Guidelines for Practicing During a Pandemic

Strong consideration should be given to the potential health risks encountered by patients and employees during a pandemic.

Below you’ll find frequently updated resources to help you understand how to reduce risk and improve patient safety while managing your practice during COVID-19. This online guide will help aid you in preparing your practice and educating your employees.

Your ProAssurance Risk Resource team will continue to monitor the pandemic and provide updates and recommendations as conditions evolve.

Culture of Safety

  • The leadership team plans and implements a strategic vision for the organization.  Leaders have the opportunity to encourage and reinforce clinical risk management with every employee, contractor, and clinician. 
  • Prioritize a culture of safety that will mitigate professional liability risk and enhance resident confidence. 
  • Leadership establishes a culture of safety through performance improvement, physician and staff engagement, and providing quality clinical care.
  • Encourage participation in patient safety education and training for medical staff and employees and support development of new risk mitigation initiatives.
  • The  AHRQ culture survey helps identify areas needing improvement, and provides tools to enhance the culture of safety.
  • Establish a chain of command (COC) protocol that empowers all employees to raise any perceived patient safety concerns with leadership without fear of retribution. Additional resources are available to assist leadership in developing a chain of command protocol, including: a sample policy, chain of command flowchart, and Risk Resource webinar.

Facility and Supply Considerations

  • Clean and thoroughly disinfect environment of care prior to re-opening facilities
  • Reconfigure office space to comply with social distancing guidelines
  • Perform equipment, supplies, and on-site medication checks, including vaccines and immunizations, for expiration dates. Test and inspect all equipment, including emergency equipment.
  • Inventory PPE and develop contingency plans as necessary
  • Review infection prevention policies, update polices as necessary
  • Refer to the CDC’s Strategies to Optimize the Supply of PPE and other Equipment for additional considerations

 Triage and Patient Flow

  • Influenza positive patients may also be positive for COVID-19. Consult existing guidance for co-circulation of influenza viruses and COVID-19.
  • Consider using CDC Scripting guidelines for telephone screening
  • Implement alternative triage options such as telemedicine or drive through assessment
  • Designate a screening area specifically for evaluating patients presenting with fever or respiratory associated symptoms
  • Complete documentation in a clean area outside of exam room
  • Cross train employees as appropriate

*Last updated 10/23/2020

  • Provide staff education about COVID-19 infection control
  • Educate staff and patients about changes they can expect to be implemented in the office
  • Re-evaluate delegating job responsibilities during emergency periods.
  • Reiterate customer care standards and patient expectations
  • Refer to the CDC’s Train and Educate Healthcare Personnel resource for additional considerations
  • Review safety practices for essential providers returning to work. The CDC has released criteria for personnel with suspected or diagnosed COVID-19.
  • Keep updated on current recommendations for expectant mothers and fetal development concerning COVID-19 risks 

*Last updated 8/25/2020

Testing

  • Verify FDA approved testing is locally available
  • Determine whether and how often to test employees
  • Understand that not all testing methods yield reliable results. Select an available method that is shown to produce the fewest false results.
  • Work with your state and local health departments on diagnostic testing protocols and procedures
  • Educate your staff on legal requirements to report COVID-19 testing results to public health officials

Tracking

 

In this video, Senior Risk Resource Advisor Laurette Salzman discusses how to adjust tracking systems to address changes in patient scheduling and patient flow models. Watch the video on YouTube.

*Last updated 6/24/2020

  • Physicians/providers should review their schedules to prioritize visits for chronic, acute, and well patients
  • Review schedule for postponed elective surgeries, biopsy callbacks, follow-up specialty referrals, lab results, annual physicals, and routine screenings, such as mammography, colonoscopy, and telemedicine visits
  • Consider pre-visit telephonic screening of patients
  • Schedule sick and well visits at alternate times

Last updated 4/24/2020

Policies and Procedures

  • Continue to use and enforce social distancing guidelines
  • Develop and/or review plans that reduce the number of staff caring for suspected/confirmed cases, create protocols, and determine isolation requirements
  • Adhere to CDC guidelines regarding home isolation pending test results
  • Educate employees on prevention and transmission of infectious disease
  • Assume everyone is a carrier
  • Educate employees on collecting and handling specimens
  • Consider methods to reduce exposure by shielding employees and other patients from infected individuals
  • If a member of your staff tests positive for COVID-19, coordinate any patient notification or contact tracing efforts with local or state health departments 

