CEOs are balancing the now, and the next, in workforce strategy.
If you look up the ingredients of effective change, most lists will include key factors like vision or resources or methodology. They usually miss one essential ingredient: timing. For health system CEOs, timing may be the missing key.
Discussions are happening in health system executive suites today that would have been unheard of just a few years ago: Pay every employee daily? Move some clinical roles to remote? Take clinical workflow away from the anchoring weight of the electronic health record? Reimagine nursing roles?
Like many opportunities, this one has come from calamity, with a once-in-a-century pandemic followed by a fiscal sinkhole that is hitting healthcare providers. Marcus Whitney, founding Partner of Jumpstart Health Investors, cautioned the assembled executives for the HealthLeaders Healthcare Workforce of the Future to keep one thought: it really is different this time.
"Healthcare has—for the better part of the past 50 years since Medicare/Medicaid came into existence—not had its fundamental value network disrupted in any meaningful way," Whitney said in the event's opening keynote. "The regulatory apparatus is highly protective of it. We have been able to leverage CONs and lobbying organizations. We have not needed to build competency around innovation because there was never a threat in the market for competition."
There is now.
"What wasn't priced into healthcare was the fundamental systemic threat of a change in society that COVID-19 brought about. Now the workforce, which is the key cog in the healthcare system, has been disrupted in every single industry."
CEOs are seizing the moment. In the CEO panel of the HealthLeaders Healthcare Workforce of the Future program, CEOs of four nationally known health systems discussed the meaning of the moment for the healthcare workforce.
Pictured: Marcus Whitney, founding partner, Jumpstart Health Investors.
1. Keep the Pace of Change
The pandemic forced quick solutions for immediate problems. Supercharging telehealth quickly is an oft-cited example of how healthcare systems accelerated the pace of change. What happened after the pandemic was that the pace of change faltered, lacking the fuel of urgency and immediacy.
What is left is the capability, at least. CEOs are looking to take advantage of those hard-won skills to shape new innovations in the workforce.
"When I talk about the pandemic, we knew before then that all these issue around digital disruption," says Catherine Jacobson, president and CEO of Milwaukee-based Froedtert Health. "We knew what we had to do. We were building capabilities, but relatively slowly. We moved fast when we had to. What we're doing right now is going back and reexamining and refining it because when you go really fast, it doesn't always come out perfect. But how do we continue to harness that speed? We've reduced the number of things we focus on so that we can move at speed on the things we really need to focus on."
Jacobson agrees with Whitney that the moment feels different this time.
"We've been pressured before, but we've never really been threatened before," Jacobson says. "And that's two different things."
Ketul Patel, chief executive officer of Seattle-based Virginia Mason Franciscan Health and Division President, Pacific Northwest of CommonSpirit Health, says competitive pressure from outside healthcare is here.
"I don't think any of us love the fact that a pandemic is driving us to do things differently, but that's the reality," Patel says. "We've learned a lot of new tools and new resources because we had to. In this community where I live in the Pacific Northwest, we have Amazon, we have Microsoft, we've got so many others that are so focused on digital support and care, particularly for our workforce. They've been models for us. And we just, frankly, haven't taken advantage of that over the last decade. This is going to force us to do that because that's our competitor. It's no longer just healthcare organizations. Our competitors are truly large organizations that have created a capacity for work not only in the 50 states, but also internationally as well."
The pandemic did, for good or bad, break some preconceptions about how certain healthcare processes had to be.
"One of the things we focused on is we tend to be a very traditional, rigid business model, whether it's in HR or revenue cycle, or in how we provide care," says Cliff Deveny, MD, president and CEO of Akron, Ohio–based Summa Health. "What we saw with COVID, we were able to pivot and make changes very rapidly when we had to. We've embraced new thought processes on scheduling and hiring and even in how we pay people. We had organizations in our community that wouldn't hire anybody that wasn't living in the county. Now, we're hiring people in all 50 states. You've got to innovate, and you've got to solve problems, not to complain about it."
Assaad Sayah, MD, CEO of Cambridge Health Alliance (CHA), a public safety net health system in Boston's metro north communities, agrees the moment to innovate around workforce is now.
"I don't think we have much choice," Sayah says. "If we're not thinking of doing something very disruptive, I think we're going to miss the game. As organizational leaders, we have to push the organization into areas outside the comfort zone we have been living in for years. If we just continue doing what we've done historically, not only are we going to dwindle into nothing, but we should dwindle into nothing. Our communities and our patients and our staff deserve better. And maybe this is an opportunity for us to act differently and look differently moving forward."
2. "Running the Business and Transforming the Business."
Not all workforce trends are interconnected. In the current healthcare workforce, some issues that seem so pressing today may eventually burn out on their own, while others present long-term strategy challenges that must also be addressed today.
"There is a short-term urgency, and then how are we going to deal with this long term," Jacobson says. "The long-term issue is about how we do the work. Here is how we are bucketing these: What are the immediate things we must address and take care of? And then at the same time, how do we transform? We're calling it 'running the business and transforming the business.' "
In the short term, Froedtert Health had to increase wages for clinical talent, particularly in nursing, surgical technicians, radiological technicians, and medical assistants. Prior to the pandemic, a 3% merit increase would equate to $30 million. Next year, Jacobson says wage increases could top $120 million for the $3 billion health system.
"When your payer mix is more than 60% governmental, there is no ability to go to your payer partners to open your contract," Jacobson says. "That all falls on us and it's disastrous." The Froedtert Health team made a commitment to do two things in response. First was to "get off the pay cycle" as market health systems try to outbid each other for clinical talent. And then, "do a better job around messaging and create alternatives to making this a transactional pay type of environment."
Pictured: Catherine Jacobson, president and CEO, Froedtert Health.
Sayah says workforce has always been a challenge. CHA sits in a market surrounded by its fellow Harvard teaching hospital partners like Beth Israel, Mass General and Brigham. Cost of living in Boston is among the highest in the nation, and CHA has 14 unions.
