As the largest not-for-profit health system in the Seattle area, Swedish Health Services was an early responder to the coronavirus pandemic in the United States. We spoke with Chief Quality Officer Chris Dale, M.D., and Interim CFO Stan Moser about how the organization prepared in the early days of the COVID-19 crisis, the pain points they have seen along the way, and their advice to other providers as the number of cases continues to rise across the country.
In all Kaufman Hall interviews, the expert opinions expressed are those of the interviewees and should not be considered opinions of Kaufman Hall. This interview was conducted on April 3, 2020.
Q: Where is Swedish now in terms of your predicted peak for COVID-19 patients?
Dr. Dale: Different places in the nation are in different phases of this. Just yesterday we were on a call with some of our colleagues in the Providence system from California, and they’re two to three weeks away from their predicted peak. Here in Washington, we’re about a week away from our predicted peak. Our volumes now are about 5 percent below the predicted peak, and our internal number actually has been pretty close to the predicted numbers, just in terms of the rate of rise in patient volumes, the ICU volumes and ventilator needs, and all those things.
Who knows what the future holds? Certainly if we were to relax social distancing or some of the other things that have really done a good job of flattening the curve, we could see a change in that, but for right now, we are close to our predicted peak.
Q: What preparations was Swedish able to make before COVID cases started mounting?
Dr. Dale: Going back to the beginning, we watched the data coming out of China and realized that this had the potential to be big. Our medical director for infection diseases, Dr. John Pauk, took important steps early on based on early epidemiologic models. We anticipated that this would get big in the United States going back about two months or so, and we began to go through the planning exercises.
I’d say three things were the foundation of our planning activities. First, we activated our HICS structure. The Hospital Incident Command System works synergistically with our normal organization design to identify individuals who have the accountability and authority to run different parts of the hospital during this time. We’ve leveraged our HICS structure to have very clear and crisp lines of command, and very clear and crisp decision making authorities among various people in that structure. That’s been tremendously helpful. We have an operations section and a planning section, a logistics section—all the traditional HICS sections—and we leverage that.
The second thing is communication. In these times of uncertainty accompanied by fear, nothing is more important than trying to communicate messages to our caregivers, providers, and the broader community. We really put a lot of effort and attention into how we go about communicating, including everything from daily emails to virtual town halls, to core leaders’ calls, to safety huddles where people can get information directly from their team leaders.
The third thing is putting our caregivers at the forefront. Our people are the heart of Swedish. If our caregivers aren’t safe and aren’t protected, if people go down in the line of duty, that tremendously impairs our ability to provide services and to fulfill our mission. So we’ve put a lot of effort and attention into making sure that caregivers stay safe, and that people feel appreciated. There’s a whole section in our HICS structure around wellness and how to care for our caregivers. We activated that and doubled down on people being physically safe and also feeling emotionally cared for. That’s been key to our approach.
Q: What has been your experience accessing tests and getting timely test results?
Dr. Dale: From the beginning of this, optimizing testing has been an integral part of our response. Testing is vital, because obviously it leads to being able to take appropriate actions around patients. If there are sick people in the hospital, it means access to clinical trials, and if they’re not sick and not in the hospital, it means even more strident isolation and shelter-in-place activities.
We’ve gone on a journey. We started with the state of Washington, because that was the only place that first had available testing from the CDC kits. Then we were fortunate to have testing from the University of Washington come online very early. But they were quickly the victims of their own success, because they were flooded with everybody in the state wanting to send their specimens to UW for faster turnaround times. After a while, we switched to using LabCorp in North Carolina for a lot of our testing, which from Seattle presents a lot of logistical challenges getting specimens to the East Coast. Flights were getting canceled and delayed. They moved a little closer to Phoenix, but again, we saw logistical challenges with flights getting canceled.
We have a number of different analyzers in the lab, and about that time the Cepheid product was licensed. It took a week or so for us to get reagents. Then we started sending all of our inpatient tests to our own in-house lab at one of our hospitals, and all the outpatient tests to Arizona.
That’s working well. Our inpatient turnaround times are now in the five-hour range. For the Arizona-based tests for ambulatory patients, we’re getting results two to four days from the time of collection. Now point-of-care testing is coming live, which our affiliate Providence is putting in some of their express care locations. We continue to see hope for expanded testing capacity, and that’s a key in controlling the outbreak.
Q: What pain points have you experienced?
Dr. Dale: We think a lot about space, staff, and resources. Do we have the right physical locations? Do we have the right equipment for staff and the right people? We really think about using the theory of constraints to conceptualize our ability to surge. Here in Washington state and in the Seattle area, we’re extremely fortunate that early interventions were put into place—social distancing, closing schools, and so forth—because our peak is nowhere near as sharp as it has been in New York City, or even some places in the Midwest. We identified early on that ICU beds and ventilators would be things that would be the most pinched, and would be our greatest constraints.
Our baseline ICU bed capacity is about 107 beds, and we identified relatively easy ways to expand that to about 200, and then, with some added difficulty, expand to the 250 to 275 range, which is where the initial projections said we would land. I can’t say enough about the section chief for logistics, Mike Denney, who does real estate for us. He’s just the master of getting the right space to help, and alter those spaces, like finding negative air pressure room conversion kits to convert all of our ICU rooms to negative pressure, and doing that within a 10- or 14-day period. It was just amazing.
