Managing Healthcare Practice Operations During COVID-19

Many regulatory restrictions have been temporarily suspended during the COVID-19 crisis; some with expiration dates and others with extensions. It is important to carefully review the current status of legislation in your jurisdiction as it pertains to the practice of medicine under ongoing COVID-19 conditions.

• Review the status of COVID-19-related legislation in your jurisdiction daily. Reference the CDC and federal, state, and local authorities for public health guidance and new legislation.

  Guidelines for Opening Up America Again (Whitehouse.gov)

  Executive Orders by State (ACS)

• Determine if your state board requires notification to patients of “Minimum Standards of Safe Practice” or some similar type of communication regarding precautions for COVID-19.

  COVID-19 Resources (Federation of State Medical Boards)

• Notify your agent or medical malpractice insurer of your plans to reopen your practice and of any changes in level of service. If you have requested adjustments in your professional liability coverage during the crisis, confirm that coverage has been reinstated at the desired level of coverage.

  Contact The Doctors Company Member Services by email or call (800) 421-2368.

• Notify licensing boards, third-party payors, and vendors of your office reopening.
• Keep COVID-19-related policies and procedures current to follow established guidelines. Document adherence in administrative files and in patient medical records, when appropriate.
• Modify messaging across communication platforms with COVID-19 in mind:
  • Voicemail
  • Telephone
  • Website
  • Social media
  • Marketing materials
• Provide a website statement and/or letter of reassurance to patients of steps you are taking in your practice to protect their safety.
• Ensure messaging references any practice limitations and changes in operational policies and procedures, including access to care via telephone assessment/telehealth/in-person visit.
• Develop and communicate pre-visit instructions for patients prior to visiting the practice on site. For example, have the patient call from the car when arriving to the practice, place restrictions on visitors, have patients maintain physical distance in the waiting room with appropriate PPE, etc.
• Provide COVID-19 educational resources to patients (e.g., a reminder to maintain physical distance, the use of masks, frequent handwashing, and to stay at home as needed to lessen community spread).

  Coronavirus (COVID-19) Resource Center (CDC)

  Coronavirus Disease 2019 (COVID-19) Frequently Asked Questions (CDC)

  Coronavirus Disease: Advice for the Public (WHO)

• Conduct an inventory and quality control check of all office and clinical supplies necessary to conduct business. This includes services for all patient types. Create a list of available vendors.
• Communicate with vendors/supply chains for patient care and infection control purposes to safeguard access to available resources, including PPE. Determine timetable for ordering supplies to avoid depletion of inventories.
• Check all medications for expiration dates. Provide quality control checks for emergency cart and vaccine storage.
• Check and document all office and patient care equipment for operability.
• Develop an updated list of community resources for patients who have undergone socioeconomic and health challenges, e.g., food assistance, medication assistance, financial assistance programs, childcare, insurance options, behavioral health, etc.
• Post front-door signage (in common languages) requiring patients and visitors who meet COVID-19 screening criteria (e.g., presenting symptoms, recent contacts, and/or travel history) to immediately notify facility personnel via telephone for instructions on accessing care.

  Communication Resources (CDC)

• Post patient instructions (in common languages) regarding use of masks, hand sanitizer, physical distancing, etc.

  List of COVID-19 Print Resources (CDC)

• Consult with your practice or human resource attorney, as needed, on issues related to the return of furloughed employees or staff making the transition from working at home back to the office setting.
• Assess IT privacy and security as your practice transitions back into the office setting. Confirm that all practice devices containing protected health information have been returned to the office and are secured. Consider having your IT professional wipe clean or permanently remove any PHI on any personal devices used on an emergency basis once they are no longer in use.

  Five Steps to Wipe a Computer Hard Drive (Norton.com) We strongly recommend that you have your IT consultant evaluate and assist with this process.

  What Does It Mean to Wipe a Drive? (Tripwire)

• Follow OCR guidance on HIPAA as you transition back toward normal operations.

  HIPAA and COVID-19 (HHS)

• Have the leadership team/ethics committee address any ethical considerations in providing care to COVID-19 patients.