"One of the things we did over the last couple of years is really define our strategic plan to rethink about the needs of the community, and how that leads to equity and excellence," Sayah says. "That led to thinking about how we can have our workforce sounding and looking like the patients that we serve. We serve a safety net population. We've had a lot of engagement with the community historically, but we never married our community engagement with our need to fulfill the workforce. These are neurons that we're growing right now."
Moving from a reactive, short-term mindset into a long-term, transformative mindset first means assessing your team's capabilities. After almost three years of crises, what skillsets have emerged or improved?
"It is a good time to transform. We have the imperative," Jacobson says. The initial COVID shutdown taught the team lessons like crisis management and incident command. Lessons from the rush to remote work also paid dividends in skills for telehealth.
"And guess what? We learned how to do a whole bunch of stuff that we have been struggling with for a long time," Jacobson says. "So, we're embedding that and hard coding that into our next operations excellence. That gets the team excited. The pandemic is not impacting our operations like it once did.. It's our job as leaders to pull them back, get their heads up to start looking for something fun to do again after the slog of dealing with the pandemic."
3. Culture: Use it to Advantage
Wage increases for healthcare talent are up and unsustainable. But is salary why people leave their jobs? A recent report by the Workforce Institute estimates that as many as 6 million healthcare workers will quit their jobs in 2022. But of those, only 10% will leave for salary reasons.
The reasons why people move jobs, retire, or relocate are complex and personal. Those underlying societal trends may have indeed shifted during the pandemic. Workers of all generations are still looking for purpose, and healthcare is in a unique position to provide it.
"We're not going to be able to spend our way out of this," Patel says. "There are too many competitors out there. Every time you turn around the incentives are getting larger. Their labor rates are unwieldy and would affect our ability to be strong in the future."
"Our culture has got to be preeminent, our primary focus," Patel says. "We have to make sure that people want to come and work for us. We must find ways to create stability and flexibility amongst our organization. We want our workforce to feel like they're part of an organization that's growing, and to be part of a winning team. We want to make sure that we're doing the right things for the community. We want to make sure that our values are there for our patients."
Pictured: Ketul Patel, CEO, Virginia Mason Franciscan Health, and Division President, Pacific Northwest of CommonSpirit Health.
It's not as if culture hasn't always been critical for running a top-performing health system and fulfilling its mission. The wrinkle may be that health systems must take advantage of that culture in new ways, both for internal team building and to recruit new talent. It's time to get the word out.
"Storytelling and social media have really helped to celebrate what our folks do," Deveny says. "Every week, we will bring up another case where a team of people made a difference in a life. And when that person is part of that little story, and they see their face—or their friends and family see their face—that brings pride. The traditional, transactional relationship with an employee doesn't really go anywhere near that."
The axiom is still true that it's far more costly to recruit a new team member than it is to keep one you already have. Sayah says making team members feel valued and engaged requires more than one strategy. Sayah participates in weekly orientation calls for new team members. The CHA leadership team has committed to answering all employee emails by the end of the day. Once a week Sayah hosts an open CEO forum virtually, which is seen by 5%–7% of the workforce live, and another 5% download it later.
Sometimes the best new ideas aren't all that new. Good old-fashioned face time—or "leadership rounding" in management parlance—is even more critical these days, Sayah says.
"As a clinician myself, I try to be out there. I put my white coat on and walk around and talk to people. I know a lot of people by name. I've been here a long time. And I grew up from the staff. People do appreciate it. They feel respected and valued at a time when our people are facing all these problems: COVID, safety from assaults, an increase in behavioral health patients. It's getting worse and worse. So being out there is very important. The best recruiting and engagement tool is still word of mouth."
Ultimately, it's important for CEOs and leadership teams to understand the dynamic of why people may leave or stay. For an hourly-wage employee with a family, a $3-per-hour raise might be just what they need to afford a rent increase, or to buy baby formula.
"People have to pay the bills," Patel says. "I think we all have to be understanding of livelihoods and what's driving people."
Culture is part of the equation.
"Culture has real value to people. Sometimes lifestyle or a financial necessity may overcome the value that team members put on culture. You may lose team members who have to move,” Patel says.
"Our job is to create such a unique place to work that they don't want to."
The HealthLeaders Exchange is an executive community for sharing ideas, solutions, and insights. Follow the community on LinkedIn. To inquire about attending a HealthLeaders Exchange, email us at exchange@healthleadersmedia.com.
Editor's note: This article is based on a roundtable discussion report sponsored by Vizient Inc. The full report, Lasting Impact, is available as a free download.
Hospitals and health systems reinvented themselves in 2020. Changes in clinical operations that once took months of meetings were done in days or even hours. Digital health rocketed high, creating new customer expectations for access. New leaders who were once buried under layers of bureaucracy emerged as innovators. The question for health system leaders now is how to capture that temporary momentum and translate it into lasting impact that improves the industry for the better.
HealthLeaders Exchange Director Jim Molpus recently convened CEOs of three of the nation’s largest health systems to discuss what they feel were the lasting impacts of 2020, and how they plan to integrate those changes going forward: Lloyd Dean, Chief Executive Officer, CommonSpirit Health; Michael Dowling, President and Chief Executive Officer, Northwell Health, and Barry Ostrowsky, President and Chief Executive Officer, RWJBarnabas Health. Adding a national perspective was Byron Jobe, Chief Executive Officer of Vizient Inc.
Overall, the challenge for leaders remains in capturing organizational momentum quickly and intentionally.
“Nothing is automatically going to change unless we make a change,” says Dowling. “There will be a tendency for an awful lot of organizations to go back to the old ways, to kind of slip back a little bit.”
The cruelty of the pandemic also exposed societal inequities in healthcare that can’t be allowed to continue, says Dean.
“As painful as the past year has been, the inequities and the strains placed on our healthcare systems are now uncovered and more visible than ever,” Dean says. “And when we talk about inequities, it is now impossible for us to open the door without having an honest conversation about this systemic inequity that has been laid at our footsteps unaddressed.”
Digital health rose exponentially at the onset of the pandemic, as health systems scrambled to create any safe access points that they could. Now that the rocket has landed, however, health systems are optimistic but measured in what role digital health will play going forward.
