AMGA CAO/COO Council: Resuming Elective and Non-emergent Procedures
April 30, 2020
This summary is based on a presentation via AMGA’s Chief Administrative Officer/Chief Operating Officer Council listserv on April 30, 2020. For more information about the CAO/COO Council, please click here.
Rose Wagner, Chief Operating Officer, AMGA Consulting: Today we are going to walk through a series of questions around resuming your elective and non-emergent procedures. To facilitate, I am going to start calling on some people to get the conversation going and then I want you to chime in with your thoughts and/or questions. I wanted to start with a question to Brad Wakefield: What procedures, surgeries, and/or care will you consider introducing first as we open up? Will you be looking at any risk stratification methodology or prioritization of patients? What leading indicators will you be looking at to predict the pace of ramp-up?
Brad Wakefield, Chief Operating Officer, Samaritan Medical Group: In Oregon, we have decided to open elective surgeries and more office visits Friday, May 1. So we have been going through the process to try and answer Rose’s question ourselves as we try to do this. We have used a lot of resources, and most of the things I will refer to are things that we are doing here in Oregon or based on things we have collected from people across the country who are thinking about this.
The first thing that we used was a “Roadmap for Resuming Elective Surgery,” which was put out by the American College of Surgeons, American Society of Anesthesiologists, the Association for PeriOperative Registered Nurses, and the American Hospital Association. First, when considering the timing to reopen for elective procedures, there are some things you can glean from this joint operating statement.
The next criteria is the turnaround on testing availability. About a month ago, it was taking four to five days to get a test back unless you were inpatient, and that really wasn’t going to be effective for reopening elective surgeries. Now we are at about a 24-hour turnaround time. Our state has come out with guidance that you shouldn’t be doing elective surgeries unless you have a 48-hour turnaround time. The next thing you need to be aware of is PPE and having some standards around those.
Then when it comes to case prioritization and scheduling, there are a list of considerations that these national organizations have come up with, and for anyone who hasn’t read it, there is an article in the Journal of the American College of Surgeons that was written about how to score an epically and efficiently managed resource scarcity for reopening surgeries. There have been some people who have created an instrument called the medically-necessary time-sensitive (MeNTS) instrument. It is something you can use to prioritize the work you will be doing regarding elective surgeries etc. We have found all those resources to be helpful. Addressing the five stages of surgical care, the perioperative, immediate preoperative, interoperative, postoperative, and post-discharge planning, all of those are in this instrument with guidelines and things to consider.
What the state of Oregon did was take the roadmap and created more specific things just for the state of Oregon. In our state, we wanted to avoid further delays in health care for the members of our state, but in a way that would minimize the risk of transmission of COVID. We also realized as a state and as a nation, we needed to get health care back to some degree of normalcy or all of our healthcare organizations will be in jeopardy moving forward. So that’s another part of this that we are working on here in Oregon.
In order to restart elective surgeries, there is a requirement that in order to do elective surgery we have 20% of our hospital beds available for a potential spike in COVID admissions and then a 38-day supply of PPE in our larger hospitals and a smaller supply in smaller faculties. Also we need testing with the two-day turnaround time, which I mentioned earlier.
When we looked at our procedures, our state encouraged us to have a medical committee. We have a triage surgical committee at each of our facilities that meets to put cases on the schedule. We have been given an upper limit of 50% COVID volume on our elective cases, so we are monitoring that. Some of the biggest considerations for these cases is if someone is going to need a transfusion (because of blood being in short supply), if they need pharmaceuticals that could be in short supply, if they are going to go to the ICU or need transfer to a skilled nursing facility. We are looking at continuing to delay those types of elective procedures. In some cases if you won’t delay any of those services, or if you can have your surgery and be ambulatory and go home right away, those people are being prioritized over the people who might need a higher level of care.
On the outpatient side, we are going to start seeing more patients in person starting Friday, May 1, and we have similar criteria for the outpatient side. We are looking at risk vs benefit based on age and condition of the patients who may be coming in. We are at about two-thirds of our volume pre-COVID from an outpatient visit perspective by using video and other means. So we aren’t in a big rush to get people back into our clinics because we feel like the video option is working very effectively for us. We are prioritizing people who aren’t able to get their outpatient services via video, but we are prioritizing and using video as much as possible before we start bringing people in to the office.
Todd Fowler, M.B.A., FACMPE, Executive Vice President, Chief Operation Officer, Holzer Health System: You mentioned two-third of your volume are back in clinic based on virtual visits. What platform are you using?
