Welcome, and thank you for joining us for this general session, the ACC Quality Summit COVID-19 Pandemic One. I am so excited to welcome some wonderful colleagues to this session. Today, you're going to hear from Diana Cobb. She's the TriStar Vision VP of the CV Service Line at HCA Healthcare, and she's going to share her experience over the last few months. We are also welcoming Sarah Clemmons. She is the Director and Primary Care Service Line Director in the Indy Suburban region at Indiana University Health, and she will be sharing their experience during the COVID pandemic. And finally, not new to the Quality Summit is Amy Dukovic. She is a Cardiovascular Service Line Consultant, and she will be sharing her unique experience during the COVID pandemic. Diana, we're excited to hear how the last few months have been treating you. Yeah, thank you. I'm excited to be here. Thanks for having me. So I'm gonna just start by introducing myself. I'm Diana Cobb. As Andrea mentioned, I'm the Division Vice President of the Cardiovascular Service Line for HCA's TriStar Division, and I'm gonna just sort of walk through what the last few months have been like for us. It's sort of been an adventure, as I'm sure everyone has felt the heat and just the overall change of COVID and the impact it's had on healthcare in general, but I'll start by providing an overview of what HCA is and where the TriStar Division specifically fits into the larger, broader HCA across the company. So our mission really is, and we take pride in this and really live by it, is to contribute to the care and improvement of human life. And so it's sort of a basic description, but it really is part of the thread of our culture, from our physicians, to our senior administrators, to our operations team, and so we really intertwine this into everything that we do across our company. So this is an overview of our divisions across the enterprise. We have over 1,000 hospitals and more than 2,000 sites of care in 21 states, and in addition to the United Kingdom. And so the other sites of care, in addition to sort of our acute care settings, include our Physician Services Group, and that is our group that oversees and employs our physicians across every specialty, every specialty from cardiology to our primary care providers. We have a lot of oversight, sort of company partnership that we have with our oncology team. CareNow is our urgent care provider, and then Health Trust and Paralon. We couldn't do what we do without the partnership of Health Trust and Paralon in terms of our supply chain, our equipment management, et cetera, and it's a big part of everything that we do. So I'm gonna just sort of provide an overview just around our colleagues and how integral they are to Health Trust and Paralon, how the role that they played even within this COVID-19 pandemic. So we've got 280 colleagues across the company, almost 100,000 registered nurses, and I'm really sort of proud to say that at being a registered nurse myself. 46,000 affiliated physicians, and that includes our employee physicians and our physicians who are aligned with us. And then we're ranked 65 in Fortune 500, and so that's as of June 30th of this year. We're really proud of the nurse residency program. I think we've seen more than ever the need to develop succession plans as we see turnover in the nursing space, whether it be due to clinical concerns and safety or burnout, whatever that may be. We're really proud of the nurse residency program and the partnership that we've had with our local nursing schools. I won't go through this for the sake of time and detail, but I do wanna touch on our partnerships with our physicians. Of course, we can't do what we do without that partnership, and we are really proud of the dyad and the sort of model that we have within the CB service line, that there's an administrator dyad, and that's me at the division level. And then there's a cardiologist who I partner with and work with consistently around quality and growth and operations. And of course, our physician satisfaction and patient satisfaction as well, our pillars related to that. I'm gonna skip through this one for the sake of time to allow time to really drill into the impact that COVID has had on the organization. But before I do, I do wanna touch on just what the broader HCA group structure is. So Sam Hazen is our CEO, and we are separated into two groups. In the national group, you can see on your left, and that includes the capital division, that includes the DC area, for instance, West Florida, sort of self-explanatory. And then I fall within the American group, and that's led by John Foster, who is our president of the American group. Central and West Texas is the Austin market. San Antonio is a little different. It's actually the market that I was in before I moved into the national TriStar division market. And it's its own division. It's a city within its own division, but it's one of our largest CB service lines across the company. And then TriStar is where I fit in. So TriStar includes the Tennessee market, the Chattanooga market. It may be easier to just put it in state, so Tennessee, Georgia, and Kentucky. And it includes 20 hospitals across all of those states. We are the leader in the CB service line in each of those markets, really proud of the work that we're doing with our physicians and our leaders in moving the needle and growth, and particularly quality. Having come from an academic health center, it was really important for me not to lose sight of the quality. And it's really remarkable to see how focused HCA is on quality. And one of our hospitals, for instance, it has a three-star, it's a three-star program. It's four out of five STS categories. So really proud of the work that the team has done in regards to quality. So how has COVID impacted us? As I mentioned earlier, it really has impacted us similarly to what we've seen across the company and beyond. This slide really outlines the level of response. During that really high kick in COVID where we were sort of, what is this? And how do we manage this? We went through the lulls and the volume declines. And so once we got to a place where we really put some processes in place as far as safety, ensuring that we had appropriate PPE and enough PPE, et cetera, we really got to a place where we felt