\documentclass[10pt]{article}

\usepackage{fullpage}
\usepackage{setspace}
\usepackage{parskip}
\usepackage{titlesec}
\usepackage[section]{placeins}
\usepackage{xcolor}
\usepackage{breakcites}
\usepackage{lineno}
\usepackage{hyphenat}





\PassOptionsToPackage{hyphens}{url}
\usepackage[colorlinks = true,
            linkcolor = blue,
            urlcolor  = blue,
            citecolor = blue,
            anchorcolor = blue]{hyperref}
\usepackage{etoolbox}
\makeatletter
\patchcmd\@combinedblfloats{\box\@outputbox}{\unvbox\@outputbox}{}{%
  \errmessage{\noexpand\@combinedblfloats could not be patched}%
}%
\makeatother


\usepackage{natbib}




\renewenvironment{abstract}
  {{\bfseries\noindent{\abstractname}\par\nobreak}\footnotesize}
  {\bigskip}

\titlespacing{\section}{0pt}{*3}{*1}
\titlespacing{\subsection}{0pt}{*2}{*0.5}
\titlespacing{\subsubsection}{0pt}{*1.5}{0pt}


\usepackage{authblk}


\usepackage{graphicx}
\usepackage[space]{grffile}
\usepackage{latexsym}
\usepackage{textcomp}
\usepackage{longtable}
\usepackage{tabulary}
\usepackage{booktabs,array,multirow}
\usepackage{amsfonts,amsmath,amssymb}
\providecommand\citet{\cite}
\providecommand\citep{\cite}
\providecommand\citealt{\cite}
% You can conditionalize code for latexml or normal latex using this.
\newif\iflatexml\latexmlfalse
\providecommand{\tightlist}{\setlength{\itemsep}{0pt}\setlength{\parskip}{0pt}}%

\AtBeginDocument{\DeclareGraphicsExtensions{.pdf,.PDF,.eps,.EPS,.png,.PNG,.tif,.TIF,.jpg,.JPG,.jpeg,.JPEG}}

\usepackage[utf8]{inputenc}
\usepackage[ngerman,english]{babel}



\usepackage{float}








\begin{document}

\title{Coronavirus~ (COVID-19): A Patient Experience - Administrative services
on the frontline~ during crisis}



\author[1]{Randal S. Weber, MD}%
\affil[1]{The University of Texas MD Anderson Cancer Center}%


\vspace{-1em}



  
  \date{June 15, 2024}


\begingroup
\let\center\flushleft
\let\endcenter\endflushleft
\maketitle
\endgroup