Wakefield: Institutionally we are using Microsoft Teams and as a backup we are using anything else that works that people feel comfortable with. But I would say 90% of our video visits are on Teams right now. Our IT department came up with that solution in about a week and a half.
Wagner: Our next question we are going to start with Lori Hulse from Lehigh Valley, and the question is what types of screening and testing are you providing prior to approval of a procedure? Will you test all COVID patients regardless of if they are symptomatic or not and do you currently have adequate supplies for testing?
Lori Hulse, M.S.W., M.B.A., Vice President, Lehigh Valley Physician Group Operations: We are part of Lehigh Valley Hospital and we are located in Pennsylvania. Similar to the previous speaker, we are at about 60% of our outpatient volume via video visits and face-to-face visits. We are using the Epic platform.
What types of screening and testing are we doing prior to approval for a procedure? We have set up specific pre-surgical testing sites. For our staff who have any part of their job that is patient contact, they must be tested. We are also testing all doctors and APCs, as well as any patients who are scheduled for procedures. We are testing 48 hours in advance of the procedures, and we are testing everyone who is scheduled for ambulatory surgical center. We have limited the patients we are performing ambulatory surgery on for the elective procedures—really just those who are under the age of 60 and those with a BMI less than 35, based on the risk factors that have been associated with COVID. Unless there is a special exception. You may have a 65-year-old who has no underlying conditions and may be pretty healthy, but is having exacerbation of symptoms. We may allow that person to move forward, but it would require approval of our Chair and periops services committee. We are requiring testing whether or not folks are symptomatic.
We currently have an adequate supply of PPE. Part of what we have put in place is that our outpatient practices as well as our inpatient units are reporting daily their PPE supply. We have that going through a central repository, and we are making predictions based on our burn rate now what we can expect to use going forward.
Wagner: Do you have kind of a ramp-up volume in mind, or as you open up, are you trying to do a certain percent?
Hulse: We have opened our operating rooms. We wanted to be able to respect social distancing, and we also wanted eliminate any backlog in our waiting areas. So we have implemented curbside check-in. The patient calls from their car to let us know they are there, and we have someone meet them at the elevators to make sure there is only one person going up in the elevator at a time. So, we have had to stagger our cases a little differently. We see the same number of patients, but we are open seven days a week and we extended our hours to 7:00 a.m. – 7:00 p.m. in the OR.
Wagner: Were you doing visits with Epic before the COVID crisis? Are you doing it through MyChart video visits and do consumers appear to be adopting well?
Hulse: Before we went to this model, we had a very select group who was piloting video visits through the MyChart application. Our providers hadn’t adopted it well, and our patients weren’t even aware that it was available. Then we launched it on a large scale, and both groups adapted very well.
Wagner: For the entire group, what video visit volumes are people seeing these days and what percentage of your visits does this comprise?
Tesha Montgomery, Vice President, Operations and Patient Access, Houston Methodist: From a volume standpoint, we have seen a significant increase in our virtual visits since the COVID crisis. We do have a couple of platforms we were doing virtual visits on. We have a virtual urgent care, which we have been using the American Will platform for, and we also have telemedicine visits which have been scheduled through Epic. Through yesterday, our volume is 2,227 a day. So we went from 40 to over 2,000 a day for our virtual visits. On the primary care side, virtual visits have been the majority of what we are doing, and on the specialty side, it has been about half and half.
Hulse: Over here at Lehigh Valley, 75% of our volume has been video visits and 25% has been face-to-face. In the coming weeks, we expect that to flip; but right now, we do about 70,000 visits a day.
Wagner: How are you handling lab and x-ray?
Hulse: So fortunately for us, those are both hospital-based practices, so in our physician practice world, we just interface with those. We have a very tight connection in terms of the turnaround time of results, and we have a great workflow, so they come into a work queue and we have a team that works that queue to call the results out to our folks. We do have x-ray in some of our practices, and we do have some patients who come in for their imaging studies.
Wagner: What are the procedures people have in place for patients who have COVID-19, and what testing are you doing for it now?
Hulse: If it is an elective procedure, we’re not moving forward if there isn’t an urgency to do that. If it is a patient we have who is emergent, we do have dedicated surgical rooms where we are performing those procedures. We have special criteria in terms of how the rooms are being placed, who can use it, and 30 minutes the room has to be vacant to allow for any droplets before it is cleaned, but we are only performing those really on emergent cases right now.
