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LETTER TO THE EDITOR
Year : 2020  |  Volume : 68  |  Issue : 5  |  Page : 944-947

Toolkit for survival: How to run and manage ophthalmic practices during the difficult time of COVID-19 crisis


SuVi Eye Hospital and Lasik Laser Center, C 13 Talwandi, Kota, Rajasthan, India

Date of Web Publication20-Apr-2020

Correspondence Address:
Dr. Suresh K Pandey
SuVi Eye Hospital and Lasik Laser Center, C 13 Talwandi, Kota, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_823_20

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How to cite this article:
Pandey SK, Sharma V. Toolkit for survival: How to run and manage ophthalmic practices during the difficult time of COVID-19 crisis. Indian J Ophthalmol 2020;68:944-7

How to cite this URL:
Pandey SK, Sharma V. Toolkit for survival: How to run and manage ophthalmic practices during the difficult time of COVID-19 crisis. Indian J Ophthalmol [serial online] 2020 [cited 2020 Jun 4];68:944-7. Available from: http://www.ijo.in/text.asp?2020/68/5/944/282899



"You never let a serious crisis go to waste… it's an opportunity to do things you think you could not do before."

- Rahm Emanuel

Since first being recorded late last year in China, the COVID-19 coronavirus has spread around the world and caused enormous loss of human life. For many doctors and healthcare specialists, the novel coronavirus is a turning point of health havoc and economic crisis, as we witness this time with a relatively unknown future filled with uncertainties. On April 1, 2020, the secretary-general of the United Nations stated that the coronavirus will cause a "great global economic recession" that probably has no parallel in the recent past. The World Bank had also warned that "significant economic pain" appeared unavoidable in all countries.

Strict lockdown, physical distancing, stress, and anxiety among the public is also affecting the medical field, and the transition from on-premises medical consultations to telemedicine, virtual consultation with doctors is perhaps one of the significant changes we are going to witness due to the corona crisis. It is the fact that many of us are developing contingency plans to recover from an unstable situation. This write-up hopes to shed light on different tips that could help ophthalmic practices stay afloat during these testing times. From telemedicine, cost management plans, resolving internal conflicts, the authors hope to offer words of wisdom that could help us to navigate out of worst-case scenarios.

However, before we delve deep into an action plan, let us take a moment to understand the severity of this situation.


  The Impact of COVID-19 on Healthcare Top


In December 2019, China witnessed the beginning of an outbreak of coronavirus in Wuhan, Hubei.[1] The Chinese doctors tried their best to contain the acute respiratory syndrome caused by a "new variant of coronavirus 2019-nCoV" but all their efforts were in vain. The disease soon spread all over the world, which compelled the World Health Organization (WHO) to label it as a pandemic on March 11, 2020.[2]

On April 15, 2020, an online database reported approximately 2,055,743 confirmed cases of COVID-19 in more than 210 countries and territories across the world. The current death toll is estimated to be 133,098 and does not show any signs of slowing down.[3] The continuous death, nationwide lockdowns, and inadequate supply of masks, sanitizers, personal protection equipment, and life-supporting healthcare equipment have had a drastic impact on the doctors, healthcare workers treating the patients suffering from COVID-19 as well as on the economy.[4]

The UNCTAD (United Nations Trade and Development Agency) predicts that the world economy will suffer gravely due to the inhibition in world trade operations. The estimated amount of loss is forecasted to be $1 trillion.[5] Even after the COVID-19 pandemic is over, it might take years to rebuild the "fragile economy."[6]

The healthcare economy will face a similar situation in the coming several months or even a few years. Therefore, it is prudent for private ophthalmology practices to prepare for the worst-case scenarios to safeguard their practices. These are the questions that haunt us as we watch the situation and hope for the best to stabilize the situation.


  Tips for Survival: How to Manage the Ophthalmic Practice? Top


In effort to limit COVID-19 pandemic, India is currently under lockdown status till May 3, 2020. It is unclear now how things will unfold after May 3, 2020. As of April 15, 2020, India had reported a total of 12,320 positive cases of COVID-19 with 405 deaths and this number is increasing rapidly. Several questions are flashing in mind of many of us like- How long the COVID-19 pandemic will continue in India and globally? Where will ophthalmic practices stand in the aftermath of a pandemic outbreak? How do they survive, or economic and other challenges (short-term or long-term) faced by doctors before things settle down?

