Risk Management for a private healthcare provider & COVID-19
How a private healthcare provider managed the risk of patient infection during the COVID-19 pandemic.
Adam Reid Johnson
Thesis submitted as a part of the Master of Philosophy Degree in Health Economics, Policy and Management
UNIVERSITY OF OSLO Faculty of Medicine
Thesis Supervisor: Trond Tjerbo
June 2021
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Risk Management for a private healthcare provider & COVID-19
How a private healthcare provider managed the risk of patient infection during the COVID-19 pandemic.
Adam Reid Johnson
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© Adam Reid Johnson 2021
Risk Management for a private healthcare provider & COVID-19 Adam Reid Johnson
https://www.duo.uio.no/
Printing: Universitetet i Oslo
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Abstract
Title: How did a private healthcare provider manage the risk of patient infection during the COVID-19 pandemic? A Case Study.
Aim: Examine the strategies utilized by Central Florida Retina (CFR) to mitigate the risk through internal infection control measures to protect both employees and patients.
Background: Due to COVID-19 being a contemporary topic, there is much research to be done on infection prevention. A vast majority of the existing literature on risk management and infection prevention of COVID-19 focuses on hospitals and nursing homes, leaving private healthcare providers unexamined.
Methods: A qualitative case study, utilizing semi structured in person interviews to collect empirical data. Post interviews, I employed inductive reasoning to determine the most applicable theory in risk management strategies and infection prevention.
Conclusion: James Reason’s Human Error and System Approach theory has utility in risk management and infection prevention at this private healthcare provider. The practice acted according to the Swiss Cheese Model and System Approach to risk management and error prevention, though did not explicitly state its utilization. The healthcare provider emphasized working together, and not placing blame on a single individual for mistakes if they were to occur, but analyzing the system failures as a whole. The Swiss Cheese Model is how a business such as CFR could think about risk especially in the context I have described in this thesis, erecting as many barriers and safeguards as possible to prevent an unfavorable outcome.
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Acknowledgments
First, I’d like to thank my supervisor and professor Trond Tjerbo for his guidance and patience throughout this process. Without whom this master thesis would not have been possible.
I’d also like to take this opportunity to thank all the participants at Central Florida Retina and your valuable insight on the events that occurred during the Corona Virus Pandemic. The selfless act of providing uninterrupted care to patients despite the danger to yourselves and your families is the embodiment of what it means to be in the medical field, and I thank you for your service.
Lastly, I’d like to express my gratitude towards the University of Oslo as a whole for this opportunity. I am the first in my extended family to have the means to pursue a master’s degree.
Without free tuition this would not have been possible. It is my hope that the policy of free tuition for international students will continue, as it opens the door to endless possibilities that may be otherwise out of reach.
- Adam
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Table of Contents
1. Introduction...……… 1
2. Objective……… 3
3. Background………... 4
4. Theory……… 8
4.1 Risk Management in healthcare as a Concept……… 8
4.2 James Reason’s book “Human Error”……… 8
4.2.1 Person Approach………. 9
4.2.2 System Approach……….. 10
4.2.3 Swiss Cheese Model………. 10
4.3 Types of Errors………. 12
4.3.1 Active Errors………. 12
4.3.2 Latent Errors………. 12
5. Methodology……… 14
5.1 Literature review………... 14
5.2 Interviews……….. 15
5.3 Physical Tour……… 17
5.4 Quantitative Data……….. 17
6. Results……….. 18
6.1 Fear………... 18
6.2 Uncertainty………... 20
6.3 Safety Concerns……… 24
6.4 Lack of Resources………. 26
6.5 Retrospection……… 27
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7. Analysis & Applicability……… 29
7.1 System Approach……….. 29
7.2 Swiss Cheese Model………. 29
7.2.1 Layer 1: Patient Vetting and Prioritization………... 30
7.2.2 Layer 2: Social Distancing……… 32
7.2.3 Layer 3: Personal Protective Equipment………... 34
7.2.4 Layer 4: Proper Hygiene………... 35
7.2.5 Layer 5: Employee Training and Precautions………36
7.2.6 Layer 6: Effective Leadership………... 38
8. Limitations………... 40
8.1 Contemporary Topic………. 40
8.2 Interviews……….. 40
8.3 Additional Research……….. 40
8.4 Personal Biases………. 41
8.5 Theory Limitations……… 41
9. Conclusion………... 42
References……….. 44
Appendix……… 50
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List of Tables & Figures
Table 1: Patient Insurance Provider Breakdown for Central Florida Retina in 2020…... 21 Figure 1: The Swiss Cheese Model version of Reason’s OAM published in the BMJ paper
(Reason, 2000)……... 10 Figure 2: Patient Flow by Month at Central Florida Retina for 2019-2020…... 24 Figure 3: Treatment Prioritization Flow Chart ……... 30
Abbreviations & Acronyms
AMD Age Related Macular Degeneration CFR Central Florida Retina
CDC Center for Disease Control COVID-19 Corona Virus Disease of 2019 EMR Electronic Medical Records PCR Polymerase Chain Reaction Test
PHEIC Public Health Emergency of International Concern PPE Personal Protective Equipment
PPP Paycheck Protection Program SARS Severe Acute Respiratory Syndrome SCM Swiss Cheese Model
WHO World Health Organization
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1. Introduction
COVID-19 also known as Sars-Cov-2, has put the world’s healthcare systems to the test. Some countries have performed better than others, but none have been completely immune to this pandemic. A relatively small private group practice, with 6 locations and approximately 40 employees called Central Florida Retina (CFR) located in Orlando Florida which specializes in diseases of the retina and vitreous has been providing uninterrupted care to patients throughout this pandemic. A vast majority of the patients being treated at this practice are considered high risk in regard to COVID-19 due to age and comorbidities. One of the predominant diseases being treated at the practice are individuals suffering from age related macular degeneration (AMD).
AMD is a progressive retinal disease primarily found in elderly patients. AMD can be treated but is irreversible, meaning vision cannot be restored once lost, and without regular treatment
usually injections once a month, the disease will eventually cause complete blindness.
(Geerlings, Hollander, & Jong, 2016). Therefore, the practice is unable to temporarily cease operations and postpone treatments unlike many other private physician group practices in the United States that have closed due to COVID-19.