\sloppy


\subsection*{}

{\label{504570}}

\textbf{Judy Overton, BFA, MLA}

Program Manager, Office of Patient Experience Officer

The University of Texas M.D. Anderson Cancer Center

T. Boone Pickens Academic Tower

1400 Pressler St

Houston, Texas 77030

~

\textbf{Kathy Denton, BS, MED, PhD}

The University of Texas M.D. Anderson Cancer Center,

Director, Patient Experience

The University of Texas M.D. Anderson Cancer Center

T. Boone Pickens Academic Tower

1400 Pressler St

Houston, Texas 77030

\textbf{~}

\textbf{Michael Frumovitz, MD, MPH}

Gynecologic Oncology and Reconstructive Medicine

The University of Texas M.D. Anderson Cancer Center

Dan L. Duncan Building

1155 Pressler St

Houston, Texas 77030

~

\textbf{Carol Lewis, MD}

Department of Head and Neck Surgery

The University of Texas M.D. Anderson Cancer Center

T. Boone Pickens Academic Tower

1400 Pressler St

Houston, Texas 77030

\textbf{~}

\textbf{Sarah Christensen, MA}

Director, Patient Education

The University of Texas M.D. Anderson Cancer Center

Dan L. Duncan Building

1155 Pressler St

Houston, Texas 77030

\textbf{~}

\textbf{Jaymesson Bezerra, MSHA}

Manager, Patient Relations

The University of Texas M.D. Anderson Cancer Center

Rotary House International

1600 Holcombe Blvd

Houston, Texas 77030

\textbf{~}

\textbf{Chris Hernandez}

Exec. Director, Patient Services, Patient Advocacy

The University of Texas M.D. Anderson Cancer Center

Anderson West

1515 Holcombe Blvd

Houston, Texas 77030

~

\textbf{Michele S. Walker}

Assoc. Dir, Pt Advo \& Pt Rel, Patient Advocacy

The University of Texas M.D. Anderson Cancer Center

Anderson West

1515 Holcombe Blvd

Houston, Texas 77030

~

\textbf{Janice P. Finder, BSN, MSN, RN}

Dirrector, Patient Exp Clin Services, askMDAnderson

The University of Texas M.D. Anderson Cancer Center

Mid Campus Building 1MC

7007 Bertner Avenue

Houston, Texas 77054

~

\textbf{Ashlyn A. Proske, BS}

Program Manager, askMDAnderson

The University of Texas M.D. Anderson Cancer Center

Mid Campus Building 1MC

7007 Bertner Avenue

Houston, Texas 77054

~

\textbf{Sanchita Jain, MBA}

Innovation Strategist, Innovation

The University of Texas M.D. Anderson Cancer Center

Mid Campus Building 1MC

7007 Bertner Avenue

Houston, Texas 77054

\textbf{~}

\textbf{Julai Whipple, BA}

Innovation Designer, Innovation

The University of Texas M.D. Anderson Cancer Center

Mid Campus Building 1MC

7007 Bertner Avenue

Houston, Texas 77054

~

\textbf{Wendi L. Martinez, ADN, BSN, RN}

Dir QA \& Perf Improvement, Inst Cancer Care Innovation

The University of Texas M.D. Anderson Cancer Center

Mid Campus Building 1MC

7007 Bertner Avenue

Houston, Texas 77054

~

\textbf{Jarod Eska}

Inst Cancer Care Innovation

The University of Texas M.D. Anderson Cancer Center

Mid Campus Building 1MC

7007 Bertner Avenue

Houston, Texas 77054

\textbf{~}

\textbf{Elizabeth W. Sutherland, MPAS}

Physician Asst, Surgical Oncology

The University of Texas M.D. Anderson Cancer Center

T. Boone Pickens Academic Tower

1400 Pressler St.

Houston, Texas 77030

\textbf{~}

\textbf{Lisa L. Triche, DNP, MS, RN}

Advanced Prac Registered Nurse, Pediatrics - Patient Care

The University of Texas M.D. Anderson Cancer Center

Anderson East

1515 Holcombe Blvd

Houston, Texas 77054

\par\null

\textbf{Elizabeth A. Garcia, BSN, MPA, RN}

Assoc VP, Patient Experience, Ofc of Chief Operating Officer

The University of Texas M.D. Anderson Cancer Center

1515 Holcombe Blvd

Unit 1485

Houston, Texas 77030

\textbf{Corresponding Author:}

\textbf{Randal Weber, MD}

Chief Patient Experience Ofc, Chief Patient Experience Officer

The University of Texas M.D. Anderson Cancer Center

T. Boone Pickens Academic Tower

1400 Pressler St

Houston, Texas 77030

\textbf{Introduction}

The COVID-19 pandemic has had a dramatic impact on care delivery among
health care institutions and providers in the United States.~
Prioritization of scarce health care resources for those afflicted by
the COVID-19 infection has disrupted delivery of health care mandating a
reallocation of care to patients with urgent needs.~ Important goals of
care are timeliness, effective treatments, and ready access.~ While
these are critical goals, they have been redirected towards acutely ill
patients in urgent need of care.~ As a categorical cancer center, we
have had to prioritize care for our patients based on acuity of their
disease, protect patients and employees from acquiring the infection
within the confines of our facilities, and provide acute management of
cancer patients with concomitant COVID-19 infections who are considered
at high risk of death.~

\textbf{Background}

In October 2016, MD Anderson formally established a division of Patient
Experience under the dyad leadership of a physician (RSW) and a nurse
administrator (EG).~ Working with their dedicated team, the patient
experience program developed key strategic initiatives to create a
culture of patient-centered care.~ Several process improvement measures
were implemented using CAHPS data to identify opportunities to create a
new culture of patient centeredness. ~In 2018, Peter Pisters, M.D., the
President of MD Anderson, transitioned the patient experience program
from an operational priority to a cornerstone of administrative and
operational priorities for allocation of resources to support cultural
change.~