Here are a few trends that many private practices and healthcare facilities are adopting these days, especially in countries that are affected by COVID-19 pandemic. Ophthalmic leaders and entrepreneurs need to devise strategies to revive their practice and to come forward with innovative solutions to address several challenges.

1. Patient Visit in Hospital during or after Lock-down Period: While seeing cases during the lock-down period, in an emergency OPD, it is essential to take all adequate precautions and follow the guidelines as suggested in an excellent editorial [1] and by the All India Ophthalmological Society (AIOS) available on its website. Better to be safe than to be sorry! All doctors and staff members should take adequate precautions while seeing emergency cases admitted in other hospitals. Use of face mask, safety glass, frequent hand washing, physical distancing, minimal touching and talking, use of slit-lamp with a protective sheet, etc., will be helpful. Patient triage and all the cautions can be remembered by acronym SCREEN: S: Sanitize hands, C: Consent/declaration/hand hygiene, use of mask by the patient; R: Rapid patient turnaround, Restrict entry of the attendant; E: Examination by flash light or use of slit lamp taking all precautions; E: Encourage physical distancing; N: No cash (encourage digital payment), No aerosol generating procedures. Once lock-down is over (May 3, 2020), all the members of the practice team should take maximum precautions (like patient triage, physical distancing, hand hygiene, sanitization, use of masks etc) while managing patients visiting for ophthalmic evaluation and surgical procedures for 6 months (depending on situation) to avoid transfer of COVID-19 from asymptomatic career. Be prepared to see fewer patients for the coming weeks scattered over the whole OPD duration to avoid overcrowding. It is important to supervise your entire hospital team and ensure everyone to take due caution and to follow the protocol/guidelines suggested by the AIOS. The practice of hand hygiene should always be followed carefully by the doctor before touching any new patient.[7]

2. The Rise of Digitization/Online Consultation: In the last few years, the corporate world is buzzing with activity as they embrace digital tools to streamline their workload. Yet, the healthcare industry kept a people- first mentality, even though we slowly adapted to incorporate technology into our daily activities.

However, COVID-19 has transformed and forced the healthcare industry to go for online healthcare services, virtual consultation as we are witnessing every day. Online screenings, consultations, and telemedicine are becoming a norm now. In China alone, there was a 900% increase in subscribers for popular online healthcare services like "Ping An Good Doctor."[8] India's largest online consultation platforms (Practo, Zoylo, Lybrate, Ask Apollo, etc.) have seen a significant increase in the number of consultations in the past few weeks. The surge of digital solutions means that patients might continue with virtual remote consultations for a some time until it is safe to venture outdoors.

Other important OPD practices include the use of slit-lamp protectors using the special protective sheet and other special customized devices that help to see ophthalmic cases while maintaining distance. Ophthalmic surgeons in the COVID-19 affected countries are considering personal protection equipment (PPE) during eye surgery and medical professionals in developed countries may consider robot-assisted surgeries,[9] so that the contact between patient and surgeon is barely required during practice. Though this option is not feasible for the ophthalmology practice of developing countries like India.

It will be pertinent to go to EMR (electronic medical records, etc., if not done so far) and begin scheduling online appointments, and collecting payment.

3. Cost Management and Financial Contingency Plans

Private practices need to start adjusting their budget plans. The finance department needs to calculate current cancellations and possible setbacks in the coming weeks (and months). Tallying those results will give an accurate picture of the financial situation. One should always consider precautionary measures to minimize revenue loss and measures to save money.[10] The unnecessary expenses could include planned extensions within the facility, renovations, or outreach eye-camp activities. We should also postpone the idea of expansion, a new instrument, or hiring nonessential staff until further notice.

4. Revive the Financial Reserve of the Practice: Assess cash reserve of the practice and prepare a plan for survival taking worst-case scenario. It is important to accelerate the collection of due amounts by the Third Party Agency (TPA) and all insurance companies and by chasing the debtors. Consider reduction of the fixed cost by converting full-time doctors to part-time, consider the option of full-time anesthetists, internists, etc., to on-call duty. One should cut short all unnecessary expenses such as minimizing cost in marketing, advertising (newspaper, television, etc.) and adapt to low-cost digital marketing using social media to maintain visibility and presence of the practice. Ophthalmologists engaged in private practices should not plan to expand or buy any high-tech equipment at present till the situation and economy come back to normal and this may take several months or even a few years. During this lock-down period, it is important to prepare the plan of action and come with innovative low-cost solutions.