This thesis is to serve as a qualitative case study analyzing empirical data gathered to present the decision-making processes, internal infection control measures, and risk management tactics utilized by CFR to tackle the obstacles caused by COVID-19. By maintaining operation, the practice has been able to prevent their high-risk patients from seeking treatment at a hospital which could result in the patient becoming unnecessarily exposed to this deadly virus. This also prevents the over utilization of scarce hospital resources, resources that could otherwise be allocated towards the treatment of COVID-19 patients. Recent studies have shown that the elderly population, CFR’s primary clientele, are disproportionately affected by COVID-19 when compared to children and young adults. (Kadambari, Klenerman, & Pollard, 2020) This topic has been chosen due to its relevance to the current situation, as well as the lack of literature on this contemporary topic. Despite there now being a vaccine, COVID-19 is not disappearing anytime soon and due to globalization and an increase interconnectedness such as air travel, pandemics such as this could become even more frequent. (Saunders-Hastings & Krewski, 2016) By
2 analyzing the risk management strategies utilized, it may create a basic plan of action and
protocols for future events.
Governmental aid and focus have been placed on hospitals and nursing homes, leaving small private practices such as CFR to mostly rely on themselves. Large hospitals have substantially more resources than most private practices, that being more financial, equipment, and shear number of employees at their disposal. CFR had to be especially careful with their human capital, to prevent a staff shortage due to infection. In addition, much of the academic literature as of late has had a strong focus on hospitals and nursing homes and how these organizations are handling the pandemic, leaving small private healthcare providers unexamined. It is my hope that this thesis may help to fill in this gap of research, so as to help gain better understanding of this pandemic’s far reaching effects.
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2. Objectives
As previously stated, this thesis is to serve as a qualitative case study analyzing this particular event and CFR’s risk management response to protect both patients and employees. Empirical data was collected through anonymous interviews of both clinical and nonclinical staff and presented in narrative form to provide practical information of the situation, as well as present the human experience of the employees at the practice. This study aims to go through the events occurring up through the end of 2020. The practice has a total of six locations around the Central Florida area, I intend to focus on their flagship and original location in downtown Orlando Florida. There are several reasons for this, mainly the administrator of the practice and primary decision makers are located at this office, if a policy is decided upon and implemented at this location the rest are to follow suit. This main office also has the most physicians and support staff which results in the highest patient flow on a regular basis. Quantitative information will additionally be utilized and presented in tables within this thesis. The quantitative data that will be presented is primarily patient flow data, comparing the year 2019 to 2020. The significance of a decrease in patient flow highlights the numerous difficulties the practice has been facing in 2020.
A single poor decision could cause a rapid spread of the virus within the practice causing a domino effect that could lead to a complete shutdown of the organization, and the potential spread of the virus to their high-risk patients. Hopefully this report might provide guidance for future decision-making practices if a similar situation were to present itself. As Judith Green and Nikki Thorogood (2018) explained in their book, Qualitative Methods for Health Research, a primary goal of a qualitative study such as this is to do research that contains external validity, so that it may be transferable and aid in the understanding of similar issues or situations.
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3. Background
On January 30th, 2020 the World Health Organization (WHO) announced that COVID-19 was a public health emergency (PHEIC) and of great international concern, the highest alert the WHO can deliver. (Burwell et al. 2020) As this thesis is being written, the vaccine is being distributed to the most vulnerable in the population, many of which are patients at Central Florida Retina.
Though, there is no guarantee that COVID-19 will not continue to mutate, for example the U.K.
or Indian strains of the virus and cause the new vaccine to become less effective. In addition, the logistical and societal obstacles can slow the vaccination process of the general population. The current population of the United States is upwards of 330 million (Moore, 2020). The logistics of producing and vaccinating that many citizens is staggering. To make things more difficult, many of the vaccines need to be kept at subzero temperatures making transportation and storage difficult without proper equipment. This is also not to mention the societal pressure to not vaccinate due to distrust in the newly created vaccine. So, it is important for medical practices to be mindful of the future and treat this situation as the new norm for the time being.
The United States is especially vulnerable to this pandemic due to the high prevalence of a variety preexisting conditions when compared to many other countries. The Organization for Economic Co-operation and Development (OECD) found that 38.2% of adults in the United States were considered obese in 2017. This is compared to the OECD member average of 19.5%
obesity rate. (OECD, 2017) A study by the CDC the same year found that 10.5% of people in the in the United States are suffering from either type 1 or 2 diabetes. (CDC, 2020) Another disease commonly treated at CFR is diabetic retinopathy, which is damage to the retina due to diabetes.
There is still much debate and research to be done on all of the risk factors associated with COVID-19, nevertheless, there has been ample amounts of evidence showing that diabetic patients are more likely to develop severe symptoms due to the virus. (Zhang et al. 2020) The United States being so large the country operates on a federal system and every state is unique in their demographical makeup and density. For example, Central Florida has a dense population and an older demographic, so it is especially vulnerable to the devasting effects of the virus. Many of the decisions associated with the COVID-19 rules and regulations are delegated to the state government, some rules can even be broken down by counties. For example, mask
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mandates were left up to individual counties, CFR is located in a county that did at one point in the pandemic have a mask mandate indoors, but no longer does. It is important to note that whether there was a mask mandate or not in the county, medical practices still required masks inside and had the right to refuse their services if the individual refused to wear a mask inside.
The practice had to ensure they were following all rules and regulations that were constantly being updated as the situation continued to unfold. The CDC (2020) put forth comprehensive guidelines and checklists on how to operate safely during corona virus for healthcare
organizations. This checklist is not rule of law, though it’s utilization is strongly encouraged by the CDC. CFR has had to navigate this constantly changing situation ensuring they were
adhering to all rules and regulations for the safety of both the patients and their employees. One person at the office was assigned the task of keeping up to date on CDC guidelines and ensure all parameters were being met. A lack of coordination between providers has become even more evident during this pandemic compared to other comparable healthcare systems. In the U.S. less than half of primary care providers are notified from specialist if there has been a change in their patients care plan. This is compared to Norway where nearly seven out of ten would have been notified of changes in their patients care plan. (Doty, 2020)
Mayo Clinic estimates that 30% of people that require medical care are delaying visiting health professionals as a result of COVID-19, many of which are afraid of catching COVID-19 at a medical practice or hospital. (Mayo Clinic Staff, 2020). As a result, 72% of physicians surveyed said that there will be serious health consequences in their communities due to delaying care for something other than COVID-19. (The Physicians Foundation, 2020) In addition the Physicians Foundation also conducted a survey in July of 2020 and found that 8% of physician offices permanently closed as a result of COVID-19, and another 4% plan on closing in the next 12 months if the situation continues. This 8% represents 16,000 practices, this is astoundingly significant given the country already considers itself to have a shortage of physicians. The
closures due to the virus not only affects private businesses and individual lively hoods, but these closures also put increased pressure on hospitals. At a time when hospital resources are already spread thin, these closures only exacerbate the issue. The study also found that 43% of
physicians reduced staff as a result of COVID-19 and suffered a decrease in overall income. (The Physicians Foundation, 2020)
6 There has been a recent surge in the utilization of telemedicine in ambulatory practices for the first time due to COVID-19. (Layfield, et al. 2020) This can prevent patients from unnecessarily being exposed to the virus at physician offices or hospitals. Insurance companies are also
pushing for the use of telemedicine, due to its cost saving potential. This is unfortunately impossible for CFR to implement due to the examination process of the eye. For example, a patient may call complaining of blurry vision or floaters which are naturally occurring but also may be a sign of a retinal deterioration. The practice can take a patient’s medical history over the phone which can be important information when considering seeking treatment, but other than that not much can be done. The retina is located at the back of the eye, so it is impossible to see anything by just looking at the superficial exterior of the eye. The patient must go into the office to have their eyes dilated and a special instruments used so the eye can be properly examined to reach any meaningful diagnosis. Telemedicine also lacks effectiveness for CFR because if an issue is suspected, there is nothing the patient can do to try and treat the medical issue
themselves. The only case telemedicine is applicable for CFR, is prescription renewal.