PPE/Physical Environment

  • Consider alternate entrances for symptomatic patients, and request patients wait in their vehicles until called by staff. Provide clear signage & directions.  
  • Discontinue use of toys, magazines, and other shared items in waiting areas, as well as office items shared among patients, such as pens, clipboards, phones, etc.
  • Review frequency and scope of office and medical cleaning.  Disinfectants are necessary in the medical practice, and many are approved for use against coronavirus.
  • Post signage in commonly encountered languages to educate patients about proper respiratory hygiene, including sneeze and cough etiquette. Remind patients to use proper handwashing techniques.
  • Provide alcohol-based hand sanitizer, surgical masks, gowns, and disposable gloves to all caregivers and staff who must be within six feet of patients
  • Instruct patients to wear a face covering to appointment. Provide a face covering to all patients who arrive without one.
  • Purchase single use towels, tissues, and mops for use throughout the office
  • Use no touch wastebaskets with disposable liners
  • Place alcohol-based hand sanitizer throughout the office

*Last updated 8/25/2020

Regulations and Reimbursement

Planning and Implementation

  • Identify technology that you already have and determine if expansion or improvements to your system are needed
  • Plan the telehealth workflow
  • Inform patients of the availability of telehealth services
  • Verify patients are tech-ready (e.g., reliable internet access, smartphone, tablet, etc.). Technological fluency and internet-access limitations of a patient population may limit the efficacy of telemedicine.
  • Identify presentations or conditions for which telemedicine provides an appropriate initial assessment

Patient Communications and Informed Consent

Although some states specifically regulate the process for informed consent in telemedicine, there are a number of general factors a physician should consider when obtaining that consent, such as the nature of the patient’s condition, confidentiality, and the technological capabilities necessary.

In this video, Senior Risk Resource Advisor Mallory Earley discusses the process for obtaining informed consent when practicing telemedicine. Watch the video on YouTube.

Sample Telehealth Informed Consent Form During COVID-19 Pandemic

Sample Telehealth Form

 

 

 

 

 

 

 

 

Download and adapt the sample form, Telehealth Informed Consent Form During COVID-19 Pandemic, also available at ProAssurance.com/SampleForms.

  • Conduct and document an informed consent discussion outlining telemedicine restrictions
  • Explain telemedicine visits may limit the ability to diagnose certain conditions
  • Follow-up with patients from virtual visits during emergency period, prioritize new patients 

Documentation

  • Follow standard documentation practices with all telemedicine encounters
  • Develop a system to identify and monitor patients requiring subsequent in-person evaluation and treatment (i.e., recall, tracking, follow-up)
  • In states without independent practice regulations, physicians supervising allied healthcare professionals should document training of all supervised clinicians in the use of the chosen telemedicine platform

Additional Considerations

  • Develop policies and procedures if you plan for long-term telemedicine use
  • Notify agent or underwriter if you plan to continue the practice of telemedicine

Resources

Telemedicine Best Practices Guide

 

 

 

 

 

 

 

 

Last updated 5/15/2020

The efforts to prevent the spread of COVID-19 amount to an unprecedented disruption in nearly every facet of daily life. These disruptions inevitably affect the psychological wellbeing of both patients and the healthcare workforce. Physicians should anticipate a greater need for mental health resources, and plan to address the needs of patients and staff. Below are some strategies you can adapt to help meet these mental health needs:

Patient Well-Being

  • Become familiar with available national and local mental health resources
  • Initiate dialogue regarding the pandemic's impact on patients’ stress, and direct those susceptible to available resources
  • Consider patient vulnerability to high-risk stressors such as job loss, homeschooling, and lack of childcare
  • Know when a referral to a mental health specialist would be appropriate, and add basic mental health screening questions to your patient assessment
  • Cultivate collaborative care referral sources in mental health disciplines, who may be willing to see patients in need on an expedited basis
  • Follow-up on behavioral health and social service referrals
  • Understand stay-at-home requirements have eliminated outside safe havens for patients vulnerable to domestic abuse and neglect. Evaluate pediatric, adult, and geriatric patients' need for protection.
  • Older patients may be particularly susceptible to pandemic-related depression, especially those quarantined in isolation. Consider resources available to provide these patients with social connection.
  • Ensure treatment plans, referral communications, and education are documented in the medical record

Employee Engagement  

  • Educate staff that certain patients are subject to stereotyping concerning COVID-19 transmission. Staff awareness of patient sensitivities may aid in providing effective patient care to all         
  • Children may interpret and respond differently to stressful events. Be prepared to address these unique needs with caregivers
  • Give consideration to health literacy variations among your patients

In this video, Senior Risk Resource Advisor Tina Reynolds discusses how to recognize and address limited health literacy when communicating with patients. This can be especially helpful for conveying COVID-19 prevention and treatment information. Watch the video on YouTube.

