AMGA CAO/COO Council: Preparing for the Surge and the Recovery

AMGA COVID-19 Resources

Presentation Summary
April 17, 2020

This summary is based on a presentation to AMGA’s Chief Administrative Officer/Chief Operating Officer Council on April 17, 2020. For more information about the CAO/COO Council, please click here.

Presenter: Todd M. Fowler, M.B.A., FACMPE, Chief Operating Officer, Holzer Health System, Gallipolis, OH

Todd Fowler: I want to thank everyone for giving me the opportunity to just share with you what Holzer Health System has done, what we are doing, and what we plan to do as it relates to the COVID-19 pandemic. I feel obligated to offer a disclaimer that I am by no means an expert on this topic, and I don’t know that we could find someone who is a true expert. Like you, I am a member of an executive team at a healthcare system, and we are doing the very best we can to support our communities, support our mission, and do the very best we can do to help our family stay safe during this time, then try to figure out what we can do moving forward. The points I share we consider to be best for us, and I don’t think they are intended to be a proven roadmap for you all to follow to the letter, but more to help you see what one other institution is doing and if we are all thinking of the same thing, so we can collectively be better.

For a little bit of background, Holzer Health System is a two-hospital integrated healthcare organization. We have a critical access hospital that is federally designated. We have a 200-bed acute care hospital, a freestanding ED, and a post-acute care division, which has added some interesting components to what we are doing. We have a 160-provider group practice and we cover five counties, primarily in southeastern Ohio. We have fortunately not been heavily impacted, likely by virtue of our rural geography. However, we have had no less preparation or responsibility than anyone else. Likewise, our wind down or up, however you want to look at it, will be similar.

A Team-Based Approach
Our COVID activities began around March 3, and fortunately for us, our CEO was attending a COVID planning session sponsored by the Ohio governor. Immediately after that, we started closing services, such as elective surgeries and non-urgent office visits. We began implementing telephonic and video visits at an accelerated pace and preserving PPE. All those things we had to do we put in place. As a hospital system, we implemented an incident command, so were fortunate to have some people here who are somewhat trained in emergency preparedness. Incident command now has become our recovery operations team. In my role as COO, I am basically leading that team. I will be sharing what that team is doing and our approach to things.

Before I get into the recovery efforts, I would like to share a couple guiding principles that we have used here at Holzer. On my chalkboard in my office, I put a daily quote. On that chalkboard now is something our CEO said: “At Holzer, we do two things. We provide health care and we employ people.” So, unlike many of the other healthcare systems that had to make difficult decisions in a different way, our decision was to keep our people employed as much as we can. We have had no layoffs and no furloughs.

That means we have people doing a lot of different things. We have surgical techs meeting people at the front door, screening them. We have clinical nurses working a screening trailer in front of the EDs. We have approached this with a little bit different mindset in that we want to ensure we are taking care of our people. We have no-work-no-pay, PTO, cross training, all those things in place, which leads to the post-COVID world and what’s this is going to look like when we unwind from this thing.

Our CEO continues to participate on the Ohio Hospital Association board and task forces. He continues to meet with the governor periodically. We are following everything to the absolute best of our ability—what our state says we should do and what the CDC says we should do—for a lot of reasons. One reason is that we hope they collectively have good insight, and the other is that when we need to go back and say where is our share of assistance after this, we want to be able to demonstrate that we have complied in every way possible.

We have not seen a surge yet, but we are designated in our region of Ohio as the lead in a potential inpatient surge. We have converted our critical access hospital into a surge hospital, and we have turned a lot of our areas almost upside for preparation for something that has not yet materialized, at least not for us.

Creating an Action Plan
Back to our recovery team, we have an action plan in place right now that consists of 22 initiatives for areas of focus across our entire healthcare system. I realized at some point, especially on the ambulatory side, we are going to have to ramp back up and do our best to find a way to reach the volume of patients we had prior to COVID-19 in some shape or form and do it quickly. The action plan started as a brain dump, and each initiative was then assigned an owner, who was typically the leader of that area of responsibility. Where we could, we assigned a dyad. So if it’s for surgical services, our medical director of surgery is working with our surgical lead team to determine what we will be doing in the surgical area.