“We found the growth for telehealth was spectacular in 2020. In some cases, the only way to see someone was to use telehealth,” Ostrowsky says. “But I think below the surface, there are clearly groups and constituencies that react differently and their embrace of this is uneven.”
In an industry that likes to talk about the need for change, 2020 only accelerated calls for transformation. Jobe is optimistic that momentum will stick.
“I do think this past year will act as a catalyst of change,” Jobe says. “There are a lot of opportunities to accelerate that transformation. My hope is that this past year not only drives some of that healthcare transformation from within, but also creates an elevated level of social awareness in the minds of all citizens that healthcare is extremely important.’’
Marcus Whitney hopes his thought leadership will start an overdue dialogue about the equity of opportunity in the healthcare sector.
Marcus Whitney, a leading Nashville healthcare entrepreneur, went to social media earlier this week to issue a "call up" to the city's $46 billion healthcare industry to end systemic racism and inequity in its leadership ranks.
Whitney is co-founder of Jumpstart Foundry, one of the city's largest early-stage innovation funds, as well as co-founder of Nashville Soccer Club, Nashville's MLS team. Whitney says he feels like his story is too much of an "anomaly" as one of the only black healthcare entrepreneurs in the city. In posts on LinkedIn and Medium, he writes:
"Nashville's healthcare industry generates more wealth than any other industry here, and Black people are not proportionally part of that wealth generation," Whitney writes.
Whitney praised the support of many white investors who he has worked with. In the last few weeks, however, he has had several conversations with other leaders asking questions.
"I am a black professional that a lot of influential white professionals who are friends of mine trust to ask for feedback and guidance in this moment," Whitney says in an interview with HealthLeaders. "I had a lot of those conversations and what I did for every one of them was tried to make sure that they understood that this moment was catalyzed by the murder of George Floyd, and preceding that Breonna Taylor, and preceding that Ahmaud Arbery. I wanted to make sure they heard it from me because I wasn't sure they had anybody else in their life who would say this to them. I want to make sure they understood that this conversation is about America's legacy of stealing 12+ million Africans and enslaving them for hundreds of years. And then the post-slavery oppression that happened all throughout the 20th century."
Whitney says he didn't have any specific actions in mind when he wrote the post, only hoping that it would start a long overdue dialogue about the equity of opportunity in the healthcare sector.
"I'm explicitly saying I'm calling you 'up' and not calling you 'out,' " Whitney says. "The last sentence is you have the power to change the world. I felt like in this instance that it was not enough to just inspire. I have to validate my own truth outwardly. I have to validate the truth of what's happened here."
Educators worry that the very leaders who will define post-COVID healthcare leadership won't have quality experience during the crisis.
In most years, June would be a busy month for thousands of future healthcare leaders as MHA graduate students would begin summer internships at hospitals and health systems. The COVID19 pandemic has forced almost half of those health systems to withdraw those internships for safety, financial or bandwidth issues.
With no clear end in sight, educators worry that the very leaders who will define post-COVID healthcare leadership won’t have quality experience during the crisis itself.
“It's a gigantic missed opportunity,” says Andrew Garman, Director, Rush Center for Health System Leadership at Rush University, and professor of health systems management. “We've got a whole generation of future leaders on the sidelines, and that's not where they should be at this point in their learning, career development and experience. We're losing a huge opportunity to transfer knowledge.”
Mark Herzog, retired CEO of Holy Family Memorial in Manitowoc, Wisc., and adjunct professor and Executive in Residence at the University of Michigan Health Management and Policy Program, agrees.
“Beyond the obvious importance of beginning careers,” says Herzog, “this crisis presents opportunities for knowledge and skill development that will absolutely be needed again down the road. Some of these early careerists could be the leaders who really make a difference in future outcomes because of the fresh perspectives to problem solving they represent. This is the big picture, and everyone benefits by extending internship and fellowship commitments.”
Nitasha Kassam, Program Manager for the National Council on Administrative Fellowships in Chicago, says a April survey of 42 member health systems found that 52% still plan to offer a summer internship program in 2020, with 33% of respondents not offering any program, and 14% unsure. That same survey of 27 graduate programs said that 67% had seen summer internships canceled.
The April survey also found that 88% of administrative fellowships—entry-level positions for 2020 MHA graduates--were going ahead as scheduled for 2020. Another survey in May found that number had dropped to 82%.
The operational and financial issues are legitimate and complex, Garman says. Many health systems have partitioned their executive and administrative teams away from clinical teams to protect both, so being able to keep the interns and fellows safe is a major factor. Housing for interns is also an issue, as they often find group housing. Finding the money to pay interns--nominal as it may be in a normal year—also becomes more difficult as many hospitals have seen pay cuts, furloughs an even layoffs as their operational revenues have dropped.
“Interns may get overlooked because they are not in the organizations yet and mat be pretty far down the list of concerns and considerations,” Garman says. “But this is a once-in-a-lifetime learning opportunity for these students. They are desperately wanting to take in everything they're learning and apply it to improving and helping the health systems. And these interns really can help the health systems. I worry that many of them will end up in the gig economy doing whatever they can for the summer versus building their skills and contributing to the health systems.”
One option might be virtual internships, but the NCAF April survey found that only 24% of fellowship and internship sites would consider a virtual option. The NCAF is asking health systems to reconsider virtual options or other contingencies that would preserve the experience for graduate students in 2020.
“Find an option that would work for your hospital, your health system, as well as the student,” Kassam says. “Develop some sort of virtual internship option or a hybrid that would allow students to still gain that experience. Or consider looking at a fall internship model so that the internship experience is not lost completely.” Interested health systems are encouraged to access the free guides to fellowships and virtual internships provided on NCAF’s website.
Garman says a few MHA programs have lined up alumni and philanthropic support to provide stipends so their student can still work in healthcare. Whatever the result this summer, Garman and Kassam are hopeful that 2021 fellowships return to normal. The May survey found that 78% of their member fellowship sites are proceeding as planned for 2021. The fear is that without support, these programs may lose ground in their goal of bringing more talented and diverse leaders into healthcare.