What follows is a summary of the patient experience team's effort to
actively support programs and processes in anticipation of the
pandemic's effect on our patients and employees. ~We will describe how
the team continues to serve in the ever-dynamic environment as we
approach the expected surge in COVID-19 cases among our patient
population, our employees, and in our community. ~

\textbf{Preparing for the COVID-19 threat to MD Anderson}

COVID-19 first appeared in November of 2019 and quickly overwhelmed
China's health care system.\textsuperscript{1}~ Subsequently, the virus
spread around the globe creating casualties that numbered in the
thousands in a matter of weeks. ~The reality of COVID-19's threat to the
United States occurred in late January 2020 with the report of the first
death on the eastern seaboard. ~The virus has spread across the country
with various municipalities experiencing sequential surges in their
afflicted population.~

Anticipating a rising incidence of infections in the Houston
metropolitan region, MD Anderson's leadership took immediate steps to
proactively protect our patients who are highly susceptible to infection
and severe complications secondary to their compromised immunity. ~

Patient and employee screening were rapidly implemented to identify
those at risk for exposure to COVID-19 or actively infected by it.~
Screening criteria included travel history, exposure to infected
individuals, fever, cough or breathing difficulties, as well as
temperature checks. ~Immediate travel restrictions were implemented for
all employees.

\textbf{Implementing a} \textbf{New Normal}

The Chief Quality Officer (CQO) quickly recognized the need to manage
the traffic into the institution as a strategy to prevent spread of
infection among our vulnerable patients. ~Early on, the CQO led a site
visit throughout the institution to determine which entrances would be
used to screen patients, visitors, and employees. ~The institution
limited points of access for employees and segregated patient/caregiver
and employee access points to facilitate screenings.

The Patient Relations Team initially provided scheduling support and
oversight of the access point screeners.~ Twenty-one employees staffed
the frontline entryways for 12-hour shifts, Monday through Friday.
Leadership quickly realized this was not sustainable. In order to avoid
screener fatigue, they quickly trained additional screeners from the
institutional workforce to support the screening needs at access points.

When data collection began on March 17, 2020, the screeners saw an
average of 8,944 employees and 2,793 patients/visitors per day. After
initiating remote work options (implemented to insure only essential
employees were on site) and a zero visitor policy with minimal
exceptions on March 24, the screeners saw an average of 4,849 employees
and 1,049 patients/visitors per day.

With the increase in reassignments of essential employees only onsite,
the available screeners decreased significantly.~ To provide adequate
screening personnel, the Department of Human Resources (HR) assumed
responsibility for providing the work force at the points or access.~
~The transition to HR allowed continued employment for staff, such as
those in research or administrative support, who might have required
furlough due to decreased clinical activity from COVID-19 preparedness.
~

\textbf{Enhanced vigilance, compassionate care}

Throughout the month of March, the COVID-19 alerts quickly escalated.
~To protect our vulnerable patients and employees in an attempt to limit
exposure in the face of community spread, executive leadership issued a
series of rapid changes to our visitor policy. ~On March 9, the policy
was adjusted to allow only two visitors to enter an inpatient room or
accompany a patient to an ambulatory center. ~Two days later, the policy
was adjusted to permit only adult visitors. ~On March 19, the
institution changed this to a one visitor policy, and on March 24, this
was further limited to a no visitor policy. Exceptions were granted on a
case-by-case basis for patients with cognitive and self-care issues and
those facing end of life.

The institution continually informed patients about the dynamic policy
changes via the electronic health record patient portal and on the
public-facing MD Anderson website. Still, many patients arrived with
their caregivers, hoping to be granted an exception to the policy.

