As COVID-19 stay-at-home orders relax and practices re-open for in-person visits, physicians must now work under new safety standards and guidelines. To help you practice in this “new normal,” please consider these risk management guidelines.
AMA guidelines
The American Medical Association (AMA), has published a checklist for physicians to ensure medical practices are ready to re-open safely. The checklist comprises the following 12 guidelines. (1)
1. Comply with governmental guidance.
The federal government and several state governments have published guidance and recommendations for reopening businesses. Federal guidelines, entitled “Opening up America again,” are available online (see “Sources” and “Additional Resources” below). (2)
The AMA has created a state-by-state fact sheet that provides directives for the “resumption of elective or non-urgent procedures.” (3) This document includes guidance from the Centers for Medicare and Medicaid Services, the Centers for Disease Control and Prevention, and the American College of Surgeons. It is also available online. (3)
In Texas, the Texas Medical Board (TMB) has created a new rule (emergency rule 190.8(2)(U) specific to COVID-19 that outlines the “required minimum standards for safe practice.” (4) The emergency rule establishes minimum standards for safe practice for all physicians providing patient care or engaging in in-person patient encounters and requires the following.
- A mask must be worn by both the patient and physician or the physician’s delegate when there is less than a 6-foot distance between the patient and the physician or the physician’s delegate.
- Providers must follow the policies put in place by the physician, medical and health care practice, or facility regarding COVID-19 screening and testing and/or screening patients.
- Before an appointment, patients must be either screened for potential symptoms of COVID-19 or verified as previously screened within the last 20 days.
- Before any medical procedure or surgery on the mucous membranes, including the respiratory tract, with a high risk of aerosol transmission, the minimum safety equipment used by a physician or physician’s delegate should include N95 masks, or an equivalent, and face shields.
- All medical and health care practices, offices, and facilities, other than hospitals as defined under Chapter 241 of the Texas Health & Safety Code, shall post a notice describing these minimum standards for practice in all public and private areas and treatment rooms. (4, 5)
If you practice outside of Texas, consult with your state medical board for guidance. Additional TMB standards can be accessed online. (6)
2. Make a plan.
Take the time and steps needed to prepare your practice for a successful reopening. Start by taking inventory of your personal protective equipment (PPE) and assess what your needs will become as you reopen. Place orders for what you need and try to have deliveries in advance of reopening.
Keep track of the appointments that were cancelled before closing. Identify which patients are more vulnerable, and prioritize those patients as appointments are rescheduled. (7)
Take a look at your office, exam rooms, waiting areas, and administrative areas. Where can changes be made to minimize infection? Consider removing magazines, children’s toys, or other clutter from the waiting area that could be harboring germs. Consider installing protective shields or barriers at desks where patients check in, pay their bills, or make appointments. (7)
Revisit your policies and procedures. Consider whether or not cancellation policies and payment policies are sensitive to what your patients may be experiencing due to COVID-19, such as financial difficulties, child care scheduling issues, or unemployment. (7)
Create an internal policy or rule about how to handle staffing and cleaning work areas if a patient, employee, or visitor is diagnosed with COVID-19 after being in the clinic. Establish when and how long employees who interacted with a diagnosed patient or visitor will be out of the clinic. (1)
3. Open incrementally.
At first, you may want to identify what patient visits can be made via telemedicine and continue to perform those visits remotely. Consider reopening your office gradually for in-person visits. For example, you may want to open up one-third of your time to in-person visits and keep two-thirds as telehealth visits. This will allow you to assess how things are going and address any challenges that arise before opening more broadly. (8)
Administrative staff who do not need to be physically present in the office should be directed to work remotely. Consider bringing employees back in phases or on alternating days to reduce contact.
Clearly communicate your office hours. Publish this information widely and often – through email to patients, on social media, and on your website. (7)
4. Institute safety measures for patients.
To ensure that patients are not coming into close contact with one another, adopt a modified schedule to avoid high volume or density. Designate separate waiting areas for “well” and “sick” patients. You might even consider scheduling well visits in the morning and sick visits in the afternoon, or vice versa. If possible, designate “entrance only” and “exit only” doors for your patients. (7)
Consider a flexible schedule for the practice, with perhaps a longer workday with more time in between visits to avoid backups. Limit patient companions to those whose participation is necessary based on the patient’s circumstances. For example, a parent for a minor; a spouse; or caregiver for a disabled patient are acceptable.