“A lot of these fellowships were set up explicitly with goals like diversifying senior leadership teams’ gender or ethnic composition,” Garman says. “Curtailing administrative fellowships could slow down progress in creating more diverse and equitable leadership broadly across the health systems, which would be really unfortunate.”
Former ACHE Chair and Malcolm Baldrige National Quality Award-winning CEO says it's time to pay healthcare workers for being the warriors they are in the COVID-19 pandemic.
HealthLeaders: What was the genesis behind pushing the idea of hazard pay for frontline healthcare workers?
Rulon Stacey: Two of my University of Colorado Denver colleagues and I started to talk about this. One has a psychology background and one has an HR background. We started to realize what we, as a society, had asked healthcare workers to do here. We needed them to step up and do what they did. They risked everything to get the country through a once-in-a-century situation, and now we watch as many of them may get furloughed. We worry about their risk of being disregarded. We think that they should be compensated for what they did. They stepped up and came through for society. And we think that society should not forget what happened.
HealthLeaders: Hospital financial margins also plummeted during the pandemic. Where would this hazard pay come from?
Stacey: I appreciate you asking that. We believe our argument is that this is a societal issue that these people kept the industry running at a time when the country needed it. Our argument in this op-ed is to elected leaders to not forget who got us through. These people are going to need support. Many of them will have to work through PTSD issues. Many of them will have endured weeks or months away from their families because they didn't want to risk infecting their loved ones. I personally know one worker who lived in an old storage shed for his family. We are here trying to address how to move forward as a society. We need to realize what we put these people through.
(Pictured: Rulon Stacey, Director of Graduate Programs in Health Administration, University of Colorado Denver, and Former ACHE Chair. Photo courtesy of University of Colorado Denver.)
HealthLeaders: Are you proposing retrospective payment of hazard pay to people who were affected the last few weeks? Or that going forward the health system compensation structure should recognize putting those workers at risk?
Stacey: We would argue that the recognition of a disaster from the country should include the fact that we essentially sent some people to war. I hate to draw those strong correlations. I've never been to war, but I think it's akin to a military veteran in the sense that we as a country needed them to step up and they did. And so, I feel like for the group that got us through, that it would be an injustice to just brush them to the side in a few weeks because we feel like we don’t need them anymore. I feel like that would be unrepresentative of who we are as a country.
HealthLeaders: How do you begin to think about compensating them for frontline pay? Is it a percentage of their income? Is it a one-time grant?
Stacey: Although we didn't get into particulars, I think that there must be a recognition of what they went through and the repercussions that will last for a period of time. There are three ways to look at this. The first is what they went through at the moment. The second is what that experience does to somebody's psyche for a period to follow. And the third is now that it's all over, we recognize their risk of being furloughed or laid off or just brushed to the side. And you can imagine if you are one of those doctors or nurses or anyone who came to work knowing that it could kill you. And now knowing that when they don't need you anymore, we're going to shove you to the side.
HealthLeaders: Do you have any sense of the political reception to this idea or are you just putting it out there?
Stacey: We don't, and we specifically didn't want to know the core reception. But we do think that there appears to be discussions on both sides of the aisle toward common solutions in this disaster. And what we would like to think—I believe I speak for my coauthors on this—that in protecting the people who stepped up, that we can reach across the aisles and find a solution to protect them. Because when the country needed them, they were there.
"Overcoming this threat means being changed by the experience."
—Gary S. Kaplan, MD, Chairman and CEO, Virginia Mason Health System, Seattle
The healthcare industry’s vocabulary has avoided the word “never.” The COVID-19 pandemic has tossed aside squishy, non-committal words like “iteration” and “evolution” and replaced them with “permanently” and “over.” Healthcare leaders are facing a very different healthcare world because of COVID-19.
HealthLeaders Exchange program director and editor Jim Molpus reached out to 17 trusted advisors to get their perspective on what will never be the same again in healthcare. The responses were passionate, diverse and hopeful:
Very little will be the same again in healthcare.
I expect very little will be the same as it used to be after this pandemic is behind us. This crisis is altering—perhaps permanently—how and where providers interact with their patients and with each other, how providers approach their work, and how health systems respond individually and collectively under intense pressures. Stay-at-home and physical-distancing directives have thrust a new telemedicine into the spotlight for giving patients more choices to be seen when and where they want to be seen.
A nice-to-have service before the pandemic, virtual office visit capability is now elevated to a must-have care delivery option. This will fuel a burst of competition as providers race with urgency to expand virtual care access. I am hopeful the lessons learned during COVID-19 will drive innovation that transforms care quality, safety, efficiency, preparedness, and patient satisfaction. I am often asked if my organization, and our nation, will weather this healthcare crisis. The answer is yes, and we will be stronger. But we also understand that overcoming this threat means being changed by the experience.
Gary S. Kaplan, MD
Chairman and CEO
Virginia Mason Health System
Seattle, WA
The Status Quo will never be the same again in healthcare.
Executives are likely to encourage employees working from home. Significant savings can be realized by eliminating expensive commercial space and allowing employees to work remotely. Remote workers are happier and more engaged without brutal commutes. As appropriate, employees can now watch over their young children, take care of older or sick family members, attend important events, and enjoy a higher quality of life. It will be hard to bring everyone back from home once they have demonstrated improved productivity, wellness, happiness, and its ultimate impact on the bottom line.
Sarah Richardson
VP Change Leadership, IT
Optum
Los Angeles, CA
Processes will never be the same again in healthcare.
Hospital operations will never rely so heavily on human processes again in the future. The days of relying on huge teams of humans to accomplish routine mission-critical process are over. Health systems will hire AI workers to take on critical "keep the lights on" processes and shift their human workforce to focus on quality of care delivery.
Sean Lane
CEO
Olive
Columbus, OH
Day-to-day hospital operations will never be the same again in healthcare.
