Restarting the New Normal - PowerPoint Presentation

1. Restarting the New NormalSAMPLE TEMPLATEOriginal: May 7, 2020Revised: May 20, 20201

2. 2PurposeAsk of You:Leverage this deck to create your market-specific Clinic Restart Plan which should be approved by the Physician Enterprise Division Leader, System SVP. Address all12 subject areas (A-L) in the Clinic Restart Plan.Communicate Restart Plan to all operators and used as the roadmap as you ramp up clinic visits. Include this information in your daily team and tiered leadership huddles.Additional Resources to reference in building your plans:Examples - Clinic Restart - Submitted by MarketsClinic Restart New Normal Reference Folders for each of 12 subject areas Communication COVID-19 Restart ToolkitAmbulatory Toolkit CommonSpirit Health COVID-19 Resource Website Local Department of Public HealthThe COVID-19 pandemic has greatly altered the delivery of primary care medicine. Concerns about patient and staff safety make continued vigilance necessary in our efforts to deliver quality and effective care.

3. Key Factors for ConsiderationItems to Address in the Clinic Restart PlanSick vs. Well ClinicsUniversal Masking PlanSource Control and ScreeningSocial Distancing and Scheduling ConsiderationsPPE SuppliesPrioritization of Visit by Types COVID-19 TestingStaff ConsiderationsClinic Cleaning and DisinfectionClinic Security ConsiderationsCommunications PlanAncillary Service Availability * Hospital Clinics Excluded; 1201A Clinics are included

4. 4A. Scheduling Sick vs. Well PatientsGuidelines for Consideration Clinics with Geographic Separation to serve as “Sick Clinics”Identify specific Sick Clinics in the market to provide: COVID-19 Assessment / Treatment Centers Clinics with Temporal Separation of Sick vs. WellWhere geographic separation is not feasible, clinics should schedule Well Visits in the morning and Sick Visits in the afternoon. **When selecting facilities for “Sick vs. Well” clinics an additional consideration is the availability of “negative pressure” examination rooms (if available). Additional Reference InformationIn order to preserve our ability to continue to perform traditional visits while preparingfor surges, review each clinic to identify:

5. 5B. Universal MaskingConsiderations on Who Wears What MaskIn Physicians and APPs: See Slide 6Medical Assistants, RN, LPN, Technicians: See Slide 6Support/Administrative Staff:Working in Offices: Surgical Mask or cloth maskPatients, Visitors, Contractors and Vendors:Under 2 years of age: No maskAcute Respiratory Distress: No maskProlonged treatment/stays (e.g., Infusion Center): Surgical MaskAll Others: Self-provided mask, if not available, provide surgical maskAdditional Reference InformationWhen considering Universal masking it is important to leverage the right mask for the right purpose.*Updated as of 5/20/2020