Consistent with U.S. Centers for Disease Control and Prevention (CDC) guidance, practices should require all individuals who visit the office to wear a cloth face covering or mask. This expectation should be explained to patients and visitors before they arrive.
To facilitate compliance, provide resources to help patients make a cloth face covering or mask, such as the CDC webpage. There are also several YouTube videos to share on how to make a mask. Visitors and patients who arrive to the practice without a cloth face covering or mask should be provided with one by your practice, if supplies are available. (1)
In addition to the AMA guidelines, here are some additional recommendations. (8)
- Communicate clearly to patients when the practice will reopen, how visits will be different, and what is expected of them. Assure them that you and your staff are taking all recommended precautions to protect their health and safety.
- New expectations will include maintaining physical distancing while in the office. Staff and patients must stay at least six feet apart unless patient care requires closer contact. Patients should also be informed of screening procedures before their appointment. (See section 7 below.)
- Some practices may adopt procedures for escorting patients directly to an exam room upon arrival. Other practices might instruct patients to send a text message to the office when they arrive and to wait in their cars until they are called in for their appointment.
5. Ensure workplace safety for clinicians and staff.
Clearly communicate to staff and colleagues that they cannot come to work if they are experiencing any symptoms of COVID-19, or if they have recently come into contact with someone who has tested positive for COVID-19.
All employees should be screened daily for fever and other symptoms before they begin work. This may be done by employees before they report to work. Maintain records of employee screening efforts and results in a confidential file, separate from personnel files.
Clinical staff should wear face masks, gowns, eye protection, and gloves when caring for patients suspected of COVID-19 infection. Masks and gloves should also be worn when seeing other patients due to the possibility of patients being asymptomatic for COVID-19 infection. (8)
Minimize person-to-person contact as much as possible, including during the employee screening process. Consider reconfiguring workspaces to increase social distancing between workers.
Establish open communication with the facilities department of your building regarding the cleaning schedules and protocols for shared building spaces, such as lobbies, kitchens, bathrooms, elevators, stairwells, doors, and other common areas. You may also want to maintain this contact to stay informed of any workers in the building who test positive for COVID-19. (1)
Additional recommendations include the following.
- Ensure that handwashing and sanitizing supplies are available to patients and staff. “Staff should perform hand hygiene before and after each patient contact, after contact with potentially infectious material, and before putting on and after removing PPE, including gloves.” (8)
- “If possible, divide staff up into shifts or teams. If one team gets exposed, the other team will be protected.” (8)
- Clean and disinfect exam rooms after each patient encounter, per guidelines from the CDC. These guidelines are found online on the CDC website. See “Sources” below. (9)
- Frequent disinfection of surfaces and objects touched by multiple people is important. Disinfect light switches and door handles daily. (8)
- Using automatic door openers or propping certain doors open will help cut down on the need and/or frequency for disinfecting these surfaces. (8)
- Display prominent signs with instructions on hand washing, cough etiquette (“cover your cough”), and respiratory hygiene (“use a tissue to cover your mouth and nose when coughing or sneezing”). (7)
- “Consider recording a video of your practice showing all the precautions you have undertaken for your patients’ and staff’s safety. Show staff wearing masks and gloves or in full PPE gear. Capture them in action disinfecting door handles, light switches, work surfaces, and so on. Upload the video to your practice website and share it across social media platforms.” (7)
6. Implement a tele-triage program.
When scheduling patients for appointments, consider using a tele-triage program to assess the need for face-to-face appointments. When a patient calls the practice, use the program to discuss symptoms and the patient’s current status. Based on the information gathered, the patient may be scheduled for an appointment or re-directed to the practice’s HIPAA-compliant telemedicine platform, a COVID-19 testing site, or to a hospital.
If your practice was already using a tele-triage service pre-COVID for after-hours calls, contact your service to determine how the service could be expanded to tele-triage daytime calls. Consider reassigning practice personnel to operate this service during office hours.
Visits that can be conducted via telemedicine should be. It is also important to verify that those patients scheduled for telemedicine visits have the necessary technology and understand the technical instructions for accessing the visit.
