WakeMed clinical leaders share key elements of the health system's response to COVID-19 and plans for a potential coronavirus resurgence.
WakeMed Health & Hospitals was spared a dramatic impact in the first wave of the coronavirus pandemic and is ready if a second wave hits.
The coronavirus disease 2019 (COVID-19) pandemic has had varying impact across the country, ranging from dire hot spots such as New York City to Montana, which reported 505 confirmed cases as of May 29. In North Carolina, there were more than 44,000 confirmed cases and more than 1,100 deaths as of June 14, according to ABC.
Raleigh, North Carolina–based WakeMed did not have to increase bed capacity in response to the COVID-19 pandemic, but the health system learned the following eight key lessons and positioned itself to respond to a potential second wave of infections, a pair of clinical leaders from the organization says.
1. Be flexible
The COVID-19 pandemic put a premium on flexibility, says Seth Brody, MD, MPH, senior vice president of physician services. "We had to evaluate ideas that were new and different. We needed to have flexibility and willingness to listen to others," he says.
For example, supplies of personal protective equipment and directives for its use shifted several times through March and April, he says. "We had to continually modify our policies for N95 masks. As more information came out, it became clear who truly was at risk."
WakeMed had to foster flexibility in its staff, Brody says. "Getting the staff to work with us through change was critical. We had to help them understand that we were adapting as quickly as we could, we were trying to be rational, and we were trying to work within our supply chain limits. We had messaging that leadership was going to be flexible and the staff needed to be flexible with us."
2. Discover your institutional potential
Harnessing WakeMed's potential as an organization was critical in the health system's response to the pandemic, says Chris DeRienzo, MD, chief medical officer and senior vice president of quality. "When we approached the first lockdown orders—the first crisis period—members of our command center learned a lot about each other and the organization. We found that we could function under high intensity pressure and focus on needs and outcomes."
WakeMed began activating the command center in January and had a 24/7 operation by March 6, DeRienzo says. At its peak, the daily incident command call had more than 60 people. The operational command teams had as many as 300 people.
"We stood up entire functions and pillars to support the COVID response that did not exist before in terms of disaster planning, inventory, testing, and other functions. We learned what we could do as an organization when we brought the focus down to things that we had to achieve," he says.
3. Implement change quickly
Under the pandemic pressure, WakeMed was able to launch and implement initiatives quickly, Brody says. "Things that would take three to six months in the past could be accomplished in three days. It was a great lesson learned in terms of how to work together to get things done. We had the talent. We had the skills. We had people to lead change."
For example, WakeMed ramped up a modest telemedicine capability within days, he says. "We had talked about telemedicine and we had it up and running, but before the pandemic we might only see 10 patients a week via telemedicine at our physician practices. When we launched telemedicine across the outpatient continuum of care, within a week we were doing more than 60 telemedicine visits at the same time."
4. Find your untapped talent
WakeMed's response to the pandemic benefited from actualizing the potential of talent within the health system, Brody and DeRienzo say.
For example, David Kirk, MD, director of the WakeMed Pulmonary and Critical Care and director of WakeMed eICU took on a key new role, helping to lead the command center's critical resources team.
"That team turned around our critical resources dramatically. Our normal supply chain people are very good, but this was a different kind of crisis. The critical resources team figured out the burn rates for our PPE and targeted critical resources. They did vetting—we were getting 15 offers a day for PPE from around the world that were 15 to 20 times the normal cost. They also helped with communication to our healthcare workers, which gave our workers more confidence," Brody says.
Kirk has been promoted to associate CMO and critical resources management will remain one of his responsibilities.
5. Appreciate your community support
The Raleigh-area community supported WakeMed on several fronts, including money for the health system's foundation, Brody and DeRienzo say.
"Our service mentality for our community is reflected in the community's service mentality to us. As we walked into the depths of the most challenging aspects of the past 12 weeks, the community stood up for us and served our people in ways that I had certainly never seen before in my career. There were donations from food to supplies, and salutes from law enforcement and first responders," DeRienzo says.
6. Ensure your physicians are compensated
During the first wave of the pandemic, WakeMed did not lay off or furlough any physicians.
Hospital-based physicians such as critical care physicians and hospitalists were kept at their pre-pandemic salary levels, and a new payment system was created for physicians on productivity-based compensation such as operating room surgeons.
"On the frontline in the hospitals, we maintained physician salaries. We realized our doctors had to get us through the crisis," Brody says.
With overall patient volumes down and the cancelation of elective surgery to boost hospital bed capacity for COVID-19 patients, physicians on productivity-based compensation were at risk. Brody led an effort to compensate these physicians at fair market rates during the crisis, with a reconciliation process after the crisis had passed.
"We are sustaining their cash flow at a very reasonable fair-market rate throughout the crisis. It's almost like an interest-free loan for an extended period of time, so that they can stay at a fair-market level throughout the crisis. We will reconcile the compensation later, but they never dropped below a fair-market level," Brody says.
7. Cooperate instead of compete in crisis
WakeMed is based in Raleigh, one of the points in The Research Triangle region of North Carolina. Competing health systems are based in the other two points of the triangle—Duke Health in Durham and UNC Medical Center in Chapel Hill.
The rivals have cooperated during the pandemic.
"With the supply chain, it made more sense for us to work together. We shared masks and swabs for testing. We also aligned policies. For example, we created similar policies for hospital visitation. Our community benefited from getting a common message from all of the health systems," Brody says.
The cooperation extended beyond The Research Triangle, DeRienzo says. "The cooperation was not just with Duke and UNC. There was cooperation at the state level—North Carolina's health systems tried to begin thinking and acting in the statewide response. When I think back to the end of March and early April, we were not just on our internal incident command calls; we were having calls with Duke and UNC, we were having statewide healthcare leadership calls, and we were having calls with local and state officials."
8. Plan for surge capacity
One of the most valuable work products of the WakeMed command center has not been used, yet.
A capacity management team with about 30 members devised a plan to increase WakeMed's patient capacity from about 1,000 beds to more than 1,500 beds. The team was led by a senior nurse, with participation of ED clinicians, surgeons, hospitalists, and others.
The surge capacity plan has three phases.
- Phase 1: Increase bed capacity by at least 25% through conversion of spaces that could readily serve COVID-19 patients such as operating rooms, endoscopy units, and post-anesthesia care units.
- Phase 2: Increase bed capacity by another 20% by setting up cot facilities in conference rooms and a rehabilitation gym.
- Phase 3: Establish a temporary hospital at a facility in the community.
"Having developed these plans, we now have them in hand. If COVID in the fall requires us to walk through that progression, we are ready. This is work that is tremendously valuable for whatever comes our way next," DeRienzo says.
Christopher Cheney is the senior clinical care editor at HealthLeaders.
WakeMed found that the organization had untapped potential to rise to the coronavirus pandemic challenge.
WakeMed cooperated with competing health systems to meet critical needs such as acquiring supplies of personal protective equipment.
The Raleigh, North Carolina-based health system put a new payment system in place for physicians who were on productivity-based compensation models.