Interview with Elaine Ziemba, MHA, JD, Vice President & Chief Risk Officer, Stanford Medicine
Talk to anyone in a hospital setting—healthcare professionals and risk officers—and they’ll share stories about the impact of COVID-19 on their institutions. The pandemic has created unprecedented situations; on one hand, extraordinary demand at some hospitals due to the need for specialized acute care or, on the other end of the spectrum, steep declines in demand for routine services. These circumstances have translated into financial hardship for some institutions and challenging risk management conundrums for virtually all organizations. Inside Medical Liability spoke with Elaine Ziemba, vice president and chief risk officer at Stanford Medicine, about the challenges she has witnessed, how hospitals have evolved to meet the needs of patients and clinicians, and what COVID-19 may mean for hospitals and their management of risk in the future.
IML: What do you think the long-term impact of COVID-19 will be on hospitals in the U.S.?
Ziemba: Situations for hospitals vary depending on geography. At acute moments happening all around the country at different times, hospital teams ramped up to be able to support whatever was coming their way. For some organizations, the financial impact was significant, irrespective of what emergency funding assistance was provided. However, these are the times that you recognize that enough is never enough. Healthcare is an arena that requires resources and those resources do cost money.
In the long run, we do know from talking with colleagues across the country that COVID-19’s impact on routine, elective, or specialized care has caused everybody in the industry to reevaluate how they provide services. It’s also probably led to a resurgence of regionalization and cooperation among healthcare entities.
I think we can certainly anticipate consolidations to continue and maybe even increase. I also believe there will be some serious thinking about methods of healthcare delivery rather than brick-and-mortar facilities—telehealth, for one, and other access points.
IML: How are hospitals managing risk during this crisis?
Ziemba: Interestingly enough, the risk profile within the organization really hasn't changed, but I have seen a shift in focus. For example, my general focus has been and still is on everything related to patient care and the risk associated with patient care. However, during the pandemic, I’ve had to be incredibly focused on the risks associated with our supply chain. How can we equip the organization in the best and safest manner with the best and safest supplies? There are risks associated generally with the supply chain and what that looks like internationally or nationally—where are materials coming from, are they up to standards, those kinds of questions.
And certainly, there’s a heightened risk profile around our human resources. We are very, very focused on the safety of our staff and the care and support that they need and receive—that’s an increasing risk factor. And having just gone through our insurance renewal, I can tell you that the insurance industry is focused on that, too.
In healthcare, we are always one step away from some disaster and have done an excellent job of contingency planning. Regionally, facilities have focused their plans on the events they experience—earthquakes in California, for example. It is how we prepare for surges of patients and compromised conditions. I think now we’ll be even better at looking outside our four walls to see how we can partner in our communities to manage risk.
Frankly, I haven't seen a change in the standard of care on any level— we’re still focused on providing the best quality care we can using similar approaches. I am, however, grateful for the liability waivers we’ve seen developed during this time because the standard of care in treating COVID-19 patients wasn’t established and we didn’t know what it would look like. We’ve seen new treatments and theories—it’s been an evolving standard of care.
We’re just starting to see some of those waivers tested; as claims arise and courts reconvene, we’ll get a better understanding of the interpretation. As far as mitigating risk in this scenario, it’s important to continue to have quality practices, good communication, and documentation. Communication is always a good practice and defensive approach—in this environment it just becomes a trickier exercise.
IML: From the risk and operational perspective, how are hospitals planning to deal with a possible flu/coronavirus surge in the winter/spring?
Ziemba: The big concern is what's going to happen as the winter comes and people will be more inclined to stay indoors because of weather conditions and what that will do to COVID-19 transmission. And of course there’s a concern about flu season as well. We’re preparing again for challenges around surge. But we also need to know how to reach patients who may need and want elective procedures. I think over the past six or seven months we have been learning how to manage the surge—or lack of surge—a little better. We’re doing that through cooperative regional arrangements or community touch points. We are developing new access points such as drive-by services, emergency departments set up outdoors in tents, and other methods to deal with more routine issues.