Additional recommendations when scheduling patients include:
- ask patients to complete intake paperwork and registration forms online before their appointments;
- ensure your website is updated with new business hours, registration forms, and instructions for patients regarding COVID-19 safety guidelines, including screenings, face masks, physical distancing, and procedures for entering the practice;
- evaluate your telemedicine tools for ease of use and long-term viability; and
- review your options for the best HIPAA-compliant telemedicine platform for you and your patients. The TMA has posted a comprehensive guide for telemedicine vendor options online. (10)
7. Screen patients before in-person visits.
Before an in-person appointment, confirm to the best of your ability that the patient does not have symptoms of COVID-19. Establish a system for staff to call the patient within 24 hours of the appointment to 1) review the logistics of the reopening practice protocol, including what to expect when they arrive for their appointment, and 2) screen the patient for COVID-19 symptoms.
Use a script of questions for your staff to follow when conducting these calls. Include questions such as the following. A full script template is available at the AMA website. (See Sources below.) (1)
- “Have you or a member of your household had any of the following symptoms in the last 21 days: sore throat, cough, chills, body aches for unknown reasons, shortness of breath for unknown reasons, loss of smell, loss of taste, fever, temperature at or greater than 100 degrees Fahrenheit? (If yes, obtain information about who had the symptoms, what the symptoms were, when the symptoms started, when the symptoms stopped.)”
- “Have you or a member of your household visited or received treatment in a hospital, nursing home, long-term care, or other health care facility in the past 30 days? (If yes, obtain the facility name, location, reason for visit/treatment and dates.)”
- “Have you or a member of your household traveled outside the U.S. in the past 30 days? (If yes, obtain the city, country and dates.)”
- “Have you or a member of your household traveled elsewhere in the U.S. in the past 21 days? (If yes, obtain the city, state and dates.)”
- “To the best of your knowledge have you been in close proximity to anyone who tested positive for COVID-19? (If yes, obtain information about when the contact occurred, what the contact was, how long the people were in contact, and when the diagnosis occurred.)” (1)
When the patient arrives at your office, he or she should also be screened before entering. Some practices may deploy staff in a designated area of the parking lot or in an anteroom to screen patients before they enter. Other practices may use text messaging or other electronic means to do such screening, subject to patient consent and relevant federal and state regulations.
Again, strictly limit individuals accompanying patients to those who are necessary. These individuals should be screened in the same manner as a patient.
8. Coordinate testing with local hospitals and clinics.
Contact your county medical society or state medical board for information on available COVID-19 testing sites. Identify several testing sites in your area and contact them to ensure that tests are available. Also, determine the turnaround time on testing results.
“Provide clear and up-to-date information to patients regarding where they can be tested and how the process works. Some health systems have instituted the practice of testing all patients who are being scheduled for elective or high-intensity procedures (such as outpatient surgeries or services requiring close contact). Depending on the nature of your practice, you may consider doing the same.” (1)
9. Limit non-patient visitors.
Minimize contact between your patients and any non-patient visitors to your practice, such as a vendor, supplier, or maintenance worker. Establish a protocol for rerouting these visits to phone calls or video conferences. The AMA suggests that a physician may want to hold “office hours” to speak with suppliers, vendors or salespeople by phone or video conference. (1)
Clearly post your new policy for non-patient visitors outside the practice door and on your website. For visitors who must physically enter the practice (to do repair work, for example), you may want to designate specific times outside of office hours for these individuals.
10. Contact your medical malpractice insurance carrier.
Contact your medical liability insurance carrier to discuss your current coverage and whether any additional coverage may be warranted during the COVID-19 pandemic. Legislation may be forthcoming in some states to expand protections to physicians treating COVID-19 patients. It's important to be in close contact with your insurer to confirm your status and level of coverage.
11. Establish confidentiality/privacy.
Before reopening, the AMA recommends establishing or updating your confidentiality, privacy, and data security protocols, policies, and procedures. Require all employees to review all new and/or updated materials and sign them to acknowledge their review and understanding of them.
Again, results of any screenings of employees should be kept in employment records only (but separate from the personnel file). HIPAA authorizations are still necessary for sharing information about patients for employment purposes. Coworkers and patients may be informed that they came into contact with an employee who tested positive for COVID-19, but the identity of the employee and details about his or her symptoms cannot be shared with patients or co-workers without consent.
