3.1.1 Knowledge sharing through epistemic communities.

Healthcare. As professionals were facing an unprecedent healthcare crisis in which decisions and information was updated almost everyday, they faced considerable uncertainty in how to adapt hospital services. One sustainable innovation to come out of the crisis was the creation and/or consolidation of online epistemic communities. This term can be defined as networks of knowledge-based experts [17]. These communities were often organized in an informal, spontaneous manner (either within existing groups or new groups created at the initiative of one or several professionals). They were made possible via online networks, in particular blogs, WhatsApp messaging services and/or group emails. At the end of the research period (December 2022), these epistemic communities continued to be active and enabled professionals to seek advice from colleagues. They continue to be used in the post-COVID period to share advice/experience on other issues relevant to their specialties. These online epistemic communities were original in context, as they allowed a new means of interacting among professionals in ways in which there had been limited coordination before the crisis.

These epistemic communities have been important in particular for professionals who felt isolated, notably those who did not have another colleague in the same specialty onsite. For instance, “Mark,” an occupational physician, said that he was largely isolated at the start of the crisis as he was the only person with his specialty at the hospital. During the first wave, but also the more chronic phases of the crisis, occupational physicians were obliged to make many complex decisions on how to protect hospital staff all the while ensuring sufficient human resources to continue cancer care. Mark describes the uncertainties faced by him due to constantly changing rules and procedures. According to him,

“We had to follow directives that were both vague and precise…so for me, it was a huge job because I had to look for regulatory texts that were constantly changing….we were in a blur because the social security did not answer and attending physicians were overwhelmed…at the beginning we knew nothing at all and so we were all alone, all alone, all alone to manage this. And so there was a blog of occupational physicians. We really exchanged a lot…we supported each other. I still get these messages now….whenever there’s a concern, you can ask your colleagues. We know that hospital occupational physicians in France supported each other like this.”

For this professional, the changing and imprecise nature of national directives [6] made it difficult to implement the recommendations. Given the necessity to guard professional secrecy to prevent identification of employees, these professionals could not turn to upper management for help. It is therefore not surprising that he repeats we are “all alone, all alone, all alone” to manage these urgent and difficult decisions. The use of an online epistemic community with occupational physicians gave him the opportunity to share information with other professionals in the same situation, all the while respecting his duty to confidentiality. The blog continues to be used to help occupational therapists agree to common strategies.

Other blogs were created at a more local level within the city, such as between nursing professionals or to coordinate care among liberal nurses and general practitioners. Both groups still exist in the post-COVID era. “Chloé,” a nursing manager, describes her use of epistemic communities:

“I remember creating a WhatsApp group connecting all the care directors around us, saying How do you do it? What is the technique that you found? And in fact, there was a lot of communication between caregivers, between care managers, between us saying but what do you have in place? And now you’re closing visits? What are you doing or how are you doing it? We found that it connected us with the city like never before.”

These kinds of epistemic communities helped the hospital to face the most severe and chronic aspects of the crisis, to create a link between the hospital and the city, and to exchange between healthcare providers of the same specialty, promoting disciplinary and interdisciplinary exchange. Epistemic communities were also organized in later stages of the COVID crisis by the regional health agency level (ARS) to consolidate the link between the city and hospitals.

Research. Epistemic communities also helped cancer researchers, in particular those working on live tissue cultures who had little institutional guidance from their structures. The need stemmed from isolation, in particular for those researchers working in the hospital campus where other professionals were not necessarily aware of their specific concerns. These researchers described how they often had to act alone in the face of uncertainty. For instance, “Etienne,” a researcher working with live tissue cultures who was concerned about the risk to his staff says,

“I contacted the hygiene committee (at the hospital)…they had difficulty understanding the notion of cell culture, and I checked with the virology reference laboratory and they confirmed to me that indeed, if you have tissue that contains virus and you put it in culture, the virus is also cultured. So there is a risk…in a lab, there are still a lot of students, a lot of people, we can’t control everyone…and that, to me, seemed too great a risk. But it’s funny…well, I found the health committee strange, they hardly understood, in fact. They didn’t measure the risk…in any case, internally, there were no specific things for us…so we went looking for them (other colleagues).”

Given the lack of guidance from his structure, this researcher mobilized his epistemic community to find answers about how to continue research and minimize risk for his employees. Without this essential information sharing among equals, it would have been difficult for “Etienne” to make a decision about how to continue research during this time.