Renee Rassilyer-Bomers leads our planning section, and she’s done an amazing job thinking through how to take an ICU nurse cohort of a certain size and double or triple their capacity. We’re using extenders—so retraining some nurses from areas like the OR or PACU who are idle because of the cancellation of orthopedic surgeries, and deploying them to work with experienced ICU nurses. On the provider side, we’re using the same kind of pyramid. For example, an ICU doctor works with an anesthesiologist, and together they can care for two times the number of people. We’re extremely fortunate to have the capacity available in terms of space, staff, and resources to be able to care for a significant number of people.
Q: On the supply side, how has the PPE and the ventilator situation been for Swedish?
Dr. Dale: Once again, we’re incredibly fortunate. We have an adequate number of ventilators for the predicted peak that we have, as well as for some what-if scenarios. We had quite a large number of travel ventilators that were acquired by the state of Washington in the H1N1 pandemic, and ultimately were distributed to healthcare facilities in Washington. We have about 40 or 50 of those transport ventilators that we don’t use routinely, but they’re very adequate ventilators and our people are relatively familiar with them. In addition, we were able to secure some ventilator purchases early, and we have some backup plans on top of that, using anesthesia machines and other resources.
PPE is a similar story. We jumped on it from the beginning through the miraculous work of Mike Denney and just the tremendous outpouring of support from people in the Seattle area. We’ve been very grateful for donations from the community, like people who run construction companies donating N95 masks. Two Seattle manufacturers that regularly make other things have converted to making either face shields or cloth masks that are ingeniously designed using drape material, and which we tested and actually perform better than the traditional isolation masks. We’re bringing in 10,000 to 20,000 of those. We can wash them and reuse them. As part of a system initiative, we are also reprocessing masks. The whole Seattle area really has risen to the challenge.
Q: How are you tracking the financial implications? How are you thinking about what this might mean financially for the organization in the near term, and in the not-so-near term?
Mr. Moser: We have an incredible tracking system for the COVID patients, and our daily capacity around how many ICUs, how many staffed ICUs, and how much equipment. It enables us to ensure we have anything that we are short on to be able to take care of the community, which is our number one goal on a daily basis. In terms of the financials, you can just imagine. When you have to start canceling all of your elective surgeries, as we did on March 9—that’s more than the bread and the butter. For a lot of institutions, that is where a huge part of the margin sits.
We actually are in the process of closing the month of March, but we track daily gross revenue. We track revenue by payer daily, so we’ve seen a huge decrement in that, and we expect that to stay with us the entire month of April. I believe the governor’s release to return to surgery at this point is somewhere in the middle of May. Until that day, unless there’s a change in that edict, we will not be doing any surgery that is not urgent or emergent.
Q: Has this presented liquidity challenges for Swedish?
Mr. Moser: It has not yet. It will. There’s always a lag to receivables. So far, those receivables we’ve been collecting recently are for work that we did in February. The cash so far has been fine, but soon we’ll see the turndown in the gross revenue become a turndown in net revenue or collections.
Q: Do you have any suggestions for other organizations on tracking the financial impact and making adjustments moving forward?
Mr. Moser: I’m sure everybody out there who can is tracking or trying to track for all of the FEMA regulations and reimbursements. We are knee-deep in that. We’re fortunate to be affiliated with the Providence Health System, because they have some people in the Shared Services Division who have really helped guide us there, but that is going to be a very big deal.
Then, just making sure that we track and code everything—all of those supplies, all of the labor that we’ve had to move over to take care of COVID preparation, planning, and execution. For example, consider the COVID patients that don’t necessarily look as ill as some other patients. Nonetheless, we would not want to send one of those patients home, only to have that patient return hours later needing a ventilator.
Medicare now has set up a system that you can get an advance on receivables. Needless to say, it will be incredibly important for us—and probably for a huge portion of U.S. healthcare providers—to be able to use that.
Q: Do you have any advice that you’d like to share with organizations that are preparing, but haven’t yet seen the volume of COVID patients you’ve seen?
Dr. Dale: It is important to have a structure where you have identified people who are accountable for making decisions. It’s very interesting from an organizational development perspective or an organizational psychology perspective how—when there’s fear in the air—things get more uncertain. As humans, I think we want a little more command and control style of organizational decision making, and a well-run HIC structure lends itself very well to that.
The second thing is that you cannot spend too much mental energy, time, or attention on communication. It’s just impossible. Communication is more important now than ever.
Third is that it’s all about the people. Our caregivers truly are the heart and soul of the organization. Lynn Welling, our chief clinical officer, said it well. He said, “We cannot afford to have a single caregiver go down because of COVID.” Having that preoccupation with making sure that we’re doing the best we can for our caregivers so that we can remain effective as an organization is critical. We want our caregivers to feel cared for. It’s scary, and it’s hard to be a frontline caregiver. The more that we care for caregivers, the better we’re able to fulfill our mission.
Mr. Moser: Inside of that structure is how finance is going to work, how finance is going to track all these effects, and how finance can possibly assist operations in any and all ways. I can’t overemphasize Dr. Dale’s comments about communication and the importance of our caregivers. As you know, that is not necessarily easy in an environment in which time and resources are constrained, but that has been a real focus here.