In this episode of Fireside Chat, we sat down with Sarah Krevans, President and CEO, Sutter Health to talk about telehealth medicine during the pandemic, communication with caregivers and the board of directors, overcoming financial obstacles, and working through PPE shortages during the crisis.

Please note: The number of COVID-19 cases and the situation referenced in this episode were based on reported data at the time of the interview and are subject to change.

Transcription

Sarah Krevans 0:02
Because providers we have to then say, how are we going to make this experience equal or better clinically? And for what patients? Is that appropriate? It’s not going to be appropriate for every patient in every circumstance. And then, again, how do we improve the workflow, so that actually the video visit becomes less expensive for us to provide and ultimately less expensive for the purchaser.

Gary Bisbee 0:25
That was Sarah Krevans, President and CEO Sutter Health, speaking about the enormous increase in telehealth visits prompted by the COVID crisis and the responsibility of providers to ensure that telehealth visits are equal to or better clinically than a personal visit and that the workflow results in a less expensive visit and less cost for the payer. I’m Gary Bisbee, and this is Fireside Chat.

Sarah Krevans 0:49
When I sent out our March financials, I sent it out with a thank you note from me. And the reason I did that is – I was worried that our managers would look at it and they would feel that they had failed. Because in the last two months of March, and again, these are unaudited and we don’t release external financials. But we are talking about this… we lost about 100 million dollars a week.

Gary Bisbee 1:12
All health systems are losing hundreds of millions of dollars due to the COVID crisis, and larger health systems will be losing billions. It has remarkably changed virtually every aspect of leadership and operations. Our conversation included Sarah’s approach to staying connected with the Sutter caregivers through adverse situations like the dramatic shortage PPE, pressure on the supply chain system going from the use of 1,000 N95 masks a day to 5000 daily, and up to 41,000 surgical masks a day. We covered the COVID-19 waterfront. I’m delighted to welcome Sarah Krevans to the microphone.

Good morning, Sarah.

Sarah Krevans 1:54
Good morning, Gary. How are you this morning?

Gary Bisbee 1:56
Excellent. Thank you. We’re pleased to have you at the microphone and welcome. The focus of this conversation is COVID-19. Thank you, again, so much for participating. We’re all facing challenges due to COVID-19. And we’ve learned that the surge is highly variable by region, what’s the status of the surge in Sutter Health primary service areas.

Sarah Krevans 2:18
So Sutter Health operates primarily in Northern California, although we do have one hospital in Hawaii. And in California, we had some of the earliest cases in the country. But we also had a state that acted very early in terms of putting in place a shelter in place. And so if you looked at some of the initial models, particularly the model out of the group from the University of Washington that I know many, many providers across the country follow many states are following. Those early models showed a surge that would happen mid to late April, and showed also a very high number of deaths of a very high number of cases and showed the health systems in California not being able without adding capacity to keep up with the demand for beds, ventilators and particularly ICU beds, and what we’ve really seen in California is what all of us had hoped for which is where starting to fall off of in an exponential increase in cases. And so if you look at it, we are not one of those states that seen a doubling of case rates every three or four days, a doubling of deaths every three or four days. While this has still been really hard in California, and we mourn every death and worry every day for our health care workers and for all of our other essential workers across this country. It has not had as terrible an impact as it might have had. It’s had obviously very, very hard impacts. But I think that early and deep action did prevent some potential devastation.

Gary Bisbee 4:03
Sounds like the early and deep action then really got you to the point where you’re past the high point of the surge?

Sarah Krevans 4:10
Well, one outbreak in a large skilled nursing facility or a large residential community could change all of that. I believe that not declaring victory too soon, continuing to be vigilant, the governor of California asked health systems to be prepared to do a 30% to 40% surge. We did all prepare to do that actually, at Sutter Health, we prepared to have a 200% to 300% increase in our ICU beds. And we did that based on what we were learning from our colleagues in New York and New Jersey in particular, who were really generous sharing with us the challenges that they were facing, and we realized that of more help than a 40% increase in overall beds would be actually doubling or tripling our ICU capacity. So we actually focused our search plan on ICU capacity. And we had numbers of patients, we have a search plan that goes in levels, one through five. And we actually ended up getting to level two. And we had a trigger point of the number of COVID positive patients that we had in our ICU. And when we got over a certain point, we went to surge level one and then a certain other point and we went to surge level two. This week, we were able to back down to surge level one. And so that was really a great sign but we are still prepared to go back up again if the need arises.

