Reopening Healthcare Facilities: Rebuilding Trust (5/8, Stanford)

Kevin Schulman, MD, MBA, Clinical Excellence Research Center, Stanford University School of Medicine

Healthcare Providers Face Financial Pressures To Reopen

Healthcare systems in the United States are suffering from a drop in volume as patients have curtailed the use of non-emergent healthcare services. The economics of this abrupt drop in demand are severe – healthcare systems have large capital asset bases, employ large numbers of essential workers in clinical and non-clinical roles, and report single-digit operating margins. As a result of this highly leveraged business model, a downward shift in volume quickly moves financial performance from profit to loss. Thus, the pressure to reopen to patients is significant from the system perspective. But, from the patient point-of-view, it’s not clear if they share the same urgency.

Unfortunately, reopening the health care system will be more complicated than just switching on the “open” sign at the front door. The COVID pandemic has induced huge fear in the population about the virus and viral transmission. Hospitals are clearly at the epicenter of this fight, but stories about courageous healthcare workers becoming ill, or protesting the lack of PPE, have been daily headlines for two months. The public is concerned that they will be the next COVID case if they seek care; whether this concern has merit is irrelevant. At this point, it’s a fixed impression.

To Reopen, We Need to Build Trust

Interestingly, this is an issue that has emerged in a lot of our research in global health – how to build trust in the eyes of the consumer or patient that the healthcare system is there to help. It’s important to realize that rebuilding trust is the essential task before us as we consider reopening.

Take The Perspective of the Healthcare Consumer

From the perspective of the patient, how do I trust that I will not get sick from an in-person visit? Here, leaders need to see the world from the perspective of the patient in a way that they have never done before.

As a thought experiment, imagine that you are the patient seeking care, and every action and activity is governed by the thought that the last person before me to do the task was COVID positive. Do I want to “sign in” at the start of a visit? Will there be a queue to check-in and will there be social distancing? Will everyone be wearing a mask? Do I have to fill out a form on a clipboard or iPad? Will the waiting room be laid out to ensure that there is separation (and maybe separation of seniors for their protection)? Are the staff congregating together? Are the floor and surfaces clean? What about door handles and elevator buttons-how often are they disinfected (or are there convenient disposable tissues so I do not have to touch a surface). Who sat in the chair before me – was it cleaned before I sat down?

I know at Stanford we have had a lot of discussions about CDC guidelines and protecting staff, and these have sometimes been heated discussions as the recommendations have evolved. But in thinking about the patient, following CDC guidelines is a start but not sufficient. We need to overwhelm them with our attention to these issues if we want to win their trust. We don’t want a post on NextDoor that says I went to the doctor and I was scared – or worse, I got sick.

Examples from Disney and Retail

Interestingly, I was once involved with a discussion about Disney and their theme parks. We all think about the parks as entertainment, but to Disney, job one is not characters on parade but safety. Who wants to take their kids to a theme park where there is any risk of harm to your family?

You have probably never thought about the effort they put into safety, but I once saw it up close. One of my children jumped into a pool in front of me before they could swim. When the lifeguard saw this, they blew their whistle and jumped into the water – fortunately, I beat them to my child and didn’t need their service.

The remarkable thing was what happened out of the water. When they heard the whistle, all of the other lifeguards immediately shifted chairs to cover the quadrant of the lifeguard who went into the water. They were trained to do this to ensure that there were not two victims that needed to be rescued. Now, that was attention to safety.

We’ve seen this all around us as businesses have evolved their internal policies and procedures to respond to COVID. My family members have remarked how clean supermarkets are now, how the aisles are one-way, how the carts are wiped down between uses, how we have social distancing markers everywhere, how the check-out clerks are protected, and how you don’t have to touch anything to check out.

Healthcare: Attention to Detail

For a successful reopening, we’ll need to adopt this level of attention to detail. And we will need to message the patients about our efforts – we’re already two months behind supermarkets in their learnings.

This will take engagement from senior leaders and line staff. Leaders and managers will have to walk the floors to ensure that patient safety is enforced throughout the organization. We’ll have to revisit SOPs to modify them for new COVID procedures and train the staff on the new policies. This would be a great time to recruit feedback from the front lines, and from patients, about ways in which we can make our system even safer for patients. Staff and providers should acknowledge the fear, explain the new procedures, and thank patients for their courage.

One delicate issue will be our newfound expertise in virtual visits. We should be careful that we maintain this capability until we rebuild trust in in-person visits, despite the economic pressures to curtail these services. Forcing patients to come in before they are ready would undermine the trust being built through all of these other actions. Indeed, rather than cut back on these new virtual services, we should build them into our standard operating model.

Looking Forward

It is not clear how long this COVID challenge will last; it could be months if we have a vaccine or years if we do not. Building trust needs to be part of the reopening plan for this new normal. The work needs to evolve based on local circumstances and progression of the epidemic.