter. But now we are actually a very risk-taking environment which requires us to be there because we have to do things quickly, and so a lot for people in management felt very uncomfortable about that” (P2)

Q39 “So I think back to the very beginning, and it was just chaotic. We were getting information coming left, right and centre, and there was an enormous pressure on us as a team to make sure that we did everything right, whatever that was, and the overwhelming responsibility of not being the ones to let the cat out the bag” (P6)

Q40 “And waiting to hear from say other health services, what they were doing, an example is of what tier PPE people were wearing and the overlay of emotion that was associated with that, the changes that were happening with our neighbouring health services that had undertaken an escalation of PPE when that wasn't very clear that was what the department wanted, but it became essentially customer practice because it was driven by the concerns of the staff” (P10)

Q41 “There had been no training around incident responses at the organisation for a long time, I don't know when the last one was” [….] “the management team in health services didn't understand how incident command works under a crisis, because there's a decision made and its implemented. The consultation period and the discussion and debate can’t happen when you're dealing with a crisis, and the health services team found it really, really difficult to change that approach. So we get considerable complaints from staff that were not getting rapid information because it was being blocked by inability to make a decision and getting consensus. The whole thing around incident command is make a decision with what information you have at the time, it's not necessarily the right decision, and it doesn't mean that that process won’t change as circumstances change, but you get on with it” (P1)