Telemedicine Impact on Ambulatory Care Facilities

The COVID-19 pandemic initiated a tidal wave of telehealth and telemedicine usage across the country and around the world. Organizations and practices that had previously saturated geographic regions with ambulatory clinics, are now under tremendous pressure to adapt as visit volume has shifted from in-person to telemedicine, and it is not likely to return to pre-COVID levels. Those looking to grow their practice will find new opportunities — namely, the ability to leverage their own telemedicine platforms to consumers and provide virtual care to patients outside the “brick and mortar” and payer restrictions that existed yesterday. We anticipate that many providers will downsize both primary and specialty care square footage and clinical staffing. These downsizings are in response to the cost pressure health systems face as they enter the other side of this crisis with weakened balance sheets and the mass adoption of more cost-efficient telehealth models.

With a telehealth visit, 95% of a patient’s time is spent face-to-face with the doctor, compared with less than 20% of a traditional visit, in which most time is spent traveling and waiting. With that said, it is not a surprise that physician practice models will continue to change dramatically as they move to virtual care. The impact will likely reduce the use of exam rooms, MOBs will have high vacancy levels, waiting rooms will become obsolete, and revenue streams historically controlled and enjoyed by health systems will suddenly become controlled virtually by providers and caregivers. Based on current COVID-19 practices, several physicians interviewed believe they could optimally manage their patient panel with only two days in clinic per week. Therefore, re-evaluation of your primary care clinics is a need-to-do initiative, considerations should include smaller clinic footprints, higher rates of rotating staff sharing office and exam space, clinic consolidations, and reduction of clinical and administrative support staff.

For example, the average six-provider family medicine practice could add an additional 800 virtual visits or 600 in-person visits to their panel each year for every 10% shift of volume to virtual visits. From a physical space perspective, if the practice chooses to maximize their provider productivity by backfilling with the 600 in-person visits, the practice still needs less exam room space than before the shift to virtual care. Clinic consolidations and the reduction of future real estate needed will help lower overhead costs and maximize revenue per square foot.  Additional clinic and exam room modifications to consider include:

  • Collaboration between call centers for registration, scheduling, vitals and check-in before transferring telehealth calls to the provider who is likely located elsewhere.
  • Drive up check in.
  • Wait in car; reduced and separate waiting rooms.
  • PPE application prior to entering front door of clinic, and handwashing stations with no-touch services.
  • Minimal offices needed since telemedicine providers are working remotely (from home or centralized call center).
  • Bigger data and electrical closets.
  • Telemedicine technology counters/tables/consult spaces to provide and educate patients on using in-home equipment.
  • Exam rooms sized to accommodate family members or friends who accompany the patient to minimize the number of people in the waiting room.
  • Multi-functional exam rooms that house supplies needed for multiple types of patient interactions, i.e., POC testing, lab draws, education/teaching, counseling, scheduling and payment;
  • Exam rooms equipped for telehealth services to allow physician/staff-patient consults virtually, these may include multi-disciplinary team consults, patient teaching, behavioral health support, etc.

While much of the conversation around Telemedicine has focused on the staff/provider-patient interaction, that is only one process of many that must be executed well, in order to achieve a high level of staff engagement and patient satisfaction.  Most of the steps that go into an efficient and effective in-person patient visit must occur in the virtual environment as well, but perhaps in different ways.  Patients still need to be scheduled, pre-registrations completed, insurance authorizations obtained, and out-of-pocket costs communicated.  The speed and access provided by virtual visits will demand that these pre-visit activities happen much more quickly so as not to delay the visit.  Staffing models for the pre-visit functions need to be assessed and adapted to this new virtual environment.

Given the rapid  provider adoption of telemedicine, high level of patient satisfaction, increase in access telemedicine offers, and current, while temporary, reimbursement by CMS, it is likely the telemedicine train has left the station.
101 W. Broadway, Suite 101
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Debbie Jacobs, Director West Region

Revisiting Resilience: Strategies to Thrive in the New Normal

As we face future waves of the COVID-19 pandemic, it is painfully apparent that these conditions have become the new normal for the foreseeable future. In recent webinars on resilience I delivered for HCE SoCAL, several healthcare leaders compared the COVID-19 journey with running a marathon. Given these conditions, leaders that demonstrate a resilient attitude and demeanor can play a significant role in helping their people remain focused and productive. However, they must make regular investments in maintaining their resilience as well as supporting the adaptability of their followers.

