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June 24, 2020

How WakeMed is meeting patients where they are at—physically and psychologically

Daily Briefing

    Chris DeRienzo is SVP and CMO of WakeMed Health & Hospitals, an integrated health care system based in Raleigh, North Carolina. He recently spoke with Steven Berkow, Advisory Board's VP of Provider Research, about changing patient perceptions of health system safety, lessons learned from incident command structures, and the future clinical workforce.

    Q&As: How top health systems are tackling Covid-19

    Question: Hi Chris, thanks so much for making time to speak with me. The past few months must have been a whirlwind for you. You'd just joined WakeMed when the new coronavirus epidemic emerged in the United States, right?

    Chris DeRienzo: Yes, that's right. I joined WakeMed in December of 2019. So, shortly after learning how to get from the parking deck to my office, it's been basically full speed Covid-19.

    Q: I'd like to start off by getting a sense of where WakeMed stands right now in terms of Covid-19 volumes?

    DeRienzo: We were fortunately spared the initial catastrophic Covid-19 burden that hit places such as New York. For most of the spring, our inpatient Covid-19 census across WakeMed's hospitals hovered in the 20s to 30s of around 1,000 total beds. That said, North Carolina entered Phase 2 of our state's reopening process on May 22. Since then, we've seen a slow but steady rise statewide in case counts, test positivity, and hospitalizations, and our Covid-19 census at WakeMed has drifted up as well.

    Q: How about looking forward? Are you readying for a second wave, or do you feel that WakeMed has sufficient capacity and structures in place to more naturally manage the pandemic's anticipated ebbs and flows?

    DeRienzo: I wouldn't say we're anywhere close to out of the woods. In fact, the recent uptick across North Carolina suggests the state may still be in the middle of our first wave. From an operational perspective though, I am confident we are in a markedly different place now than where we were in March. We have solid capacity management and critical resource plans and teams with exceptional talent backing them up, and made many operational adjustments to be able to safely serve our community across the entire spectrum of care, Covid-19 included.

    Q: So what's it going to take to get your patients to come back at pre-Covid-19 volumes? Obviously, there are clinical steps health systems must take to ensure safe care environments. But health systems around the country are reporting a reticence among patients to come back because they don't feel safe—no matter how many safety measures health systems put in place.

    DeRienzo: This challenge has been atop our minds and a focal point of our planning efforts for months. Even though our communities never looked like New York, Spain, or Italy, our patients are still concerned—and I understand why. They've been inundated with information from news and social media about the severity of Covid-19 and the risk of exposure. They have seen images from some of the hardest-hit states and countries. And we've literally told them to stay home to stay safe.

    We know that helping people overcome the scary images while respecting what this virus can do is a tall order. We need to help our community understand that they can trust us to provide the care they need in the safest manner possible. With that in mind, our communications team has been brilliant in helping us connect with our communities and share our deep commitment to patient and family safety. We developed a community wide campaign titled "Always Safe. Forever Here.", which is the central theme around all of our communications.

    Additionally, helping patients re-engage across the spectrum of care isn't just about overcoming patient fears. It's also about accommodating their new realities. For example, many patients now have young kids at home and struggle to find enough free time to come in to see a provider. Others are hesitant to use public transportation, particularly if they have high-risk health conditions or live with somebody who does.

    To get out in front of all of this, we formally tasked the Reconnections Task Force in our incident command structure with how to best re-engage patients in ambulatory care. They in turn stood up five subgroups to address different components of this challenge, and in six weeks, they completely transformed our ambulatory care access processes.

    What has struck me the most about these incredible teams is how hard they've worked to truly meet patients where they are, with respect to both safety and the new complexities of patients' lives. This included scaling up telemedicine from zero to 1,000 visits a week and setting up drive-thru lab testing so that patients needing lab work can get it without even leaving their car. More than 95% of our 90+ ambulatory sites are now live on a virtual arrivals process that includes GPS-based tracking and e-check-in, and we are working on even more no-touch or low-touch processes throughout. 

    But whatever the care setting, our approach here hasn't been to just say "we are safe"—we have to say it, show it, and narrate what we are doing to ensure our patients understand why we are doing what we are doing to help everyone stay safe.

    Q: Can we go deeper on that last comment? Why is what clinicians say at the point of care so critical to overcoming patient concerns about facility safety?

    DeRienzo: Whenever patients engage with us for care—be it at an ED, ambulatory clinic, OR, or even a home health visit—we must ensure they fully appreciate all we are doing to keep them and us safe.

    Again, most patients are neither clinicians nor Advisory Board researchers. They won't notice many of our most critical safety practices unless we explain the what and why of our safety measures as we deliver care. This is when we have our patients' full attention, and our physicians, nurses and other clinicians are some of the most trusted people in our community.

    We recognize that narrating care does not feel natural for many of our providers; pointing out and explaining why I'm conducting an examination without touching you or why we're asking you to walk yourself to an exam room hasn't typically been part of their day. Our aim is to ensure that patients not only are safe, but that they feel safe in every interaction with WakeMed. By doing so, our patients avoid delaying the care they need—and their confidence in WakeMed grows.