3.1.2 Interdisciplinary and inter-service coordination.

Healthcare. In all of the interviews conducted with healthcare providers and researchers (n = 22), new forms of interdisciplinarity, inter-service, and intra-hospital coordination were highlighted as a positive aspect to come from the crisis. According to “Marie,” a pharmacist who worked in interdisciplinarity with several departments, the crisis, “made room. It broke down a lot of organizational barriers.” Both professionals from public and private hospitals shared hospital resources, including human and material resources. They also responded to urgent needs such as vaccination by working (often for the first time) between departments and specialties and took on cases from other hospital sites. This coordination in particular worked well within the same hospital group, where “hub systems” were put into place. These hub systems helped services facing resource shortages to find beds and not to refuse patients in need. Interdisciplinary coordination also worked well at the national level in “small” specialties such as pediatric oncology which could more easily coordinate on a wider scale due to a small number of cases. Several examples of these new kinds of interdisciplinary work are still in place and their impact is summarized in Table 2.

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Table 2. Examples of new interdisciplinary coordination during the crisis.

https://doi.org/10.1371/journal.pgph.0002366.t002

COVID reflection cells. Interdisciplinary coordination was also reinforced at the hospital level via COVID reflection cells, which helped to decide overall hospital policy and to collectively debate difficult cases. During the crisis, it was essential to have different professionals’ views and sources of information in these meetings. According to “Anna,” a hospital manager,

“That’s what collective decisions are all about, feedback from the field. It’s really important for the caregivers, for the administrators, to know what they are facing, to allow them to adapt. It’s pretty amazing how much discussion is needed in these meetings because everyone has information from different sources.”

These new forms of interdisciplinary coordination enabled hospital managers and heads of service to better coordinate decisions and regulations during the duration of the crisis, as well as to find practical solutions through collective reflection. At the end of the research period (December 2022), these interdisciplinary coordination meetings either continued to be active, or were put on hold, but it was believed possible to reactivate them quickly. According to professionals, this kind of interdisciplinary work and coordination permitted the hospital to have a certain “agility” during the crisis, a capacity to act together which had not been present before and will be easier to reactivate in future crises.

One of the facilitating factors was the roll-out and widespread adoption of teleconference technologies. According to several professionals interviewed, this technology has permitted better interdisciplinary coordination between large structures, in particular between different sites at the large public hospital. In this past, the fact that professionals were spread across several campuses made it difficult to favor collective decision making. However, with the introduction of new teleconference technologies, meetings can now be held more frequently, allowing managers across services to be more agile and to take decisions together as a team. This has impacted COVID reflection cells, but also regular multidisciplinary meetings. As elsewhere [18], most of these meetings either continue in online or hybrid formats post-COVID.

Limitations of interdisciplinary coordination. Interdisciplinary and inter-service coordination was more difficult to organize at the city and regional level, particularly between different types of hospital structures (private or public). As “Etienne,” a management professional describes,

“The hospitals were all alone, so we decided for ourselves. I think this is the major lack during the crisis. Everyone organized by themselves. All the hospitals have some capabilities to answer to the crisis. But there is no coordination between all the healthcare organizations in the region. In my opinion, this is the most important thing to do in case of a large crisis like COVID. We have to organize differently…the good level is not the hospital. It is the region or the city, but not (just) the hospital.”

As we can see from this quotation, although online epistemic communities made it possible to share information at the city and regional level, it was more difficult to share resources as hospitals had different functions/statutes. The interdisciplinary coordination we have described here is therefore principally centered at the hospital level.

Research. A new interdisciplinary work was also put into place during the crisis for research in clinical trials, in particular via large European studies on COVID which mobilized different structures and services at a hospital site. In comparison to research on live tissue cultures (where researchers suffered from isolation within their hospitals and had to seek wider epistemic communities), those working on clinical trials benefitted from increased interdisciplinary coordination within their structures. In the post-COVID era, this has helped research teams to structure regular research work and share human resources among teams. According to “Martin,” a Clinical Research Associate (CRA), during the crisis,

“We realized that we did not have an exhaustive vision of all the research personnel present at (the hospital group) in order to redeploy these personnel correctly and efficiently in the services that needed them most…since then we have been working on structuring ourselves and getting to know better the agents who work in research….COVID made us realize that we didn’t have this exhaustive view, especially of our research staff.”

This restructuring led to a creation of a new HR policy in the public hospital to allow them to centralize information on their research personnel. According to “Martin,” this will enable them to avoid skills loss and (hopefully) to better anticipate future research needs.