Workforce Well-Being

  • Create an atmosphere in which employees can freely express concerns about personal wellness and the pandemic's impact on work performance
  • Ask employees how they are coping with the pandemic's demands. Listen and empathize without making judgments
  • Recognize a fundamental principle of staff care is that employees should feel valued, appreciated, and supported
  • Acknowledge that providing care during the pandemic is stressful to staff members. Suggest appropriate stress mitigation techniques to assist staff in coping. View our new online seminar for insureds, A Comprehensive Approach to Physician Wellness for recommendations.

Preview A Comprehensive Approach to Physician Wellness on YouTube.

  • During the pandemic, ProAssurance-insured physicians and insured advanced practice healthcare providers can receive confidential, non-reportable coaching, compliments of ProAssurance. 

Support for COVID-19 Stress Winning Focus flyer

Download the Winning Focus flyer for more information.

Last updated 8/13/2020

With COVID-19, patients and staff are stretched to their limits, and documentation may suffer as a result of rushed, less detailed, and error-prone entries. While electronic medical record (EMR) workarounds may seem like the fastest way to capture information, use caution to maintain an accurate chart. These steps may help improve comprehensive documentation during the COVID-19 pandemic.

  • Consult the ProAssurance Risk Resource Guidelines to review documentation fundamentals, available on the secure services portal
  • Develop a screening policy (i.e., temperature, cough, difficulty breathing, new loss of smell and taste) to identify high risk patients. For patients exhibiting signs and symptoms compatible with COVID-19 follow state and local health department guidelines for testing
  • Document screening information in the patient’s medical record. Consider creating a template with other relevant screening criteria, such as: travel history, on-site hand sanitizing, and face mask compliance for long-term use in the practice
  • Current conditions make informal modes of communication more attractive to clinicians. All patient interactions, regardless of the mode of communication, should be recorded in the medical record
  • Medication reconciliation documentation should include all new medications, dosing changes, all discontinued medications, supplements, and medications prescribed by others
  • Consider a template to consistently document staff use of PPE, social distancing, and other appropriate precautions
  • Record evidence that routine preventive screening and services (i.e. colonoscopy, mammogram, etc.) were offered in accordance with the organization’s practice guidelines. Document patients’ refusal to comply with clinician recommendations
  • Provide training on all EMR platforms to employees whose responsibilities have expanded to include documenting in patient charts. Document this training with an employee skills checklist
  • Correct errors and addenda, per best practices guidelines
  • In the event of a claim occurring during the pandemic, keep a record of all regulatory changes and waivers issued by federal and state agencies

 

Last updated 5/27/2020

Regularly monitor exposure risk in your area to determine whether scheduling changes are required in your practice. Evaluate the exposure risk created by activities in the practice, and modify policies as needed to protect employees and patients. Flexibility is essential in operating your practice, because circumstances of the pandemic are changing at a rapid pace.

Note the following key considerations to determine if further modifications to your practice are required: 

  • Respond appropriately  to staff exposure
  • Review infection control process
  • Track and follow-up on deferred annual screenings, specialty referrals, and diagnostic tests
  • Ensure adequate inventory of PPE
  • Capture all patient interactions, regardless of the means of communication, in the medical record

Last updated 8/25/2020

 

New Information

Influenza positive patients may also be positive for COVID-19.  Consult existing guidance for co-circulation of influenza viruses and COVID-19.

*Information can be found in the "Prepare the Practice" section.

COVID-19: Returning to Practice videos

COVID-19 State Guidelines for Returning to Practice

Get up-to-date information on guidance and requirements states have issued on returning to full-time practice as social distancing restrictions are lifted.

Visit the State Guidelines for Returning to Practice page.

External Resources

American College of Surgeons COVID-19 Clinical Guidance (Local Resumption of Elective Surgery Guidance and Roadmap for Resuming Elective Surgery)

CDC Information for Healthcare Professionals

NEW Centers for Medicare & Medicaid Services (CMS) Recommendations Re-opening Facilities to Provide Non-emergent Non-COVID-19 Healthcare

The White House Opening Up America Again Phase One

This section updated 6/11/2020.

COVID-19 Information Center

Visit the Coronavirus (COVID-19) Information Center