  OCR March 28, 2020: BULLETIN: Civil Rights, HIPAA, and the Coronavirus Disease 2019 

• Review telehealth procedures and identify areas for improvement. Give patients the opportunity to “opt-in” to future telehealth visits.
• Develop instruction guides to help patients navigate telehealth technology.
• Review telehealth medical record documentation for completeness. Consider developing a template specifically for use with telehealth encounters. Review telehealth documentation requirements.

  Nine Tips for Clinical Telehealth Documentation (The Doctors Company)

  Federation of State Medical Boards Telehealth Licensure Requirements

  COVID-19 Telehealth Toolkit (National Consortium of Telehealth Resource Centers)

• Revise budget, project revenues, evaluate debt, and review accounts receivable and accounts payable. Meet with your financial consultant as needed.
• Contact your patient safety risk manager for guidance on complex practice issues related to COVID-19. Report any claims or incidents (including medical board or regulatory issues) to your medical malpractice insurer.

  Reporting a Claim or Incident to The Doctors Company

• Consider these suggestions for providers or staff who refuse to wear a mask:
• Masking is a basic infection control practice and part of the standard of care during the declared public health emergency (PHE). Current CDC guidelines for healthcare providers and patients still require universal use of a well-fitting facemask for source control. In areas with moderate-to-high local levels of infection, respirator masks should be used for direct care of symptomatic patients.
• The PHE declaration is still in effect. In a January 22, 2021, letter to state governors, the Secretary of Health and Human Services (HHS) stated, “We have determined that the PHE will likely remain in place for the entirety of 2021, and when a decision is made to terminate the declaration or let it expire, HHS will provide states with 60 days’ notice prior to termination.”
• Although refusing to wear a mask in a healthcare setting during a declared PHE appears reckless, this behavior may also be a symptom of anxiety, depression, and/or burnout. Interview the individual(s) to determine the root cause of mask refusal, and address it as appropriate with education, emotional support, or a corrective action plan. Potential burnout interventions might include referral to an employee assistance program/behavioral health provider or a temporary reassignment (for example to telehealth services). For more information, see The Doctors Company article, “Burnout During COVID-19: How Healthcare Professionals Can Manage Stress.” Managing reckless behavior requires establishing clear expectations and the consequences for failing to meet them—including any disciplinary actions required. For more information, see the following AHRQ PSNet resources: Disruptive and Unprofessional Behavior and Culture of Safety.

• Notify licensing boards of activations/deactivations and changes in supervising physician for advanced practice providers if required by your state’s licensing board.
• Review status of professional licenses; monitor updates in credentialing requirements and status of credentialing for practitioners. Some restrictions were temporarily lifted in some jurisdictions during earlier phases of the COVID-19 crisis.
• Review and, as needed, obtain training for new billing, coding, and documentation requirements as they relate both to COVID-19 and telehealth.

  Special Coding Advice During COVID-19 Public Health Emergency (AMA)

• Prior to reopening your practice to patients, provide and document refresher training to staff on:
  • Patient screening and triage.
  • Infection control.
  • Use of PPE.
  • Patient communications.
  • Cybersecurity issues (risk of phishing, etc.).
  • Any revisions in policies and procedures that were made to adapt to the evolution of the crisis.

  Telephone Triage and Medical Advice (The Doctors Company)

  Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic (CDC)

  Guidelines on PPE (OSHA)

  Strategies to Optimize the Supply of PPE and Equipment (CDC)

  Training Videos (CDC)

  Defending Against COVID-19 Cyber Scams (Department of Homeland Security)

• Train staff to utilize tools and strategies to achieve situational awareness within your office operations and in the provision of patient care.

  TeamSTEPPS for Office-Based Care-Situation Monitoring (AHRQ)

• Following CDC guidelines, screen healthcare personnel daily for COVID-19. Maintain logs and file in administrative records. Assess and monitor any unprotected occupational exposure by staff members, supported by thorough documentation.
  