3.1.3 Telemedicine and teleconference technologies.

Healthcare. Telemedicine was greatly expanded during the crisis. At the time of writing, in the Lyon Metropole, it continues to be widely used in oncology care, including by different categories of professionals (oncologists, pharmacists, nurses). Table 3 summarizes the perspectives of the healthcare providers and researchers interviewed about teleconsultation, its value for the healthcare provider and patient, as well as the temporalities/spaces where it was not recommended by the professionals interviewed.

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Table 3. Use of teleconsultation in care and research.

https://doi.org/10.1371/journal.pgph.0002366.t003

While professionals interviewed differed in their perceptions of the benefits for patient care, the crisis helped test the possibilities and limits and has had lasting effects into how cancer care is organized. The difference between the pre-COVID era and the post-COVID era is flagrant. According to “Anna,” a hospital management professional,

“Eight weeks before the first lockdown, we did 25 teleconsultations. Eight weeks after, we had done 5,584…it’s something that has continued…even today, about 20–25% of consultations have been teleconsultations. It is almost paradoxical what I am going to tell you, but we observed that many patients could reach us more easily on the national territory and even beyond, in Europe in particular…they have transformed our practice and since then it has become common practice.”

Our results suggest specific temporalities in the care journey when telemedicine should be practiced by healthcare providers, as well as when telemedicine should not be used, such as breaking bad news. These results largely concur with other qualitative research conducted in oncology on the use of telemedicine in France during the crisis [19]. However, further studies are needed to understand patient perspectives and to better understand how they differ from healthcare providers. For instance, a qualitative study on acceptability of video visits for serious or bad news delivered from the patient perspective has suggested that there was no consensus on patient preference for video or in-person visits [20], a finding that differs greatly from the perspective of all of the healthcare providers interviewed in this research project which were categorically against it.

Research. During the crisis, and in particular during the first wave, teleconsultation was also used in research to facilitate clinical trials, whether it be for cancer research or for clinical trials for COVID research. Teleconsultations were organized as a first step by the doctor/researcher with patients and in a second step by CRAs to answer further questions and permit patients to give their electronic informed consent. This was permitted during the crisis because they had a special authorization from regulatory authorities to use electronic consent. This allowed clinical trials to proceed even during the most acute part of the crisis. Trial modifications with the introduction of digital health technologies and trial decentralization were also used in other countries during the pandemic [10, 21, 22]. While the participants interviewed believe that this was a “good possibility/alternative option,” they believed it is unlikely to be used on a wide scale in normal cancer research in France due to the reinstatement of regulatory restrictions. They also said that seeing the patient in-person was the best way to ensure their informed consent. International research [21, 23] suggests however that remote monitoring and e-consent for clinical trials will be envisaged for future trials, in particular as digital consent has been shown to increase participation among rural and minority populations [24].

3.1.4 Creativities in the care plan.

As in other sectors of healthcare during the crisis [25], this special period also led to new creativities in the care plan. These creativities were seen in cancer care in the Lyon metropole (as in the community in general) and this in spite of increased workloads. This took the form of experimentations of arts methodologies to enhance dialogues with patients, particularly among nurses and other paramedical professionals. For instance, according to “Chloé,” a nursing care manager,

“I’ve never seen so many caregivers show their creativity. One started drawing and making comics for patients to explain their illness…we made comics, newspapers, there was one person that made drawings with the patients and exhibited the drawings…one started to make music and brought in instruments to give out to the patients…I’m thrilled to see all the movement and talent coming out of our teams.”

These new creativities were important not only to the patient, who was able to experiment with art practices to find alternatively ways to express and understand their illness, but also to healthcare professionals, their quality of life at work and their sense of purpose in their professions. According to this professional, these creativities are part of an ongoing reflection on how to improve healthcare and will help work toward a more person-centered perspective in oncology in the years to come.

3.2.1 Harmonizing treatment decisions.

The interviews showed that the level at which treatment harmonization was possible during the crisis was in an individual hospital service, where there was a capacity to act quickly and with other professionals to harmonize treatment protocols. While these adaptations were often initiated by the head of the service, they worked on the ground because they were agreed and reviewed by the healthcare team. In addition, while these changes were made for the health crisis, they also accelerated transformations in hospital functioning that have lasted in the services which experimented them. As “Marie” (a head and neck specialist) explains,

“We were not really affected (by the crisis). An explanation is that we reviewed our processes….we said we clearly need to harmonize the prescription of treatment among MDs. We know that MDs by definition…have to have the freedom to decide what they do for their patient. Here we were in a crisis and potentially a big and long crisis. So we needed to refine things…we need to say, sorry, no, let’s everybody do the same depending on the urgency, depending on the complexity of the pathology. So we divided the treatment into four categories….these were reviewed every morning…we believe we did not put patients in danger. We strongly believe it….we all agreed together…and everything was really smooth at the end.”

