This range of experiences allowed for rich discussion and insights, primarily focused on the challenge of restarting scheduled procedures. Below are six takeaways on how CSOs are approaching their reopening strategies.
1. It's a dimmer switch, not an on/off switch.
Restarting services won't happen all at once. All CSOs said their organizations will take a phased approach to restarting scheduled procedures.
Service line and physician leaders are making decisions collaboratively, choosing specific procedures within each service line, rather than restarting all procedures within some service lines and none in others. Most leaders are prioritizing procedures that meet these criteria:
- Clinically time-sensitive: Cancer and CV services were most commonly mentioned;
- Same-day or short LOS, with no ICU or SNF stay required;
- Financially beneficial and/or represent a market share risk or opportunity;
- PPE required is reasonable relative to benefit of performing procedure: Some said they were holding off on endoscopies due to their PPE demands.
Leaders planned to monitor bed capacity carefully, holding additional reserves and limiting transfers between community hospitals and AMCs.
2. Engage your surgeons and referring physicians
Beyond involving physician leaders in decisions about what to restart, CSOs noted the need for significant communications with surgeons and referrers. Many surgeons are anxious to get back to work and are considering shifting cases to facilities that re-open sooner or offer faster turnaround times for pre-operative Covid-19 testing. To keep those surgeons on board and maximize capacity for rescheduled procedures, organizations must:
- Explain their rationale and timeline projections for what procedures are allowed, and when;
- Address surgeons' concerns proactively and monitor what competitors may be offering them;
- Understand whether surgeons are willing to flex to create capacity, such as by extending OR time blocks, working with unfamiliar teams, or performing surgeries at night or on weekends; and
- Provide surgeons and their staff with talking points to reassure patients that it’s safe to have a procedure. (More on this below.)
CSOs also highlighted that the drop in primary care and specialist office visits will create a drop in procedural demand several months from now; it may also result in sicker patients at higher risk for surgical complications. Leaders should engage PCPs and referring physicians now to plan for ramping up office visits and sustaining telehealth services.
3. ASCs have new advantages and new challenges
Some health system CSOs expressed concern about increased competition from ASCs. During the epidemic, CMS is permitting ASCs to furnish inpatient services under arrangement with a hospital or enroll as a hospital, and patients may perceive freestanding facilities as safer from infection risk. However, ASCs may struggle to maintain sufficient PPE, and additional safety procedures may limit daily volume for ASCs, which typically rely on high OR turnover to generate margin.
4. The fear factor is CSOs' biggest fear factor.
CSOs voiced uncertainty about how, after telling patients to stay away, they can convince them it's safe to return. For many, patient anxiety is more of a concern than PPE or testing.
One key insight: to rebuild trust, the patient experience must feel meaningfully different—the entire care pathway, from scheduling to post-discharge follow-up, must be redesigned to reflect a commitment to infection control. These changes will affect patient flow and reduce the number of patients that can be accommodated. Several organizations have established operations workgroups to tackle the redesign. Changes include:
- Scheduling fewer procedures to space patients out;
- Testing patients in advance and requesting self-quarantine in interim;
- Completing registration and payment collection online or via phone;
- Asking those who are able (including caregivers) to wait in their cars, not the waiting room;
- Providing temperature screenings, masks, and hand sanitizer at the door;
- Designating separate entrances and exits as possible;
- Using furniture arrangement and floor decals to create one-way flow and 6-ft spacing; and
- Converting pre- and post-op appointments to telehealth visits, when possible.
To communicate the changes, most are using one-on-one outreach to patients whose procedures were postponed. They're providing clinicians and staff with scripts and FAQs that emphasize both the safety precautions and the importance of receiving care.
Some organizations have started broader community outreach campaigns, but many have yet to receive the green light from their state government and want to avoid messages that could be seen to conflict with government messages.
5. Current testing is used to screen out positives, not guarantee patients are free of Covid-19
Most CSOs said their organizations are working to build in-house testing capabilities, and they plan to test each scheduled procedural patient, asking them to self-quarantine between the test and procedure. Test validity remains an issue. Therefore, most organizations use tests to screen out Covid-19-positive patients, who are not eligible for scheduled procedures; those who test negative can get the procedure, but staff will wear PPE and take other precautions, mindful that the patient could still be Covid-19-positive.
6. Restart plans may include service rationalization
Several CSOs commented that the pandemic has shown them how quickly their organizations can make decisions when they really need to. They're hoping to draw on these experiences to accelerate long-lingering decisions, particularly those related to systemness and service rationalization. Some organizations will incorporate service rationalization into their restart plans by not restarting some services at some sites, or converting sites to different uses.
We plan to hold more of these small group, confidential sessions in the coming weeks to discuss both near- and long-term planning issues. If you're a CSO and would like to participate, please reach out to firstname.lastname@example.org.
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