Reopening clinics safely in a pandemic
Adaptability, efficiency and focus on improving patient experience keys to success
“Adaptability, adaptability, adaptability wins the day.” That’s what Arthur B Cummings MMed(Ophth), FCS(SA), FRCS(Edin), PCEO, said of the successful reopening of his Dublin, Ireland, cataract and refractive surgery clinic after seven weeks shutdown during the first wave of the COVID-19 pandemic.
Just as important is focusing on improving the patient experience while increasing clinic efficiency, noted Guy Sallet MD, FEBO, of Aalst, Belgium. Drs Cummings and Sallet outlined the steps they took to reopen their private clinics in the ESCRS Practice Management & Development Webinar “Rebuilding Your Practice in a Challenging Environment”, which took place in January and is available free of charge online.
ACTIVELY INVOLVING STAFF
At Dr Cummings’s Wellington Clinic, which does about 2,000 procedures annually with 90% in cataract, refractive and keratoconus, the road to reopening began as soon as the clinic closed on 27 March 2020. “The very next morning after the lockdown was announced, the team got together; myself, [clinic manager] Lisa [McLoughlin RGN, RM, BSc] and [clinical support/research manager] Liz [Brennan BSc, MSc] to think about how we would get through.”
The most immediate concern was cancelling appointments over the next few weeks. Wellington was able to do it quickly and efficiently using the text messaging capability built into its electronic medical record (EMR), Dr Cummings said. Inbound phone calls were routed to the clinic manager’s cell phone.
Next, they did a staff analysis, dividing staff into four groups; critical, essential, helpful and not essential. Then staff processes were reviewed with an eye toward limiting staff-patient contact as much as possible, for example by conducting postoperative visits online or by phone when appropriate, Dr Cummings said. Other early steps included setting up connections so key staff could work remotely, sourcing vital personal protective equipment (PPE) and setting up an online shared appointment tracker to keep everyone informed of cancellations and restarting the clinic.
During the lockdown, optometrists and nurses phoned patients for postoperative appointments and virtual visits, reducing the wait list for reopening. Weekly staff meetings via Zoom helped keep the full team up to date and brainstorm work return plans. “This was more often meeting than before, but we felt it was necessary to keep everyone up to date.” Virtual consultations were offered to continue some services to patients.
One month before returning, Dr Cummings asked each staff member to submit suggestions on reworking the patient journey and process changes in writing. These were consolidated and discussed during a half-day Zoom meeting. The team voted on the best ideas and the final processes developed were a hybrid of all the staff ideas. A new patient appointment diary was configured to allow all the new processes, which were designed for maximum safety and efficiency.
Process changes included creation of an e-pack for prospective patients that includes all they need to get started. “It used to be we got all the information in a lengthy phone call. Now the phone call is quite short and all one needs is an email or text address and we send the e-pack,” Dr Cummings said. It includes a link to Wellington’s online medical history form using FormStack (formstack.com). Online payment options include Stripe and PayPal to further reduce time in the clinic.
Involving all staff in developing the new processes had multiple benefits, Dr Cummings said. “Many heads are better than one but it also helps to provide a sense of control to a team in uncertain times and it encourages their adoption of new processes.”
MINIMISING CONTACT, MAXIMISING EFFICIENCY
Dr Sallet took similar steps early on at his Eye Institute, including creating a new patient flow and scheduling template allowing all preliminary diagnostic testing to be completed before patients see the doctor with an eye toward minimising clinical contact. For cataract this includes, topography, biometry, fundus camera and OCT; for glaucoma, perimetry, non-mydriatic fundus photography and OCT; and for pre-refractive, topography, tomography, biometry, fundus camera, dry eye assessment and cycloplegia. The doctor reviews the results and has a good idea of the case before seeing the patient.
“This means the patient spends less time in the doctor’s office but the contact with the doctor is more intense. We are not looking at our files at that moment so we have more time for the patient,” Dr Sallet said. The result is a more professional approach and better patient experience, he added.
Dr Sallet’s clinic also relies on technologies such as OCT and non-mydriatic photography to reduce reliance on perimetry, which reduces the frequency of visits to monitor glaucoma progression. To reduce visits for cataract surgery, he is moving toward doing more same-day bilateral procedures, though this is a financial challenge because currently the second procedure in a day is not reimbursed in Belgium.
At Dr Cummings’s clinic most cataract and refractive surgery day-one appointments (except for LASIK) are now done remotely “and it is working absolutely, perfectly well”.
REARRANGING OFFICE SPACE
Meeting patient expectations for safety is critical, and that begins with rearranging offices and installing plexiglass shields throughout the clinic to protect both patients and staff, Dr Sallet said. In his case, he was fortunate that his clinic was undergoing renovation, so creating larger exam rooms was easier – though it comes at the expense of seeing fewer patients in a larger space. Dr Cummings followed similar steps before reopening.
Having less waiting room capacity and the need to schedule fewer patients to avoid crowds and make room for emergencies further cuts the number of patients each doctor can see in a day, but is necessary both for safety and to reassure patients that the practice is safe, Dr Sallet said. “Patients expect less crowding.” Upon reopening, Dr Cummings introduced temporary longer opening hours to address this need for social distancing and reduce an extensive waitlist from appointments cancelled during the lockdown.
Actively communicating the steps taken to protect patients is also essential, Dr Sallet added. He does this through announcements and posting on the clinic web site. Emphasising the safety steps he is taking has helped patients feel more comfortable coming to his ambulatory surgery centre than to public hospitals, a trend he expects will continue after the pandemic.
Indeed, the pandemic has pushed him to think more directly in terms of improving patient experience and flow rather than relying on approaches such as seeking accreditation, which is expensive and does little to affect patient experience. “COVID-19 has taught us some things that can improve patient experience after the pandemic.”
Another bright side of the pandemic is it has renewed interest in refractive surgery, in part to help patients cope with masks fogging eyeglass lenses, Dr Sallet said. Increased disposable income due to less travel and eating out is also driving the trend, as is a renewed focus on personal health and comfort brought about by the need to stay home most of the time, Dr Cummings said. In addition to laser refractive surgery, he is seeing greater interest in multifocal IOLs for cataract patients.
The increase in refractive procedures has helped Dr Sallet’s clinic offset some of its losses from closing and serving fewer patients. At Dr Cummings’s clinic high interest in refractive procedures allows him to fill appointment cancellations almost as fast as they occur – which is essential for the clinic’s survival.
“To remain financially viable, you have to do enough procedures,” said Dr Cummings, whose private clinic was among the four out of 14 refractive clinics in Dublin to survive the 2008-2009 financial crash. He recommended keeping up with consumer confidence and economic trends as much as clinical developments, and constantly adapting to keep pace and provide the best possible patient experience and outcomes.