6. B. Universal Masking for CliniciansConsiderations on Who Wears What MaskDon a surgical mask at start of shift, ensuring mouth and nose remain covered. Don’t remove or discard mask until it becomes soiled, saturated, or damaged OR contaminated by use in direct contact with symptomatic patient (without careful reuse procedures).Are you entering into the room of a COVID + or person under investigation (PUI)?Are you entering into the room during an aerosolizing generating procedure (e.g., intubation, extubation, breathing treatment, CPAP/BiPAP)? Remove surgical mask and place in breathable paper bag or container. Don N95 or PAPR/CAPR during patient care. Don additional PPE, including gloves, gown, and eye protection. Use careful reuse procedures.Remain masked according to Universal Masking Guidelines.Remain masked according to Universal Masking Guidelines. Don additional PPE, including gloves, gown, and eye protection according to facility protocol. Use careful reuse procedures. N95 – Careful Reuse ProcedureCover N95 with surgical mask if using goggles.ORCover N95 with integrated mask and shield.ORCover N95 with full length face shield.Follow PPE removal steps to make sure not to contaminate N95 when removing surgical mask, facemask, or face shield. You may doff N95 and return to surgical mask (in paper bag), or choose to keep N95 on continuously if caring for multiple COVID + or PUI patients in airborne/contact precautions.Remember to follow careful reuse precautions when caring for COVID + or PUI patients. PAPR/CAPR – Careful Reuse ProcedureRemove used white hood from the hose and clean hood using appropriate disinfectant wipe (cleaning inside first, then outside of hood).Discard gloves and wipes.Allow hood to dry.Perform hand hygiene.Store in clean location.Discard hood if visible damage/holes/tears or does not properly seal.Re-don surgical mask from (paper bag) according to Universal Masking Guidelines until patient care for COVID + or PUI patients in airborne/contact precautions is required.Goggles with mask ORintegrated mask and shield Discard mask/integrated mask with face shield and don new regular mask after exiting the room. Goggles may be cleaned inside/outside with approved disinfectant wipe.Face shield with maskIf face shield extends below the chin level, leave mask on until it becomes soiled, saturated, or damaged. Discard when any of those occur or when going on break or leaving for the day. Face shield may be cleaned inside/outside with approved cleaner/disinfectant wipe.YESYESNONODistributed by: Patient Safety Safety National Office on April 3, 2020 *Updated as of 5/20/2020

7. 7C. Source ControlPre-screeningImplementation PlanningActionComments / Supportive DocumentsScreen patient 24-48 hours prior to visit for COVID symptoms using technology or via reminder phone call. CDC Patient ScreeningScreening Technologies: Phresia, NotableDuring screening, inform patients of changes to operations such as:Visitor restrictions Masking requirementsParkingEntrance On-site screeningCalling upon arrival to check-inWaiting in car for appointmentTelehealth Visits, leverage as appropriate. Examples may include:Lab/diagnostic testing follow-upPost operative Medication follow-up Episodic/same day onset illnessesComplex Care maintenance appointments COVID/Flu screeningAdditional Reference Information

8. 8C. Source ControlProcessSource Control ProcessActionReasoningComments / Supportive DocumentsProvide a facemask to all persons before entering the facility if not already wearing one (excludes persons 2 years of age or younger or anyone unable to wear a mask (e.g. difficulty breathing).  Limits spread of illnesses.Facemask types for patients/visitors: cloth mask, dust mask, or other masks not deemed healthcare grade PPE. Use surgical mask only if other options are unavailable. Instruct all persons to perform hand hygiene before and after wearing mask, or after touching face or facemask. Limits spread of illnesses.Hand Hygiene Flyer(print as a handout as well in multiple languages)Instruct all persons how to wear a facemask properly and at all times while in the building/clinic or in public. Insures proper use.Facemask Flyer (print as a handout as well in multiple languages)Screen all persons for COVID-19 symptoms using the Source Control Screening Tool – which includes a questionnaire and temperature.  For everyone’s safety, any persons refusing to be screened or have a temperature check will not be permitted into the building/clinic.Identifies persons who may not realize they are ill or could be contagiousSource Control Screening Tool (next page)

9. 9C. Source ControlImplementation PlanningImplementation PlanningActionComments / Supportive DocumentsEnsure screening at all entry points to the building. Set up a work schedule to staff the entry points. Consider limiting entrances as needed to ensure adequate screening.Set up area daily for all staff, visitors and patients. Ensure adequate signage in multiple languages.Stock screen stations with Respiratory Etiquette supplies, thermometer and trash cans. Ensure items are secure when not attended.Ensure individuals in line maintain 6’ distance if there is a line of people upon entry.Set up area daily and ensure you have adequate signage in multiple languages.  See supplies necessary on page 45 of the Toolkit: Respiratory Etiquette StationsWhere possible, consider propping open the front door to limit additional contact points.Consider setting up hand sanitizing stations.