The onsite Patient Advocate, along with frontline staff, provided the
important rationale for these restrictions, and if appropriate, sought
assessment of exceptions from the nursing and medical teams. The message
was delivered with compassion and professionalism to our patients and
their families, explaining that we were placing their safety first and
foremost. ~

Exemptions to the no visitor policy were granted based on the detailed
criteria developed by the executive leadership team.~ The nursing teams,
in close collaboration with the attending physician, were charged with
assessing if a patient met the exception criteria.~ This shared
decision-making empowered those providing care on the front line to
mitigate the risk of exposure for patients and staff to visitors who may
have an asymptomatic infection with the virus. ~

At times, patients and family members disagreed with the exception
criteria set by the institution. In these cases, patient advocates
facilitated the Chief Quality Officer's review of the case. ~Virtual
family care conferences were held with involved caregivers to provide a
thorough explanation of the criteria and to work through communication
accommodations, such as video conferencing with family members and care
teams.

The institution developed a process to ease the impact of the no visitor
policy on patients and their loved ones. Nursing leaders were available
at each entrance to assist, in real-time, with any difficult
conversations, and reassigned employees were available to escort a
number of patients to their appointments. ~

\textbf{Clear, concise and thorough communication}

Clinical teams in the askMDAnderson call center were made available 24/7
to inform patients about COVID-19 testing sites. They scheduled patient
appointments to testing sites, reviewed their test results, and ensured
patients received urgent medical care in the right place and at the
right time.~

Consistent messaging to internal and external stakeholders was
maintained through a collaborative effort between Patient Education and
Strategic Communications. ~Together, the teams developed consistent
dynamic content for both patients and employees. ~The process typically
originated in brainstorming sessions with clinical working groups in
which processes were broken down into the elements of utmost importance
to patients and their caregivers. ~

As a result, Patient Education has produced numerous COVID-19-related
information materials that are available to all stakeholders:

\selectlanguage{ngerman}·~~~~~~~~ Coronavirus Disease (COVID-19) Screening Next Steps

·~~~~~~~~ Self-Quarantine Instructions (in English and Spanish)

·~~~~~~~~ MyChart Video Visit Instructions (English and Spanish)

·~~~~~~~~ MyChart Video Visit Instructions (online video)

Additional documents and videos remain in production to address the
dynamic changes and offerings in processes and are being disseminated
upon completion.

To facilitate the need to frequently update content, Patient Education
materials were made available via URL rather than using PDFs. In
addition, Strategic Communications established a website dedicated to
the dissemination of MD Anderson's COVID-19 response.

\textbf{Technology-based creative solutions}

MD Anderson rapidly implemented a combination of virtual care solutions
for our patients, families, and providers to meet a range of needs in
situations when in-person visits are not possible or ill-advised.~ The
institution had already moved to implement virtual care, but the onset
of COVID-19 accelerated the needs to use these various options.~

While some clinicians continue to see patients in outpatient clinics and
inpatient settings, the institution launched the use of MyChart video
visits, an online telemedicine tool that combines Epic (Verona, WI) and
Zoom (San Jose, CA) to decrease the number of people who entered our
facilities.~ This option protected our patients who are at very high
risk because of their cancer, as well as our
employees.\textsuperscript{2} ~~Providers and conducted more than 2,000
scheduled visits within the first three weeks of the launch of the
MyChart virtual visits.

The Virtual Care Task Force, a multidisciplinary team led by MD
Anderson's Innovation team, studied the use of the technology and
launched a virtual care solution, with the approval of executive
leadership. The virtual care program is meant for follow-up
appointments, consults, and research study coordination across several
specialties. It also meets Center for Medicare Services criteria for
billing and offers inbuilt billing technical support in an environment
of constantly shifting legal requirements. ~The suite of solutions
offers provisions for patients to connect with their socially distanced
families and video monitoring technology for admitted patients under
investigation (PUI) for a potential COVID-19 infection.~

All disease sites were included in the launch of the virtual visits.~
Standardized patient satisfaction surveys are being implemented to
evaluate, obtain feedback, and continually improve the value of video
visits. ~

The Virtual Care Task Force is also responsible for the implementation
of Vivify Health, a remote patient monitoring application utilized to
virtually monitor COVID-19 symptoms. ~The app serves as a guide for new
out-of-state patients with future appointments at MD Anderson who are
required to self-quarantine, with monitoring and reporting of symptoms,
for 14 days before their initial visits.~ The quarantine is waived for
the patient to receive robust symptom assessment and COVID-19 testing
when the medical condition warrants it. ~Patients monitor their health
with the guidance of a case manager who will conduct a virtual check-in
with the patient twice per day, at 9 a.m. and 5 p.m. ~This is a free,
optional service and can be helpful for those patients who may not have
access to virtual care services through their primary care physicians or
those who do not have a primary care physician.~ The institution is
looking to future use of the remote patient monitoring application for
discharged patients.