Gary Bisbee 5:38
Sure. Well, that makes good sense. For those of us that aren’t as familiar with Sutter, could you please describe Sutter, it’s always great to hear the CEO describe her health system, it just gives you clarity.

Sarah Krevans 5:50
If I had to describe it today, I would just tell you it’s a little over 50,000 employees and about 12,000 alliance physicians who are working together, from my perspective, in just miraculous ways. The way we usually describe it, of course, is the way people talk about healthcare. They talk about we have this many hospitals and we have 24. And we have this many outpatient clinics and we have ambulatory surgery, and we have homecare. And that’s all true. But if I had to tell you today, I’d say what we have is a network that came together to respond. We have thousands of people in a staffing pool have volunteered to work in different locations, many of whom have been retrained to work in different jobs. we closed our ambulatory surgery centers, we canceled elective surgery, which I think is what responsible health systems have done across this country. We’ve postponed any routine care that could be safely postponed that couldn’t be delivered by video. And as a result, the people who’ve worked in those locations, literally hundreds and hundreds of them have gone through re-training so that they are capable, for example, if they’re a nurse who used to work in a hospital that’s been working in an outpatient setting for many years, so that they got the skills and the comfort to be able to come back into the hospital setting if we needed them. We’ve really responded in a very, very coordinated way. And we have buildings that are closed, but we’ve opened respiratory clinics and tents and parking lots. So our care delivery system, it’s the same people. It’s the same values, it’s the same mission, but where the care is being delivered is dramatically different than it was two months ago, just dramatically different.

Gary Bisbee 7:41
And you’ve also had experience with other crisis with fires in particular, I can remember. Was that helpful just in terms of the mindset of your caregivers that they know this kind of thing can happen?

Sarah Krevans 7:53
I think it was helpful in that we learned a lot of lessons during the fires. In my entire career, I had never had to evacuate in an emergency a full-service hospital. Either in my career at Sutter Health or when I worked prior to Sutter Health at Kaiser Permanente. And we’ve had to evacuate full-service hospitals, four different times in the last several years, and so you learn a lot about responding in a crisis. We’ve also come to understand the importance of being really prepared in a disaster in the ambulatory arena. And most of the regulations and much of the drilling typically focuses on hospitals in terms of disaster preparedness, but in a fire, you really need to know where all of your staff where all of your patients you need to know a lot about all of your buildings, whether they’re a medical office building or a fire, because you’re concerned about air quality and physical safety and all of those locations. That kind of thinking really helped us as we stood up what has been still something like we’ve never experienced. This doesn’t affect one geography, it doesn’t affect one clinical service. It’s not time-bound in the same way. It doesn’t follow a predictable pattern around. You have normal operations, you have disaster operations, and then you have normal operations again. So we’ve learned a lot as we’ve gone through this. And one of the things that’s just been incredibly gratifying to me, is the sharing that happened among healthcare providers and healthcare leaders across the country. And your network is a part of this, right? We all talk to each other and we all say, what are you doing about this? What have you learned about that? Can I ask you this question? I saw that communication, How was that received? And I think that the level of cooperation between health systems in this country has been really good.

Gary Bisbee 9:55
Impressive thing about healthcare is that you do communicate with each other. It’s so important. Speaking of communication, how do you think about communicating with your communities?

Sarah Krevans 10:06
So many things that were built primarily for one purpose. We’ve learned, what are all the different ways we can use them, right? So think about all the gnashing of teeth people have had about the electronic healthcare record. people refer to it sometimes not me, but you hear you hear people refer to it as “it’s a necessary evil,” or it hasn’t accomplished what we wanted it to accomplish. And many of us do wish that the systems that we had were more intuitive that the documentation was easier on our physicians and other clinicians. It’s not that we think they’re perfect, but we would not be able to do what we’re doing if we didn’t have that backbone. So before this pandemic struck, we were doing maybe 50 video visits a day. We had less than 100 clinicians that did video visits. Last Monday we did 6000 video visits in a single day. And we have thousands of physicians that are doing them. We push information to our patients through my health online, which is our electronic, you know, medical records that are portal for our patients. We had adapted many of our communication vehicles to work across multiple channels so that they work on a laptop, they work on a tablet, they work on a smartphone. All of those things that were originally devised so that people could easily book an appointment or check their lab results or communicate by email with their physician. All of those things now are actually a part of the care process. And so I would say that that communication has been important, but it’s also important to be out there communicating in the other ways patients get their information and being sure that we are part of getting responsible, accurate information out on the public media on social media, everything from participating in what are some very large neighborhood sort of chat kinds of environments, to how do you get information out on county websites and on the school websites that are accurate. Because there’s no shortage of information that’s going out about what works, what doesn’t work, what you should be asking for thinking about in this pandemic, and it does change. And that’s confusing to people because they could read something from two weeks ago, but what we know now is more than we knew two weeks ago, and so, really helping all the different channels that people get their information from, be accurate, is I think a part of our responsibility as a healthcare provider.