From social distancing guidelines to how we greet one another, the way we manage the day-to-day operations of healthcare will never be the same. Small conference rooms will make people uncomfortable; handshakes will be frowned upon and face- to-face meetings will be replaced by Zoom and GOTOMEETING. Losing the human connection will be a concern that everyone will think about … but I am confident that new ways of communication and operations will evolve to ensure that the human contact is not lost.
Beverly Bokovitz, DNP, RN, NEA-BC
Vice President & Chief Nurse Executive
UC Health
Cincinnati, OH
Healthcare spending will never be the same again in healthcare.
The U.S. will emerge from this pandemic with WWII levels of debt. The trillions in debt will require healthcare spending to be on a different trajectory. There are a few levers of change that can be pulled:
More preventive care, but that does not appear to be solving the cost problem so far.
How we behave: what we eat, use of drugs/alcohol, etc.
Deliver less care: Other countries invest less in certain services than the U.S., such as knee/hip implants, spine fusions, cardiac caths, proton beams, etc.
Deliver healthcare like we deliver other services, with as much globalization and technology as possible, and the human touch has been ratioed to those paying a premium.
Neil Carpenter
Vice President of Strategic Planning
Array Advisors
Washington, D.C.
Our collective sense of health and security will never be the same again in healthcare.
For most of us, health, or the lack thereof, is personal. We suffer alone with heart disease, cancer, or possibly dementia. COVID-19 is different. It touches the national psyche. Whether young or old, white or black, each of us and our family is at risk. COVID-19 presents a unique opportunity to rethink what we want from our healthcare system. As Americans, we tend to focus on the new and novel, a cure for cancer or some other esoteric disease, while ignoring ancient foes like bacteria and viruses, mundane public health concerns. What are we willing to give up in order to get a safer future for all of us?
Alan Pitt, MD
Professor
Barrow Neurological Institute
Phoenix, AZ
Health systems' relationships will never be the same again in healthcare.
With their team members (Did we keep you safe? Were we transparent and selfless?); with their communities (Could you count on us? Were we prepared?); with their patients (Did we show compassion even under extreme duress? Did we let a loved one die alone?); with technology (Had we already invested in reliable platforms for telemedicine, robotic process automation, virtual care, and more? Were we playing catchup, with too little too late?). Every crisis creates challenges and opportunities with relationships. A chance to make bonds stronger and more permanent, or the loss of what once was and what might have been. The COVID-19 crisis is an extreme example of this reality.
Ronald Paulus, MD
Former CEO
Mission Health
Asheville, NC
The Status Quo will never be the same again in healthcare.
Society's acceptance of status-quo healthcare as acceptable is over. We now know that a suboptimal public health and healthcare system can bring our entire world to a complete stop, result in a needless number of deaths, and put our wonderful healthcare workers in unnecessary danger. Our collective demand for prioritized investment, higher standards, and embrace of innovation will become the norm. Leaders will be on notice.
Marcus Whitney
CEO & Co-Founder
Health Further
Nashville, TN
Hospitals will never be the same again in healthcare.
Emergency preparedness will be a differentiator. One in four will face insolvency unless a federal bailout keeps them afloat. Telehealth will be mainstreamed. Workforce safety will be a testy issue. Consolidation will accelerate. Insurer’s leverage, uncompensated care, and physician disaffection will heighten. And capital portfolios will be adjusted to rationalize investments more strategically.
Paul Keckley
The Keckley Report
Nashville, TN
The Hospital administrator-clinician relationship will never be the same again in healthcare.
As someone with friends on both sides of the aisle, I believe COVID-19 has strained the relationship to the point where clinical leadership will now demand greater accountability over hospital operations and emergency preparedness. There has always been a fascinating dynamic between business-minded hospital strategy versus day-to-day patient care. However, during times of extreme duress, the clinicians on the COVID-19 front lines have disproportionately borne the brunt of the pandemic. I think there will be some tough but necessary conversations about emergency supply storage, hazard pay, sick pay, or relocation benefits to avoid family contamination moving forward.
Andy Mychkovsky
Healthcare Strategy Consultant and Creator Healthcarepizza.com
Washington, D.C.
Speed to innovate MUST never be the same again in healthcare.
This crisis has revealed the unquestionable need that we commit to human experience at healthcare’s core for those we serve and those who serve as human beings caring for human beings. It too has shown us it does not and must not take us months or years to innovate to ensure the best in care. Innovations in process, protocols, and products should no longer be stuck in extended analysis and review. We can identify, analyze, and act to address opportunities quickly and must do so in a new healthcare world that will require a delicate blend of agility and compassion.
Jason Wolf
CEO
The Beryl Institute
Nashville, TN
Face-to-face physician visits will never be the same again in healthcare.
In the face of this pandemic, we condensed a planned 18-month rollout of our telemedicine program to just nine days. We went from zero telemedicine visits in October, to a handful of doctors being trained and us all being very excited when the first video visit was conducted in November, to where we are now: nearly 3,000 telemedicine visits a day, about half of which are video visits. These are conducted by more than 800 providers across primary care and specialty care lines. This is working well for all involved. So, I don’t think we will ever go back to the old way of seeing and treating patients.
Chris Van Gorder
CEO
Scripps Health
San Diego, CA
Business strategy will never be the same again in healthcare.
Healthcare organizations will think about business strategy in terms of anticipating disruption versus reacting to disruption. Leaders will be thinking through their strategies as a collection of unique scenarios to be more agile, bold, and forward-thinking. Two important elements will become the foundation of many healthcare strategies—people and partnerships. Organizations that put their people at the center of strategy will engender trust, loyalty, and gain a competitive advantage. Partnerships with traditional and nontraditional healthcare organizations will be the key amplifier for growth.
Public Health will never be the same again in healthcare.
Most healthcare leaders and practitioners have a belief system grounded in science and rationality and use these when committing to improving the system, at least within their vision of what is possible. It is too easy to forget that the political system which regulates public health and funds local health departments does not share or assume this thought process, and oftentimes unqualified individuals are elected to oversee and fund public health. We cannot afford any longer to assume government is doing its job to ensure adequate public health. Perhaps now the time is right for combined political pressure from the AHA, et al., to form public interest coalitions to lobby for change at all levels of government.
