COVID-19 Lessons Learned: A Conversation with University of Washington Leaders

Dushyant Sahani, M.D., chair and professor of radiology, University of Washington

Mahmud Mossa-Basha, M.D. associate professor, medical director of MRI, and vice chair of clinical operations, University of Washington

In February, the University of Washington saw the first case of COVID-19 infection in the United States. This incident put them on the forefront of the outbreak that has quickly spread to include more than 625,000 patients across the country.

Over the following months, as social distancing and other protective measures cut deeply into the volume of imaging studies, Washington’s radiology department implemented measures to protect the viability of its office and the financial solvency of its providers. On April 2, officials declared the state had reached its peak. Although there’s no date yet for when office operations will return to normal, planning has begun for how the department will handle the large volume of postponed studies.

Diagnostic Imaging spoke with both Dushyant Sahani, M.D., chairman and professor radiology, and Mahmud Mossa-Basha, M.D., associate professor, medical director of MRI, and vice chair of clinical operations, about their department’s experiences and the lessons they have learned so far in this pandemic.

Diagnostic Imaging: How has the COVID-19 pandemic impacted the image volume that your department has seen over the last few months?

Sahani: The COVID-19 crisis is a pandemic, and almost everyone is vulnerable to that illness. Because we have instituted social distancing as one of the commonsense measures to reduce the spread of this contagion, we have canceled a lot of elective procedures, including a lot of imaging that comes with the elective procedures. So, we have seen a substantial drop in our outpatient imaging volume – close to a 70-percent drop in overall radiology volume, and close to a 50-percent drop in overall radiology.

We did see some increase in a certain type of imaging like chest CTs, chest X-rays, portable imaging – a lot related to the COVID-19 patient volume we saw in the hospital in the ICU. Some of the acute care patients, like those with cardiac events, stroke, and trauma, also dropped because of the edict from the governor to stay at home. So, that was the biggest impact. We saw a substantial drop in overall imaging volume with some increase in the ED in chest volume.

Diagnostic Imaging: What financial steps did your department take to be able to navigate the outbreak with as minimal an impact as possible given the drop in revenue?

Mossa-Basha: We’ve taken a varied approach, and we’ve proposed a lot of things within our department in terms of ways to mitigate the loss. We have posed several things to the faculty in order to have a consensus decision in terms of how to save money and reduce the impact.

The first step was deciding to defer our incentive payments in terms of the biannual incentive that the faculty get. We’re considering deferring 75 percent of the incentive payment to a later date. We’re in the process of consolidating our support staff, and we’ve accelerated that process in order to mitigate some of those costs.

In addition, we are looking at consolidating our call schedules and eliminating supplemental pay for extra shifts. We’ve had this discussion with our faculty, and we’re putting forth a plan in regards to how to accomplish that. Basically, in this time of lower volume, people are going to cover both the main hospital and the other hospitals we typically cover with extra shifts.

We’re just trying to come up with creative ways in order to reduce our costs in the short term by really focusing on the big picture in the long term to increase our revenues. Hopefully, these measures will overcome these issues and maybe strengthen our position in the future to manage pandemics.

Sahani: Our priority in this process is to ensure that faculty salaries – and the overall academic mission – is preserved. And, to do that, most of our faculty has been very supportive. This is not something we opted into. We couldn’t opt out of the pandemic. This is a crisis, and we are not unique. The entire country is going through this crisis. I think we have a good support from our faculty and other staff to ride this crisis out and also support these commonsense types of measures.

Diagnostic Imaging: How effective might these measures be, and what reasoning was used to chooses these avenues to protect the department’s financial security?

Sahani: We wanted to be very pragmatic and make sure that this is a collective effort. There will be some compromises made by everyone, starting from the top. We all will have to make contributions through extra shifts. We are working a little bit harder. Over time, including during summertime, we collectively agreed to reduce the number of vacations we will take if the exam volume is high because our primary focus is making sure patient care and our academic mission is preserved.

You learn through any approaches that you apply, and you learn over time that you might have to change your direction a little bit. So, if we have to change our strategy over time, let’s say nine months from now – and we might – we are prepared for that.

Diagnostic Imaging: If the pandemic lasts for several more months, what steps are you prepared to take?

Mossa-Basha: We’ve laid out a plan of things that we could do, steps that we could take that range from relatively small reductions in the short term to things that may be slightly more prominent. One thing we proposed is a hiring freeze for six months. Now, if this continues to extend and the financial impact is larger than we had expected, that’s certainly something that we could extend further.

Identifying inefficiencies and removing inefficiencies is another thing we’re working on -- streamlining our imaging and making our imaging more efficient and increasing our volumes through that process. That’s more of a growth aspect. In addition, it’s something that can certainly help with reversing the impact going forward. Shutting down inefficient research cost centers is something we’re working on – really identifying those inefficiencies, resolving them, and having options of rolling assessments for some of the steps that we’re taking.

Sahani: The COVID-19 crisis has disrupted healthcare, but this is also an opportunity to do things more efficiently. Healthcare is one of the most expensive industries, and due to a lot of redundancies in the system and the regulations, we haven’t embraced technology as well.

One great example of how technology is enabling better access and lowering cost is through the growth in telehealth. It’s one of the solutions we have deployed during the crisis, and we might see how that can be applied in the future practice to gain the efficiencies in our system that will not only lower the cost, but also improve our productivity.