10. 10C. Source Control Screening ToolSource control includes screening everyone entering a healthcare facility regardless of symptoms ALL PERSONS ENTERING BUILDINGNOTE: If anyone refuses to be screened or have their temperature taken they will not be permitted to enter the building or report to workScreeningActionDo you have any of the following:Cold like symptoms / runny nose * HeadacheCough * Sore Throat Chills (with or without repeated shaking) * New loss of taste or smellMuscle pain / body achesIf NO, ask next question. If YES, see instructions.Have you had a fever of 100.0º F (37.7º C) or higher in the last 72 hours?If NO, ask next question. If YES, see instructions.Are you having or had any recent shortness of breath?If NO, ask next question. If YES, see instructions.Have you had any close, in-person contact with someone who has tested positive for COVID- 19 in the last 14 days?If NO, ask next question. If YES, see instructions.Take person’s temperature (touch free). Was the temperature reading 100.0º F (37.7º C) or higher? If NO, ask next question. If YES, see instructions.ACTION FOR ANY “YES” ANSWERHCP/ClinicianPatientsVisitor/Others Instruct HCP/Clinician to keep their mask on, stay 6 feet away from others and go home immediately. Leader to contact Employee Health immediately for further direction.Have patient wait in their car and consult with provider for further guidance.Instruct visitors/others (delivery personnel, couriers, visitors, etc.) that due to the safety for all, they are not permitted in the building. FOR HCP / CLINICIANS - REPORTING TO WORK DIRECTIONS:If you develop any symptoms listed above or fatigue, GI symptoms (nausea, vomiting, diarrhea), even if mild, notify your leader immediately.

11. 11D. Social Distancing and SchedulingScheduling ConsiderationsDuring initial days of restart consider limiting to 1-2 patients per provider per hour in the office. Intersperse telehealth visits between office-based visits.Avoid bringing the most vulnerable patients to the office, using telehealth when clinically viable.Use telehealth when clinically indicated for acute medical illness. Examples would include mild cellulitis and uncomplicated cystitis.Use extreme caution before bringing any acute illness to the office for assessment, only doing so when clinical confidence is extremely high that the illness is unrelated to COVID. Use initial days to assess and correct problems with office workflow that infringe on universal precautions. Office managers will work with Physician Enterprise leadership to ensure practice readiness prior to initiating new workflow.  Clinic management should plan and coordinate schedules with input from providers and clinic staff to optimize spacing between patients across common segments of office workflow (ex: check-in, lab, and check-out). Additional Reference Information

12. 12D. Social DistancingClinic Implementation Check In / Waiting Room / Check OutGuidelineConsiderationsRemote check in / drive up check in and wait in car until exam room is availableParkingOutside TemperatureIdentify the maximum number of patients your waiting room can hold and actively monitor to ensure you do not exceed the allowable number of patients in waiting areas. Escort patient directly to exam room whenever possible.Set up reception area furniture and signage in a manner that enables patients to be 6 feet apart. This may include indicating that some seating areas out of service. (See communication toolkit for signage.)See page 8 of Toolkit: Waiting Room and Front Desk GuidelinesWhere serving both well/sick in the same common areas, use Non-COVID Care zones (e.g. separate sick and well waiting areas) Put away articles such as magazines, toys, coffee, or anything else that may be handled by infected persons.Arrange office flow such that patients enter and leave through separate doors where possible. Consider arranging a separate entrance forsymptomatic patients. Modify check-out procedures to minimize/avoid any patient time in central area or at check-out desk. Consider in room checkout.