5. Force Majeure Clause and Equipment Maintenance: Consider reduction in rental cost by following the Force Majeure clause (if applicable) or by handing over the extra space that is not needed at present. Consider the extension of Comprehensive Maintenance Contract (CMC) and Annual Maintenance Contract (AMC) of important equipment by 6 months. Train and sensitize your staff to save money by preventing wastage and by minimizing the use of costly disposable items (for example use a reusable cassette rather than disposable cassette during the phacoemulsification surgery).

6. Review the Inventory of IOLs, other Supplies: Firstly, do an inventory of the intraocular lenses (IOLs), cassette, viscoelastic products, surgical adjuncts, pharma items/drug supplies in-stock and those we require in the future. Return all IOLs, disposable items, eye drops etc. which are excessive to consume in the present scenario and all the near expiry items.

7. Insurance Cover for COVID-19 and Business Interruption Insurance: Review the insurance policy to check if they cover COVID-19 associated liabilities. Understanding the validity of your insurance coverage and its potential will make it easier for you to make an administrative decision. Request them to provide coverage for preoperative COVID-19 tests. One can also request banks to waive off or reduce installment during this period. Business interruption insurance may be an option for the practice if we have significant business losses as a result of shutting down the medical practice from the pandemic. We can discuss insurance management about business interruption insurance to cover unexpected major events and see what qualifies for coverage. It may not cover this emergency, but we would be better prepared for the next time the medical practice suffers similar economic losses

8. Legal Aid: Besides, consult with a legal advisor to ensure that our medical practice will not be held liable in the event of a COVID-19 outbreak within the premises

9. Staff Salary and Incentives, etc.: Start developing a financial contingency plan with the charted accountant or financial expert. We must inform employees about possible cutbacks in the salary, bonus, incentives, or other amenities they use. Also, request them to cooperate if there is a delay in their annual salary, bonuses, and incentives. Communicate and sensitize the entire team to be ready for a salary cut, extended working hours, working on weekends, and laying off the low-performers in the worst-case scenario. These small steps will ensure that the practice does not struggle with major financial problems during and post-COVID-19 pandemic.

10. Reshaping Contract, Medical Protocols, and Collaborations: The worldwide pandemic of COVID-19 and its ophthalmic implications and precautions are highlighted aptly in a recent editorial and article.[1],[11] There the authors talk about the risk of contracting the virus during slit-lamp examinations and other ophthalmic procedures. Due to this, it becomes essential that all ophthalmic medical practitioners within the facility take complete precautions while they are with a patient. These include the use of safety glasses, wearing N95 masks covering the nose, eye, and mouth during surgery and using the PPE (if necessary) in the OT and taking all other important measures for OPD and OT as suggested for All India Ophthalmology Society and American Academy of Ophthalmology.[12]

Besides this, we should make an effort to minimize any crowding in the OPD for a few months once lockdown in India is over (May 3, 2020). The best strategy is to keep updated every day and modify your plan based on the situation. To minimize the risk of spreading COVID1 19, we can consider canceling nonurgent appointments and consultation of patients who have fever or cough. We should also ask the staff to stay home if they are having a fever or cough. Besides, make sure that all employees are updated about COVID-19 guidelines and regulations. This will make it easier for them to respond to emergencies and act quickly in case of an emergency. Moreover, the hospital staff must reevaluate their assignments. We must cultivate a feeling of camaraderie and community amongst peers.[13] Ask them to assist each other during emergencies, swap clinical hours whenever required

The practitioner needs to prepare the revised contract of all doctors and staff members working at the practice and include all details about COVID-19 pandemic and the possibility to get infected while working in the hospital. It is important to get it duly signed (as advised by legal expert) by all the doctors and staff members to minimize the risk of legal implications. Following these guidelines can mitigate the spread of infection as well as it will save the practice from legal implications if some staff come positive COVID-19 and files compensation case against the hospital.