  Interim U.S. Guidance for Risk Assessment and Health Management of Healthcare Personnel with Potential Exposure in a Healthcare Setting to Patients with Coronavirus Disease 2019 (COVID-19) (CDC)

• When a provider or direct patient care staff member tests positive for coronavirus and/or is diagnosed with COVID-19, conduct and document a risk assessment identifying contacts, type of interactions, and PPE in use. Contact the local public health department for additional guidance on patient notification, including:
  • Who is responsible for identifying contacts and notifying potentially exposed individuals?
  • How will such notifications occur?
  • What actions and follow up are recommended for those who were exposed?
• Disclosure to patients may be necessary depending on the type of exposure that occurred, if any, but always take necessary steps to protect the privacy of the infected employee. Telephone calls directly to the patient are the most efficient method of notification, followed by mail. Suggested notification may include “We are calling to inform you that someone in our office tested positive for COVID-19 on the day of your visit…” followed by recommendations for assessment and any needed follow up. Contact your patient safety risk manager at The Doctors Company, as needed, for additional guidance.

  Health Departments: Interim Guidance on Developing a COVID-19 Case Investigation and Contact Tracing Plan

  Clinical Questions about COVID-19 (See Infection Control section)

  COVID-19: Frequently Asked Questions (AMA)

• Follow CDC return-to-work guidelines for staff with suspected or confirmed COVID-19 diagnosis. Document compliance with guidelines in administrative files.

  Return to Work for Healthcare Personnel with Confirmed or Suspected COVID-19 (CDC)

• Assess and adjust staffing to limit the number of employees in the office based on anticipated patient volume. Create a back-up plan in anticipation of potential staff quarantine/illness. Identify those employees who can continue to work from home or who fall into an “at-risk” category.
• Acknowledge the need to provide emotional support to staff who may be dealing with fear or other stressors through an employee assistance program or other support mechanisms. Communicate resources to employees.

  Burnout During COVID-19 (The Doctors Company)

  Coping with Stress (CDC)

The spread of COVID-19 and its impact on communities has naturally raised questions about transmission and environmental safety within healthcare facilities. It is crucial that practices reassure and communicate to patients that all necessary CDC guidelines and precautions will be carefully followed for infection prevention and control. That message of reassurance should be offered when scheduling patient appointments, on the practice website, and perhaps in a letter or portal message to returning patients. Similar to your HIPAA Notice of Privacy Practices that tells patients what you do to protect their health information, you can describe your infection control practices in writing to educate and reassure. It is vital your office staff follow all necessary precautions precisely. Your patients will be keenly focused on all environment-of-care interactions, and any failures could result in anxiety, distrust, and anger. Make sure your staff understands the apprehension some patients may experience as they re-engage with your practice.

• Continue to follow the CDC’s Standard Precautions and Transmission-Based Precautions for all healthcare staff interacting with patients/patient care areas.

  Standard Precautions for All Patient Care (CDC)

  Transmission-Based Precautions (CDC)

• Post signs to instruct patients and staff to follow infection control protocol.

  List of COVID-19 Print Resources (CDC)

  Educational Resources for the Public (WHO)

  Contact Precautions (CDC)

  Droplet Precautions (CDC)

  Airborne Precautions (CDC)

• Follow CDC handwashing protocol for healthcare providers. Best practice is to perform hand hygiene upon entering and exiting the exam room.

  Clean Hands Count for Healthcare Providers (CDC)

• Designate at least one staff member to serve in an infection prevention role.
• Stay current with CDC, public health, and medical specialty and society recommendations.

  Information for Healthcare Professionals About COVID-19 (CDC)

  National Voluntary Accreditation for Public Health Departments (State Health Departments)

  Infection Control Guidance for Healthcare Professionals about Coronavirus (COVID-19) (CDC)

• Screen all staff for COVID-19 daily before starting work. This should be the responsibility of administrative staff. Maintain screening documentation in administrative files. Sick staff members should stay home and follow CDC return-to-work guidelines.

  Universal Source Control Guidelines (CDC)

  Return to Work Guidelines (CDC)

• Coordinate with your local public health department on reporting, contact tracing, coronavirus testing protocols, locations, and testing kits.

  Directory of Local Health Departments (National Association of County Health Officials)

Determine PPE needs as follows:

• Ensure you have adequate supplies of routine patient care PPE, including surgical masks for all staff (and patients who do not bring their own) and gloves.
• Assess the need for high-risk procedure PPE (gowns, gloves, N95 masks, face shields, and goggles).

  PPE Burn Rate Calculator (CDC)

  FAQ on Use of Respirators (CDC)

Prepare and monitor your waiting area:

• Space chairs at least six feet apart.
• Provide respiratory hygiene supplies (surgical masks, alcohol-based hand rub, tissues, touch-free trash cans) in proximity to the entrance(s).
• Remove magazines, pamphlets, toys, and other potential vectors for infection.
• Ensure patients are maintaining physical distance and utilizing hygiene supplies and masks.