13. 13E. PPE and SuppliesKey ConsiderationsGuidelinePPE:Adequate stock of PPE for current needs as well as potential surge needsEstablish PAR levelsReport daily inventory on hand / daily usage reportingFollow CDC guidelines for extended use and reuse of PPE Screening and Testing Supplies:Plan core supplies, including PPE, and equipment needs by ramp volumes and patient typesOrder SuppliesMaintain supply inventoryDistribute/redistribute supplies across market as neededGeneral SuppliesIncludes cleaning suppliesDisinfectant WipesConservation of Supplies:Bring Your Own MaskAdvise patients, vendors, contractors, etc. to wear their own masksEstablish a PAR for daily and weekly usage of PPE. Prepare to ReprocessEstablish plan to save N-95 masks in preparation for reprocessing in the future.Identify reprocessing options in your areaUse linen gowns Contact local linen suppliers for gowns as disposable gowns are not readily availableCollaborate to Order SuppliesWork with your VP of Supply Chain. Be prepared with the numbers you need and justify your ask.Send Collective request to County Health Department; combined asks have been more successful.Request help from Henry Schein and McKesson.Secure InventoryEnsure inventory is secure and being trackedIdentification of Testing Supplies NeededWork closely with your local labs to identify swabs and other testing materials needed if performing in-office testing.

14. 14E. PPE and SuppliesCalculating SuppliesTo calculate PPE, consider the following data points from the last 2 months at your clinic:PPE usage Number of patientsNumber of staff membersThen adjust that number by the expected increase in patient volume. Example from a California Clinic:Surgical Masks: 1.7 surgical masks per patient (which would cover staff and patient needs)N95 Masks: 3% of total number of masks Face/Eye Protection: Reusable preferred; Need enough for each staff member and provider. Protective Gowns: Consider leveraging linen suppliersDisinfectant Wipes: Identify usage in past 2 months and increase based on additional cleaning/disinfecting requirements.Testing Supplies/Swabs: If providing testing on-site. Consider oral swab substitution for Abbot Test and work with local labs to identify specific needs.POC Testing: Identify what reagent and control solutions are required.PPE Burn Rate CalculatorAdditional Reference Information

15. 15F. Prioritizing Visits by TypeTo ensure we maintain a safe environment for our staff and patients, we will need to prioritize our visits and leverage virtual visits as appropriate.Recovery DecisionsGuideline Facilities and offices shall establish a prioritization policy for providing care and scheduling.  Clinical prioritization should consider clinical impacts of treatment delay and the current surge status of the health care infrastructure in a community. Extended hours should be considered to limit the number of patients in an office at any given time. Facilities and offices should also consider scheduling special or reserved hours for elderly or immunocompromised patients, to minimize the risk of infection to vulnerable patients.Establish a process to ensure Clinicians continue Virtual Visits whenever appropriate for patient and condition.  Priority scheduling for in-person visits:Patients with acute illness that cannot be handled through Virtual Visit.Patients with chronic illness, including behavioral health, that have not been seen due to stay-at-home rules and need an in-person visit.Preventative services including well child and vaccines, adult clinical preventative servicesPatients requiring a treatment or examination that cannot be handled virtuallyPreviously cancelled or postponed patientsOther patients needing in person visit to monitor status of assess illnessNote: Telehealth/telephonic modality should be used for all appropriate patients and conditions.  

16. 16G. COVID-19 Testing Priority OrderDetermined by the clinician and documented as part of the plan

17. 17H. Staff Considerations Manage virtual and in-person clinic workflow, including check-in and check-out processes.Oversee screening, safety and patient flow, including Respiratory Etiquette Station staffing.Oversee clinic cleaning and disinfecting, public areas, exam rooms, bathrooms, high-traffic areas.Designate IT/help desk support.Generics Identify necessary staffing and clinic hours to support restart of clinic.

18. SOP Clinic Cleaning and DisinfectionAdditional Reference Information18I. Clinic Cleaning and DisinfectionAssumptions and Next StepsNext StepsAttached is a generic policy to reference against your existing standard operating procedures for cleaning and disinfection clinic spaces. Please revise current SOPs and reeducate staff as needed. Work with vendors to ensure they are meeting the new standards and implement a checklist that they can submit on each visit to show all items were completed.Generics Assume everyone is COVID-19 positive, since they may be asymptomaticClinics will need to update their standard operating procedures around cleaning and disinfection.Clinic staff and vendors will be required to perform COVID-19 detailed cleaning procedures.