like we had a lot of the operations and the process improvement sort of initiatives hardwired. And so then we started discussions about how do we introduce our services back into the market at a time where patients are still afraid to enter our hospitals. And I think we're seeing that even now, particularly in the CV service line with semis, for instance, we've seen delays in patients presenting to the ER because they're just afraid to go to the hospital. So there's been a lot of work around educating the community, partnering with our EMS teams to ensure that patients are aware of all that we've done to ensure their safety. And then of course, we have moved into this sort of model of low acuity versus high acuity. And what does that mean? And at what point do we turn the switch on for low acuity cases? And we're really there now. And of course, we're still monitoring as we still don't know what the future of COVID holds, but this slide really outlines how we moved forward in the plans of care based on the patient's acuity status. We have an interventional cardiology work group. And as I mentioned earlier, we partner really closely with our physicians in this dyad model. And our division interventional cardiologist physician dyad lead, that was a mouthful. He really served as the physician champion for this model. And because of the depth and breadth and size of HCA and even Tristar division, we have set up calls with all of our interventional cardiologists and talked about best practices that we've seen within each hospital and how do we scale that across the division. And in some cases, we even scale it across the company. That's one benefit of having a model where we share best practices so that there's one hospital that doesn't have to reinvent the wheel that's still trying to figure it out. There's always that collaboration that happens. And this is one example of how we did that. So I was asked when I had the pleasure of being asked to present for this group, how did we integrate our staff? And within the CV service line, of course, we've got the bedside sort of boots on the ground employees that are so integral to the success of our programs and our patient safety and quality. But then we've got a model that is called actually a nurse navigation model and it's called Care Shore. It's a program that HCA built from the ground up. It's sort of a, it's unique to HCA. And then we also integrated our abstractors who worked remotely and we moved them into, as volume started to decline, they had capacity and bandwidth to get creative and partner with us and identifying patients to present it to the ER with COVID symptoms. Without going through every missing cranny of this pathway, I do wanna highlight how we were able to identify patients in the ER, collect data around patient names, date of birth, et cetera. Those patients who weren't acute enough to be admitted, but still needed to be monitored because of their temperature, for instance, we use a program called Vivify and we turned this whole model into Vivify Go where the abstractors and our care, our nurse navigators working from home were able to monitor patients, their temperature. And if there were temperature spikes, for instance, or the patient became more symptomatic, we were able to escalate that patient to a higher level of care and connect the patient to one of our local physicians. So that data collection skillset that the data abstractors do every day, we were able to leverage that and use that in this model while allowing our employees to still work and keep their hours and use them in a really productive way to ensure the safety and quality of our patients. We also recently piloted a remote discharge process. So as I mentioned earlier, we do have nurse navigators who usually are right in the hospital in the day-to-day, but we've sort of put the foundation of our nurse navigation model on pause while we had to prioritize COVID needs. And so I'm not sure where I am on time, but just really quickly, I do wanna highlight how the nurse navigators were able to partner with our nurses who are actually in the hospital, relieve some of the work that they had in terms of discharge planning. The navigators do that all day, every day, similarly to how I described the data abstractors who abstract data all day and we were able to use them for remote monitoring. The care assured nurses were able to relieve the local nurses, the hospital nurses, sort of boots on the ground nurses at the hospital level from going through the discharge education. And we were able to do that virtually. So there's a camera in the patient's room and instances where that made sense, or we were on the phone with the patient going through their discharge instructions, their med reconciliation, ensuring that they didn't have any questions before they were discharged. We then followed up and connected them even to a cardiologist for those who triggered into the dashboard. So we went back into our foundation navigation model for those patients who needed follow-up. So all that to say, there was a lot of creativity. And I think this time really highlighted some of the unique innovative things that sometimes we don't do because we're sort of stuck in, this is the way we've always done it. And the beauty of COVID, as ugly as it's been, it's allowed us to really think outside of the box because we had no other choice but to do that. So I think that, well, yep, that wraps it up. As Andrea said, my name is Sarah Clemons and I'm the Cardiovascular and Primary Care Service Line Director for IU Health for our Indianapolis suburban region. And what I'm gonna be discussing is how we organized information, how we handled our surge, how we rebounded from that surge and what we learned going forward. To start, Indiana University Health is a statewide organization. My scope is three community hospitals in the suburbs of Indianapolis. And that's IU West, IU North, IU Saxony. And we also have a critical access hospital, IU Tipton. And that centers around our academic health center, which is in downtown Indianapolis. And that's made up of Methodist Hospital, University Hospital and Riley Hospital for children. Just to give you an idea, capacity by each facility, IU West has six adult ICU beds and 127 total beds. They have very minimal peds. We only have two pediatric