Gary Bisbee 12:57
Right for sure. What about communicating with Sutter Health caregivers?

Sarah Krevans 13:02
For people like me and maybe like you, right when we were growing up as leaders, the mantra was management by walking around. And to me, a good CEO is out there rounding all the time. And that’s always had its limits when you have a large healthcare system because you can never be everywhere. And you can never touch every employee physically. And so it was a great way to stay in touch, but it never accomplished everything. And now, with social distancing, and early on in this pandemic, with the dramatic shortage of PPE and the need to conserve all personal protective equipment for those who are directly involved in patient care, you really have to think about how do you stay connected in different ways? So we’re doing multiple different things. We have social media channels that are internal only. We have social media channels that are external, we use both of those to provide Communication and support and recognition of our employees. We do really short video broadcasts. When we evolved our approach to masking as a healthcare system, we actually did a short video interview between myself and the physician who is over all of our supply chain talking about why we were changing our requirements and you know, really short, just push it out there. We’re doing virtual town halls. And the one that we did just this past Tuesday, we had so many employees go on that it couldn’t be accommodated. Skype is having its challenges right now because everyone’s on it. But people literally couldn’t sign on there was so much interest so multiple channels and still not enough ways from my perspective to thank and recognize and listen to because it’s one thing and it’s we should always do it. We need to thank and recognize all of our teams that are out there working. But we also need to hear back from them. And that two way listening, I think is harder in this environment. But it’s really, really important.

Gary Bisbee 15:08
Right? For sure. Sarah, how’s the morale are your caregivers?

Sarah Krevans 15:12
I would tell you that I’m so impressed. We have more people volunteering to go and work in the hospitals, then we have shifts for them to fulfill. So we are not having a problem having people work in our inpatient units, including taking care of COVID positive patients. We have staff we went to universal screening at all of our buildings. So we do a health screen and a temperature checks. We have people who’ve only worked in an office environment who are saying I so want to help like let me go to the medical center and “I can take people’s temperatures or I can do screenings.” So I would say the morale is good. And yet people are worried they’re worried for themselves. They’re worried for their family. They’re worried for their colleagues. Some of the things that we’ve done, for example, we have partnered with Airbnb. And we’ve partnered with a company that actually, I really love this one, they provide trailers that they’ll deliver to somebody’s driveway. So maybe you have a spouse or a parent that lives with you who is in a high risk category, and you want to continue working. But you don’t actually want to be living in the same house with them. But you’d like to see them like your description of how you visited with one family member and you sat 10 feet apart on a lawn. We have housing options for people, if people have volunteered to work at a facility that’s not their home facility, we have housing for them. We’ve gotten great philanthropic support from the community, although we could use more. Because the financial impact of this on our healthcare system has been enormous. But we’ve had great support from the community, particularly in terms of people stepping up and offering housing, food, things like that. But it’s hard. It’s hard… it is a hard thing.

Gary Bisbee 17:10
Yeah, it’s hard. It’s gonna be hard for a while. You spoke about video visits, dramatic increase of video visits up to 6000 a day. Do you see that continuing, Sarah? Is this going to work its way into the way we treat patients.