Each owner has been provided that initial list—I call it a brain dump—from me of functions or tasks for them to consider. Since they are leaders, we are giving them the freedom to modify the list. We have given them not only the authority but the responsibility of identifying things in their area that may need to be modified. The overwriting directive here is to think about undoing what you have done as we went into COVID-19. Think about things you have done that we may want to continue in some form or fashion and how we can do that, and then think about modifying things based on what we have learned, because we were always a very busy and fast-paced industry.

I talked to my friends from college and elsewhere about other industries, and it is really interesting to me how they can’t relate to how fast-paced health care really is. We really went from making decisions from over a month, to a week, to a day, and now we find ourselves sometimes making decisions by the hour as to what we are going to do next. Simply because we don’t know what the future is going to hold, and when a governmental change occurs or a new ordinance from the CDC, we have to act. So we don’t even know yet when an opening will occur. In Ohio, our governor has taken a very aggressive and conservative approach. In hindsight, we would say job well done, but we are not looking at a two-month or so rollout for getting back to normal. There is no going back. This will be our new normal moving forward.

Before I get into the details of our plan, I read an article from a leader at Geisinger and let me paraphrase what the author said: We will have no better opportunity to implement change than the opportunity we have before us now. We have all been in a constant state of change for weeks, so it is a good time for us to look at what we wanted to do in the past that we always struggled with, the reasons why we couldn’t do it, and try to figure out why and how we can.

Executing a Plan
Some of the things we are doing here at Holzer: We are looking at early or accelerated reopening opportunities and those are 100% driven for us by government. Until the government says we are in a relaxed state and you can do something, we can’t do it. But, we need to have those plans in place. We are looking at simple things like office spaces that use very little to no PPE that we have eliminated, such as sleep studies or pain management, and we have designated them to the leaders to decide what we will be doing with them.

We were dipping our toe into telemedicine. We had a platform ready to go and our plan was a point A to point B situation, as opposed to opening it up to all patients. That was one of those decisions that needed to be made on an hourly basis, and now the question is, how does that fit into our future in regards to culture and operations? We have a team dedicated to just our virtual care.

Another category is our urgent cares—how patients show up for visits in urgent care and sit in the waiting room with other sick patients, then being taken back. Is that going to be an acceptable way of delivering care in the future? So, we have a team dedicated to looking at the delivery of our urgent care, as well as the locations of our urgent cares within our facilities, for social distancing and other things of that sort.

The biggest category for us is what we are doing to be doing in our ambulatory clinics. We are doing things with backlogs, reaching out to patients, pushing hard for online scheduling and registration, etc. We are catapulting ourselves into a technological world of assistance, and we have teams that are dedicated to that. We are currently conducting virtual visits, and some providers are doing just as many of those as they were doing office visits. Each medical department with their medical lead and their lay manager are looking at what staff’s roles will be.

The acute care world is a little bit outside of my hands, but we are first and foremost looking at the surgeries. We probably do about 5% of the surgeries we used to do. The vast majority of our surgeries were ambulatory and only 20% of those were inpatient. Now the only ones we do are inpatient, and we are working on ramping that back up. As part of our surge, we cleaned out a lot of our surgery suites and moved some stretchers to places so we could make beds in the event of a surge. We have plans to move that stuff back over a two-week period to have those surgery units ready to go again. Our providers have been asked to provide a priority list for our backlog procedures by use of PPE, so we can start to get patients in the backlog that need the care and attack it from a strategic approach as opposed to opening the doors and letting the phones ring. We are also working from a pharmacy standpoint; we have three retail pharmacies within our sites.

We started doing really cool things in terms of social distancing and patients not getting out of their cars, and a lot of those things are going to stick whether we want them to or not. We are looking at laboratory and radiology for the preventive screenings and making sure we keep our equipment calibrated and ready to go.

We are looking at therapy services and population health. That is an area you get scored on quality indicators and measures, and we have absolutely fallen behind and will be making a huge push on that. Our marketing/communications will be focused on why is Holzer now safe because we know they may not feel comfortable right away so we need to assure them we are a safe, welcoming, and prepared place to offer them the services that they need.

Another area is provider compensation. Our providers are on a work RVU formula, and we froze their draw for March and April but didn’t take into consideration bonus dollars, which they will have to forgo. We have been tracking all of those in our lost revenue and submitting it in our reports in the event we may be able to recoup some of that. We are doing models as to what those virtual visits will have to look like for some of the providers in order to keep them whole. Our finance teams are tracking and reporting all lost revenues for the future, so when it comes time to report those, it has already been done and we aren’t scrambling to do that.