beds there. We are soon to have 173 beds. We are undergoing construction currently and we'll end up with 14 ICU beds in a closed unit. So total, we're adding 46 beds. We see about 400 PCIs annually and we average about 20 STEMI activations per month, which in our market is pretty significant. We're the only 24 seven cat lab in Hendricks County. IU North has eight adult ICU beds and 189 total beds. But of those beds, they have very strong peds population. They're a branch of Riley in our suburbs. So they have six PICU beds, 23 NICU beds and 10 peds. They really only see about 115 PCIs annually though. And they see about three STEMI activations per month. Others very strong CV competition in that market. IU Saxony has four adult ICU beds, but they're more PCU beds that are ICU capable. So they have 32 total beds and very minimal peds, just like West. But they do see about 300 PCIs annually and about seven STEMI activations per month. Again, IU Tipton is critical access. So their beds are PCU capable and they do not have a cath lab and they send those patients for STEMIs to Saxony. So first things first, how did we organize? How did we transfer our data across a statewide organization? So what we did early on was adopt an incident command structure at the regional level, but also at the statewide level. So we started the mornings with a statewide call to where the system incident command would transfer information to our regional incident command. Then we'd have another call where that information was transferred to site level leadership. And then they had Q&A sessions right behind that for our site level managers in order to be able to convey information. And they then were able to take at the site level or managers could go back to the teams, convey information, gather feedback, concern. And then they started in reverse order for the afternoons. Excuse me. So site level leadership would then reach out to regional, give any feedback that the staff had or concerns that would then escalate back to the system level. And it gave our system leadership time in the afternoon to make decisions. And it started all over again the next day with the cascade of information. So the staff really felt like they were heard. Their concerns were quickly addressed and they had information very quickly, which was very important to our team. I highlighted the medical branch and staging branch because that was part of my role on a regional incident command since I already had regional coverage. So how did we care for that many patients? Where are we gonna put all of these people? My role for staging branch was converting med surge beds into ICU beds. So for our region, we went from 18 ICU beds across three facilities to 128 ICU capable beds in two months. We did that mostly through our partnership with our ambulatory surgery centers. Since they weren't able to do electives, they offered up all of their equipment. They stripped all the ambulatory surgery centers of suction, oxygen monitors, and sent us all of that equipment. As I said, IUS was undergoing construction. So we had, and construction had been significantly delayed. So we got lucky and we had a lot of that equipment physically onsite that we could use to outfit med surge beds. And we also were able to transfer ventilators very quickly across our system. In our partner hospitals downtown at Methodist University in Riley were able to send us all the available ventilators that they had. So we had enough onsite thankfully to take care of our patients without having to dip into anesthesia machines. Our medical branch in conjunction with our staging branch activated a tiered staffing model for pandemic that you can see there on the bottom right. And in that model, one ICU physician can supervise four non-ICU physicians. And similarly one ICU nurse could care for six patients as long as she had a care team of three support RNs that were non-ICU. So those partnered care teams were able to care for more ICU patients than what they normally would be able to do. In order to free up beds again, we had to make the hard decision to go on STEMI diversion at North and at West. That was very hard for West given that we're the only 24 seven cath lab in the county and we do get a lot of activation. So for about a three week period, we diverted our STEMIs to our downtown campus in order to free up those beds specifically at West who was getting hit pretty hard with COVID patients. We also transferred within our region. We adopted Saxony as more of a quote clean facility. So our orthopedic fractures, for example, those urgent and emergent orthopedic cases, we transferred to Saxony. So those patients could be cared for there and free up more beds at North and West where we were seeing the most COVID patients in our region. Also with North's partnership with Riley Hospital for Children downtown, they actually shifted their pediatric patients to Riley. Since they had so many of those ICU capable beds by shifting that pediatric population to Riley, it freed up more of those beds to be able to be cared for for an adult population, which was very helpful for us. So once we had all of the beds, what do we do with all of our caregivers? without having electives going on, we have a lot of caregivers that can be supported. And again, we were not going to furlough any of those caregivers. So we had cath lab RNs, of course, with ICU experience, some of which were very recent, had come from ICU with our expansion. So we put those nurses back in primary ICU roles. Other cath lab nurses were used as support roles in that care team with those ICU nurses. Echo techs were trained into support roles as PCAs, and door screeners. We used our cardiac rehab teams in the same fashion. And also our quality coordinators played a very important role. They brought facility questions forward that really resulted in a weekly CV operations call that brought all of our leaders together to make sure that we were handling our CV patients for urgence and emergence, the same across the board. They developed a CV dashboard so we could keep track of our case volumes, PPE, staff, and where everybody was, which was very helpful to know. Our pharmacists validated an order set for the use of Lytics and educated our nursing and physician leaders on these drugs that they're just not used to using on a