Wakefield: On the outpatient side here in Oregon, we have dedicated some of our clinics as respiratory and non-respiratory, so we have tried to have anyone whom we needed to test to confirm or rule out for COVID come to particular places or come to our drive-in clinic versus going to any clinic or their primary care provider. We call them wet or dry sites.
Wagner: This question is for Linda Gifford. How will you ensure that you have adequate resources for non-emergent care as well as COVID-19 cases that may resurge? Do you have any current practices in place for the following resources: staff, supplies, and PPE or facilities?
Linda Gifford, Chief Operating Officer, Henry Ford Medical Group: In terms of resources you listed, I will start with facilities. We have 44 ambulatory sites within the Henry Ford Health System in Detroit. Nationally, Detroit was one of the hot spots. So we are still in the process of recovering. We have 44 sites, and we closed 16 of those sites early on to conserve PPE, environmental services, and reduce the number of sites we had to staff, because we immediately went to a virtual care action plan as well.
The other piece was we established a couple sites as surge locations in the event that the hospital needed additional space. Two were off our main campus, and one was within our clinic building on the Henry Ford campus. In terms of reopening those sites, we are looking at different tiers of sites. We are going to keep the 16 closed for an indefinite amount of time. We are ramping up the other sites sequentially and starting, like you all are, with time-sensitive procedures. We are going site by site so we can concentrate our infection control team at that site and make sure that staff whom we are bringing back are very comfortable with PPE management and that sort of thing.
In terms of volume, we averaged 53,000 visits per week in person and now we are only at 14,000, so it is about 27% of our usual volume. In terms of virtual visits, we were doing about 350 visits and now we are doing about 8,000 a week, so we ramped up.
From a workforce perspective, in the medical group alone, we furloughed 950 people, which is 650 FTEs. We will be bringing them back strategically. One of the challenges I am concerned about is it is more lucrative for some of our MAs to remain on unemployment then to come back. We are thinking through how we will manage that.
Testing supplies was on that list, and we have an option for 3D printing for our nasal pharyngeal swabs. So we are good on testing, and the turnaround time from our in house lab is about 90 minutes. We have four pickups a day, and we are testing every procedural patient the day before. The sites are open six days a week, so the only challenge is that if we have an OR case on Monday, we have to have that test performed on Saturday. The PPE burn rate is a real issue. We are basically monitoring by procedure what kind of PPE we will need.
Wagner: Our next question is around patients feeling safe to come into the clinic. What steps are you taking to ensure patients feel safe coming into your environment? How will you market your services to your patients and communities so that they feel safe to return to receive elective surgical care? Jake Bast is going to answer that question to get us started.
Jacob Bast, FACMPE, FACHE, Senior Vice President and Chief Operating Officer, St. Elizabeth Physicians: We serve the greater Cincinnati market and the majority of our services are on the Northern Kentucky side of the Ohio River, but we serve this whole tristate area. Like most of you, we went through the planning phases of what our recovery ramp-up plan would look like. We developed seven streams that we farmed out to teams to work on. They were things alone the line of understanding government guidelines, stewardship for our PPE, minimizing exposures in the practices (and all of those had to do with physical barriers), PPE standards, social distancing (even how we are spreading out patient appointments), balancing access with safety, hardwiring our virtual visits, managing the staffing pool that was created with excess staff during the event, and what was our public communication plan.
It was called out pretty early by members of our team that this would not be a “build it and they will come back” sort of thing. The majority of our patients have had it drilled into them that they need to socially distance and they need to stay away. Coming to a healthcare environment, where they might perceive a lot of sick people to be, is not the place they will rush back to. It is up to us to issue a high level of reassurance that every one of our facilities is providing a safe environment for patients to come to.
We also had to set expectations for those visits. It is likely that the majority of patients whom we want to try to draw back in have not been in one of our practices since this whole issue started, and the workflows they are going to experience—the temperature screenings at the front door, being directly roomed, and xyz—will likely be a different experience for them. So we have done a lot of work in helping communicate what to expect when you come in. A big issue is wayfinding, not necessarily in the sense of signage in our facilities but which facilities to go to. For our call center—at the time appointments are made and appointment reminders—there has been a lot of communication to make sure patients know where they are going. We have designated specific centers to be our respiratory care clinics and that is where symptomatic patients and those who are going to be tested are being funneled. But now that we are beginning to open ambulatory centers again, patients need to know where to go. These components are really orchestrated together to try to provide patients with the reassurance and confidence to come back in. While a lot of our focus today is centered around setting surgery back up again, other than a little pent-up demand, we are not going to see the increase of surgeries that we need to unless we get our ambulatory practices back up and running because that is where those referrals are going to come from.