Social distancing practices have also been a powerful tool in fighting the virus, especially protecting geriatric patients with multiple chronic conditions. (Stein, 2020) The office waiting areas are relatively small so social distancing protocols can be difficult to adhere to. One way to alleviate this problem is only allowing the patients into the waiting areas, having anyone
accompanying the patient to wait outside. Despite this effort to maintain social distancing within the office, the real problem is once the patient leaves CFR. Many of the patients live in nursing homes or assisted living facilities where it is difficult for them to adhere to social distancing protocols. A recent study found that 40% - 45% of COVID-19 cases are asymptomatic, and in some cases, can transmit the virus longer than 14 days (Oran & Topol, 2020). So, there is always a fear that a patient will unknowingly bring the virus into the office infected employees and patients alike. This is compared to your common flu which symptoms on average begin after only 2 days and are most contagious after only 3 to 4 days after infection. (CDC, 2018) So you are more likely to know you are infected sooner and the time you transmit the virus is of shorter duration when compared to COVID-19.
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This pandemic has been a game how to properly allocate scarce resources. This not only being monetary, but CFR’s human capital is of equal if not more important to its success. Numerous of studies have been carried out this year on the emotional struggle faced by healthcare workers.
Many employees have felt fear of becoming infected at work and then unknowingly bringing the virus home to infect family members. (Nembhard, Burns, & Shortell, 2020) In addition to support staff, specialist physicians are especially irreplaceable making the need for a structured and safe plan of action vital. (Stephens et al., 2020) If a physician becomes infected at a small practice such as CFR and has to go into quarantine, the practice will suffer greatly.
Asymmetrical information between support staff and management has been also been an issue during this pandemic. An open-door policy within organization to voice needs and concerns is imperative in protecting the practices human capital.
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4. Theory
4.1 Risk Management in healthcare as a Concept
Healthcare risk can be defined as the probability a person could incur injury, disease, or death as a result of medical intervention. (Riehle, Braun, & Hafiz, 2013) Similar to many other complex systems such as engineering or aviation, if not managed properly, healthcare’s complex system can create an adverse event that may lead to a fatality. (Cagliano, Grimaldi, & Rafele, 2011 as cited in Vincent, 2006) Healthcare providers need to look to these other industries to observe what work has already been done in the field of risk management strategies for guidance. (Chera, Mazur, & Marks, 2015) CFR can be considered a high reliability organization, meaning it needs a high level of reliability to maintain success. This is why it is important to create risk
management analysis and strategies for their success during this pandemic.
The best way to handle and calculate risk is through previous experience. Having a full
understanding of all the associated variables can aid in your risk assessment and decision-making process. COVID-19 being a completely new phenomenon for our lifetime, makes risk
management and planning especially difficult for the healthcare field. This lack of experience and knowledge of handling a pandemic drastically increased the risk of maintaining operation for CFR.
4.2 James Reason’s book “Human Error”
How can the application of Reason’s theory of errors help provide guidance in creating preventative measures which can protect patients and employees from becoming infected by COVID-19 in the workplace?
The theory of error was originally introduced in James Reason’s book “Human Error” in 1990.
Reason’s theory comes from a long-standing field of error identification and risk management to improve the workplace. One of the first related theories being Herbert Heinrich’s Domino Theory in 1931. This was one of the first schools of thought that brought a scientific approach to risk management and error prevention. The “Domino Theory” presented how there is a causal chain of events that can lead to an incident. This theory was originally applied to the industrial
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fields, where accidents were rampant at the time and sometimes deadly. (Heinrich, 1931) This school of thought was later applied to the medical field to identify the causation of adverse events, for example, giving a patient the wrong medication resulting in patient harm. A relatively simple model and theory, “Domino Theory” focused on which individual was at fault for the error, instead of delving deeper into the organizational structure and policy that could have caused the adverse event. (Heinrich, 1931) James Reason believed this approach was much to simplistic, only utilizing a linear chain of events to a very complex organization with many moving parts, and to some degree counterproductive to organizational improvements.
According to James Reason’s Theory of Errors, there are two approaches in dealing with human errors in a complex work environment, the system approach and, the person approach, both having unique ways of error identification and prevention. Reason’s explained that you cannot change a humans conditions, but management can change the conditions in which they work.
(Peltomaa, 2012) I propose looking through the lens of James Reason’s Theory of Errors to identify the best course of actions in the prevention of COVID-19 infections at CFR. In addition, how this theory can serve as a risk management technique for CFR.
4.2.1 Person Approach
The Person approach to identifying error aligns similarly to Herbert Heinrich’s Domino Theory of causality. This approach focuses on the blaming of an individual for their short comings, despite a possible underlying reason that may have led to their mistake in the first place. This approach can attribute an error to anything from an individual’s forgetfulness, lack of motivation to perform the task effectively, or simply carelessness. The person approach can be very obvious and tends to be much more emotionally driven and satisfying when compared to the system approach. (Reason, 2000) Long term, this approach is must less effective in the overall improvement of the organization. By singling out and possibly punishing one individual, this does not address the much deeper underlying factors, and the error may very well happen again in the same manner to another employee.
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4.2.2 System Approach
The system approach is much more applicable in a high reliability healthcare organization such as CFR. This approach concentrates on the conditions under which people work under and attempts to build defenses from there. (Reason, 2000) The system approach to risk identification and prevention, delves much deeper into the source of the issue compared to the person
approach. Asking what policies or structure are in place that caused this either latent or active errors? This is much more difficult and time consuming than just pushing blame on a single person. The person approach can be seen as only a temporary fix to a much more imbedded organizational problem that will sooner or later happen again to the same individual or another.