As this example shows, harmonizing treatments among professionals in the service was done both from a perspective of working toward equality (treating all patients the same), but also with the ambition of improving organizational efficiency (to improve organizational processes in a time of resource shortage but also for the future). As Marie’s example shows, this adaptation put into tension the individual autonomy of clinicians (who generally have the freedom to decide what to do for the individual patient even if they generally follow recommendations discussed at the tumor board in line with standard-of-care guidelines) with public health needs. It is however telling that Marie, as head of service uses “we” in explaining the context of these processes of harmonization and puts an emphasis on collective agreement and review, without which support for this harmonization would not have been possible.

3.2.2 Improved processes to better support patients.

Healthcare. during the crisis, hospital services sought to reduce the duration of hospitalization, a process already underway that was accelerated during the crisis. In the face of this new reality, two heads of service adapted by initiating new or improved processes to better support patients in healthcare pathways. According to “Colette,” a gynecologist:

“This (crisis) made us realize that there are many things that can be done more in an outpatient setting…with COVID, we tried to shorten stays as much as possible…it also forced us to anticipate and take care of things beforehand. The woman who is going to be hospitalized and who is going to go home in the evening, she cannot go to the pharmacy beforehand. So, we have intensified the prescription of medicines in advance, so that she can go to the pharmacy before the operation, so that when she goes home, she rests and she has what she needs. We also now call the patients back to see if they’re okay…we accompany them.”

According to “Colette,” although these procedures were beginning to be put in place before the crisis (as she expressed it, they are part of the “evolution of medicine”), the crisis forced professionals to rethink their care plans to better support patients. These new processes gave a realistic means of allowing patients to be able to transition to home care on the same day of the surgery. While reducing hospital stays was a reality for many hospital services both leading up to and during the crisis, this is not to suggest that replacing inpatient hospital surveillance with a (relatively unsupervised) hospital outpatient setting is necessarily the best option, particularly in some procedures which may incur additional risk; however, the reality of the acceleration of these processes did enable a few professionals and services to adapt to better anticipate and accompany their patients.

Pharmacy. New processes were also put into place to support patients who normally received medication via the hospital. These processes were put into place in both the public and private hospital. Given the necessity to put into place teleconsultation during the crisis, this led to new care processes for patients. According to “Benjamin,” a pharmacist:

“It allowed us to think about how we can transmit information to patients when we are remote. Because we don’t handle the medication box and so on to explain the intake plan…it also allowed us to measure the proportion of patients who could be receptive or well equipped for remote consultations…we (also) switched to remote consultations for patients who were receiving treatment in clinical trials, something we had never done before.”

According to “Benjamin,” these adaptations and innovations are helping to rethink pharmacy care post-crisis, and in particular the appropriate use of teleconsultation to reduce the burden for the patient and ensure they had the resources for responsible use of their medication. This was also the case for research and follow-up of patients in clinical studies. Pre-COVID it was not possible to get the treatment in the city pharmacy and it had to pass through the hospital pharmacy, which resulted in considerable time burden for patients who did not come from the city. During the crisis, pharmacists set up networks to deliver treatments to patients via city pharmacists, ensuring continuity of clinical trials during this time and giving benefits to patients in terms of medication access.

3.2.3 Streamlining healthcare pathways.

Two oncologists (heads of their service) interviewed were able to use the COVID crisis to refine their procedures in order to optimize planning schedules in their department. This gave not only a clear plan of action for the patient, but also helped to better organize their services to become more efficient. For instance, according to “Marie” (a head and neck specialist),

“We said we need to streamline….the day the patient comes to the CT, he agrees, and he will have his first treatment two weeks later. It’s a different way of organizing it…it was for me really big plus in the time of COVID crisis and we still apply it today…in other words, by streamlining things, by really maximizing the slots that we booked for a particular patient, we minimize the losses and this was somehow macroscopically an advantage for department…for me it was a really big plus in the time of COVID…we still apply it today.”

As we can see from Marie’s account, the value of efficiency is prioritized to enable the department to “minimize losses.” However, for “Marie”, this streamlining also represents a benefit for the patient, who knows concretely when they will be treated and therefore has a clearly defined care pathway. By streamlining these processes in her services, “Marie” says they may also ensure greater equality, as each patient now has the same treatment delay.