It is just as important, if not more so, that we make those environments comfortable for people to return to. We are using several tools to communicate this. This is an example of one of our social media spots.
There isn’t rocket science to this, but it is one of those queues you can pull up on Facebook or others, and then someone can click to go further. The next example is of a billboard piece that is going to be up and around in the area.
Another example is a portion of a dedicated landing page on our website around the theme of open, safe, and right here. To add context, “right here” is an ongoing consistent marketing tagline that we have been using.
Wagner: For those who are doing curbside check-in, is that something you think you will continue moving forward even when we are passed this pandemic?
Johnny Roberts, Vice President of Physician Practice Services, United Regional Health Care Services: We are doing curbside check-in at our ambulatory clinics and at our elective surgeries at our hospital surgical center. We perceive doing curbside check-in for quite some time to try and maximize social distancing in our seating areas. This is a delicate choreography now, as we try to maintain a certain number of people in seating areas and have the rest sit in their car and wait to be paged or called for their appointment. We plan to continue curbside registration for some time.
Bast: We are currently doing it at St. Elizabeth’s. I don’t think we have even gotten around to asking whether or not it will be a permanent addition to our workflows. I do see it staying through our three phases of ramp-up. I am a little old fashioned and I do like the face-to-face stuff, but it is certainly a tool in the tool box, and as we experience other public health-related things in the future or maybe during your annual flu season, we now have some tools to pull out if we need them.
Wagner: Are you using any registries to find patients with chronic conditions who should be called in?
Bast: We were already pretty assertive with that and made quite an investment in our clinical transformation activities, and some of that is not quite as aggressive during this. As we started to identify patients who need to come in and haven’t had their opportunity for med checks or chronic condition checks and screening exams, we can employ a lot of the same workflows for that. I am going to ask Hank Kerschen, who is on the line, to speak to that.
Hank Kerschen, Assistant Vice President, Primary Care and Clinical Transformation, St. Elizabeth Physicians: One of the things we are anxious to do is get our chronic patients back in. Part of that is to start to tier our patients into four tiers based on emergent need, chronic conditions, and a whole host of things that we are going to use to try to coordinate outreach and scheduling for bringing those patients back in in an appropriate manner. A lot of the work we did in clinic transformation didn’t stop. It just shifted into different types of work. We are ready to fire as soon as we get the go ahead.
Wagner: The next question is for Chris Scalfani. What is your ramp-up plan? How many cases will you begin with? How quickly do you plan on ramping up if your county moves from phase one to phase two relatively quickly?
Christopher J. Sclafani, PE, M.B.A., Chief Operating Officer, CareMount Medical, P.C.: The timing of this is almost ironic because our governor today announced that three of the counties in which we currently provide care can start elective procedures. One of the decisions we made as we went into this process about six to seven weeks ago was related to continuing this. We had about 45 sites and now have about 18 sites open. So in about four of our open sites, we have been doing urgent elective procedures. The procedure suites have still been open. At each site, the medical director and the surgeon had to go through and document why they thought the case had to be performed. We never shut down those sites, which will make it a lot easier for us to ramp up.
We are still trying to determine as this is evolving how many cases we are going to do in those locations. Probably next week we will go about 50%. But the difference, and the challenge, is that not more than 48 hours before, you have to be tested for COVID and have a negative test. If you have a positive test, we aren’t going to do your procedure. When you do show up, you will have your temperature taken, and if you have a temperature north of 100, you won’t have your procedure done, as well.
We are slowly working towards ramping up the staff. When this all occurred, we furloughed all our staff on a 50/50 basis, so 50% of our staff worked one week and 50% of our staff worked the next week. We do operate one ambulatory surgery center. Unfortunately, this is in Westchester County, and that is the county due north of New York City. I think they have more cases then most counties, so we were hit pretty hard in that area, and I don’t think the governor is going to allow us to do procedures there in the near future. Here in New York, we have been hit really hard and it has adversely affected how we do not only procedures but all of the missed preventive appointments.
We are in the process now of going out and trying to start utilizing Salesforce as a patient communication tool and slowly start bringing patients back in—it was upwards of 50,000 appointments. Not just procedures; it is appointments and it is all the mammography and breast imaging. I am really concerned about our cancer screening and bringing those patients back in, as well. I think the hardest part is that we are in this between phase. We aren’t shut down, but we aren’t working at a very scale-bound function.