11. Group Practice and Models Sharing the Costly Equipment: Other initiatives include sharing hospital facilities (e.g., surgical facilities, investigations, laser, and surgical equipment) with other private practices to decrease overhead charges. If possible, one can share medical staff and send terminated employees to aid understaffed practices. Mutual support will strengthen our professional network and also pave the way for possible business opportunities in the future.

12. Virtual Conferences and eCMEs: At present, international travel as well as domestic travel to attend the conferences are also banned to limit the spread of COVID-19 pandemic. The World Ophthalmology Conference (WOC), Cape Town, South Africa (scheduled for June 26–29, 2020) was recently canceled. The WOC will be organizing a virtual meeting (WOC2020 Virtual®, 26–29 June 2020). All India Ophthalmology Society successfully organized an eCME activity on April 4, 2020, and on April 15, 2020 on the subject of the economy of ophthalmic practice after the COVID-19 crisis. This was attended very well and learned speakers shared pearls of wisdom to deal with the current situation.

13. Leadership in Lockdown: The coronavirus pandemic is described as humanity's worst crisis since World War II and definitely will take time to resolve. It is important to over-communicate and communicates effectively, spread positivity, portray realistic pictures, handle trouble spots, instill the importance of institutions over self, maintain transparency, and provide frequent updates.


  Conclusion Top


Coronavirus outbreak (COVID-19 pandemic) is one of the worst crises in the history of mankind leading to loss of human life and causing the greatest global economic recession in modern history. As an ophthalmic practitioner, we should hope for the best, but be prepared for the worst. We have to safeguard our life as well as our livelihood. We should keep in mind "5 R" for the rapid recovery of the economy. These include resolve, resilience, return, reimagination, and reform (exhibit). In the end, strong leadership is the key to the current situation.

India is fortunate to have a strong political leader as our prime minister and All India Ophthalmology Society is also fortunate to have a strong leadership guiding its 23,669 life members at every step. We are being guided by members with rich academic experience and also ophthalmic entrepreneurs with high experience of running the chain of eye hospitals. The COVID-19 pandemic has taught us that only unconditional passion for this profession and resilience can help doctors cope with a pandemic. We must, however, not forget the importance of pragmatism. Doctors and administrative staff should use their collaborative efforts to create a practical and cost-effective plan for the future. The plan should include everything from cost management, patient care to adopting digital solutions and all the items (masks, protective glasses, etc.) to safeguard ourself, team members and our patients. Along with this, healthcare facilities must arrange a contingency plan to respond quickly in the event of a disaster. With that said, we must not forget the humane quality of our profession. Do not let digitization weaken the doctor-patient relationships we have forged with our patients. Make sure that they are updated on any changes and also listen to their feedback. This way, we can continue providing them with the best care possible. Let us keep a close watch of how the situation unfolds and adopt innovative solutions to solve the problems emerging on all fronts. It is the only way to ensure that our ophthalmic practice, or any medical practice for the matter, can survive a crisis.

The toolkit for managing the ophthalmic practice during the crisis caused by COVID-19 Pandemic can be emphasized by the acronym CORONAVIRUS- C: Consent/declaration from all the patients, Cut down unnecessary expenses; O: Outline the plan to manage the practice such as standard operating procedures/Protocols to ensure safety for all the team members as well as for patients, Over communicate/communicate clearly with your team members; R: Review Finances and prepare realistic plan keeping the worst case scenario in mind; O: Outstanding bills/dues to be collected from insurance company; N: No to buying costly equipments and No to new expansion of practice till practice volume comes to normal; A: Arrange all necessary items to stop or limit COVID-19 transmission (masks/sanitizers/safety glasses/personal protection equipment, if needed); V: Virtual Consultation (Tele-Health) or consultation on phone/WhatsApp for follow up patients; I: Inventory management (check IOL stock, other inventory and return the excessive or near expiry items you do not be needing, Implement all measures, follow protocols/AIOS guidelines to manage your OPD and operation theater to avoid contamination; R: Review the situation everyday and take appropriate step, Rental agreement ; U: Update yourself and entire team and ensure (and document) guidelines (from AIOS) are to be followed; S: Staff management (special consent/agreement about job and salary, working hours, etc.), Social distancing, Sanitization, etc.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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2.
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