During the pandemic, CFR needed to anticipate and supply themselves for the worst-case scenario, in this case employee or patient COVID-19 infection outbreak. It was imperative that CFR is able to build a high reliability conditions to build effective defenses against the virus with the scarce resources they have. They can do this by focusing on policies and structures in place instead of solely focusing on an individual’s short coming or mistake as in the person approach.
By asking the questions, how and where their defenses failed? They can identify problem areas in the organization as a whole.
4.2.3 Swiss Cheese Model
Figure 1: The Swiss Cheese Model version of Reason’s OAM published in the BMJ paper (Reason, 2000)
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The Swiss Cheese Model (SCM), a form of system approach to risk management, was originally developed by James Reason in his book Human Error in 1990. A block of cheese may be
considered an odd analogy for risk management and error prevention, but its familiarity and simplicity has made it a popular option for analyzing medical errors and accident causation.
(Perneger, 2005) If you were to cut the block of cheese into slices, each slice would act as a barrier against an undesired outcome. The holes in each layer of the slices can be thought of as imperfections or errors waiting to happen in the system. If for a moment, all the holes line up and a linear movement can go all the way through the block of cheese, then there will be an
undesired outcome or incident. This helps highlight James Reason’s idea that an adverse event is seldom a result of a single problem, but a complex collection of shortcomings with many
contributing factors. (Reason, 2002) No organization is perfect and in a perfect world the cheese would be a solid clock containing no holes. This is of course impossible to attain so the primary goal is to identify and minimize these holes in each layer as much as possible. While also developing as many layers as possible to minimize the possibility that the holes will line up and led to an adverse event.
The SCM has even become popular in nationwide healthcare planning and infection control during the COVID-19 pandemic. New Zealand a country that has been commended on their handling of the COVID-19 pandemic has utilized Reason’s SCM to plan their layers of defenses to defend their island population from the novel virus. The University of Auckland’s Faculty of Medical and Health Sciences created multiple Swiss Cheese Models for the nation to adhere to during the pandemic. Their layers included border control, social distancing, and proper hygiene to curb the possibility of a nationwide outbreak. As time went on and the pandemic improved, New Zealand could slowly remove some of the layers to return the country to form of normality.
(Wiles, & Morris, 2020)
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4.3 Types of Errors
There are two types of errors associated with Reason’s Theory of Error. Both types work together to cause the eventual accident to occur.
4.3.1 Active errors
Active errors also known as “sharp end errors” occur on an individual level. Though, these are still a result of a larger systematic issue within the organization that needs to be mitigated. In the realm of healthcare organizations, these active errors occur at the point of contact between healthcare provider and patient. There are multiple reasons for active errors, such as, poor judgement, policy violations, or mental lapses. (Collins etc al., 2014) In the case of CFR and COVID-19 infection prevention, an active error may be a policy violation in the form of not questioning an arriving patient if they had been in contact with an COVID-19 infected individual recently. There could be any number of reasons this policy violation happened, including a simple mental lapse, and forgot to ask the question. So, this active error occurred, now the question is why it occurred. What policy or lack thereof caused this situation? The easy response is singling out and blaming the individual, though Reason’s system approach would argue there is a much more seeded issue at hand. For argument purposes, let’s say the employee is working to long of shifts causing the mental lapse as a result of fatigue. So, the deeper underlying issue that needs to be addressed is the shift structure at the organization. If this error was to occur, another layer of defense would hopefully block and prevent further progression of a possible infection event.
4.3.2 Latent errors
Alternatively, latent errors, also known as blunt end errors, are the result of an organizations poor policies and protocols and are much less apparent than active errors. (Reason, 2000)
Unfortunately, these can be very difficult to identify within a complex organization and are considered inevitable given enough time. Many situations may cause latent errors, for example, organizational policies, lack of leadership, the inadequate working environment, and substandard procedures in place at the institution. (Collins et al., 2014)Each layer in the SCM contain known and unknown latent errors or imperfections. An example of a hypothetical latent error is there’s inadequate staff leading to employee fatigue which can then cause the active error of a mental
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lapse and forgetting to ask patients if they have been in contact with an infected individual. To assess this accident causation, management needs to understand how the individual and system interacted. (Collins et al., 2014) For each layer of defense there are inherent latent errors, it is up to management to identify and correct them before they cause an adverse event to occur.
(Reason, 2000)
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5. Methodology
This case study primarily utilized an inductive analysis of empirical data to devise the theory to answer the research question; how did a private health provider manage the risk of patient infection during the COVID-19 pandemic? I chose to perform semi structured in depth
interviews with employees at Central Florida Retina. The goal of the one on one interviews was to capture the subjective human experience while gaining practical knowledge of how Central Florida Retina managed the risk of the COVID-19 virus. I firmly believe that attaining this primary data can help build a complete picture of the events that occurred. I utilized four sources of information to answer my research question, these included documents, interviews, direct observations, and archival records. As Robert Yin (2018) pointed out in his book, Case Study Research and Applications, this type of research requires discretionary behavior from the facilitator. Since the participants are not being video or audio recorded in any way, if the
participant says something that could possibly reveal their identity, then I have to decide whether or not to omit that piece of information from my notes to protect the participants identity. As seen in the results section of this thesis, quotes are used, but the interviewees are simply given a number to protect their identity. As the only researcher in this study, I am the primary instrument in gaining the data.
5.1 Literature Review
Before formulating the questions used for the interview process and my final research question, I performed an in-depth literature review on the topic of COVID-19. This was not only to identify gaps in knowledge about the subject so I can better focus my research, but more importantly to develop more decisive and insightful questions about the research topic itself. (Yin, 2018). Due to COVID-19 being a new on-going event, there is a natural gap in the information and research on the topic. I used key search terms which included but not limited to, COVID-19, healthcare risk management, crisis management, and COVID-19 risk factors. The terms brought up numerous studies within the last year around the world. Though, most studies focused on an entire field or subsection of medicine, whereas my intention is to focus on this specific practice and how it dealt with the pandemic. After the literature review, I created the interview questions and process.
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5.2 Interviews
The questions used for the interview which can be found in the appendix of this report, were overall open ended to encourage creative and reflective thought from the participants. A relatively small sample size, seven participants, drawn from available staff willing to be interviewed at Central Florida Retina’s main location was used. Both clinical and non-clinical support staff were interviewed to better understand all aspects of the pandemic and how it affected the practice as a whole along with them on a personal level within the workplace.
Naturally some staff had more direct contact with patients and possibly the virus than others. All of the staff interviewed were current employees that worked throughout the pandemic.