    Q: You mentioned that the task forces charged with reengaging non-Covid-19 patients are part of your incident command structure. Can you describe the larger structure?

    DeRienzo: We activated the incident command structure in January. We knew it was important to think through who needed to be in the room to help the group make the best and fastest decisions together in the moment. So, we landed on a 30 to 40 person command team that encompasses a wide range of roles, from WakeMed's CEO to frontline team members.

    That team met on a daily basis for up to three hours, for weeks on end, during our highest intensity response period, and spawned several special teams, taskforces, and subgroups focused on resolving specific challenges quickly. We learned how to pull on talent from every corner of the organization to ensure we had the right mix of people to think, solve, and act rapidly. This metric-driven, action-oriented organizing philosophy enabled us to be more agile and efficient.

    For example, our critical resources team includes folks from pharmacy, critical care, supply chain, infection prevention, performance engineering, research and innovation, and more. They've created entirely new personal protective equipment (PPE) supply chains and worked with North Carolina State University to manufacture specialized face shields from scratch. Right now, they are perfecting a 3D-printed KN-95 mask brace that we plan to share as open source design once we complete testing—and they've done all of this while still doing their day jobs, ranging from engineers to VPs to bedside clinicians.

    Q: Nearly every health system executive I've met in the last month has lauded his or her incident command structure for the same reason you just shared: its ability to cut through bureaucracy and pull forward timely solutions on a wide and changing range of issues. Are you thinking about keeping some aspects of your incident command structure in place post-Covid-19?

    DeRienzo: You just read my mind. Health systems traditionally operate as highly matrixed and complex environments with multifaceted goals, and it can be really hard to get the right people in the room at the right time to decide and execute well with speed. The incident command structure is the perfect way to break down those silos, and we've been fortunate to have an exceptionally strong team with significant experience in past disasters to lean on for leadership and support.  

    Under an incident command philosophy, we were able to 1) get everyone we needed into one room quickly (with masks of course); 2) say, "OK, we must do these five things if we are going to make it through tomorrow"; and then 3) go do them. Incident command teams are not based on levels or reporting lines—they intentionally pull in the knowledge and support needed to find and implement smart solutions, wherever that knowledge and support may exist. And if any team or task force hits a roadblock, the full incident command leadership group is right behind them to provide immediate help.  Honestly, I don't know how to respond to an existential crisis like Covid-19 without incident command.

    We've spent a lot of time in health care trying to draw out very detailed reporting structures. Yet people are often frustrated. How we matrix things and our systems and inter-relationships are only becoming more and more complex. I think the reason incident command structures have worked so well for health systems during Covid-19 is because they are 1) grounded in shared situational understanding; 2) focused on a small number of must-achieve goals; 3) run metric-driven and action-oriented meetings; and 4) marshal the right people to solve a challenge with the authority to actually make things happen—regardless of their solid or dotted lines. Covid-19 has forced us to try new things; we've got to learn from them and apply these learnings to how we operate every day moving forward.

    Q: Let's shift the focus a bit. We've been talking about how Covid-19 has prompted WakeMed to change how it operates and cares for patients in a matter of weeks. What about changes to its clinical workforce? Do you think WakeMed needs to re-think who will comprise its clinical workforce, or is it more about getting your current mix of clinicians to adapt?

    DeRienzo: Covid-19 has no doubt changed things, but in many ways I think it's more about accelerating change rather than fundamentally shifting its direction. It's widened the spectrum of when and where we engage our patients in the short term, and I think most of these changes will stick in the longer term because they offer patients more flexibility.

    Take telehealth as an example. The health care industry has been slowly revving up a telehealth engine for years; once Covid-19 removed all the barriers to implementation we just flipped on the hyperdrive. WakeMed's new hospital-at-home program is just one example. Hospital at home is not a new concept in health care, but Covid-19 enabled us to accomplish in weeks what would have taken years. 

    Now, there will be always be people who prefer engaging in one specific setting—for example, I'm sure some providers will move back to 100% in-person visits as soon as possible. Others, however, have told us they'd prefer only doing telehealth for the rest of their careers because they love engaging with patients on their terms in their home setting. In a post-Covid world, all of these options will exist both for patients and providers, creating opportunities to better match individual providers with a type of care delivery that both meets patients' needs and brings them personal joy.

    Q: Any final thoughts in our last few minutes?

    DeRienzo: I'd like to express my deep gratitude for the entire WakeMed community. We are incredibly proud of our clinical teams' work, including the many, many nurses across our system who cross-trained whenever we asked them to take on a new challenge.

    I'm also incredibly proud of all the people who support these clinicians—the folks behind the scenes whose work ensures our bedside caregivers have the space, the time, and the things they need to care for our community. I know firsthand that these team members are just as dedicated to WakeMed's service-oriented mission as our clinicians, and the community has responded in kind. From chalk drawings in our parking lots, to thank-you notes left in people's yards, to donations, it's clear that this community appreciates us as much as we appreciate them. That the energy that keeps me up every night and gets me up every morning to keep doing my best for them.

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