We are trying to thread the needle of bringing the patients back in a safe fashion and make sure we have the resources to be there. Everybody wears a mask, the nice couches in our waiting areas are gone, and we have seats as far apart as possible. We are doing everything we can and communicating that to our patients. We are doing curbside check-in and having people call from their cars to check in and then we call them so they aren’t in the waiting area. We want to do that so we get more people in for preventative care, because the longer this goes on, the bigger risk we have to our organization. We are self-insured for malpractice, and I am petrified of the long-term impacts of people not coming in. There is no cure for cancer or heart disease, but we are going on seven weeks where we haven’t done those procedures or provided those activities for our patients. The longer that goes on, the more concerned I become.
Wagner: How often are you testing staff? Will staff be dedicated to non-COVID sites?
Sclafani: We have not commenced testing staff. That is something we are about to embark on. I don’t know if this is a blessing or a curse, but there is no such thing as a non-COVID site here. This disease was ramped in our community, so we were never really able to separate the two. We try to see our well patients in the morning and our sicker patients in the afternoon. As things go down here, we might migrate to staff testing, but unfortunately, we have had so many cases that we couldn’t separate the sites. What we have been telling everyone is that you need to assume everyone has been exposed to COVID or has it.
Wagner: How much pent-up demand do you think you have and what percent of patients do you feel won’t come back? Do you think you will ever get back to pre-COVID volume?
Sclafani: Here at CareMount, we do not anticipate that in 2020 we will get back to 100%. We are modeling ourselves to get between 85% and 90%. The real question is: At what point will we take our furlough off and bring all our staff back? We are still trying to model that out.
Wagner: Have you thought through the planning of how you will bring back staff? Is it based upon demand, seniority, and specialty? Do you think you will be bringing back all of your furloughed staff?
Sclafani: One of the challenges we have seen is that some of our employees have gotten really comfortable on the furlough and collecting unemployment. As we have tried to bring them back, they are not all that enthusiastic about coming back. We are doing this in a targeted fashion based on needs. The HR department keeps us from getting in trouble on bringing people back.
Wagner: As a result of the pandemic and telehealth that is exploding, have you had any providers who may want to work from home when you reopen? Providers who may want to work part time or have retired as result of this?
Kerschen: We haven’t had any providers make any decisions on future employment based on this, but I do think this will change the way care is being delivered. Our ramp-up to video visits was so much faster than we expected, going from 30 in February to 2,000 a week. I think we will have providers tell us that they will be willing to extend hours into the evening longer to be able to do them from home or the sidelines of soccer practice. I think it will change the pace of care in the community, the hours in which we deliver the care, and where that care is being delivered from. But not, in my mind, in a negative way. If anything, we have seen people step up and lean into it. If you are immunocompromised, video visits are a great way for you to deliver care during a pandemic because you don’t have to worry about physical connection and getting ill. I think we will see some positive come out of this.
Wagner: What percentage of visits does everyone think will be virtual when you reopen?
Kerschen: That is the million-dollar question, isn’t it? I think we will have some providers who will embrace it much more fully then others. But I think patients will be asking for it and will see the benefit of not having to drive to the clinic, wait in the waiting room, wait for the physician to finish documentation, etc.
Hulse: Our plan is to continue with the platform, and we think it will be about 75% face-to-face and 25% virtual, but really leveraging it in key access areas where we have some real challenges to be able to offer folks to do these visits in the evening or for postop visits so we can get new surgical volume into offices. We plan to use it a little bit more strategically, as opposed to a blanket video visit. Our access challenged areas will really be a focus for us.
Anne Walsh-Feeks, M.S., PA (ASCP), FACHE, Assistant Dean and Chief Operating Officer, Stony Brook Medicine: Out on Long Island, we were in the epicenter for COVID. The interesting thing that happened with us for telemedicine was we ended up using Microsoft Teams, and we went from 0 to 100 in a matter of days. We routinely have had 4,000 outpatient visits per day and we are up to 1,400 through video visits, and then we have a very small number of patients coming into the offices. Our strategy is that the physicians love it, the patients love it, and we previously had a really high no-show rate in our ambulatory sites. We have a group of navigators who connect with our patients before the visit to make sure they have downloaded the app and know what to expect. So we have a lot of backlog in our subspecialties where we have not been able to get patients in on a timely basis, and we are hoping to use telehealth as a core product to allow us greater efficiency in our practice and address the bottlenecks that we previously had.