The interviews were conducted over a two-day period on February 22nd & 23rd 2021 in person at the main CFR office in Orlando Florida, USA. This location was the best option because it saw the highest volume of patients and had the most staff. COVID-19 restriction and regulations were adhered to, myself and the interviewee remained 2 meters apart and wore masks during the duration of the interview. Additionally, I had received a COVID-19 test shortly before the interviews to provide an extra layer of assurance that I was not caring the virus. Central Florida has been a hot bed for COVID-19 infections due to a high population density and lack of overall regulations. So, it was imperative that I took all necessary precautions to perform these
interviews.
Due to such a small sample pool I utilized strategic sampling, choosing who I considered the most relevant and qualified employees to this study. I interviewed seven employees at the practice, four of which were nonclinical support staff while three were considered clinical and having constant direct contact with the patient on a daily basis. I consider all seven of these participants credible, giving valuable insight into the events that occurred. It may have been beneficial to interview all staff at that location, as well as interview the staff at the other five CFR locations to give a larger sample size. Unfortunately, due to logistical difficulties and time constraints this was just not feasible at this time. For example, I focused my interviews at one location because on the unlikely chance I contracted COVID-19 before or during the interviews I did not want to then go location to location spreading the virus and possibly infecting the entire practice.
16 Before the interview officially began, I first explained the nature of the study to ensure they in fact wanted to participate. To maintain complete anonymity for the participants, no questions that could be considered personally revealing were asked. In addition, the interviews were not video or audio recorded to further maintain the anonymity of the participants. I’d encourage the participants to provide personalized answers but dissuade them from providing me with
information that could be deemed revealing to their personal identity. From my part, I assured the participants that no names were going to be linked with any answers and they would remain entirely anonymous. I simply transcribed and took notes on what the participant said. I scheduled an ample amount of time for these interviews to be conducted with each individual, taking between 30 minutes to 1 hour depending on the participant. Since this is a semi structured interview, I wanted to give the participant plenty of time to answer the questions and say whatever else they thought might be relevant. Having ample amounts of time also gave me the opportunity to come up with and ask follow-up questions based on the answers the participants provided. This is another reason I chose to utilize this method of research, there is no clear cutoff point for data collection. (Yin, 2018). In addition, these interviews were conducted one at a time to ensure that someone else’s presence would not affect the way the participant answered a question. For example, if a superior was present for the participants answers, the individual might not be completely honest or only give a partial answer to avoid possible future conflict, which would jeopardize the integrity of the study.
In these one on one direct in person interviews you can hear their tone of voice and also analyze telling facial expressions, which can help further demonstrate how the pandemic and resulting changing within the practice affected the individual. Once this qualitative data was collected, I expressed this information in narrative form, as seen in the discussion section of this report. I was able to categorize their responses to identify themes and patterns to better convey the information.
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5.3 Physical Tour
Another benefit of performing the interviews in person, was I was given a tour of their facility to gain direct observations for my research. I could see the social distancing protocols they put into place, new signage, and other physical changes that were made to the office as a result of the virus to protect both employee and patient.
5.4 Quantitative Data
Quantitative data in the form of patient flow records have also been utilized and presented in the results section of this case study. The goal of these records is to develop a paradigm between the patient flow of 2019 and 2020, to show how COVID-19 affected the amount of business the practice was receiving and how that may in turn affect the decisions being made by management.
For example, if the practice is receiving fewer patients due to fears of COVID-19, should the practice decrease the hours of operation to save costs? By decreasing the number of hours in operation, management runs into the moral dilemma of bookings appointments close together so patients would have more contact with each other in the waiting room possibly spreading the virus. This information can also give a glimpse into the financial hardship the practice was enduring to remain in operation while not decreasing the number of hours in operation or terminating staff to cut costs. It is important to note that the data was anonymized before I, the researcher, received it from the staff at CFR. I was not the one to collect or have access to CFR’s patient database. The staff at CFR keeps track of patient flow data regardless of my research, so it was as simple as requesting the data to attain it. Luckily, they were more than happy to oblige this request. In no way can any patients be identified in this data, simply the number of patients seen in a given month.
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6. Results
The aim of the interviews was to identify common themes in CFR’s risk management approach and where holes in their defenses may lie. In this section the primary findings are presented after interviewing seven employees at CFR. A questionnaire study in Denmark among frontline workers found the primary feeling of insecurity amongst employees is fueled by insufficient information, a lack of access to PPE and having poor managerial response to the crisis (Nabe- Nielsen et al., 2020 as cited in Houghton et al., 2020) I found many similarities amongst the employees I interviewed as well.
The following were common themes that emerged from the interviews:
• Fear
• Uncertainty of the Future
• Safety Concerns
• Lack of Resources
• Retrospection
6.1 Fear
“The first patient we lost due to Corona Virus shook the entire team due to their age”
- Interviewee #1
Over the course of 2020 several of CFR’s patients passed away due to COVID-19. Fortunately, none of these deaths were tied directly to the practice and an infected employee. Based on the interviews I conducted, the first patient that CFR lost was by far the most impactful. The first patient to die was in their late 30’s, and with few preexisting conditions. This occurred in early April at the beginning of the pandemic. This is a relatively young age to die due to COVID-19 based on current evidence of which demographic is most at risk.
This was particularly scary for much of the staff because not only someone they knew died of COVID-19, but the staff saw themselves in this young patient. Many of the CFR staff are around
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same age as this individual that died. So, the mindset around the office went from COVID-19 being a distant issue in other countries to one in their own backyard. In addition, little at this point was known about the virus, and it was still uncertain as to whom the virus affected most, such as age group and comorbidities. The main fear became if it could kill someone a similar age to myself, then it could kill me or young loved one as well.
After the loss of the first patient being so young, some staff based their fear on historical
influenza events such as the Spanish Flu of 1918. Unlike the normal seasonal flu whose victims tend to be either very young or very old, a pandemic such as the Spanish Flu of 1918 had a high mortality rate among young adults due to their very active immune systems. (Short, Kedzierska,
& Van De Sandt, 2018) The fear from the staff was COVID-19 could be something similar. This made the staff fearful to even leave their homes, much less go to work and possibly exposing themselves to the virus. According to the individuals I interviewed the most prominent fear was catching the virus at work and then bringing it home to their family members.
“Putting myself in harm’s way is one thing, but putting my family at risk was my main concern.”
