Executive Session: Building new safety measures into a medical practice’s “new normal”

As the COVID-19 public health emergency evolves with social distancing and other factors prompting areas of the nation to begin a phased reopening, many medical group practices and other businesses are resuming operations.

Frank J. Chapman, MBA, director of strategic development, Ohio Gastroenterology Group, recently joined the MGMA Executive Session podcast to share insights into how his group is responding. Chapman has been part of the workgroup for the American Society for Gastrointestinal Endoscopy (ASGE) that recently crafted Guidance for Resuming Elective GI Endoscopy and Practice Operations after the COVID-19 Pandemic, a substantial paper with relevance beyond GI specialists in terms of a framework for reopening a practice with patient, provider and staff safety top of mind.

The paper includes specific guidelines for how to:

• Screen patients prior to a procedure
• Create a safe facility with appropriate distancing
• Establish appropriate use of personal protective equipment (PPE) to safeguard patients, staff, and providers
• Create a written scheduling policy that prioritizes patients with the most need
• Provide checklists that cover patient check-in, the pre-operative and postoperative rooms and (more importantly) the procedure room
• Clean the procedure room.

Chapman’s work as a Medicare surveyor of endoscopy centers for the Accreditation Association for Ambulatory Health Care (AAAHC), among other credentialing efforts, makes him well suited for the task of helping determine the efficient operation of endoscopy centers in response to COVID-19.

The effects of COVID-19 on practices

For a GI group with five endoscopy centers, Chapman noted the Ohio Gastroenterology would normally have about 35,000 cases and about 62,000 office visits in a normal year, but that’s been shut down in large part for two months. The group is still trying to do infusions, and hospital and emergency procedures have continued through the broader shutdown.

Communication channels with primary care physicians and referring physicians have remained open to screen patients in dire need of surgical procedures that normally would be done in the hospital.

When it comes to using telehealth, Chapman noted most of it is related to routine matters, such as prescription refills. While many physicians quickly took to the new method of communicating to patients, Chapman cautioned that the transition should also include ensuring staff who assist physicians are prepared for the new workflow, such as having a patient records ready for a physician’s review.

ASGE guidelines: What practice leaders should know

The ASGE guidelines that Chapman helped review acknowledges that our understanding of COVID-19 is evolving and that the guidelines work from the evidence available today.

“There’s so much that we don’t know,” Chapman stressed, that the paper’s recommendations are founded on the possibility that every patient is a possible COVID-19-infected patient. For example, testing a patient for COVID-19 about 48 hours ahead of a visit only gives staff a point-in-time result and does little to ensure the patient is not infected at the time of the visit. “You have no idea the exposure that patient has undergone” since the time of the test, Chapman said, underscoring how different care delivery will look going forward.

“We’re familiar with universal protocols that came out of the era of HIV/AIDS. I think we’re entering a new universal protocol in terms of how you have to assume a patient may be infected and how to treat them,” Chapman added.

Key considerations in preparing practice spaces for reopening

The paper’s overview of distancing and PPE considerations for a medical office recommends patients wait off premises or in a vehicle until they are called in for a visit. Day-of-procedure check-in process recommendations for endoscopy centers reflect the need for completion of a COVID-19 questionnaire; similarly, the paper notes the ongoing debate over the usefulness of onsite forehead temperature measurements of both patients and staff, given the large percentage of infected patients who are asymptomatic.

Facility changes

To ensure the safety of patients and staff alike, the reworking of facility spaces extends well beyond rearranging waiting area space. In some scenarios, a patient would proceed directly to a pre-operative bay or room, bypassing a waiting area altogether, according to the paper.

The extent to which practices must refocus efforts on cleaning all spaces is critical for leaders to consider. In addition to room layouts, Chapman noted that “people need to take more vigilance in terms of cleaning everything,” including stretchers, soiled linens and more.

In some organizations’ procedure rooms and surgical areas, it’s common to see countertops filled with syringes, pathology bottles and other supplies, left out between patients. “You need to develop ways to make sure that you’re storing those in a ferry and bringing those out and then putting them back in, as needed,” Chapman said.

“You may need to rethink what’s in an exam room for office encounters, because everything in that room should be considered infected and needs to be cleaned as soon as the patient leaves,” Chapman said.

PPE, costs and risk management

Given the increased use of PPE and expansion of cleaning efforts, practice leaders should keep in mind the increased cost of those supplies and the decline in productivity from the added time to ensure appropriate cleaning is done at the determined intervals.

Practice leaders also should encourage everyone on staff to be vigilant. “Everybody needs to watch everybody else,” Chapman said. “Buddy systems, when they can be established, are excellent ideas. … The biggest thing to come out of this is, we can only get started if we’re willing to be safe.

“This is not a dry run. … This is the new normal, and people need to get used to it,” Chapman said. “It’s still going to take some time, and I think we need to realize that.”

Prioritizing care

Additionally, the paper recommends a priority tiering system for urgent, semi-urgent and elective patients, reflecting the potential severity of outcomes if procedures are delayed. This prioritization should help practices schedule appropriate dates to help minimize negative care impacts as a result of delays.

“There have been published reports expressing concern about the entire country basically going several months without cancer screening in all specialties — not just GI,” Chapman said, noting the downstream effects of cancer identification delays can cause patient health to worsen and prompt scheduling issues. “Obviously want to get your patients whose risk is higher than others scheduled first, but even patients in a fairly low risk procedure, like colorectal cancer screening, are still important,” Chapman said.