routine basis. And importantly, they were also able to make sure that we had at least one dose at each facility available to us, and were able to redistribute those drugs as needed across the facility in a quick fashion. So when it was time to come back, we did that in a staged approach. The first week we went to 50% of budgeted elective volumes. We monitored to make sure that PPE was holding out and they were able to bring back enough caregivers to care for those patients. Week two, we went to 75% of budgeted electives and week three, we were able to go up to 100%. Again, staged that to make sure that our PPE could hold out and that we had enough caregivers to take care of these patients in conjunction with our surge that was still happening. We were bringing back caregivers who opted out, took a little bit more time. In the beginning of COVID, our caregivers were given the opportunity to opt out based off certain factors, age, pregnancy. Some of our caregivers were caring for elderly family members at home and were just very concerned. So they were given the opportunity to opt out and we were able to then bring those caregivers back once we hit that 50 and 75% ramped up approach. We did reserve the ramp up at the 50 and 75% level for EP. We found that we were still doing a good job of maintaining our urgent and emergent cases for cardiovascular patients through COVID, but EP was one of those areas where those patients were beginning to push out. So we utilize that 50 and 75% volume ramp up for EP to be able to clear those volumes out early. And then we were able to shift those back to peripheral vascular and cardiovascular electives at the 100% level. I think we learned a lot through this pandemic. If we had it to do again, of course, hindsight's 2020. As a staging branch, we were so proud of ourselves. It only took us two months to stage 128 ICU beds, but we were never gonna be able to staff that many beds. So really we spent a lot of effort converting those beds back to med surge beds, but we really wouldn't have needed to stage in the beginning. I think new construction is gonna look very different. We've been living at West in construction for a couple of years now, and we found that when we were choosing monitors early on, it was bare minimum monitors for the type of room that those rooms are gonna be, but that really hindered us when we were trying to convert those beds into ICU beds. We really got lucky having those ICU capable monitors from our ambulatory surgery centers and from expansion, but in wave two with electives that aren't going to be diminishing, that's not gonna be available for us. So it's gonna look very different. Suction regulators and oxygen ports and rooms, again, by facility, that really varied. At North, for example, all of our med surge rooms had the capability of at least plugging in for suction regulators. At West, our med surge beds were not like that. We could only plug in two. So we were finding with the ICU patients that were COVID, they were requiring much more suction than your standard ICU patient would normally take. So going forward, I think as we plan new constructions, we really need to think about that as we're planning our headwalls of each of our rooms, that even though this is a med surge room, we really need to think about that going forward as capabilities for us. Use of waiting room space. We've always prided ourselves as a lean organization that throughput is important. You don't need much waiting room space. That really came back to bite us. Our waiting rooms are very small and there aren't as many of them, but as you're trying to social distance, even a small number of patients, it really has become difficult for us with smaller waiting rooms. So where I can appreciate being a lean organization, we really need to look at that going forward in new construction and how we're gonna manage that. I learned that cross-training of RN staff really needs to continue to be ongoing. We were lucky that some of our caregivers had recently come from ICU training, but just at least helping our nurses understand that they don't always get out of the cath labs very often, but making sure that they're at least comfortable knowing where they are in their facilities, knowing people and trainers in other units, just so if you have to go to another unit that you feel good that you at least know where things are. And I think that's gonna be important going forward on an ongoing basis. And I also think disaster supplies are gonna look very different. In the staging branch, we were moving supplies around a lot and just the types of supplies we keep in our disaster supplies, we really didn't think about minor equipment being part of disaster supplies. And I think we're gonna need to think about that going forward and not just PPE. I believe we're having a Q&A session coming up. So with that, I will turn it over to Amy. Well, hello everyone. As Andrea mentioned before, I'm Amy Dukovic. I'm a former cardiovascular service line director and currently now in the consulting world with a focus on cardiovascular services. So I'm gonna take some of the general things and big things that my colleagues here have told about their experiences. And I'm gonna now focus in on the data managers experience. So what I'm gonna do is tell you what data managers have been experiencing directly and give you some tips on how to prepare for the future based on the work I've done with some of my clients. So here we go. So first, I just wanna take a look and summarize what my colleagues have talked about is just the general effects that we've seen of this COVID crisis on hospitals in this country. First, obviously there were a lot of bed shortages and personnel shortages, as you've seen how people, you know, built their plans to make up for those things. And then of course, a lot of elective cases were either stopped and or severely limited based on certain criteria, which then led to a very significant revenue loss in a lot of places, which then led to some decisions that had to be made about certain, about cutting, making cuts, which was, it's never pleasant, but unfortunately that is what had to be done. And of course there was the all hands on deck approach, which then caused people to either be completely reassigned or partially reassigned. So now what I'm gonna do is