One-Year Retrospective on COVID-19: Looking Back, Looking Ahead

Healthcare executives reflect on the strategic, innovative, and clinical opportunities hospitals have realized during the pandemic and contemplate the future. 

This article appears in the March/April 2021 edition of HealthLeaders magazine.

In the spring of 2020, the American healthcare industry experienced an unexpected paradigm shift as COVID-19 spread rapidly across the country.

For many hospital and health system leaders, early February was when they began to recognize the first signs of what would eventually become a global pandemic.

What followed were weeks and months of economic calamity, public health confusion, and hospitals stressed beyond the point of capacity. The healthcare sector, like the country at large, still hasn't fully recovered from the damage sustained last spring.

However, a year later, provider executives are emerging from the pandemic with a greater understanding of what their organizations did right in response to the outbreak and where there is opportunity for improvement.

HealthLeaders spoke with several hospital executives for their reflections on the one-year anniversary of the domestic spread of COVID-19 and what the path going forward looks like for provider organizations.

The strategic perspective and role of a CEO

Dan Woods, CEO of El Camino Health, a nonprofit 420-bed hospital based in Mountain View, California, says that his organization's initial response to the coronavirus was to establish an incident command center, similar to how the military handles mass casualty events.

Woods says he first reached out to the local chief of police's public information officer about how to stop the spread of an infectious disease and maintain the community's trust in the provider organization.

Woods acknowledges that many health systems will establish incident command centers during a crisis, but he notes that those are primarily designed for short-term use. El Camino's was slightly different: Through a contact who is a commanding officer in the Air National Guard, Woods sought out strategies to handle mass casualties, maximize use of assets, and bring the military approach to disasters into healthcare.

"All the other hospitals created an incident command center, which we had, but we also layered on top of that something we learned from the military, and that was creating a command center focused on one thing: What's coming over the horizon?" Woods says. "We figured out earlier that we could create a predictive analytics [model]. We had burn rates that monitored PPE on a daily basis, so that predictive layer was helping prevent some of the mass shortages. We knew ahead of time, as much as seven to 14 days, when we could potentially run out of PPE, which we never did."

Woods says that some of the approaches El Camino implemented during the pandemic, such as utilizing certain facilities to take care of patients infected with COVID-19 while non-infected patients went to other facilities, could be used again in the future.

He says that during a difficult flu season, El Camino could again look to cohorting patients as an option, mentioning the importance of "maximizing the utilization of physical and employee assets."

Related: 4 Financial Opportunities for Health Systems Amid COVID-19

"The thing about this kind of lesson learned is you can take a logical approach. But when you have such uncertainty and fear, you must address the emotional aspect of employees as well as the community," Woods says. "When the community knows that this site does not have COVID patients, suddenly it's clean. They don't have as much fear and self-selecting out. So, you must approach [these events] from the logical perspective. But you also have to address the emotional aspect of what people are going through."

Woods notes that there are several things the organization could have done differently in its response to the coronavirus but stresses that CEOs should recognize the value in "humble leadership" amid a crisis and that "old solutions can't fix new problems."

"The lessons learned are to never underestimate the innovation and ingenuity of your staff," Woods says. "Never underestimate the level of support from your community; we had people asking, 'How can I help? I want to help.'"

Two merging health systems reflect on a year of challenge

In early 2021, CHI Franciscan, a subsidiary of CommonSpirit Health, and Virginia Mason finalized an agreement to merge.

Under the deal, the two Washington state–based health systems will operate as a new entity, Virginia Mason Franciscan Health (VMFH), structured through a dual-CEO model led by Ketul J. Patel, CEO of CHI Franciscan, and Gary S. Kaplan, MD, CEO of Virginia Mason.

Both organizations had unique experiences navigating the pandemic, so HealthLeaders reached out to each CEO for their thoughts on the year dominated by COVID-19.

'Inspired and proud'

Patel says that in reflecting on the past year, he remains "inspired and proud" of the work his organization undertook to combat the coronavirus.

He says that CHI Franciscan was able to serve as a model for other health systems during the pandemic due to having a "robust emergency preparedness strategy" in place ahead of the crisis.

Having clarity around infection prevention protocols and a transparent emergency preparedness strategy was a critical aspect of CHI Franciscan's response effort, Patel says. As seen during the pandemic, leaders must be adaptable to changing circumstances and do what is best for the population they serve, he adds.