19. 19I. Clinic Cleaning and Disinfection ScheduleCleaning Frequency: Exam Rooms, Patient Area and KeyboardsDescription FrequencyImmediatelyAfter every patient encounter3+ times per DayDailyWeeklyAny item or area that appears soiled or has blood or body fluidsX    Bathrooms (suspected or known patient infectious diarrhea)X    Exam Room – Limited (exam table, pillow covering, chair tops, blood pressure cuff, counter tops) X   Medical equipment used during patient visit X   Keyboards – Exam and Procedure Rooms X   Medication Preparation Areas (in patient area) X   Keyboards – public areas for public use  X  Medication Preparation Areas (separate room/area)   X Draw Stations   X High Touch Surfaces (stethoscopes, chairs, knobs, etc.)   X Exam Rooms – Complete (including lamps, lights, equipment, etc.)    X

20. 20J. Clinic Security ConsiderationsClear communication of expectations that are written in multiple languages is the best way to prevent conflict.Ensure you have security plan in place with specific guidelines on how to access security in case there is a patient unwilling to follow social distancing rules and masking.

21. 21Our Approach: Create a national communications (tell) and marketing (sell) toolkit to support clinic restart efforts, customizable to division nuances. Lead with communications, follow with marketing. Themes: Safety and Reassurance, Don’t Delay Care, Open for BusinessOur Messages:Staff, Physicians, APPsSafety, health and well-being of every patient, staff member, physician and APP is our highest priorityNew ways we’re adhering to best practices and guidelinesPatients/CommunitiesStaying on top of your health has never been more important, whether an ongoing health concern, a chronic condition, or a routine checkupOur clinics are open to safely take care of your health care needs, whether in person or virtually. K. Marketing and CommunicationsApproach and Messaging

22. 22Patients/CommunityPatient Reschedule Scripting for Staff/Call CenterPatient FAQ and Email TemplatesCommitment to Safety and Social Distancing FlyersPayor/Aligned Broker Template Providers and StaffInternal Announcement MemoFAQK. Marketing and CommunicationsCustomizable tools to help communicate our message consistently

23. 23Patients/CommunityWebsite CopyDigital DisplaySocial MediaK. Marketing and CommunicationsCustomizable tools to help communicate our message consistently

24. 24K. Marketing and CommunicationsContact InformationBrooke BurgessDirector - External Communications, CommunicationsBrooke.Burgess@DignityHealth.orgMara BurkeSystem Vice President, MarketingMaraBurke@chifranciscan.orgTom DesantoSenior Director, Marketing and CommunicationTom.Desanto@DignityHealth.org

25. 25L. Ancillary ServicesConfirm ancillary services are available to support clinic referrals.

26. Appendices26

27. Top Ten Best Medical Forehead Thermometers

28. 28Top Ten Best Medical Forehead ThermometersiProven DMT 116A, Medical Forehead, and Ear Thermometer, FDA Approved, Authentic Professional ThermometerDMT-489 iProven Medical Ear and Forehead Thermometer3 in 1 Easy@Home Infrared Forehead Thermometer, NCT-301 for Baby and AdultDr. Madre Talking Forehead, Medical Infrared, Non-Contact Thermometer, Updated 2020 ModelMedical Forehead by Innovo and Ear Thermometer, In-House Updated Clinical Data and Upgrade for Proprietary SoftwareSinopie Medical Forehead, Digital Thermometer Instant Reading, Non-Contact, Room, Surface and Body OptionsDr. Meter Medical Forehead Thermometer, No Touch, FDA Approved, Infrared Professional ScannerDual Mode Simplife Forehead and Ear Digital Clinical ThermometerTouchless Most accurate REMEDIES Forehead, Temporal Thermometer, for Fever Reading in Kids/Babies with Options for Surface/Room Temperature ReadingEquinox International Dual Mode Infrared Forehead and In-Ear thermometer, High Contrast LCDSource: https://www.hqtext.com/top-10-best-medical-forehead-thermometers-reviews/