We were asked by the governor to lead a hospital surge plan, and that forced us to work with providers and systems in our region that we typically had not worked with. We are looking at how to continue those relationships in the future to strengthen all of our health systems in a collective manner instead of competing against one another.

We are also looking at locations. When we open back up, do we do so in a different place?

We just started our recovery efforts about two weeks ago, so we’re still in the discovery phase. We are looking at purchasing an inventory management system. Our post-acute care division has been a real scary area because it can be devastating to the elderly populations. We have been great with screening and have been really lucky to see no outbreaks in our post-acute care facilities. But think about how we let loved ones and families back in to see their loved ones.

We are focusing on all services, including non-patient facing areas. I challenged the team to find what we are not catching, and we hope to get a lot of feedback from all staff on this topic. We do daily huddles, and we meet daily as an incident command team. We have a meeting every other day for the recovery team, and each leader will report out in that meeting where they are on their task.

This is just our experience and some of the things we are doing may not be everything, but hopefully listening to this helps you helps your organization do a better job as we come out of this. I do think this is our new normal, and we won’t return to our historic volumes once this is all said and done.

Question: Who is part of your incident command team?
Fowler: The incident command team consist of a range of people, not all executives and not all managers. We have our emergency preparedness individual from a hospital standpoint who leads it, a manager over our hospital operators is a lead role in it, I participate, and our CNO participates, as well as our director of quality, our director of operations, purchasing, and infectious disease manager. We report out daily statistics on our experience with COVID-19, our number of tests, our number of inpatients, patients under suspicion, and so on.

Question: Do you think you will bring upper respiratory tract infection (URI) patients back into the clinic or care for them in a separate environment and designate certain sites as sick or well locations?
Fowler: What we have done is designate one of the units in the hospital. It includes our critical care as the COVID unit. Our medical director of hospitalist services volunteered to be the primary COVID provider, so if we get persons under suspicions, we send them to that unit. In regards to EDs, we have a trailer outside of two, and a big, heavy-duty tent outside of the third. Patients who have suspicions based on criteria will be tested there instead of in the facility. We send them home under quarantine and let them know their test results when the results come in, and we tell them if the symptoms get worse to please come back. If the test is positive, we get them back to hospital if need be based on their medical condition. We have a hotline and try not to have patients come into urgent care or see their providers if they are under suspicion, according to the CDC.

Question: Could you talk about why you think the volume will not return?
Fowler: That is just a gut feeling. I think our society is going to be heightened in sensitivity to social places, and we believe that we are going to have to work hard to bring people in for preventive care while they are healthy, at least for the next several months. I am hoping we come close to our volume and supplement it and succeed it with virtual visits.

Question: Are you testing in house or sending out the tests, and how are you handling the testing for procedural patients? Are you testing everybody?
Fowler: We are not testing everybody. We have been conservative with our tests. We are currently sending tests out. We have been directed in Ohio if they are sick patients, those tests need to go to the Department of Health lab. If they are meeting criteria but not really sick, we are directed to send them to commercial labs or hospitals that have approved labs. Most are going to LabCorp. Our reason for not bringing it in-house is that the testing kits are in such short supply. So we are having to send the tests out.

Question: Are you conducting any employee screening, temperature screening or other screening, when they come to work? Have there been conversations to continue that?
Fowler: Yes, we are screening at entrance to every one of our facilities. We started using a color-coded dot that pertains to each day. So, when you go through the door, your temperature is taken and you are asked a series of questions about whether or not you have been exposed, and if you pass, you get a sticker and your badge. We have limited access to our buildings.

Question: Can you further elaborate on compensation for those on work RVUs? Did you keep whole or prepaid with a reconciliation at the end of the contract year?
Fowler: We’re on a fiscal year, so we will end in June. We had a great year up until March, when it crashed around us. The way our physicians are compensated is they are either salaried early in their career or they are on a productivity model driven 95% by their productivity. What we do is we give them 90% of their previous year in a monthly draw, and if they produce less than that, we begin to tweak their draw back on a monthly basis. If they produce more on a six-month basis, then we give them a bonus. For COVID, we have frozen the draws for March and April and possibly May. We have a compensation committee that is on board with this, and we don’t know exactly what we will do on the back end. I can speculate that we will have to leave our comp at a salary draw level, and that will help some providers who have dropped and hurt those who have increased. We personally aren’t in a situation where we can absorb a big financial hit. So, we won’t be able to do a lot for our providers to keep them whole with their draw.

