Managing new practice risks in the COVID-19 world

Medical practices across the country are reopening. But are they doing it safely? Although physicians are eager to return to normal, it’s vital that they have robust protocols and procedures ready to ensure patients and staff are safe. Medical Economics® sat down with Kerin Torpey Bashaw, vice president of patient safety and risk management with The Doctors Company, to discuss how physicians can prepare to reopen and manage their risk in this new normal of health care after COVID-19.

The following interview was edited for length and clarity.

Medical Economics® What criteria should physicians be using to make reopening decisions?

Bashaw: I think it’s really important for them to have a framework to use. So when we think about opening a practice, I would recommend four things.

The first thing is for them to look at their operations pre-COVID-19, because that’s what the staff is used to. That’s what the patients are used to. They also need to take a look at what’s happening from a federal perspective and from a state perspective. Local, it’s all about local public health, but the physicians should be getting their direction from the local public health authority; that’s where they’re going to get the most information that’s relevant to their practice. Then it’s really important for them to be checking, every single day, those websites with that information — so, having a framework, getting the information together and then making sure that the staff are up-to-date and know what’s going on. The staff and the patients, especially, are very, very frightened. Physicians are telling us that the patients are not coming in; hundreds of patients are not coming to their appointments. So, they’re fearful. Getting communication out, making sure that the patients know that you’re following the CDC (Centers for Disease Control and Prevention) guidelines, is going to be really, really important. And the criteria for opening really come from that local public health authority.

ME: Let’s talk about staff training. What kinds of training should be conducted or refreshed?

Bashaw: In general, you want to train staff regarding infection control principles. And the nice thing is, you can go right to the CDC website and pull it down at the staff training page. You cannot educate staff enough, because the rules have all changed. So before you even reopen your office, provide standard training regarding infection control and use of PPE (personal protective equipment) donning and doffing. If you are on the primary care medicine side, you’re probably used to wearing gloves, but you’re not used to wearing a mask. If you have a procedure or you’re doing wound care or something that has to be done in the office, you’re going to want to gown up, and you need to put that on correctly. For example, most practices are not used to using an N95 mask.

Communication cannot be stressed enough. Your staff members are afraid. They have been through a lot.

I highly recommend a leadership evidence-based practice: the daily huddle. So, at the beginning of your day, every day, you’re going to check the CDC website, you’re going to talk about the plan for the day, you’re going to look at the patient list and see who’s there and what their issue is. And you can explain what your process is; make sure that everyone on the team knows what the plans for the day are for the patients. And then do check-ins during the day. The staff will do many things that they have never done. Tackling COVID-19 is about standardization. It’s about standardizing your practices, so you can improve them and then tweak them every single day.

So, a huddle at the beginning of the day is going to be key, but you also need a debriefing at the end of the day. What went well? What didn’t go well?

I have a story, if you want me to share it. We had a practice call. The practice had done extensive work: They had their protocols in place; everybody was trained; they had their PPE. They did all their work offline with regard to educating the patients. The patients didn’t come into the waiting room. They didn’t allow family or staff to come in the patient rooms. In this instance, the provider went to give a deep injection and pulled the mask down to have a conversation with the patient and then left it down partway while giving the injection. And the family of this elderly person went ballistic, because that is not the standard of care. There are so many things that are changing, and one little slip is a break in the standard of care, which can be very, very problematic. Despite the extensive work that happened with this practice, one little slip—it can cause immense problems.

So, standardization, education briefings, debrief at the end of the day so you learn from your mistakes and figure out what you can do differently tomorrow. That’s going to be really important for keeping up staff morale and making sure that they’re energized and feel cared for and that they have a voice about what’s happening in the practice.

ME What have you found to be some of the best practices in terms of communicating a standardized message?

Bashaw: People want to know that you’re doing the right thing. We have had a couple of stories about patients walking in videotaping or wanting to videotape the whole visit because they want to make sure that people are doing what they are supposed to be doing. It’s a good idea to call your risk manager so you can have a conversation and understand what the patients want.

We had a practice call in because they had a problem. They said they have had hundreds of patients cancel and not show up for appointments that were either scheduled or that are for follow-up, and there can be some liability in that. So the practice standard was “Hey, you know what? We’re going to call a patient who misses an appointment, and in three months we’re going to send a letter and document that we asked the patient to come in.” You can do that via your website or the patient portal, however you want to do it. But I can’t overemphasize the need to document all your attempts to communicate with your patients. And if you do communicate, you need to put that information in the chart, so it shows your due diligence by reaching out and communicating and making sure that the patients understand the implications.

ME: Is there anything else that you think is important for physicians to consider as they reopen their practice?

Bashaw: Physicians go into medicine because they want to practice good medicine. No physician goes in with the intent to harm. And so I think I would be remiss if I didn’t use this opportunity for those that aren’t physicians. You know, right now, our physicians and nurses are heroes, and they are putting their lives on the line to help their patients because they care about their patients. I can’t say it enough: I think we need to support providers and offer them protections. These are crisis times, and practices are doing the best they can. Malpractice is about not meeting the standard of care, and the standard of care is changing daily. But when you’re trying to do the best that you can in a complex and ever-changing environment, I think we owe it to our providers to take a stand and provide them with some protection. I don’t need to tell the physicians out there that going through a medical malpractice case is incredibly stressful.