show you what the data managers told me that they were experiencing. So first thing I did was I wanted to see if other data managers across the country were experiencing the same things as my client. So with the help of some people on this team and a few of my other colleagues, I sent out a survey across the country for data managers and the administrators. So as you can see, I had 82 respondents. And as you can see here on this slide, they were pretty well spread across the country. So I got a nice distribution. So I can feel relatively confident that this is a reflection of most of the country. The first question I asked was, did your facility put any type of limitations on elective cases? And as you can see out of these respondents, pretty much everybody's institution did. I believe that no portion is literally just one answer. So this had then a lot of effects. So some of the issues with the stoppage of elective cases were big revenue loss. These are, especially in cardiovascular cases, they are generally the big money makers for a lot of these facilities. So in turn, that led a lot of hospital administrators to have to make some very, very difficult decisions, despite the fact that in some places, people were given other duties with the all hands on deck approach. In other facilities, that was not the case. So the next question then I asked was, were you or your colleagues either furloughed or had your work hours decreased? So that was also based on the experience of one of my clients. The data manager in one of my clients was actually furloughed for a couple of months. I didn't even get to meet her until I was literally halfway through the engagement. So as you can see here, then a little over half of our respondents reported that either they or their colleagues were also furloughed or had their work hours decreased. And a little under half, of course, did not. So it's a almost even split. So the next thing then I asked, if you were furloughed, how long? And as you can see by these responses here, the general time period was between one and three months. And I believe in my client where the data manager was furloughed, it was three months. And a few of them were a little longer than three months. Which then led to the next question, which then led to the next question for those that weren't furloughed, were you reassigned to other duties? And a little over a third of those folks were reassigned or not completely, but either given some duties or had to add on or given total new duties during the crisis. And then a fair amount of them, though the majority of them though were not. Which I found to be rather interesting. So now that we saw how long folks were reassigned, let's look at the types of reassignments that people told me they were assigned to. As you can see, a lot of this does tie in with what my colleagues previously presented. And there was a variety of types of reassignments. Temperature screenings, call center duties, covering for their colleagues that were furloughed. And in fact, in one of my clients, the chest pain coordinator was taking over the duties of the data manager who was furloughed. And she took over, she managed Cath BCI and STS. It was a fairly low volume facility, but that's still quite a bit to take on for a chest pain coordinator, because again, STEMIs are still coming through the door. They had to do PPE distribution, fit testing, helping with data analysis in other departments. Those that are nurses went back to the ICU on the floors, COVID reviewing cases, exposure tracing, and safety coaching. So as you can see, there were a large amount and a varying types of reassignments. And again, if you look at the times they were reassigned, generally again, the reassignments lasted between one to three months. Or the only difference is if you look at the still reassigned, there was a fair amount more that were still reassigned. And this at the time of the survey, and this was in late August. So they were still going with their extra duties, assuming most of the crisis interventions started around late March, early April. So I found that to be interesting also. So then of course, people started coming back. There were various types of ramp ups across the country. As you saw some examples earlier, I will say in my clients, they were both smaller private facilities. So, and one was relatively low volume. So they just started right back up. They didn't, there was no ramp up, they just went. And that, if you're still on a reassignment or you're just coming back from furlough, trying to scramble to catch up, that tends to give you this hair on fire scenario, which is what I worked with, with my clients. I know in some cases, there were some deadlines that were extended that were much appreciated. But there was just a ton of catch up work because STEMI still came in the door, urgent non-STEMIs came in the door and cases still went on and didn't quite decrease at the level they thought they would. And a lot of people were still on their reassignment duties, as you can see with the all hands on deck scenarios. So that's why I put the person there with their hair and looking like their head is on fire. So what I've now been doing with these clients is working on helping them prepare for the next wave that our experts are predicting is gonna come quite soon with the advent of flu season. So there are a couple of tips here, but I gave you some tips here, but I wanna say that they are all based on good communication. As I have always told my staff in my former life, if you think you're communicating too much, you are probably just barely communicating enough. So all of these again, but these are specific communications that you really need to make sure you're doing. First is find out what the hospital or your institution is deciding to do with elective cases. Are they gonna suspend them? Are they going to place limits, put in a tiered system like you saw in one of the previous presentations? I know that one of my clients said they will do things very differently this time. They are not going to stop cases, elective cases completely. There was just too much revenue that they lost. So you really need to get a handle on what you're gonna see coming in at that point. Also, if you were a reassigned person, work with the department where you were reassigned and make