While certain HIPAA requirements related to telemedicine have not been enforced during COVID-19, generally HIPAA’s privacy, security, and breach notification requirements must continue to be followed. (1)
12. Consider legal implications.
The AMA states, "New legal issues and obligations may arise as the practice reopens. For example, some practices may not have had to make decisions about paid sick leave (per the ‘Families First Coronavirus Response Act’) because they were on furlough; as the practice reopens, these sorts of employment obligations should be considered and decisions about opting out or procedures for requesting these leaves communicated to employees…Lastly, coordinate with your local health department as provided for by law; provide them with the minimum necessary information regarding COVID-19 cases reported in your practice, and stay informed of local developments." (1)
Additional resources
- CDC website: Information for Healthcare Professionals about Coronavirus (COVID-19). This site includes clinical care guidance, including a telephone response guide, guidance by patient type, infection control, optimizing PPE supplies, and FAQs. https://www.cdc.gov/coronavirus/2019-nCoV/hcp/index.html
- Texas Medical Association: COVID-19 Resources. This site includes links to state mandates for new COVID-19 Safety Rules; TMA guides, and FAQs. https://www.texmed.org/CoronaVirus/
- Texas Health and Human Services: Coronavirus Disease 2019 (COVID-19) website. https://dshs.texas.gov/coronavirus/
- The Institute for Health Metrics and Evaluation (IHME) COVID-19 projections. https://covid19.healthdata.org/united-states-of-america
- Johns Hopkins University of Medicine: Coronavirus Resource Center. https://coronavirus.jhu.edu/
Sources
1. COVID-19: A physician practice guide to reopening. Updated May 1, 2020. American Medical Association. Available at https://www.ama-assn.org/system/files/2020-05/physican-guide-reopening-practices-covid-19.pdf. Accessed May 8, 2020.
2. Opening Up America Again. Available at https://www.whitehouse.gov/openingamerica/. Accessed May 11, 2020.
3. Factsheet: State action related to delay and resumption of “elective” procedures during COVID-19 pandemic. Advocacy Resource Center. American Medical Association. Available at www.ama-assn.org/system/files/2020-05/state-elective-procedure-chart.pdf. Accessed May 11, 2020.
4. Rule § 190.8(2)(U)(i)(ii). Chapter 190 Disciplinary Guidelines. Subchapter B Violation Guidelines. Issued May 8, 2020. Texas Medical Board Texas Register. Available at https://texreg.sos.state.tx.us/public/regviewer$ext.RegPage?sl=R&app=1&p_dir=&p_rloc=375272&p_tloc=&p_ploc=&pg=1&p_reg=375272&ti=22&pt=9&ch=190&rl=8&issue=05/08/2020&z_chk=. Accessed May 11, 2020.
5. Chapter 241. Hospitals. Section 241.003 (5). Definitions. Title 4. Health Facilities. Health and Safety Code. Available at https://statutes.capitol.texas.gov/Docs/HS/htm/HS.241.htm. Accessed May 28, 2020.
6. Coronavirus Disease (COVID-19) Response. Texas Medical Board website. Available at http://www.tmb.state.tx.us/page/coronavirus
7. Road to Practice Recovery: A guide for reopening your practice post COVID-19. Texas Medical Association. Available at https://www.texmed.org/uploadedFiles/Current/2016_Public_Health/Infectious_Diseases/Road%20to%20Recovery.pdf. Accessed May 11, 2020.
8. A checklist for reopening your practice for “non-essential” face-to-face visits. In Practice blog. FPM Journal. May 4, 2020. American Academy of Family Physicians. Available at https://www.aafp.org/journals/fpm/blogs/inpractice/entry/reopening_a_practice.html. Accessed May 8, 2020.
9. Reopening Guidance for Cleaning and Disinfecting Public Spaces, Workplaces, Businesses, Schools, and Homes. Coronavirus Disease 2019 (COVID-19). Last reviewed May 7, 2020. Centers for Disease Control and Prevention. Available at https://www.cdc.gov/coronavirus/2019-ncov/community/reopen-guidance.html. Accessed May 11, 2020.
10. COVID-19: Telemedicine Vendor Options. April 2020. Texas Medical Association. Available at https://www.texmed.org/uploadedFiles/Current/2016_Practice_Help/Health_Information_Technology/Telemedicine/Telemedicine%20Vendor%20Options.pdf. Accessed May 11, 2020.
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