"The role of leadership communication and presence is vital—not only to be a voice of support, but to ensure our teams on the front lines are receiving the most accurate, up-to-date information available as they care for patients," Patel says. "As we experienced in the beginning of the pandemic, and now as we administer the vaccine, the only constant is change—federal, state, and local guidelines are evolving by the day. Leaders have to be agile, a principle that we will keep practicing in the future."

Related: Health Systems' Road Map to Financial Opportunity

Patel says that CHI Franciscan, like many other health systems, expanded its telehealth services in response to COVID-19. CHI Franciscan offered virtual urgent care to its communities and cared for more than 13,000 individuals, while also training more than 1,200 providers across 36 specialties to care for more than 220,000 people.

Looking ahead, Patel says that VMFH will continue to increase its virtual care footprint since it's "cost-effective, offers a convenient option for patients, and it allows us to extend the reach of our providers throughout our communities."

"As healthcare leaders, our strategies will need to evolve to better meet patients' needs. I'm hopeful that a positive outcome from this pandemic is refocusing the conversation around moving people out of our hospitals and instead increasing access to virtual health and ambulatory settings, which have a smaller footprint and are more cost-effective. The more we keep patients out of the hospital, the better it is for all of us. COVID has only reinforced that belief for everyone across the industry."

Systems engineering approaches for healthcare

No individual can make all the decisions for an organization amid a crisis, Kaplan says. A key lesson Virginia Mason learned was to rely on discussions that factor in interdisciplinary groups and use this approach to "drive innovation that transforms care quality, safety, efficiency, emergency preparedness, and patient satisfaction," he says.

Hospitals can expand revenue streams and increase their financial stability by using systems engineering approaches that can make healthcare organizations more efficient and robust ahead of unforeseen crises, Kaplan says.

"While healthcare leaders must always be open to assessing the value of new or expanded services for their patients and their organizations, it is equally important that we continually affirm the appropriateness, value, and efficiency of the services already available. The pandemic has underscored the importance of a systems-engineering approach to healthcare delivery, such as we have with the Virginia Mason Production System (VMPS). VMPS standardizes work to remove unnecessary variability, reduces the chance for human error, and enables our team to collectively act as a nimble responder to change in crises and non-crises," he says.

He adds that Virginia Mason also used VPMS to fast-track the rollout of its virtual care options during the pandemic while noting that such options were available in ambulatory settings beforehand.

Looking to a post-pandemic landscape, Kaplan says that hospital executives should appreciate the continued importance of "leadership, communication, and collaborative relationships."

"The pandemic has underscored the need for healthcare leaders to be committed to continuous, incremental improvements; be learners who are open to new ideas and innovation; and always striving to be better tomorrow than today," he says.

A pandemic puts racial health inequities on full display

COVID-19 briefly earned the nickname "the great equalizer" early in the pandemic, but it has become painfully clear that vulnerable patient populations, namely communities of color, have suffered more than most.

Dr. Efrain Talamantes, COO at AltaMed Health Services, a Federally Qualified Health Center based in Los Angeles that provides care to impoverished patients in southern California, says the coronavirus has "exacerbated" racial health inequities.

"The one thing that I would say through all of this is that we've done our best to remain the most trusted source of healthcare for our communities and the hardest-hit areas," Talamantes says. "On the workforce side, I would say we struggle because we feel like heroes, but oftentimes we are not given any of the resources to continue to do the great work that we know we're doing."

Talamantes says AltaMed dealt with a lack of resources during the initial COVID-19 surge, namely testing capabilities and PPE, along with experiencing a higher COVID-19 positivity rate among its patient population compared to Los Angeles County as a whole. While lobbying county and state officials for assistance has helped mitigate some of the damage, Talamantes says that the vaccine rollout has put disadvantaged communities in a difficult position.

"Now, as a vaccine rolls out, we find ourselves in the same situation: where again these communities that historically have been underserved continue to be overlooked, and these are the hardest-hit communities. [At the time of HealthLeaders' interview], the percent positivity rate at AltaMed was close to 49%," Talamantes says. "It just gives you a good sense that this pandemic has devastated these communities. I've had to not only hear about family members passing ... but [also] that the hope isn't there [in the community]. And that's because we have no visibility and no understanding of when it's going to be our turn to be able to vaccinate our community."