- Interviewee #2
The administration’s solution was to hold a zoom meeting after work hours with all employees to discuss these concerns, fears and how they were going to move forward. It was imperative that all employees were present, and their concerns could be heard. At this meeting they also
brainstormed ideas on how to make the practice safer for employees, and what is to be expected for the months to come. Administration also reminded staff that they were all medical
professionals that provided a necessary service to their patients, and therefore had a
responsibility to continue coming into work despite these fears. Administration reiterated and stressed their open-door policy after this meeting, that all employees are encouraged to keep an open dialogue on what they feel is important. Of course, during these times of social distancing, the term of having an open-door policy is simply an idiom. Now all communication is done electronically to prevent the spread of the virus.
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“Their (patients) vision is everything to them, something you don’t truly to appreciate until you begin to lose it”
- Interviewee #6
Many patients had a very difficult decision to make as a result of Coronavirus. They could either stay at home to avoid contact with others to decrease the risk of contracting the virus. As a result, the patient would then run the risk of losing their vision due to not seeking treatment and
receiving monthly injections for their AMD. Or, the alternative was to leave the safety of their home and running the risk of contracting the virus, but in turn receiving treatment and preserving their vision. Their fear of losing their vision overcame the fear of contracting Coronavirus for a vast majority of the patients. The staff I interviewed mentioned this dilemma for the patients multiple time. For the patients, the choice was an easy one. They wanted to preserve their vision at all costs despite being in a high-risk group. Many of the patients had friends or knew someone that had died from the virus, but that didn’t seem to matter when it came to their vision.
6.2 Uncertainty
“The lack of concrete information from our government and health officials was very difficult. This also made long term planning nearly impossible. So, we just decided to treat the situation as the new norm and expected it (COVID-19) to continue for the foreseeable future.”
- Interviewee #7
The primary uncertainty was, if the practice is required to temporarily close due to either financial or safety concerns, how long would it be closed? Or, would the practice end up like many other private healthcare providers and never open again. Mass closures were commonplace amongst private medical practices in the United States. This could be because a practice
encountered financial difficulties with a decrease in business, or a practice might not want to take on the risk of treating patients during this pandemic. Another reason a practice might close their doors is they do not view themselves as an essential business, so why take on the risk of seeing patients during the pandemic when the patient can just seek treatment at a hospital? Many of
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these initially risk averse private healthcare providers did not stay closed for long, really until the virus was better understood and what precautions they needed to take to provide safe care to their patients. This is unlike CFR who did not have the luxury of temporarily closing due to the
conditions they treated. Though, as previously mentioned, there were practices in the United States that closed due to the pandemic and are expected to never open again.
Table 1: Patient Insurance Provider Breakdown for CFR for 2020 Private Insurance 27%
Medicare 58%
Medicaid 12%
Uninsured/Self-Pay 3%
A little practical knowledge of how payment is derived at CFR. The way payment is derived in general for private medical practices in the United States healthcare system can be complex when compared to many systems around the world. Income for CFR is a fee for service structure, the more patients treated, the more the practice earns. As seen on the table above, a majority of patients being treated at CFR are Medicare patients primarily due to their age. An individual is eligible for Medicare, which is the government funded healthcare insurer, if they are 65 years of age or older, under 65 with a qualifying disability, or suffering from end stage renal disease that requires dialysis. To be eligible for Medicare at the age 65, an individual or a spouse would have worked for at least 10 years paying into the Medicare tax. (U.S. Department of Health and Human Services, 2014) Patients are covered by Medicare Part B when seeking treatment at CFR, which usually covers doctor visits and outpatient procedures. Most of these patients that have Medicare also have a private supplemental insurance, usually known as Medigap. This private insurance covers things Medicare B does not cover entirely such as co-pays and deductibles.
Because the patients being seen at CFR needs treatment on a regular basis, they would accumulate a large amount of co-pays or deductibles. This is why it is in their best interest to have supplemental insurance in addition to their Medicare. Alternatively, the patients that have Medicare but do not have a supplemental insurance, usually have Medicaid to help cover the additional costs not covered by Medicare B. Under Medicare the U.S. Government has a complete list of how much they will pay providers/suppliers for a specific service called a Fee
22 Schedule. (Center for Medicare & Medicaid Services, 2021) This schedule is updated on a
regular basis and is what CFR can expect to receive as payment for services provided.
Medicaid on the other hand, is U.S. government insurance reserved for low income or pregnant individuals. The number of patients being seen at CFR that have Medicaid is around 12%. It’s a relatively small proportion of their patients seeking treatment because most are eligible for Medicare due to age or disability. As previously stated, the primary condition treated at CFR is age related macular degeneration (AMD) which usually onsets after the age of 65.
A little over a quarter of the patients seen at CFR are privately insured. This private insurance is based around the concept of managed care, a common method of insurance structure in the United States. The insurance provider begins by negotiating and creating a contract with private practices such as CFR. In the contract CFR agrees to provide services at a reduced cost to the insurer. So, CFR is considered as in network with this specific insurance provider. If a consumer is a member with that insurance company, they will need to be seen at an in-network practice if they want their visit covered by the insurer. This contract guarantees a certain amount of business for CFR, so it is important for them to participate with these types of managed care organizations. In addition, CFR is not required to be in contract with only one insurance provider at a time, they can have several contracts simultaneously with multiple insurers. It is important to note that private insurers pay more for the same service compared to Medicare or Medicaid, so it is in CFR’s best financial interest to direct marketing strategies and treat as many patients
privately insured as possible.
“A few of our patients had to forego treatment after losing their insurance that was provided by their job. Which they lost due to Coronavirus.”
- Interviewee #4
In the situation that a patient does not have insurance and is seeking treatment as self-pay, they are given a discount and pay the same rate as the U.S. healthcare system under Medicare. Based on the interviews, the employees seemed sympathetic towards self-pays, but at the end of the day the practice is a business and needs revenue to continue practicing. As seen on table 1, the
amount of self-pay patients is negligible compared to the overall patient flow of the practice.
This is due to the high cost of treatment even with the Medicare rate.
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To curb the financial uncertainty CFR took out a Paycheck Protection Program (PPP) loan. Due to the pandemic, the United States government was issuing loans, that if used to pay employees, did not need to be paid back. This type of loan was a way incentivize businesses to keep
employees working and on payroll during the pandemic and prevent the downsizing or closure of the businesses. (U.S. Small Business Administration, 2021) It is still considered a loan because if it is spent on anything other than employee payroll, it would need to be paid back with along with a low interest rate.
Employees worked between 1-3 days a week depending on what team they were a part of. As a result, employees were not working their usual 40 hours a week. Most of the employees are paid hourly like many in the medical field under normal circumstances. If an employee is only scheduled to work one day for a given week then that employee is only able to log eight hours for said week. This would be a significant loss of income for the employee if they were only getting paid for 8 hours compared to a usual 40. Many of the employees had a spouse or partner who was laid off or furloughed from their job due to the pandemic, bringing the household income dangerously low. Management at CFR was aware of this fact and paid employees the equivalent of 30 hours a week no matter how many hours they actually worked. The practice began this 30 hour a week salary structure immediately, even before the PPP loan began. This was to help support the employees and their families.