Mark Herzog, FACHE
Consultant and CEO, Retired
Holy Family Memorial
Manitowoc, WI
Supply chains for pharmaceuticals and essential medical equipment will never be the same again in healthcare.
The COVID-19 pandemic has shown us critical deficiencies in the supply chain of essential drugs, even as basic as medications for sedation. Even with certain drugs formulated within the U.S., the APIs (Active Pharmaceutical Ingredients) are sourced from foreign countries. Most of the generic drugs in the U.S. are also sourced from Asian countries. Cost alone cannot dictate the supply chain—the proximity and accessibility will be factors that will have to be dealt with. This scenario holds true not only for pharmaceuticals, but also for medical devices and medical gear for clinicians. The next pandemic which hits us globally could very well be more potent, both in terms of its mortality and infection rate, and plans to rectify the supply chain deficiencies have to be addressed immediately.
Jay Srini
Chief Strategist
SCS Ventures
Pittsburgh, PA
Being taken for granted will never be the same again in healthcare.
The assumption that while the world turns, few consider healthcare until they are in need. Into the future, our world will recognize the significant impact that healthcare can have on ALL areas of our lives. Into the future, we will become much more important and relevant.
Britt Berrett
Program Director
University of Texas at Dallas
Dallas, TX
Telehealth will never be the same again in healthcare.
Telehealth’s rapid scale up has been critical in the public health response to COVID-19. Now, telehealth has reached its tipping point, with consumers unlikely to revert to the previous reality once we are beyond the pandemic. Looking post-pandemic, telehealth will be critical to addressing access to care issues and helping mitigate the clinician shortage. For the former, providers must figure out sustainable pricing models that hold clinicians and patients accountable. For the latter, they will need to determine which clinicians should deliver what types of care services via telehealth and which ones should be elevated to higher levels of practice elsewhere on the continuum.
Steven Shill
Partner and National Leader
BDO Center for Healthcare Excellence & Innovation
Orange County, CA
Your crisis communications strategy has the basics, but this moment in healthcare demands being mindful of just how big the messages are right now.
COVID-19 has reinforced some classic crisis communications best practices about being transparent, while also adding new nuances giving the perception of healthcare workers performing heroic service on the front lines. The first step in developing a message is to understand the moment, says David Jarrard, President and CEO of Nashville-based Jarrard Phillips Cate & Hancock, and author of Healthcare Mergers, Acquisitions, and Partnerships: An Insider's Guide to Communications by HealthLeaders.
"Acknowledge the high emotions of this moment," Jarrard says. "When you communicate, speak to the emotional toll on your community, reflect the deep gratitude everyone feels for the nurses and physicians on the front line."
"Your people are hungry for stability," Jarrard says. "The pandemic has fundamentally unsettled most every healthcare organization; it will not be the same on the other side of it."
The communications dilemma is that COVID-19 disrupts the normal flow, with seemingly a new plan or change coming every day. Even in that chaotic scenario, it's still possible to project stability, he says, even as organizations make difficult decisions in response to the very real economic impact of the pandemic on their revenue.
"If you can't give your colleagues a firm vision for the future today, give them a clear approach for how you will build that new picture of tomorrow. Structure and a path will be welcomed, even if many of your decisions today may be challenging."
Operationally, it's important for all communications across the system to have consistent timing and messaging from all leaders.
David Jarrard, President and CEO of Jarrard Phillips Cate & Hancock. (Photo courtesy of Jarrard Phillips Cate & Hancock.)
2. Pick the right messenger
Hospital teams must appreciate that the COVID-19 crisis calls for different messengers within the team. The public, for example, may be far more likely to trust an MD in a white coat or scrubs to deliver the message about patient care or the spread of the virus than an executive.
"The messenger is part of the message," Jarrard says. "In fact, your choice of messenger can be more important than the message itself."
CEOs should continue with messages on mission and the community, while HR leaders might continue to reinforce team engagement. Even board members play a key role in communicating with local business and government leadership.
3. Prepare for the rebound
The natural human reaction after the active pandemic fades will be to relax and recover. The challenge for healthcare leaders will be to pivot, at that moment, to the projected rush to process a backlog of elective volume.
"Recognize in your communications that, even if the immediate threat of the COVID-19 surge passes, the hard work for you and your team is not over," Jarrard says. "There will be a surge of patients who have postponed procedures returning to your health system. How they are scheduled, served, billed, treated—their experience—matters a great deal to your stabilization and recovery."
Perception and experience will still be critical, he says. "This first wave of patients will be powerful communicators to your community."
The leadership team at San Diego-based Scripps Health has experience at disaster preparedness and emergencies but even that preparation could not quite prepare any team for a public health emergency the scale of COVID-19.
It was the first week of February when 167 American citizens being evacuated from Wuhan, China, touched down in San Diego, on their way to being quarantined at Marine Corps Air Station Miramar. Now some two months later, projections from the University of Washington show that the state of California could see its peak number of cases in the next week.
The leadership team at San Diego–based Scripps Health has experience at disaster preparedness and emergencies, dispatching medical relief teams to Haiti and Nepal after earthquakes, to Houston after Hurricane Katrina, and to the California wildfires of 2018. Not even that preparation could quite prepare any team for a public health emergency the scale of COVID-19, however.
HealthLeaders editor and leadership programs director Jim Molpus caught up with Scripps Health CEO Chris Van Gorder and Chief Medical Officer Ghazala Sharieff, MD, a few days ago on what they are expecting.
HealthLeaders: What have been the higher priorities as the team readies for the expected surge in COVID-19 patients?
Van Gorder: We are moving into a higher preparation phase. We are starting to work on our surge capacity. Our staff members were getting very nervous about contamination, so we put up our surge tents out in front of our hospitals and clinics. We quickly designed a methodology in which patients who were worried about potentially being infected could call, and our staff—in proper PPE—could approach them in their car and take test swabs.
HealthLeaders: When did you start to look at the supplies you would need for this sort of outbreak?