  Preparing Workplaces for COVID-19 (OSHA)

• Create a standardized cleaning checklist and schedule (with documentation) for hard surfaces in all public areas and restrooms. Per the CDC, include tables, hard-backed chairs, doorknobs, light switches, phones, tablets, touch screens, remote controls, keyboards, handles, desks, toilets, sinks, floors, etc. Ensure these areas are monitored, restocked, and disinfected frequently throughout the day.

  List of Disinfectants Effective Against COVID-19 (EPA)

Prepare and maintain patient registration and check-out areas:

• Install a barrier (window or sneeze shield) between these areas and patients.
• Thoroughly wipe with disinfectant anything handed to a patient (e.g., clipboard and pen) after single use. Consider the use of disposable pens. Remember, to be effective, the disinfectant must be fully dry before the next use of any commonly shared item. (Implement a rotation system that permits the disinfectant to “dwell” before adding the item back into the rotation).
• Using disinfectant, wipe down telephones, chair arms and feet, desktops, door handles, computer monitors, and keyboards regularly.
• Assign high-risk frequently used items such as headsets or phones and keyboards to a single individual. When this is not possible, staff should use hand sanitizer before touching a frequently used device.
• Keyboard covers (that are molded to fit over keyboards) may be used to prevent microorganisms from entering spaces between keys. These can be removed for disinfection.

For treatment and exam rooms:

• Develop a standardized checklist and schedule for cleaning treatment rooms between patients.
• Develop a standardized checklist for terminal cleaning of treatment rooms at the end of the day.
• Develop a standardized daily cleaning checklist for housekeeping (tables, hard-backed chairs, doorknobs, light switches, phones, tablets, touch screens, remote controls, keyboards, handles, desks, toilets, sinks, floors, etc.).
• Maintain documentation of adherence to all cleaning checklists/schedules in administrative files.
• Consider the use of air purifiers and UV light disinfection for areas in contact with patients and staff.
• Wipe down all surfaces that touch or are touched by a patient and allow to dry before next use.

  Enforcement Policy for Sterilizers, Disinfectant Devices, and Air Purifiers During the COVID-19 Public Health Emergency (FDA)

  Per the CDC: The efficacy of these disinfection methods against the virus that causes COVID-19 is not known. EPA only recommends use of the surface disinfectants identified on List N against the virus that causes COVID-19. EPA does not routinely review the safety or efficacy of pesticidal devices, such as UV lights, LED lights, or ultrasonic devices. Therefore, EPA cannot confirm whether, or under what circumstances, such products might be effective against the spread of COVID-19.
• Follow CDC standards for waste management.

  Waste Management Guidelines (CDC)

  Per CDC: Medical waste (trash) coming from healthcare facilities treating COVID-2019 patients is no different than waste coming from facilities without COVID-19 patients. CDC’s guidance states that management of laundry, food service utensils, and medical waste should be performed in accordance with routine procedures. There is no evidence to suggest that facility waste needs any additional disinfection.

• Remind staff to report any infection control issues immediately to practice leadership.
• Address concerns surrounding COVID-19 vaccination and healthcare workers, with the following strategies:
• Create a plan for accessing COVID-19 vaccine for employees. Forced or mandatory vaccination is not recommended.
• Avoid implementing measures that identify employees who have or have not been vaccinated (such as banners, badges, ribbons, pins, or stickers). Should patients inquire about the vaccination status of employees, you must protect the privacy of the individual employee. A blanket statement such as this may be appropriate: “We are encouraging all staff members to be vaccinated. Due to federal and state privacy laws, we cannot provide specific information about the vaccination status of any individual employee. Since the vaccine is not 100 percent effective, we also continue to follow CDC guidelines for PPE, social distancing, and other precautions.” Remind patients that obtaining the vaccine for themselves is their best protection.
• Regardless of vaccination status, until advised otherwise by state and federal public health officials, all frontline healthcare workers should continue to follow PPE guidelines.