sure you can work out some kind of schedule and see if you can be there certain times as opposed to just on demand. Because this next part is very, very important. You really need to get with your administrators and make sure you negotiate time to keep up with your registry. Like I said before, cardiac cases aren't stopping. Heart disease, STEMIs, none of that took a break. So you still have your work to do. Also, if you are fortunate enough to be in a group, make sure you can familiarize other colleagues with your registry. So I'm working now, so in the client where the chest pain coordinator had to take up the duties, I'm working to make sure she's comfortable with CAP, BCI and STS. Although the data coordinator may not get furloughed this time, there's still gonna be a lot of work in catching up. And hopefully they can, and I'm doing the same with the other data managers so to make sure they can help cross cover each other. Also, it is very important to make sure your administrator understands how much of your work is backlogged so that they can help support you and make sure you have the time you need to get this data in and through to the registries. And last, again, if you are fortunate enough to be in a group, you can plan, make sure you get with your colleagues and you guys can plan out who's going to do what, when and where. And maybe if there are reassignments, have certain number of people go on reassignment a certain day and the other folks collect data and then switch that around as needed. So that is all I have for you. And first I wanna take a couple of acknowledgements. I wanna thank Andrea for helping me with distribute the survey across the country. Thank you, Andrea. Also Jennifer Bobbitt and Amy Newell who supplied me with some very, very good information. And last but not least, you folks, you data managers and CV service line administrators who took the time to answer this survey for me and really give me the information I need so I can turn around and help you. I believe now we're gonna go to a question and answer system. So I will hand it back to Andrea. Thank you so much for those three very informative presentations. Over the past few months, I think it's so interesting to hear everybody's different experience through COVID. And I really appreciate you guys taking the time to share not only your personal professional experience, but share what your teams have done and how your organization handled the last few months, which has just been an extraordinary year for all of us. So a few questions that have come to mind. One is thinking back, what is something that you are so thankful that you had invested pre-COVID that allowed you to be agile during the first COVID surge? Diana, would you mind to kick us off sharing your insights? Sure, you know, Andrea, that's a great question. And I think hindsight is 20, 20. And in this case of the question, you make a good point and sort of got my will spinning. One of the things I would identify is our governance structure. We've got a governance structure of all of our subspecialties that consists of our physicians and our administrators. And it provided an opportunity for quick communication because we already had the structure in place and we were living it and it was hardwired prior to COVID. And so as things were changing so rapidly, it gave us an opportunity to streamline that communication and bring awareness to the physicians while they were sharing information, clinical information on their side. That's from sort of a physician administrator perspective. And then at the operations level, we have a similar communication process with all of our CV leaders. So we've got an established regular cadence of touch points with our CV leaders and we've had that for some time. And so at the time when there was, again, things happening so rapidly and you have to quickfire communicate something, we have that process and model in place for early communication. Even at the clinical nursing level, there was always that ongoing communication with nursing leadership as well. I mean, quality, but it's structured process and outcomes, right? I mean, nothing more than COVID in 2020 has definitely had that. Sarah, how about you? We had a very strong enterprise asset management team already in place that had a system-wide lens on equipment. Anytime equipment was going to be taken out of commission, they had a lens on that. They had a warehouse already for a lot of that equipment. So as we needed equipment, they were our first lane. So we went straight to them. They could tell us where we could find what we needed. And then they actually facilitated a lot of the transfers for us as well with our couriers. So already having that in place, that's not something you can quickly throw together and expect it to be able to function last minute. So thankfully we already had that in place and we wouldn't have been able to make it without it. Yeah, I think that definitely brings out, we've used essential workers a lot during the COVID pandemic and caregivers are definitely front of mind, but talk about couriers and resources in our healthcare systems that really help support the whole care team. Important. Amy, what about you? So in my one client is a very small facility kind of on the low volume side, but they were part of a very large, large national organization, which actually had a very good network of data managers and a hierarchy of directors and things. So that was great in that they were able to communicate with the directors on how much you could take on, how much you needed to leave. And they really did a good job of keeping track of what they needed to moving forward. Once the worst of the, once the brunt of things died down a bit and they were moving on and bringing back elective cases, I would say their communication system amongst their data coordinators in the system was very good. Sounds great. So we're all trying to prepare, like we don't know when the next wave is gonna come. There's even conversations on, has the first wave actually stopped yet? So every day it's a little bit different in this world for the country, as well as for our healthcare system. So tell me, what are you currently doing to prepare for the next surge, the next wave of cases that may or may not happen later on this year? Sarah, would you like to