Van Gorder: Two months ago, we started trying to buy supplies and realized very quickly we were going to run out. Our major vendors, like Medline, and our GPO HealthTrust were already telling us that supplies were in short supply. Our supply chain people have done a phenomenal job of trying to source all sorts of things. And of course, through social media and on the internet now, and I must get half a dozen emails a day in which somebody knows somebody who can get a mask from China, et cetera. And our supply chain people run down every single one of those leads. Most of the time you find out that the masks that they're talking about are not accessible in the United States, or they're counterfeit, or they can't actually deliver the masks in short order.
HealthLeaders: How has the difficulty in testing affected the response for your team?
Van Gorder: Even going back to those first flights of quarantined patients from China who landed here, even then we wanted to test, but they didn't fit the very narrow criteria, so we couldn't get them tested. But right after the FDA allowed for emergency licensure of laboratories—literally within 48 hours—our laboratory was licensed, but our capacity was very limited. We could do up to between 40 and 80 patients a day, which is nowhere near what we needed.
Hologic is a lab manufacturer of equipment. They're here in San Diego, and have a machine called the Panther Fusion. That was to be the key machine if we could get ahold of it. At that time, [New York] Gov. Cuomo was calling Hologic and saying he wanted all [that] the company had in New York. And so, it took a little bit of local pressure, but we got the machine.
But then, after we got the machine that could do up to a thousand tests a day, we couldn't get the reagents for it. The reagents for that machine just came in two weeks ago, but we're limited to a total of 2,400 tests. Now our godsend may be the Abbott point-of-care testing equipment. It’s a complete kit with its own swabs. We can do a turnaround in five minutes on the positive test and about 13 minutes on a negative test. We'll be able to do a couple of hundred tests a day now, if the reagents and supplies last.
(Chris Van Gorder, CEO at Scripps Health. Photo courtesy of Scripps Health)
HealthLeaders: Have you begun to measure the financial impact?
Van Gorder: We stopped all our elective procedures and our visits and all those things. We're losing money as a healthcare system now for sure. Once you canceled that much work, our costs now are clearly exceeding our revenues. But we've got a strong balance sheet and can weather the storm. Hopefully, the government will continue to help hospitals catch up and get reimbursed.
HealthLeaders: Projections seem to change every day for what type of surge to expect. How do you plan for that?
Sharieff: We must be very creative at Scripps. We are thinking of how we can use our ambulatory surgical centers. Or can we use anesthesia machines in a surge to hold us over instead of ventilators. We are tracking throughout the day how many patients we have in ICU, and how many in medical-surg units.
Van Gorder: It’s a difficult question. How do you plan when you don't know what the numbers are going to be? We've looked at the national and state projection. We took the Johns Hopkins modeling, and our own data scientists had done our own modeling. It's frightening. We have roughly 1,200 beds, and our projections if we were successful in our community with a social distancing at 30%, then by June, Scripps would need 8,000 beds to be able to keep the capacity needs that this community is going to require.
That's why I've been so aggressive in working with the community, and we need to continue the urgency for social distancing and sheltering in place.
HealthLeaders: How do you keep communication up when things change so fast?
Sharieff: We do a daily update to all our staff, and they look forward to that daily update so we can share with them how much activity we have seen. And sometimes, even just within a single day the guidelines for treatment may change, so we're trying to keep all our staff informed on that as well.
HealthLeaders: Chris, on a personal level, you have some particular skills that may help, as a former police officer, reserve assistant sheriff for San Diego County, and a licensed EMT. Scripps also led medical relief efforts in Haiti and New Orleans after hurricanes. Do you think some of those lessons learned will help in a public health emergency of this scale?
Van Gorder: In a way, I feel like I’ve been training for this my entire life, but at the same time, how can anyone prepare for such an unprecedented situation? In Haiti, we expected not to have the tools we would normally have to do the job. As a result, we did what we could for those we could help. Katrina was much the same, and we were okay with that. As a law enforcement officer, you never know what you will run into, but you know you must trust your training. You know you’re expected to run in when everyone else is running out.
This emergency will require a different attitude from those in healthcare. Here at home we expect to have everything we need, and if we don’t have it, we know we can ask for it and get it right away. But as we see some areas surge beyond their capacity and critical supplies become harder to come by, we have got to learn to be more flexible and innovative, and maybe even break the rules to help our patients, community, and even each other.
HSS suspended all nonessential surgeries, expanded capacity, and is treating patients from other hospitals in need of emergency orthopedic surgery, medical-surgery and critical care, regardless of COVID status.
Hospital for Special Surgery, based on Manhattan’s East Side, is the largest and most highly rated orthopedic hospital in the United States, annually performing more than 32,000 surgical procedures. This week, HSS became a general acute care hospital as New York City faces the COVID emergency.
HSS has suspended all nonessential surgeries, freeing up most of its 215 licensed beds to act as overflow for non-COVID patients from other Manhattan hospitals, says HSS President and CEO Louis Shapiro.
HSS has also expanded virtual care and created four ortho urgent care facilities to take the volume of patients still needing required orthopedic care. For hospitals across the country, the question that HSS faced may come to them: no matter what your usual mission, what can you do to help?
Shapiro spoke with HealthLeaders editor Jim Molpus about the opportunity to lead right now.
HealthLeaders:Tell us how you started to flip the switch so HSS could provide essential care during the outbreak.
Shapiro: HSS continues to provide essential on-site care and has added a rapidly broadening virtual care offering as well as urgent ortho care options at four locations throughout the tristate area. By proactively suspending all nonessential surgeries on March 17, we made bed capacity, supplies, and staff available to help neighboring hospitals treat their COVID-negative patients who require essential orthopedic surgery, medical-surgery, and critical care.
As the strain on the New York City healthcare system continues to grow, we recognize the need to do more and are further executing on our surge plan to use all available capacity across our system. We are working closely with neighboring NewYork-Presbyterian to fill an expanded HSS capacity of well over 200 beds by also receiving COVID-positive patients starting today [Wednesday, April 1]. We are now treating patients with emergency orthopedic needs, regardless of COVID status. We will also treat COVID-positive patients who require ventilators or intensive care. We will continue to care for COVID-negative patients on several floors of the hospital as well, including medical-surgical patients and patients who have had other types of surgeries.