Effective screening, triage, phone/telehealth/on-site management, patient education, and communication remain essential, but you may need to revise your plan with the evolution of the disease within your community. Revisit your emergency plan and adjust policies and procedures accordingly.

If your office has been closed for several weeks, you will need to prioritize care based on patient acuity. Using an established standardized tracking system, determine which patients require the most immediate follow-up for laboratory, diagnostic testing, and referrals. A systematic approach to test and diagnostic tracking will enhance patient care by ensuring that tests ordered are completed, results are received in a timely manner, and patient follow-up is initiated. Critical to patient safety, an effective review process will reduce the likelihood of missed results while reducing patient harm, improving quality, and possibly avoiding a liability claim.

Prior to opening your doors/seeing patients:

• Reconcile overdue patient appointments (including those cancelled due to office closure).
• Prioritize in-person visits according to medical priority/necessity. Keep in mind limited office capacity, need for physical distance, and risk level of patients. Route patients to telehealth visits when necessary.
• Reconcile telehealth appointments that occurred during office closure, including review of documentation for completeness. Consider developing a template specifically for use with telehealth encounters.
• Have staff conduct pre-visit patient training on connecting to telehealth prior to their initial appointment. Obtain all necessary documents and consent prior to the visit. This will provide for a smoother first encounter and save time. 
• Utilize CDC guidelines for COVID-19 screening of patients when scheduling appointments. Document process. Triage (using licensed professionals) and manage patients according to presenting symptoms.
• When communicating the appointment reminder to patient, screen/document once again for COVID-19 symptoms.
• Conduct outreach to high-risk patients continuing to shelter-in-place to ensure adherence to pre-COVID-19 medical plan of care, assess current medication supply, and ensure knowledge of when to seek medical care for respiratory illness or otherwise. Suggest periodic use of the COVID-19 self-check assessment tool.
• For patients (or those with family members/significant others) who test positive for COVID-19, provide patient education on prevention, disease management, and medical disposition.

Self-Check Tool (CDC)

For patients arriving for on-site visits:

• Utilize CDC guidelines for patient COVID-19 screening on the day of appointment (e.g., taking of temperature, reviewing symptoms/contacts/travel, etc.) Document process. Manage suspected positive patients according to CDC guidelines. 
• Advise patients to complete pre-appointment paperwork online prior to the appointment. Have patients notify staff by phone or text when they arrive for their visit. Advise patients to wait in the car, when possible, as an alternative to using the waiting room.
• Limit in-office visit to patients only. If the patient must be accompanied, screen that individual for COVID-19. Limit visitors to essential visitors only (one per patient if absolutely needed).
• Instruct all patients/essential visitors who enter your facility to wear a face mask, including those who have been fully vaccinated with a COVID-19 vaccine. Also instruct all patients to utilize tissues, practice good hand hygiene, and dispose properly of any contaminated protective equipment/tissues in a designated waste receptacle. 
• Follow physical distancing and use different doors for entering and exiting.

When You've Been Fully Vaccinated (CDC)

Interim Clinical Guidance for Management of Patients with Confirmed Coronavirus Disease (COVID-19) (CDC)

Overview of Testing for SARS-CoV-2 (CDC)

Use and Care of Masks (CDC)

For patient follow-up care:

• Prioritize reconciliation of outstanding clinical laboratory and diagnostic tests (tests ordered prior to the COVID-19 pandemic but not yet completed or report not yet received).
• Prioritize reconciliation of outstanding specialty consultations.

• Ensure specialists have a robust triage system to see high-needs patients first. Consider if a telehealth visit is appropriate for the patient in conjunction with the specialist.
• Confirm your specialist referral process includes all needed information, progress notes, test results, reason for visit with timeframe indicated—anything needed for the specialists to quickly and accurately evaluate need for visit. 
• Consider positive clinical and diagnostic tests results as priority for notification and referral processing, if applicable.
• Prioritize medical and cardiac clearance for anticipated surgical volume increase.
• Prioritize prescription refills accordingly.
• Obtain an updated socioeconomic history from the patient. Assess whether the patient has experienced changes with any of the following: employment, finances, insurance, living arrangements, access to medications, transportation, etc.
• Conduct daily staff huddles, just-in-time huddles throughout the day, and end-of-day debriefs. This provides all staff opportunities to discuss anticipated issues during the day and identify concerns pre- and post-clinic, including COVID-19 updates.
• Assess the need for providing emotional support to patients who may be dealing with fear or other stressors during this time.