Sarah Krevans 17:23
I think that ever since there was the capability to do video visits, there have been many of us that have been puzzled on the slow uptake of video visits. I know when we added to our health benefits for our own employees, we added video visits and we thought, “Wow, it’s gonna take off like crazy.” But it didn’t. So I think that you have a number of things that came together to make video visits so preferred by patients and by providers. One is that they were actually the only way that certain kinds of care was offered. So we have canceled routine appointments that can be safely postponed if they’re in person. So if you want to be seen for certain kinds of things, things that could be safely postponed, or things that could be done by video, you are seen by video. It’s a video first option, as opposed to a video alternate option. Now, we still will see you in person if you need to be seen and many patients do need to be seen, but many do not. Patients prefer it. So I think in the past, there were patients who felt like a video visit was “less than.” It was a not as good version of an in-person visit. Now patients actually don’t want to be sitting in a waiting room with other people. They’re concerned about being out and about, and so patients prefer it. And then the other thing of course that happened is that it’s now reimbursed. So we didn’t have an economic model for video visits from most health plans or from the federal government. And so all of those things have come together. And I hope that as we get through this and get to the other side of whatever the new normal is, which is not going to be what normal was in February of 2020, it’s going to be something else. I hope that that continues because there’s a lot of the video visit that is more convenient for the patients. Ultimately, when we reengineer the workstreams, and we figure out how to do additional aspects of the documentation and screening so they’re less burdensome on the physician. It should be less expensive, I think, yes, it should remain it should become an important part of how we deliver health care.

Gary Bisbee 19:46
Yep, that’s generally the feeling. I think we should count on that. The question is, will CMS – and I’ve heard a number of good things about how Sima Verma has handled all this – but the question is will CMS recognize that this is the new order and continue to reimburse and continue to loosen regulations in this space?

Sarah Krevans 20:06
there were a number of changes that were slated to go into place in 2021. And I’m hopeful that we will just decide we’re just gonna not remove these things and then put them back in 2021 that we’ll leave the reimbursement in place. I think there are some other really interesting things that we’ll see whether or not these are more difficult politically, things like the artificial boundaries that we’ve had by state line on who could do the videos as well, will those things go back? I think there are additional possibilities in homecare, and that’s been an area where not all of the restrictions have been lifted in terms of what kind of care can be done by video. I’m impressed with what’s come out of CMS on this. I’m impressed and I know that this is a state by state issue, but I’m impressed in California with the cooperation and support we’ve gotten from commercial health plans on the coverage of video visits. We’ll see whether those things continue beyond the pandemic. And then I think as providers, we have to then say, how are we going to make this experience equal or better clinically? And for what patients is that appropriate? Not going to be appropriate for every patient in every circumstance? And then, again, how do we improve the workflow? So that actually the video visit becomes less expensive for us to provide and ultimately less expensive for the purchaser?

Gary Bisbee 21:31
Right. Impressed but more to do. Could we turn to Sutter Health’s economics through all this, and I think everybody understands that 2020 is going to be a very difficult year financially, arguably even 2021. But what’s your feeling about that, Sarah?

Sarah Krevans 21:48
When I sent out our March financials and we don’t publish our monthly financials externally, but of course, like every organization, we track them and we share them with our managers very broadly. When I sent out our March financials, normally they go out from our finance department with a dispassionate analysis: volume was this, we had this variance to budget, this variance to last year. And it’s just numbers. When I sent out our March financials, I sent it out with a thank you note from me. And the reason I did that is I was worried that our managers would look at it, and they would feel that they had failed. Because in the last two months of March, and again, these are unaudited and we don’t release external financials, but we are talking about this. We lost about 100 million dollars a week. In the last two weeks of March. And I did not want our managers to feel like they had failed, that they had failed the organization that they had failed each other, that they had failed their mission. Every decision we made was about “what is it going to take to keep our patients safe and to keep our employees and physicians safe.” And that meant canceling all the kinds of care that typically support a healthcare organization: elective surgery, diagnostic imaging, all of those things were canceled. And what we had were half-empty hospitals filled with staff waiting for patients to come in, some of whom came in and fortunately, many of whom did not. And we trained thousands of staff that fortunately, we haven’t had to use. The cost of our equipment, just you know, one example. Before COVID-19 we used less than 1,000 N95’s a day. Now we’re using about 5,000 a day. We’re using about 41,000 surgical masks a day. So the cost of what we’re doing to protect our patients and protect our staff has gone way up. And we have a lot of staff, we’re paying to be ready… hoping that they don’t have to be used.

Gary Bisbee 24:02
Do you think that this is going to carry over into 2021 as well?

Sarah Krevans 24:07
Everyone is hoping that some combination of better screening, contact tracing, and maybe – although there’s no certainty yet – maybe that one of the antibody tests will actually help us discern who may have immunity and who may not. Everybody is hoping that the combination of those things will mean that there will be a safe way to gear back up and still protect our communities. But I think that the economic impact of this to healthcare organizations is unique because it’s been devastating for many businesses, so many businesses, but many of those businesses have shut. What we’ve done is continued to operate with actually a higher cost picture than we had before. But without having the revenue that we had before. I think it’s a unique challenge for hospitals. But I’m also very aware – and for physicians – but I’m very aware that across this country, we have businesses shuttering literally going bankrupt. I think we do need to be thinking about the fact that absent a different model for how we think about how we support healthcare systems, that we are going to have bankruptcies in health care across this country if things don’t change.