HL:Have you calculated the financial impact of that?
Shapiro: March 17 was when we published our own guidelines on what the definition of essential musculoskeletal care was. When we implemented that, we quickly ramped down from 100% to less than 20%. You do the math yourself. We are a $1.8 billion organization. The cost to the enterprise is enormous, but in this environment, united we stand. We are all in, every way you could be in.
HL:We’ve all read the stories of the incredible sacrifice and stress that healthcare professionals in New York are under. How is your team holding up?
Shapiro: They're all heroes, number one. They are all heroes. If you go outside in New York at 7:00 PM, you hear a chorus. That's everyone coming outside going to their balconies applauding healthcare workers. I can only speak for our situation, but the people here are extraordinary. We had more than 900 people volunteer to go to NewYork-Presbyterian to help them. We’ve deployed about 50 of them. The culture is what drives our reputation and our results. You just never, ever cease to be surprised by the commitment and passion for people we have.
HL:How's the supply chain breakdown affecting HSS?
Shapiro: Don’t forget we are in a short tunnel. The peak in New York is in 11 days or more. It's a problem. We have a lot of academic relationships with China, so we have been purchasing supplies through the global supply chain. And there are good people who have been donating PPE. But PPE is still a challenge for the industry, for sure. Ventilators is the major problem, which is, I think, catastrophic for a variety of reasons.
HL:Can you share any crisis management direction you have given your team?
Shapiro: Our leadership team has two goals: Earn your leadership position and make HSS more accessible. For the organization, we have five principles that have been guiding us for the past three weeks: Protect our staff, protect our patients, protect our organization, protect society, and communicate frequently and transparently. As soon as I know something, you'll know something. And literally every decision can be put against those principles.
Recent versions of legislation recognize the existential financial threat many healthcare organizations are under as they fight the COVID-19 outbreak.
The $2 trillion Coronavirus Aid, Relief, and Economic Security (CARES) Act has more than $100 billion in aid for healthcare organizations, but in some cases, leaders had better act fast to get it.
While previous versions of the legislation contained less assistance for providers large or small, recent versions recognized the existential financial threat many healthcare organizations are under as they fight the COVID-19 outbreak.
"The intent of the CARES Act is to deliver relief to providers who face the double whammy of the loss of elective procedure revenue and the costs of preparation for the pandemic," says Martie Ross, managing principal, Kansas City Office of Knoxville, Tennessee–based PYA, P.C.
The bill contains provisions that range from payroll-based loans under a Small Business Administration (SBA) Act provision, as well as Medicare payment acceleration for providers already losing elective volume revenue. In certain cases, the funding remains unallocated, so finance teams may need to act fast to get first in line.
According to Ross and David McMillan, CFO and managing principal of PYA’s consulting practice, there are three provisions of the CARES Act that healthcare providers should analyze immediately for their direct financial impact:
1. "Paycheck Protection Program" Loan and Forgiveness Provisions
The SBA has underwritten loans for years to provide relief for companies to meet working capital obligations after a natural disaster. The "Paycheck Protection Program" is an expansion of the SBA Act that may provide up to $10 million in loans at 4% interest for business (including 501(c)(3)s) with fewer than 500 employees. The largest benefit, however, may be the provision that allows borrowers to apply to have all or a portion of the loan forgiven.
"It’s a way to protect and help businesses continue to employ their workforce," McMillan says.
The loan amount is based on a formula that takes the average monthly payroll expenditure for the previous 12 months and multiplies that by a factor of 2.5. Businesses receive loan amounts equal to the lesser of that amount or the $10 million limit, McMillan says.
The unforgiven portions of the loan are repayable over 10 years. While repayment deferrals ranging from six to 12 months are also available, the unique aspect of the program is its forgiveness provision. For businesses that maintain their workforce for an eight-week period after the funds are received, a portion or all the loan may be forgiven. And whatever portion is forgiven is tax free, McMillan says.
2. Public Health and Social Services Emergency Fund
The CARES Act adds $100 billion to the Public Health and Social Services Emergency Fund to reimburse providers for expenses and lost revenue attributable to COVID-19. Presently, this fund is administered by the Assistant Secretary for Preparedness and Response (ASPR) under the U.S. Department of Health and Human Services (HHS). In a single act, this agency goes from administering an annual budget of $2.6 billion to a $100 billion program.
Guidance is still pending, much of it may be on whether parts of the fund are allocated for rural hospitals, or cancer hospitals, or other specific providers, or whether the program is "first-come, first-served," Ross says.
"At this point, my advice would be first to file, until they say something differently," Ross says. "The language in the statute is that there's just no categorization. It's just a hundred billion dollars." The provisions cover not only lost revenue, but also certain capital expenditures that may result from COVID preparedness, Ross says.
As it stands, the program is not rolled out under the usual regulatory review and time frame, but guidance is soon expected from HHS on how the program is to be administered, Ross says. But don’t wait. Get your numbers ready, Ross says.
"The sooner your team can come up with a reliable calculation of the loss you are experiencing because of declining electives or lower ER volume, the better. Also be prepared to quantify any additional expenses incurred due to the pandemic. You will want to have these numbers ready to plug into whatever formula they provide," Ross says.
3. Medicare
There are three key provisions of the act that relate to Medicare, Ross and McMillan say:
"The first two are really game changers," Ross says. "Advance payments will allow providers that are losing revenue to apply to CMS to accelerate Medicare payments, essentially as an advance payment on future Medicare billing," Ross says. A more direct boost will be a temporary elimination of the 2% sequestration cut that will go into effect in May and continue for the rest of the year.
Both Ross and McMillan will be featured in a webinar, "The CARES Act: Your Piece of the $2 Trillion Pie" Monday, March 30 at 1 p.m. (ET). For more information, go to https://www.pyapc.com/insights/cares-act-webinar/