Resilience Defined
Resilience consists of a set of skills and resources that help people cope with and navigate adversity. It also includes a process for adapting to adversity and setbacks, and for some people, it may result in growth and thriving. Other facets of resilient leaders include:

  • Drawing upon internal and external 
resources to respond powerfully in crises.
  • Using coping strategies to navigate the emotions of failure and move into problem-oriented coping.
  • Draw upon an internal locus of control enabling them to perceive they have some level of control over their successes and failures and an optimistic self-appraisal
  • Buffer themselves to future setbacks by experiencing positive emotions.
  • Perceive threats as challenges, thereby avoiding fight or flight behavior.

While a lucky few seem to have a natural ability to rebound and thrive in a crisis, the good news is that resilience is you can strengthen your resilience muscles through deliberate and consistent action.

The Case for Resilience
Partly a result of the COVID-19 pandemic, an increasing number of organizations embrace resilience as a core competency for professional and leadership success:

  • McKinsey and Company Consulting recently concluded that resilience is an essential skill that organizations need to build in their people to building operating-model resilience as an integral element of rebounding from the first wave of the pandemic.
  • The U.S. Army has offered resilience training for soldiers to prepare them for the traumas of warfare and hopefully inoculate them against PTSD and the possibility of suicide.
  • The Office of Personnel Management (OPM) identifies resilience as an essential change leadership skill.
    Resilient leaders are the most effective according to a study by Zenger Folkman, a leadership development firm.

Part 1: Strategies for Sustaining Your Resilience
Airline flight attendants remind us to put our mask on first before helping others. The same is valid with resilience – it is tough to help your team build and sustain resilience if you are vulnerable to setbacks.

So how can you build your resilience muscles and improve your capacity to lead in the new normal? Based on my doctoral research on resilient managers in New Orleans during Hurricane Katrina and other studies, there are four key strategies to consider:

  • Strengthening your physical well-being
  • Building and maintaining your support networks
  • Revisiting your vision and purpose
  • Expanding your coping strategies

Strengthening Your Physical Resilience
Physical resilience is the foundation of psychological resilience. Consider the last time you felt sick and how that impacted your sense of optimism and performance. Resilient people regularly and consistently invest in self-care activities, including a healthy diet, exercise, and adequate sleep.

One aspect of physical resilience and self-care that is particularly challenging for many of my executive coaching clients is sleep. Recent research has found that sleep-deprived people experience apathy, reduced attention span, memory issues, and blocks to their creativity and it contributes to chronic health issues, including heart disease, diabetes, and obesity. A 2016 study cited in the Harvard Business Review noted four
 aspects of leadership effectiveness
 that are negatively impacted by a lack 
of sufficient sleep: results orientation, problem-solving, seeking alternative perspectives, and supporting others.

There are numerous ways to improve the quality and quantity of sleep. Some of my favorite strategies include:

  • Use an Apple Watch or Fitbit to track your sleep, including the time to bed, time awake, and total hours of sleep.
  • Develop sleep rituals as you prepare for bedtime, such as turning off technology, a warm bath, and dimming the lights in your home.
  • Avoid caffeine at least six hours before your regular bedtime.
  • Use a white noise app to reduce the impact of background noise at night.

A great way to improve your physical resilience is by establishing accountability for your self-care habits with your network, the second resilience-building strategy.

Building and Maintaining Your Support Networks
In my 30s, I studied with several well-known trapeze flyers to learn their craft. Knowing that a net would catch me when I fell from the trapeze empowered me to take more significant risks. Our personal and professional support networks function in similar ways to the net for trapeze flyers. Resilient people cultivate personal and professional networks to help prevent setbacks, set more significant goals, and navigate challenges.