Diagnostic Imaging: Turning to what comes next, there will be a time when we finally come out of this situation and everything seems to be under control. What strategies do you have in place to work through all the postponed studies?

Mossa-Basha: There are still some unknowns in terms of how long the virus will stay in the community. We might have to follow the social distancing norms for the next few months. That may present some challenges in how much we can ramp up our imaging operations from Day One.

We will take a more scalable model gradually over time, making sure we still protect our workforce, as well as patients who might not be infected. And, then, we will gradually build it to make sure we are able to handle those volumes. This will require teamwork, and we are creating those teams. It will require amazing communication both with referring physicians, as well as with patients. We are also planning on extending hours of operations of our high value imaging equipment, including making weekends part of the regular schedule, if need be.

We’re looking at some other measures to streamline our workflow, such as what takes a lot of time, and if we can make shorter protocols. We are looking at technology solutions to allow us to do better, smarter scheduling or cluster scheduling. We’re being thoughtful about how we deploy our workforce. We can only come out of this crisis with the support of our workforce.

We are fortunate that we have amazing talented people from the front line to the leadership positions to the trainees – everyone is involved. We’re making sure people are engaged in the process, and we protect them, allowing them to also read remotely from home.

We’re making sure we’re not stretching our most valuable resource – our people – during this crisis. Because of the reduced volumes, we’re giving faculty, staff, technologists, and nurses the option of taking their paid time off now, whether it’s because their kids are home, and they need to be home for childcare or if there’s concern about vulnerabilities for poor outcomes in COVID-19 infection or general anxiety about infection. We offer them the option of taking their paid time off now so that we’ll have increased access to the workforce once that post-COVID surge occurs.

In addition, we really looked at maximizing the efficiency of our scheduling, as well, maximizing the workflow efficiencies of the imaging modalities, the utilization of our imaging centers, and really creating a dynamic scheduling process where patients can get scheduled between sites much more efficiently.

Diagnostic Imaging: What steps have you considered or do you have in place to ensure you re-engage patients, bringing them back in for needed services?

Mossa-Basha: With scheduling postponements, patients appreciate that we leave it in their hands and those of their ordering physician to reschedule. For patients that feel their imaging is really critical and time-sensitive based on their symptoms or based on underlying disease, they are afforded the opportunity to reschedule or postpone as they see fit. We send them automated text messaging that communicates the urge to reschedule based on the COVID-19 pandemic and the risk of infection. We communicate to them that they should contact their ordering physician in order to reschedule, and we provide them the rescheduling line. If a patient feels they need to get their imaging done because their symptoms are so severe, they have the option of doing that.

The patients that end up postponing go into a queue. We haven’t immediately rescheduled them because we don’t know when this pandemic is going to subside and when we’ll be able to open up the imaging environment again. We wouldn’t want to reschedule them for May 5 or 10 and, a week later, have to tell them we’re postponing their appointment again. We want to ease the communication, anxiety, and the stress on our patients while also providing them the optimal care and the diagnostic imaging they really need. Hopefully, once we get to the point where we know a target date, we will begin actively rescheduling.

Diagnostic Imaging: Finally, as Washington was the first state to see the emergence of COVID-19, you’re slightly ahead of the rest of the nation in dealing with this, reaching your peak around April 2. What lessons have you learned that you can provide to other radiologists as they continue to weather the storm?

Sahani: There are many lessons. First, take this disease seriously. You need to really put the measure for social distancing well in place. This requires effective communication and also leadership that leads by example. Put together a good team in advance and make sure that people know their roles and responsibilities.

Be sure there is a common channel for communication. Have more engagement from different groups, and make sure you protect your frontline staff as much as possible because they are your valuable resource. If they get infected by COVID-19, then it creates more challenges. Provide them with personal protective equipment. Engage with referring physicians and patients as you defer certain exams, such as non-critical screening procedures, or elective procedures for a later date.

Communicate with your staff on a regular basis. Something informal like a town hall style meeting can be effective. It can minimize the number of emails you want to send out. There’s so much news about COVID-19 that produces anxiety and fear that you want to make sure you’re transparent. Share the data, but do so without creating fear. Keep your staff engaged and being very optimistic about the purpose and mission and passion that we have for patient care.

And, after social distancing and hand hygiene, testing has been the most impactful thing. Washington was one of the first states to ramp up testing from a few hundred patients or samples to, now, more than 5,000 samples a day. The lab is running 24-7, and I think that has made a tremendous difference, especially with testing the workforce. If they are infected, that sends panic among the rest of the staff. Preserving the workforce, keeping them motivated, and keeping them engaged is critical.

Mossa-Basha: From the operational perspective, one important thing to keep in mind is being prepared before you need to be prepared. It’s something that the University of Washington and the University of Washington hospitals do really well. Because Harbor View is a trauma center, it’s something we’re used to thinking about and dealing with. I think, it’s one of the issues that a lot of the hospitals across the country have had difficulties with, especially with having sufficient personal protective equipment, ventilators, and beds to accommodate patients.

In radiology, our role is having adequate and sufficient imaging capacity to manage the crisis as it happens, having portable X-ray equipment, having portable CT equipment that can really provide the imaging access that’s needed for these patients where they need it. That’s very important for hospitals to consider. And, try to position your hospital such that you’re financially viable enough to where, if a financial hit happens, you can continue operationally as normal and remain solvent without having to be concerned about furloughing.