share? Sure, actually, we found the tiered staffing model was something that our nurses just were not used to. They were not comfortable with it at first. We didn't have a lot of time really to train to that model. So that's what we're working on now. So helping our nurses to be trained towards a tiered staffing model, what the responsibilities would look like and just making them more comfortable. So in the event we have to go back to that level of tiered staffing, that they feel better about it this time around. Learning from the fact that we staged way more beds than we needed, getting a handle right now on, we won't have ambulatory surgery centers for a second wave to give us their stuff. All of our expansion equipment is now in play. So really getting a better handle on what assets are currently available to us and where are they positioned, so we can make sure to transition those quicker if we see a strong surge again. And Diana, how about you? How are you preparing your region at HCA? I'm having audio. Oh, can you hear me now? Yeah, there we go. All right. Sorry about that. I accidentally, and I was just going away. I accidentally hit mute because my speaker with my earpiece had fallen out. Sorry about that. Let's start over. Yeah. Yeah, great question, Andrea. As we look at what the future holds, and we really don't know that, and my sort of perspective is at the division kind of broad strategy level. And so we've seen that virtual consult has been really important and instrumental in ensuring that we continue to provide care in this COVID world. And so we've done a lot in terms of making it easier for our referring physicians through technology to share images across the division, follow up post procedure with our referring physicians. And that's something that's been ongoing for some time and really tightening our virtual experience for our patients and our physicians. So as we look at the surge or the potential for another surge or another wave of this, we've got processes in place that don't disrupt the care of patients and allow them to continue to see their cardiologists remotely. Great. And Amy, given your clients, I know you shared a couple of insights at the end of your presentation on how to better prepare. Can you go into that a little bit more about how our data managers need to prepare? Because chances are most facilities will not be canceling the elective procedures. And so that looks a little bit different for those watching today and what their work may look like. So that's a great point, Andrea. You know, currently I have two clients I'm working with and they're in very, very different parts of the country. One client is in a part where they had a very low number of cases. So they did modify the elective cases, but they still kept going with the guidelines actually similar to what Sarah had mentioned in her presentation. They classified what's urgent, non-urgent and so forth. So with that person, I sat down with them and said, look, you're still going to be doing your same job here. So I think what you have to do is negotiate the time to do your job versus the time you get pulled away and reassigned. And you're going to have to be honest with them and say, look, if we're not doing cases, I need, or if we are still doing cases, we have to, you know, I have to limit my time that I can be out passing out masks or doing other work and encouraging that place to take a look at the, take a look at the whole picture from just, you know, from their perspective. And again, they're a small, they're part of a small organization that's only two acute care centers. So they really don't have, this person had no one else to rely on to do registry data. So I encouraged that administration to keep her in place and give her her time she needs. Whereas my other client is in an area that did very poorly and had a ton of COVID cases. And they had to basically stop all electives. They were only doing people that were in-house that came in with a non-STEMI or unstable angina or something. However, I did talk to them about not just using the chest pain coordinator to take up some of her work, because that person, you know, when we talked, she said it was very difficult for her because her workload basically did not change. And they were just adding on. So they are all part of a very large, large organization. So I sat and talked with their administrators, the director of the data coordinators for the system and asked if she could look at maybe dividing work a little bit differently. Because they were all working, even those that weren't furloughed, they were working from home anyways. So they should be able to collect data in another hospital because you're still all in the same system. So really, I think it has to be based on your facility, what type of an organization you're in and what is going on in your area. And you have to tailor it to that, those factors. Yeah, I think you bring up really good points. And as a CV operation leader, I've heard Sarah and Diana highlight cross-training for your nursing staff and for your clinical staff. But I think you really bring a good point on trying to cross-train and support your registry data team as well, creating a checks and balance and kind of a professional group within your organization that can help support, especially during these times. Yeah, and I also had differences in the backgrounds of my data coordinators. One was a nurse and one is an RCIS. So you can't pull an RCIS to go take care of an ICU patient. It just isn't gonna work like that. Right, yes, definitely. So in many ways, it really feel like, it really, sorry, can we stop and start from the top? All right, we've got about 10 minutes left. Are you guys good if we go over just a couple of minutes? Cause we got 10 minutes of recording and we've got like eight minutes. You guys are good for a couple of minutes? Okay. Yeah, sure. All right, are you ready? So it really felt like the world stopped. And in so many ways we had to keep on going. How did you navigate the everyday staffing challenges such as retirements, maternity leaves, onboarding of new staff members, in addition to everything else that changed in the COVID environment? Diana, would you like to start us off? Sure, that is something that is ongoing and then it just felt even more strange during COVID when