Numerous leaders across industries have shared with me that the unprecedented nature of the pandemic with so much uncertainty means there is no rulebook for how to lead and plan. Agile organizations have recognized a need to leverage emerging best practices from institutions that have achieved early wins. Therefore, building and sustaining professional networks is essential to think and act strategically in navigating both the current realities of the pandemic and future waves.

For a network to be most 
effective, it needs depth, breadth, and currency. Depth consists of a range of trust levels in a relationship – from acquaintances to confidantes. Breadth includes connections from 
a variety of sources, including your organization, profession, and industry sector. Currency equates to how well you maintain your relationships over time. I recall the experience as a career coach working with managers downsized after the 9/11 terrorist attacks. Sadly, many of them confessed to me their sense of isolation they felt facing a job search without support because they had not maintained their networks.

Some strategies you can use to enhance your support networks include:

  • Proactively share information with colleagues relevant to the challenges they are facing.
  • Create an inventory of your top 10 professional contacts and assess how current the relationship is; use this to prioritize people with whom you need to engage.
  • Once a week, make a point to introduce colleagues who share interests.
  • Assess your existing network with an eye toward relationships you need to end; are there negative, pessimistic, or toxic people that sap your energy and focus?

Revisiting Your Vision and Purpose
Resilient people articulate and periodically revisit their vision and purpose to stay focused 
and sustain momentum in the face to setbacks. Clarity and focus on your vision also restore a sense of hope and optimism in light of the level of uncertainty faced by healthcare organizations.

Consider the experiences of psychologist Viktor Frankl while a prisoner in a concentration camp during the Holocaust. In his book Man’s Search for Meaning, he attributes his resilience to a compelling vision he had of himself after being freed from the camps lecturing to a group of students about his experience. His vision allowed him to reframe the camps’ horrors
 as the source of insight for his future students.

A compelling personal vision and purpose easily transcend into our organizational lives. I challenged one CEO client to revisit the mission, vision, and values of his healthcare organization with his leadership team as their true north to sustain focus.

Strategies and rituals for revisiting your vision and purpose include:

  • Translate your vision or purpose into a compelling image and display it where you see it regularly.
  • Create an accountability partnership with a trusted colleague and schedule a lunch check-in periodically to review progress toward your vision.
  • Clarify and live your personal values daily.
  • Consider enrolling the low-cost class offered by the University of Michigan – Finding Purpose and Meaning in Life.

Expanding Your Coping Strategies
People who are resilient develop and practice two types of coping strategies to navigate setbacks, emotions-centered, and problem-centered. Rather than getting trapped in their emotional reactions, they use practices such as asking for support, exercising, mindfulness, and revisiting challenges for factors they can control. Once you address your strong emotions, you can use problem-centered strategies such as planning, scenario building, goal setting, strategic thinking, and gathering information.

One particularly critical coping 
skill used by highly resilient people is positive self-talk. Self-talk consists of the internal messages you give yourself when experiencing both success and setbacks. In her book Grit: The Power of Passion and Perseverance, psychologist Angela Duckworth suggests that optimistic self-talk leads 
to increased perseverance.

Other strategies and rituals for expanding your coping strategies include:

  • Keep a file of accolades and positive 
feedback you have received; re-read these messages when faced with a daunting challenge or while recovering from a tough situation.
  • Develop exercise routines you can use after experiencing adversity to discharge your emotions and help you refocus on taking action.
  • Design your life to create meaning and joy from multiple domains, such as church, friends, family, or volunteer work; this will allow you to maintain perspective on potential setbacks at work.
  • Read biographies of accomplished people who overcame setbacks to feed your sense of optimism.

Part 2: Supporting the Resilience of Your Team
Your approach to supporting your team’s resilience can take many forms but begins with your ability to model resilience and an optimistic demeanor. Strategies used effectively by several of my executive coaching clients include:

Build community and connection in creative ways
During crisis and uncertainty, community and connectedness become even more important. As a leader, it’s critical to find creative ways to build and sustain community despite the limitations of social distancing guidelines. One clinical manager I worked with recognized this need but was unable to find a space large enough in her clinic to meet with her team and also ensure adequate social distance. She solved the problem by convening the team outside of the clinic in the parking lot. Other managers have shared how they have used text messaging, video applications, and audio recordings to maintain a connection.