Question: Is your ICC migrating to become a recovery team or is the recovery team a separate team?
Fowler: It is a subset of the ICC. Our ICC leader said this is a natural progression that sometime you go into recovery. I participate on ICC, but lead recovery. There are some who are on both, but recovery is much bigger. Our CEO said shutting things down was easy, but ramping up will be hard, so our recovery team is bigger.

Question: For those of you who offered video visits prior to COVID-19, what percent of total visits were video? How did you decide which visits were appropriate and which required face-to-face, and did you provide seven days a week and what hours per day?
Fowler: We did not open wide-open video visits prior to COVID-19. We had a plan to do it in June or July. We jumped to televisits immediately, and our volume on a daily basis total was 40% of our total volume max.

Question: Who do you think you will test to allow procedural volumes to ramp back up? Everybody or some people?
Fowler: We do not have a plan right now to test everybody, other than the screenings that we are doing now for symptoms. We are implementing a masking policy, and we will have all employees masked in some shape or form based on where they are and what they are doing.
Kimberlee Sherbrooke, M.H.A., FACMPE, Vice President & Chief Operating Officer, Office of Johns Hopkins Physicians, Johns Hopkins University, Clinical Practice Association, Baltimore, MD: We are not doing anything elective, and we started this week doing pre-op testing of all patients. In terms of workflow, it has been a little chaotic, so we are still sorting through what that is like. I don’t know that we will keep it up when we recover or ramp up. To the other point, we started masking everybody last weekend; anybody in any of our facilities staff or visitors had to be masked. Bring your own mask to work and bring your own mask to the clinic.
Frank B. Panzarella, Jr., MHSA, Network Vice President and Chief Operating Officer, Bassett Medical Group, Bassett Healthcare, Cooperstown, NY: Bassett is in a similar place. It seems like the Northeast region may be a bit ahead on COVID curve. We started testing pre-op patients last week, as well and now anybody who is pre-op coming in is being tested for COVID-19 to ensure we don’t put them in a worst place if they end up developing symptoms after they have a procedure done. We’re starting to test non-anesthesia-assisted procedures as well. We aren’t doing anything elective, but there are cases that are urgent and we feel need to be done and care needs to be provided.

Question: How are people handling those procedures that may have been deemed elective a month ago but now seem more imperative to get people scheduled? Who is handling that and how is it being handled?
Panzarella: At Bassett, we have our clinicians make those decisions about who needs an operation or who needs a procedure—whether it’s anesthesia-assisted or non-anesthesia-assisted based on clinical need. Then if they determine that it is an invasive procedure and the risk is high, they need a COVID test prior to the procedure. We have a process we have begun to put in place to test those.

Question: At what point will you inform all the providers, staff, etc. on your plans to move back to normal, and how will you do that?
Fowler: I mentioned earlier we’re following directives from our governor, and we are in close contact with him. The way we will communicate that is first verbally. We have on Monday-Wednesday-Friday meeting at 7:30 a.m. via WebEx across the system for all our physicians and managers. I think the greatest number I’ve noticed is 198 participants listening. That’s where our CEO gives an update. I would imagine we would communicate that we have a plan and it will be coming out. Then we would communicate to our medical directors and their dyad management to ramp things up. It is interesting to hear Frank say they are doing surgeries the way they are. We have been a little hesitant to allow that to occur because of the strictness from the government. If we allow that to happen, all the surgeons will find every reason in the world as to why this is a critical surgery and they need to perform it.
Claude Deschamps, M.D., President and Chief Executive Officer, University of Vermont Health Network Medical Group, Burlington, VT: We are in Vermont, and it is much blunter then we had predicted, thankfully. One of our biggest challenges has been the present system and our non-network nursing homes. We have 25 non-network nursing homes, and one was close to Burlington had 25-30 patients who were COVID positive, and the nursing home was overwhelmed. Travelers refused to go work there, and had we not sent nurses, doctors, and supplies, we would have been overwhelmed ourselves with getting those patients back in. I want to tell people of that experience because we set up a task force that is meeting tomorrow at 10 a.m. to discuss re-entry. This task force is similar to the task force that led to our shutdown, and we’re still concerned about the nursing homes. We think the private hospitals, just like what was mentioned, will reopen elective, and there will be patients contaminated, and they will get to rehab centers, and we will get our second waves of COVID patients. I just want to alarm everyone to that possibility because we are concerned about it.