As many states are now seeing a resurgence of COVID-19 cases, some hospitals are once again experiencing a rapid rise in admissions. This is a dynamic situation and requires close attention to COVID-19 data for your region. Anticipate that state and local guidelines will remain stringent, and providers should be attentive to any changes.

For those areas where elective procedures are being performed, the surgeon or proceduralist will want to consider the following recommendations. Patient clinical status, socioeconomic support, surgical facility resources, community health resources, and support networks may all have undergone change with the crisis as it waxes and wanes. As you move forward, patients will need evaluation on a case-by-case basis, setting priorities for those most in need. Discuss with your patient the potential outcomes for surgical procedures in a COVID-19 environment.

• Check with the state medical board and local authorities to confirm that criteria have been met to safely resume elective surgeries; identify approved surgical settings in your jurisdiction.

  American College of Surgeons Executive Orders by State (ACS)

  COVID-19 Resources (Federation of State Medical Boards)

• Contact your specialty organization for recommendations and guidance.

  COVID-19: Elective Case Triage Guidelines for Surgical Care with Links to Major Subspecialties (ACS)

  Local Resumption of Elective Surgery Guidance (ACS)

• Confirm that the hospital, ambulatory surgery center, or medical office where you practice has adequate staffing, medical/surgical supplies, equipment, and PPE to safely perform the scheduled procedure.

  Non-Emergent, Elective Medical Services, and Treatment Recommendations PDF  (CMS)

  Other PPE Recommendations (ACS)

• Prioritize patients requiring surgery in the COVID-19 pandemic.

  Pre-Procedural Screening (The Doctors Company)

  Resources for Resuming Elective Procedures During COVID-19 (The Doctors Company)

  New scoring system empowers surgery departments to prioritize medically necessary operations that should not be delayed because of concerns about hospital resources or risk associated with COVID-19 (ACS)

• Communicate the traditional risks, benefits, and alternatives of the procedure as well as the risk of proceeding with the surgical procedure during the COVID-19 pandemic. Include discussion about complications should the patient contract COVID-19 in their postoperative course. Document the informed consent discussion with the patient including both the clinical rationale for proceeding with the procedure and all safety measures taken for the provision of safe practice.

  Informed Consent for COVID-19 Risks: Frequently Asked Questions (The Doctors Company)

  Elective Surgery Informed Consent and Shared Decision Making During COVID-19 (The Doctors Company)

  COVID-19 and Surgical Procedures: A Guide for Patients (ACS)

• Identify patients requiring preoperative medical and/or specialist consultation prior to scheduling surgery. Confirm consultants have a triage process to consider patients with high-level needs and are available to evaluate those patients prior to scheduling procedures.
• Follow any preop COVID-19 testing protocol if required at your facility or within your jurisdiction.

  The ASA and APSF Joint Statement on Perioperative Testing for the COVID-19 Virus

Operating hours of testing facilities may change during the crisis. Identify availability/operating hours of preoperative testing facilities in the community to accommodate:

• Radiology studies.
• Laboratory testing.
• EKG tracing and interpretation.

Confirm with the patient they will have the following resources to safely care for themselves at home:

• Family member or caregiver to be at home with the patient.
• Access to meals (Consider Meals on Wheels or grocery delivery, if needed).
• Access to medications.
• Access to transportation for postoperative visits if telehealth visits are not an option or if an in-office visit is medically necessary.

Determine the patient’s ability to participate in telehealth postoperative visits, if appropriate: 

• Create telehealth instructions and provide them to the patient during the preoperative visit.
• Schedule a trial telehealth visit with a staff member several days prior to surgery to screen for fever, illness, and travel.
• Schedule the postop telehealth visits during the preoperative visit.

Identify postoperative care plan needs:

• Provide postoperative education and instructions during the preoperative visit (e.g., dressing changes and wound care).
• Order postoperative equipment and have it available in the patient’s home prior to surgery (e.g., walker, cane, CPM machine, etc.).
• Order dressing supplies, gloves, etc. and have them available in the patient’s home prior to surgery.
• Coordinate home health telehealth visits.
• Coordinate telehealth physical therapy visits.