Demonstrate visible empathetic leadership
Based on focus group data I evaluated from one of my healthcare clients, staff voiced their desire to experience their organizational leaders’ presence. They wanted senior leaders to empathize and acknowledge their fears and concerns – even if their leaders did not answer their questions. In many organizational cultures, visible leadership presence can have much more of a positive impact than using virtual methods.

Educate your team about resilience
Raise the topic of resilience in team meetings and enlist members in a discussion about the challenges they face and the resilience strategies they are using. Consider sharing your challenges and some of the techniques you are using, as outlined previously in this article. Ask your team for their input on actions you can take to sustain their resilience.

Ensure your communication is aligned and focused on the right message
There is nothing worse in a crisis than mixed messages being shared with staff, creating confusion and higher anxiety levels. It is essential to establish a cascaded alignment process for organizational communication so that there is alignment between middle managers and senior leaders. By doing so, front line managers and supervisors can reinforce key messages from the top.

One way to determine the effectiveness of organizational communication during the pandemic is to conduct a communication audit. An audit can consist of focus groups with various stakeholders to find out what they hear from above, their concerns, and the most effective channels to communicate.

Establish certainty when possible
As noted, locus of control is an essential building block of resilience – focusing on what can be controlled or influenced, letting go of other issues. David Rock, a co-founder of the NeuroLeadership Institute, suggests that leaders should find ways to establish and reinforce control and certainty for their teams despite the longer-term questions that remain associated with the pandemic. Examples include explicitly communicating routine activities such as crucial deadlines, core priorities, or schedule communication for staff:

We will be sending our team a daily email at 4 pm daily, updating everyone on COVID statistics.
Our core patient-focused purpose is more important than ever as we face this crisis.
While we don’t know what lies ahead for the number of infections this autumn, we will establish teams of managers to evaluate our response to the first wave and make recommendations on how we can prepare for the future.

The COVID-19 pandemic is an unprecedented crisis that challenges even the most seasoned healthcare leader. The key to effectively leading your people throughout the pandemic’s inevitable future waves is regularly investing in sustaining your resilience. It all begins with you.

Dr. Kevin Nourse is an executive coach, researcher, author and professional speaker who has a passion for helping leaders resiliently navigate change. He works extensively with biotech, healthcare, and pharmaceutical organizations. He is a member of HCE SoCal and can be reached at

Message from ACHE Regent – Spring 2020

Undesignated Leaders

I knew the call was coming. All day there were reports of a large demonstration moving toward our hospital.  There had been significant looting with the previous night’s protests, and we expected that clashes would ensue between police, protestors and outside agitators.

We activated the command center around 4:00 pm.  I put on my scrubs and headed in from the west, judging my route by the position of the police and news helicopters in the distance.  The hospital parking lot was eerily quiet and as I walked in, there was a sense of anticipation…and readiness.

The nurses and staff in the center were assessing staffing and receiving reports of employees unable to get to the hospital due to street closures.  As I walked to the Emergency Department, it was already busy with acute surgical emergencies, heart attacks and elderly patients who had fallen, with fractures.  I was pleasantly surprised to see not one, but three chief residents there, along with a similar number of Trauma attendings.  Normally, we have one of each.  No one had to say anything, they just came in.

I made it a point to walk through the floors and the ICUs.  At the stations, the nurses were a bit surprised to see me there on a Saturday evening.  They expressed concern for their staff – both those coming in and leaving. One of them was on Facetime with a colleague caught in her car in the middle of a protest.  She was clearly terrified, but fortunately had her hospital ID and scrubs on.  She wasn’t injured and made it in.  By the same token, we hesitated to send one of our Fellows home.  He is African American and we had concerns about him being stopped.  We worked with a local hotel to provide housing for any employees who were concerned about their safety after completing their shift.  Some just asked to keep working and helping.