there's shortages. You know, we really try not to decline vacations, for instance, I think more than ever, this is a time where people just needed to take a break when they needed to take a break and we were really sensitive to their sort of work-life balance. What we've done recently within HCA, we've actually centralized our data abstraction, our data quality department into one group. And what's great about that is it allows us to leverage resources better. And so if there's a person out, like you touched on earlier, that cross-training is already embedded and it's created and sort of natural versus when we were siloed, it feels a little different when someone takes time off. And so having those resources combined that instills a sort of collaboration across the company and allows us to have that time off without feeling the hurt and grunt of that happening. Yeah, definitely. Sarah, what would you like to add? I wish I had a silver bullet for that one, but we just got lucky. We had a lot of extra caregivers here with our construction that was delayed. So our units were supposed to go live with our new cath labs in this past November and we just went live actually today. So we had a lot of extra people around still in training. So we were able to redistribute a lot of those caregivers. And we also had a lot of support from our resource pool from the academic health center downtown. And they did shift a lot of the resource nurses to us to help us during our highest point in the surge. So that was very helpful as well. And Amy, I know you've shared some coaching and how you've kind of helped some of your clients. Anything additional you would like to add? I think only to reach out to other departments also, especially in my one client where her reporting structure was actually to the quality department and not the cardiovascular service line. So I think there was also helping out with, planning, like I had said before. I will help you guys out with this, but in turn, I will need you all to help me with data abstraction and here's how we do it. So again, it's very much based on the system. Yeah, and the other client, I asked them to look at it. They had a very strong centralized data extractor group. So I asked them to like kind of communicate more and work more together as a system and help cover each other. Yeah, that's a really good point. I know we have had our registry team both in the CV operations and the quality department. And currently we're in the quality department and the additional need to support virtual visits and COVID has, it's been a very big task for sure. So I have one final question for you all and then we'll wrap up. I really appreciate everybody's time today. So COVID has brought us all to think about things a little bit differently than what we ever would have before 2020. Some of these changes we've thought about before COVID, but really the last few months really forced us to embrace these changes. What are a few things that you'll continue even post COVID? Amy, do you want to start us off? Sure, definitely. I mean, the thing that comes to my mind immediately is letting the data coordinators work remotely. A lot of them, they just, they've been wanting to work. It's funny because in one of my clients, they wanted to work remotely. They'd been asking to work remotely and now COVID forced the issue. And so the administration's been able to see that things worked out. So we're gonna keep them remote for as many days a week as possible and just make sure they're just showing up for meetings or even not even meetings yet because all meetings are on Zoom. So they will let them stay remote for the foreseeable future. I call those the essential remote workers. Make sure you guys coin that down whenever you're talking to people. Like that, great job. Yeah, we are essential remote workers. All right, Sarah, what do you have to add? Along those lines of working from home or virtual meetings, we found that I actually have gotten better attendance from my physicians because it was easier for them to call in. On-time starts in our cath labs is mission critical for us and it's a strong focus, but we were finding a lot of on-time starts were declining because they had meetings offsite or they had to be downtown for this and they couldn't get out here until a certain time. But now in the world of virtual meetings that they're getting used to it, our physicians can take those meetings from onsite and be ready for those first cases. So that's definitely something that we're gonna continue. I love how you're tying the financial component to the on-time start to the virtual meetings. I'm gonna file that one away. All right, Diana, can you wrap us up? Sure, I think that the other ladies touched on some really important and good points. And I mentioned it earlier as far as virtual meetings and also virtual clinic follow-ups with patients. I think I can't elaborate on that enough. I think now more than ever, it's just really highlighted the need to think creatively and the role that the data abstractors play in that is they are really essential in, does that make a difference in our quality and our outcomes will tell us that. A patient who may have been seen in person but doesn't feel comfortable going to the practice, they've got options now to see their cardiologist virtually. And prior to COVID, at least I heard a lot from our physicians that, oh, patients, they wanna see me in person and they wanna be in the practice and they wanna be visible. But I think we've all realized that, you know what, this could work and we've seen the benefits of it and for patients and physicians, our data abstractors prove that to us in our quality outcome. All great points. And I cannot thank the three of you enough for taking time to share your experience. I just wish we could all be in Orlando together to see everybody, but I am so glad to see you guys here and thank you so much for sharing your experience. I know many that are calling in and listening to this conference will have a lot of good takeaways from your presentations and sharing your thoughts on the last few months. Thank you. Thank you. My pleasure. Thanks, everybody. Thanks.

ACC Quality Summit

COVID-19 pandemic

healthcare impact

patient care

communication

collaboration

flexibility

virtual consultations

remote work