Gary Bisbee 25:35
Yeah, I agree with that. Let’s turn to the governance function. How often are you communicating with the Sutter Health Board of Directors?

Sarah Krevans 25:43
Our board of directors, if you look at their official calendar, meet quarterly and then they usually have an extra meeting in December to do end of the year business. Obviously, when different things are happening there have often been times I would have a monthly CEO update call that was not a regular board meeting that was an informational meeting. Occasionally when something special was happening, we would call a special telephonic board meeting. I decided with the support of our board chair, that it was important for all of our boards across the system. We have some subsidiary boards as well to be very updated. And so I have been holding weekly phone calls. With it’s an all board phone call. So the Sutter Health Board is invited. But so are our subsidiary boards. Every week, myself and my management team, including my clinical leadership, we have an hour-long Skype video call with all of the boards. We start off with a reflection on how things are going. We do a clinical update, we do an operational update, and then the bulk of the meeting is spent answering their questions. And so we’ve been doing that weekly for all of our leaders and weekly for all of our boards and they are hungry for it.

Gary Bisbee 27:01
One of the questions I’ve been asking for those of you who are doing virtual board meetings, any tips for how to conduct a smooth virtual board meeting?

Sarah Krevans 27:10
When we do the actual board meetings, I would say we have learned a few things. So those are really informational. But when we do the actual board meetings, a few things we’ve learned is layout…I don’t want to say the ground rules, but lay out the rules of engagement at the beginning of the meeting. We’re going to do the presentations, then we’re going to take questions, we’re going to take questions by actually first calling around the role. We often do that because otherwise, as you know, whoever talks turns off the ability of anybody else to talk at the end, right, you end up with some people not being heard. So we have a formality on our video meetings and our phone meetings that is a little different than when we’re all sitting around a table and you can see when somebody has something they want to say. So I would say a tip is: be really clear about how you’re conducting it. I think it’s really helpful to keep the presentations short but to get through the presentation, and at least with our board, we found it helpful before we open it up for dialogue to go around, literally go around the roll call and see if people have clarifying questions.

Gary Bisbee 28:19
Sure. This has been a terrific interview. We appreciate your time. I’d like to ask one final question, which is we’ve talked several times today about the new normal, what will we learn from and take from the response to the COVID-19 crisis?

Sarah Krevans 28:35
Specific to healthcare systems or healthcare overall?

Gary Bisbee 28:38
Let’s go with the overall. I think that would be interesting.

Sarah Krevans 28:41
I don’t think that we’ve always been a country that’s been particularly interested in public health as a country. I hope that what comes out of this is a deep respect for the role of public health, in health and well being, and also how important public health is to everything that we do including the economy. My hope, in terms of what we will learn from this is that understanding investing in and supporting public health efforts is really good for everybody. It’s not nice to have. It’s really a must-have. And that’s my hope for what we have coming out of this. And I think that’s really going to be the way forward for us in terms of being able to incrementally start to safely return some people to work, and some people to school and maybe even everyone to school, but maybe not everybody in the same setting. And I think it’s really going to be about that deep respect and understanding of public health and using the different disciplines and science within public health to understand how to safely return this country to a fuller life.

Gary Bisbee 29:52
Absolutely. Well said. Sarah, thanks so much for your time today. I know it’s busy times for you.

Sarah Krevans 29:57
Thank you! My pleasure.

Gary Bisbee 29:58
This episode of fireside chat is produced by Strafire. Please subscribe to fireside chat on Apple podcasts or wherever you’re listening right now. Be sure to rate and review fireside chat so we can continue to explore key issues with innovative and dynamic healthcare leaders. In addition to subscribing and rating, we have found that podcasts are known through word of mouth. We appreciate your spreading the word to friends or those who might be interested. Fireside Chat is brought to you from our nation’s capital in Washington DC, where we explore the intersection of healthcare politics, financing and delivery. For additional perspectives on health policy and leadership. Read my weekly blog Bisby’s brief. For questions and suggestions about fireside chat contact me through our website, fireside chat podcast dot com, or Gary at hm Academy dot com thanks for listening.

Transcribed by Otter