IML: Is it possible to identify a benefit of the pandemic response? Will some of the practices hospitals have adopted during this challenging time be useful post-pandemic?
Ziemba: This circumstance really caused us to reevaluate everything. How we do things, the resources we need, how the government reimburses us, and any number of issues. The pandemic has really created a tremendous environment that arguably forced us to look more quickly for efficiencies and effectiveness and how we deliver healthcare or how healthcare is accessed. In many ways, we’ve fast forwarded the change to enact new solutions.
Some of the changes that have occurred are tremendously beneficial—like going from 0 to 60 with telemedicine. We’ve also broadened our risk focus to look at every nook and cranny a little differently than we might have in the past. And in doing that, we’ve expanded our appetite for innovations that may not have gotten our attention before. All good things that point to a changing healthcare arena that is able to continue to adapt and meet challenges in the safest, most effective manner.
IML: Has anything changed with risk financing? Has the pandemic exacerbated what many are describing as a hardening market? Are captives experiencing any unexpected challenges?
Ziemba: Having just gone through our insurance program renewal, the insurance industry has really had to adapt to a lot over the course of a brief year. The markets are hardening and rates are going up. That’s not surprising given all that’s been going on in the world, from natural disasters to COVID-19.
I believe there will be an evolution of new products to meet risks that we may not have anticipated previous to this. Certainly, there will also be policy language changes around certain aspects that may not have been clearly articulated before. What we’ve seen is not just a disease or diagnosis centralized to a country or region. This is global and that’s what is different.
And for those of us who have captives, apart from the logistical challenges of working with a company outside the U.S., COVID-19 forced companies to close up and change practices so our administrative practices had to change a little. But generally the only real change I’ve seen is that it may accelerate evaluation of the insurable risks we put in our captive.
IML: The use of telemedicine has exploded—patients and physicians have adapted and are using this type of care more than ever. What impact has telemedicine had on hospitals?
Ziemba: I've been a huge fan of telemedicine. When the capability first emerged, insurers rightfully were concerned about the potential for increased risk. Wide adoption of telemedicine was still developing. And prior to the pandemic, we know telehealth has been supported by medical professional liability insurers as simply the practice of medicine using another modality. But widespread adoption was not fully realized.
Today, we have seen telemedicine use increase and the risks well integrated into the insurance world as simply an extension of the practice of medicine—the same rules apply as far as standards of care, appropriateness of care, and care delivery.
What then, in my experience, became the next set of challenges was simply integrating telemedicine into routine practice. Then came COVID. The interest in and use of telemedicine grew significantly—almost immediately. People were and are squeamish—perhaps appropriately so on some levels—about seeking services directly within healthcare entities. Physicians started looking around for ways to continue to be able to treat people, to “see” people, and telehealth was brought to the forefront again. Telemedicine could accomplish two things: Keep people engaged and involved in healthcare, and have physicians be able to meet the needs and interests of patients.
That said, I think we still have tremendous challenges around the practice being fully integrated and accepted because we still don't really have a national mechanism to deal with the availability of this technology matching the current status of the regulations and various laws around the practice of medicine in particular.
Also, there are the logistics of the technology. I work in an organization that has equipped everybody appropriately with the technology necessary to be able to perform telehealth services in a high-tech and safe manner. That widespread familiarity with and access to technology may not be the case, not with just practitioners, but also with patients who may not have the technology apart from their cellphones and home computer networks.
Looking ahead, we’re hoping for the continued interest in and support for telemedicine because it does so much to increase access. We really hope there will be great support on the federal level for making sure the necessary technology is available, for a solution to the licensing issues as well as any other issues related to what physicians and advanced practitioners would naturally be concerned about—the integrity of their practice and the ability to provide this kind of care safely.
IML: What do you think are the implications for healthcare in general as a result of COVID-19?
Ziemba: I think we're all going to be evaluating delivery models and methods. I also believe we’re going to have to work hard to re-earn everybody's faith in us as a safe, thoughtful, accessible industry. We will rebuild that confidence. But we have to talk more about how safe we really are and what goes into our planning and preparation for these kinds of unimaginable events.