But Talamantes says he is optimistic for AltaMed's future given the Biden administration's public statements supporting community health centers.

As advice to fellow healthcare leaders, he says he wants them to understand the importance of racial and social justice in light of the pandemic.

"[There are] countless examples during this pandemic where I could see, whether intentionally or unintentionally, either the policies that we have in place or the way that we practice have been outdated," Talamantes says. "The fact that the pandemic came in to disrupt the way we practice has given us an opportunity to see things that otherwise we wouldn't have seen. That effort, while it feels overwhelming and it does take more energy and time, that's the same effort we should be putting into healthcare all the time. We need to get out into the world and see the patients from the perspective that they're experiencing healthcare."

Telehealth's mainstream moment

One of the undeniable opportunities that rose out of the pandemic was telemedicine care delivery, which entered the mainstream in the absence of face-to-face medical encounters.

A RAND Corporation study released in January found that telehealth use increased 40% for chronic care treatment between mid-March and May 2020, along with a 50% increase for behavioral health treatment over the same period.

Paul Fu Jr., MD, MPH, is the chief medical information officer at City of Hope Orange County, a cancer research and treatment center in Irvine, California. He says Hope Virtual, the organization's telehealth program, was set up prior to the pandemic and experienced "increased appreciation and adoption" during the outbreak.

He adds that City of Hope followed a two-pronged approach to meet patient demand amid the temporary cancellation of in-person elective procedures.

"First, we made sure every physician and advanced practice provider across our Southern California enterprise had the right hardware and training to provide patients with compassionate, personalized care using Hope Virtual," Fu says. "Second, we communicated with patients to ensure they had all the information needed to access this remote platform and used patient navigators to run 'tech checks' to reduce patient concerns related to the technology behind the telemedicine visit."

Reflecting on the growing interest in digital health, Fu says that telemedicine is "here to stay," though he urges lawmakers at the federal level to continue to extend waivers for provider organizations to utilize virtual care services even after the pandemic.

"Once the technology is in place, there is no reason to stop using and improving it, especially when many more patients request this service as they become accustomed to the convenience of it," Fu says. "Telemedicine is a platform that can improve patient outcomes and reduce disparities to healthcare access resulting from socioeconomic status, distance to high-quality healthcare institutions, and lack of access to specialty doctors."

City of Hope's clinical considerations

Vijay Trisal, MD, the CMO at City of Hope, says that while the hospital wasn't expecting a pandemic to strike, it was prepared as best it could be for the clinical impact of the coronavirus.

According to Trisal, some key protocols put in place included a separate COVID-19 ward with its own air filtration system along with on-site, drive-thru COVID-19 testing. He adds that the organization tested asymptomatic patients prior to "most procedures or treatments and before enrollment into clinical trials."

Additionally, City of Hope took action to protect its most vulnerable patients, including specialized training for its workforce and allowing for remote work to reduce in-person interactions at the facility.

Trisal says City of Hope also introduced a "labor pool" that consisted of employees "whose usual job functions were hindered or paused due to the pandemic." These employees screened patients and staff prior to entering clinical areas and helped to escort patients.

He says City of Hope leadership also prioritized the need to communicate, at times "overcommunicate" with both staff and patients, about the status of the coronavirus.

"We had weekly virtual forums with managers and frequently hosted virtual town halls for all staff. These meetings were led by our CEO, COO, and me, as well as HR and transformation leaders," Trisal says. "As the pandemic, unfortunately, became a part of regular life, we decreased the frequency of these forums and communications, yet the town halls continue to be interactive meetings that offer managers and staff opportunities to ask questions in real time."

Looking ahead, Trisal says that he hopes other healthcare leaders don't ignore the lessons learned from the pandemic: namely, to remain prepared and vigilant for highly communicable diseases.

"The pandemic taught us that when people come together, when we put manpower and resources toward a shared goal, things can happen at light speed," Trisal says. "Vaccine development usually takes at least eight years, but the world's scientists have developed clinically approved COVID-19 vaccines in less than a year. We now live in a world that has a global highway. We can't and shouldn't isolate ourselves because when the world comes together with a singular focus, wonderful things happen, and they happen so much more quickly than when we work alone."