This guaranteed pay structure of 30 hours a week did not come without its criticism. On the surface, this pay structure is beneficial and helps employees during these difficult times but was deemed unfair by some staff. Staff that worked one day a week and the staff that work three days a week were paid the same wage, the 30 hours weekly. This upset many of the employees that work three times as much yet were paid the same wage. The way the skeleton teams were designed, which I will go into much more detail in the discussion portion of this thesis, there wasn’t much of an alternative option. Once the governmental PPP loan was approved, the
weekly pay went from 30 hours a week to the usual 40 hours a week regardless of hours worked.
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6.3 Safety Concerns
“A major safety concern for us (CFR) was ensuring that patient appointments were evenly spread out to maintain social distancing and not be overwhelmed with medically necessary treatments.”
- Interviewee #4
Figure 2: Patient Flow by Month at Central Florida Retina
As seen from the figure above, there was a significant drop in patients being seen during the month of April 2020 after the initial lockdown. The employees I interviewed all said the same thing, the patients were simply afraid to leave their homes to seek treatment. Administration was terrified that this trend would continue, and patient numbers would continue to drop each month.
This is not only bad for the bottom line of the practice, but also bad for the health of the patients.
As mentioned previously, patients suffering from age related macular degeneration (AMD) must receive monthly or at least bi-monthly injections to treat the progressive disease. If they forgo
0 500 1000 1500 2000 2500 3000 3500
Number of Patients Seen
Month
CFR Patient Flow
Year: 2019 Year: 2020 State Lockdown
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their monthly injections that artificially coat the retinal membrane and prevent its deteriorating any further, then the patient will begin losing their vision entirely at an accelerated rate. This is of course is irreversible even with future treatments. Administration knew this decrease in patient flow would only be temporary, though not knowing for how long. Eventually the pandemic and fear would subside, or at least become more manageable for the country. Though, this posed an entirely new dilemma. If patient flow continued to decrease, administration was worried that they would have a sudden and drastic uptick in business due to the huge backlog of patients that had forgone treatment previously due to the pandemic and initial fear of leaving their homes. The practice would then be overwhelmed by patients seeking sudden treatment, making it difficult to schedule this high volume of patients while still adhering to the social distancing guidelines.
Because the practice wouldn’t be able to handle that number of patients all seeking treatment at the same time at the first signs the pandemic was subsiding, this would cause a further delay in treatment for many patients. CFR wanted to have the constant manageable flow of patients that they were accustomed to.
The only way to mitigate this issue was to get the patients back as quickly and safely as possible, and to flatten the curve of patient flow. This can be considered the similar thought process as the early on in the pandemic for hospitals spreading out the patient flow. Be proactive and contain the pandemic as best possible to buy time to prepare for future patients and prevent hospitals from becoming overwhelmed.
Administration made the decision that their office was sufficiently safe to treat patients at a patient flow similar to pre pandemic. So, employees began a “safety assurance” call campaign.
The employees literally called each patient that had canceled their appointments and provided assurance that the necessary precautions have been taken to provide safe care while reiterating the importance of their continued treatments to prevent their disease from worsening. In addition, the support staff began calling patients with future appointments to give them the same safety assurance to prevent them from canceling and further delaying treatment.
These quality assurance calls were also to explain what is expected of the patient when coming in for an appointment. For example, they are required to wear a mask in the office at all times, their temperature will be taken at the door, and they cannot be accompanied by anyone like a family member while in the office. This might all sound straight forward and understandable, but
26 CFR’s client base is primarily elderly. Most of these patients had been going to CFR for many years and had become accustomed to how things operate. From the interviews the support staff expressed how difficult these calls were to perform, explaining that elderly are not as adept to change as many younger patients. It was also difficult to convince some of the patients that the office was in fact a safe environment and all the necessary precautions were being taken to prevent the spread of the disease. Despite the difficulties experienced, by May the practice had recovered to at least the number of patients being seen at the same time in 2019.
6.4 Lack of Resources
“Our greatest shortage were gloves and sanitizer, which are what we needed most.”
- Interviewee #5
Acquiring personal protective equipment (PPE) early on in the pandemic turned out to be one of the greatest challenges for the practice. Once Coronavirus was announced as a global pandemic and states began going into lockdown and panic buying amongst the general public ensued.
Unlike hospitals, these smaller private practices must fend for themselves to acquire the necessary PPE to continue providing care. Hospitals received government aid and supplies because they were top priority in regard to resource allocation during the pandemic.
Understandable, since hospitals are the ones in fact caring for the COVID-19 patients. Though, practices such as CFR have to continue caring for their patients as well.
The United States like most countries, saw huge shortages in PPE as a result of the pandemic.
China, where COVID-19 is expected to have originated from, produces an estimated 50% of the worlds PPE. Once the pandemic began, China halted the export of PPE products so they could better handle the virus. (Ranney, Griffeth, & Jha, 2020, cited in Bradsher & Alderman, 2020) This shortage was especially evident in specialized PPE such as the N95 masks which is estimated that China produces 95% of the world’s supply. (Dai, Bai, & Anderson, 2020)
“Not only did our staff go to the store to buy PPE and sanitizer, but we recruited our family members as well to buy supplies for the practice”
- Interviewee #7
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When the virus was announced as a global pandemic, management needed to act quickly to secure as much medical supplies as possible. Of course, no one knew how long with this pandemic would last, so it was important to get as much as possible until production of PPE could meet the overwhelming demand. Buying quotas were put into place everywhere for many items such as gloves and sanitizer. Employees were asked when they were out at a store to purchase supplies for the office as well, to increase the amount of supplies they could acquire.
Purchasing sanitizer became so difficult, management contacted a distillery that produced a high alcohol content grain alcohol. The product is very strong at 90% alcohol by volume, that would under normal circumstances be used for consumption, was now being used to sanitize the office.
Management was able to secure a deal with the distillery that insured the practice’s sanitizer needs would be met for the duration of the shortage.
6.5 Retrospection
At the end of every interview I asked everyone the same question. “If you or the practice could have done something differently knowing what you know now, what would it be?” I thought this question might be a beneficial way of identifying holes in their layers of defense.
“I wish our practice would have provided a clearer protocol on what to do when in contact with a positive COVID-19 patient sooner. In this case we were reactive rather than proactive.”