The Trauma pager went off.  A steady stream of injuries began to flow into the Emergency Department.  I watched as a multidisciplinary, multiracial team stabilized and evaluated the patients.  I knew some that were active in LGBTQ issues, others that had been discriminated against in their native countries, many for whom English was their second language.  They worked with a flow and beauty that seems at odds with one’s images of a trauma unit.

Three bays apart laid an LAPD officer and a protestor.  Both had been struck with projectiles – both would soon be in our operating room, having bleeding stopped and fractures repaired.  Both survived.

The surgical suites had a limited number of staff.  We coordinated and triaged, not just for injuries related to the protests, but also for other life-saving care.  A kidney would be arriving for a transplant around 1:00 am.   Another family was mourning the death of their loved one, yet had consented to organ donation – this too needed to be arranged, including safely bringing the transplant teams in from outside hospitals.

I walked into a case of a gunshot wound to the abdomen. The young trauma attending was working with our chief resident.  Her two fellow Chiefs were in the room providing support and being available to help with other cases.  The anesthesiologists were doing a masterful job keeping up with blood loss.  Once again, many genders, many races, many ages.  At 63, I was the oldest person in the room.  Gazing over the ether screen, I could appreciate the path of the bullet – have been there far too often.  We talked about other potential injuries and developed a plan to temporize and come back in a day for definitive treatment.  That patient, too, is alive and recovering.

My office is on the 8th floor, with a normally beautiful view of the Hollywood sign and the lights of the city.  Tonight, there was smoke in the air and the reflection of emergency vehicles on the windows below.

By 1:00 am the riots had burned themselves out.  A curfew was declared, and the streets began to quiet.  We felt it was safe to send some residents and attendings home to rest for the next day’s battle. I drove by broken glass and dumpsters in the street.

At 7:30 Sunday morning, we had a WebEx with other operational leaders.  In appropriate tones, we discussed security, staff morale and what we, as the appointed leaders, could do.

I smiled to myself – the true leaders that night didn’t have formal titles.  The were nurses, techs, residents, attendings, security and housekeepers.  They maintained equanimity in the face of chaos.  They did their jobs not because they were asked, but because it was in their hearts.

They are all of us.

Harry C. Sax, MD, FACS, FACHE
ACHE Regent – Southern California

Professor and Executive Vice Chair
Department of Surgery
Senior Physician Liaison
Cedars Sinai Medicine Clinical Transformation Initiative

President’s Message Spring 2020

Dear Colleagues,

Over the last several weeks we have come together for our patients, family, friends and community in extraordinary ways to learn how to be safe during the COVID-19 pandemic.  As we practice social distancing in a new way, we are seeing the benefits of preparation and collaboration.  We count on our many talented leaders, colleagues and national experts in emergency planning, clinical care, research and operations to help guide our roadmap.

This pandemic is precipitating a set of events unprecedented in our lifetime.  The American College of Healthcare Executives (ACHE) and Healthcare Executives Southern California (HCE So Cal) have changed how we provide education and networking events by offering virtual webinars.  Our goal is to stay connected and to collaborate together.

As I ponder how healthcare organizations may change from the pandemic, several things come to mind. First, organizations will need to address brand strategy and marketing messaging to ensure how we communicate safety and security and deliver on our core values.

Second, patient access to care will change to offer virtual alternatives.  Telehealth can help attract new patients, reduce no-shows, boost revenue by turning on-call hours into billable time, and possibly reduce overhead for physicians who decide to switch to a flexible work-from-home model for part of the week.

Third, physician offices and hospitals will need to reconfigure services and spaces to provide patients a sense of security.  Mixing symptomatic and asymptomatic patients in crowded waiting rooms will be a major dissatisfier and threat to people’s safety.  Organizations may want to consider redesigning facilities and create separate entrances for the sick and well patients.

Finally, how we come together in different ways will impact the communities we serve.  In the words of Walter Payton “Together we are stronger than we are alone.” Thank you for all you are doing during these challenging times.

With deep appreciation,

Tricia Kassab, EdD., RN, FACHE
President, Healthcare Executives So Cal