- Interviewee #1
The lack of accurate information from government officials about the pandemic made this very difficult. For example, the likelihood of someone being asymptomatic. Also, if someone in fact had been exposed to an infected individual how long should they remain in quarantine before it was safe to return to work. Not having testing readily available early on in the pandemic also made being proactive difficult.
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“It would have been nice to have more cleaning supplies stocked up for a situation like this, no matter how unlikely”
-
Interviewee #2
Nearly all the employees I interviewed said the lack of supplies was the most difficult part of the pandemic in some facet. Without the proper supplies the practice could simply not guarantee the safety of its patients. CFR also went into the pandemic with the assumption that the government would allocate the necessary resources for medically essential private practices such as CFR, but this was not the case. Resources were almost exclusively directed towards hospitals, leaving everyone else to fend for themselves. So, CFR was on a level playing field with the average citizen.
“We should have extended hours to spread of the patients more to prevent
overcrowding in the office. It would have given us the opportunity to see the less urgent patients as well”
-
Interviewee #4
The financial insecurity dilemma played into this decision to not extend hours. Before the PPP loan CFR was unaware how long they would need to survive simply on savings and the revenue they were still procuring. As soon as the pandemic began, the billing department at CFR had difficulty receiving payment from private insurers. Private insurance employees immediately began working from home, and during this transition they were difficult to reach by phone and there was a lag in payment. As a result, CFR decided not to extend hours and rely more heavily on patient prioritization.
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7. Analysis & Application
7.1 System approach
Since CFR is a high reliability organization their margin of error is small and they need to be proactive in their risk analysis and prevention, adding as many layers of defense as possible to protect both their patients and employees.
7.2 Swiss Cheese Model
The Swiss Cheese Model will present CFR’s layers of defense against COVID-19. This model might also help identify holes in individual layer defenses. Once the holes are identified action can be taken to at least minimize these holes as much as possible to protect patients. I intend to put additional emphasis on latent errors since these are traditionally more difficult to identify.
This may provide insight into what are areas for improvement that administration may not yet be aware of. It should be noted that none of these layers are impenetrable as they should not be treated as such. If one layer fails, it is not a complete disaster as long as the infection is blocked by a subsequent barrier. (Wiles, & Morris, 2020)
I have identified six primary layers of defense against COVID-19.
- Layer 1: Patient Vetting & Prioritization - Layer 2: Social Distancing
- Layer 3: Personal Protective Equipment - Layer 4: Proper Hygiene
- Layer 5: Employee Testing & Precautions - Layer 6: Effective Leadership
30 No
Yes Delay Treatment
14 Days No
No Yes
Yes
7.2.1. Layer 1: Patient Vetting and Prioritization
Figure 3: Treatment Prioritization Flow Chart assuming the appointment is medically necessary Has the Patient tested positive
for Covid-19?
Yes
Has it been at least 14 days and received 2
negative tests?
Has the patient come into contact with someone who tested
positive?
Does the patient have a temperature >38°C upon arrival or show
related symptoms?
No Treatment
Treatment Referred to PCP
and come back with negative test
Has the patient traveled internationally or to a hotspot for the virus?
No
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Arguably the most important line of defense, the first layer in CFR’s defenses is deciding if it is medically necessary to see a patient. This layer can prevent the virus from even arriving to the building. Deciding who received treatment early on in the pandemic was a difficult decision only the doctors could make. In theory, all of the preexisting appointments were medically necessary, but to maintain a sustainable patient flow and adhere to social distancing guidelines some appointments had to be rescheduled. Critical diagnosis’s that required immediate treatment are patients suffering from wet AMD that required monthly injections, hemorrhages, and retinal detachments. The patients that had a 6-month follow-up appointment were put on hold or rescheduled to a later date.
I developed a flow chart on patient prioritization as seen on the figure above based on the
information I was able to gather during the interviews. Once it was decided that the patients visit was medically necessary, a vetting process took place. Upon arriving at the practice, the patient would be asked a series of questions outside the building. First, has the patient tested positive for COVID-19, if so when? Treatment would be denied if they had tested positive for COVID-19 within the last few weeks. The patient would need to wait a minimum 14 since the positive test and receive two negative tests before being seen. If a patient’s appointment was canceled as a result of a positive test, or a patient tested positive after visiting the practice and called to inform CFR. The practice used a specific code called a COVID-19 red flag indicating the appointment was canceled specifically because of a positive test or the patient tested positive post visit. This code allowed the practice to build a timeline and track when the patient had been to an
appointment last. Then the patient would not be scheduled for an appointment until it had been at least 14 days and two negative tests.
Next, has the patient come into contact with someone who tested positive recently? Whether the answer is yes or no to this question the patient will be asked if they have had any symptoms and their temperature would be checked. If the patients temperature is above 38°C, which is the recommended temperature threshold by the CDC, then the patient is denied entrance and referred to their PCP and must procure two negative tests to reschedule the appointment. A COVID-19 red flag code would be used to ensure the patient adheres this request before returning. Lastly the patient was asked if they have recently traveled internationally or been to areas within the
country considered a hot spot for the virus, for example the densely populated North East U.S. If
32 the patient had in fact traveled, the treatment would be delayed for 14 days and appointment rescheduled. To make things even more difficult, many ophthalmologist and optometrist offices closed during the pandemic. Under normal circumstances, patients would be referred to CFR from one of these specialists. Now the entire vetting process and deciding whether or not to see a patient was up to the physicians at CFR.
Weaknesses in Layer 1:
• Hole 1: Human error, deciding to treat a patient that is not considered medically necessary.
• Hole 2: A mental lapse by the employee and not asking the vetting questions over the phone or upon arrival.
• Hole 3: Employee ignoring policy or taking shortcuts to save time.
• Hole 4: Patient not being honest during the vetting process in order to receive treatment.
7.2.2. Layer 2: Social Distancing
Social distancing has been a powerful defense against COVID-19. To help mitigate the risk of employee to employee infection, administration split the organization into teams. Each team had their own physician, clinical technicians, and support staff. The teams would not come into contact with each other under any circumstance to prevent cross team infection. If a team
member becomes infected, the team would then go into quarantine for 10 days and return after 2 negative COVID-19 tests. Because patients would see the same doctor every time they visited the practice, the patients would have the option to reschedule the appointment once the team had completed the duration of their quarantine. Alternatively, the patient could see one of the other teams to receive their medically necessary treatment. Though necessary, there were problems with this plan. The rescheduling of patients to another physician would cause greater strain and patient flow to that alternate team. If the patient was rescheduled to a later date with their usual physician, then the team that had been in quarantine would have a backlog of appointments that they would have to catch up on. This would cause scheduling difficulties due to a sudden rush of patients. The team would have to handle this rush while keeping social distancing protocols in mind.