\textbf{Triaging surgeries and access to care}

Overarching goals for managing patient access to the institution
included delivering care to those whose disease required rapid
intervention, while conserving resources (PPE, hospital beds, etc.), in
anticipation of a surge in COVID-19 infected patients who might require
inpatient care. ~The criteria for current onsite appointments included
new and existing local patients (those within 150 miles of the Houston)
and those with rare cancer tumors, without geographic restriction.

In accordance with state mandates, elective surgeries, including those
for benign disease, have been postponed to make hospital beds available
in anticipation of a surge in COVID-19 diagnoses among our cancer
patients. ~Urgent or emergent surgeries still occur after a careful
daily review of prospective procedures based on specific prioritization
criteria. ~A multidisciplinary review committee carefully evaluates each
posted procedure, factoring in disease-specific factors, historical data
on transfusion requirements, the likelihood of Intensive Care Unit (ICU)
admission based on procedure type, as well as the potential need for
other resources, including personal protective equipment. ~

\textbf{Adjusting State Mandates for our Patients}

As of March 22, 2020, Texas Governor Greg Abbott issued a mandate that,
effective March 23, all travelers from national hotspots, including our
neighboring state of Louisiana, had to self-quarantine for 14 days upon
arrival to Texas. At this time, many existing MD Anderson patients were
traveling from these locations for planned appointments and surgeries.~
The quarantine not only imposed delays in care, but required patients to
find housing and resources in Texas for 14 days before receiving care.~
Within days, MD Anderson created a policy that patients can
self-quarantine at home or a hotel before traveling to MD Anderson for
appointments.~ A team was created to follow and check on these patients
before their travel to and upon arrival to MD Anderson.~~~

\textbf{Advancing the use of the Advance Care Plan}

The pandemic has elevated the patient and family experience for those
who are at the end of life by centering on the patient's goals of care
(GOC) and presenting an opportunity for the institution to be very clear
on available treatments. These measures were implemented to provide
clarity on the GOC and to prevent unnecessary admissions to the
inpatient setting or escalation to the intensive care unit when not
consistent with the disease state and patient's agreed upon GOC.

Supportive Care leadership heads a Goals of Caring (GOC) Rapid Response
Team (RRT) that has developed a strategy in response to the crisis and
is comprised of ~three components: 1. deploy, at short notice, a
Supportive Care faculty to join an oncologist in the outpatient or
inpatients setting to help conduct GOC conversation; following a short
briefing, both physicians enter the room and conduct the GOC talk,
following a specially-developed check list; 2. implemented a GOC rapid
educational program with formal live education for oncologists, five
different scripts to cover multiple inpatient and outpatient scenarios,
a daily drop-in, one-hour coaching clinic, and five minute
mini-tutorials; and 3. provide a daily review of all inpatient
admissions and all ICU admissions to identify patients who may quality
for the GOC RRT and to educate the primary oncologist on the importance
of anticipating these events with GOC conversations.

\textbf{~}

\textbf{Conclusions}

MD Anderson institutional leadership set forth priorities to protect
patients and staff while minimizing disease impact on our community.~ As
patients and staff adjust to sweeping changes that serve these goals,
our patient experience team has proven both instrumental in providing
clear and effective communication with patients and critical in
advocating for patients and addressing their concerns and grievances.~
Our patient advocates were quick to offer options to family members to
engage with their loved ones through video, FaceTime and updates from
the nurse or a chaplain. We gained insights on making adjustments that
will benefit all of our stakeholders in this challenging situation. ~~

Throughout this process, employees, particularly those who are
consistently on the frontline in direct and indirect encounters with
patients and caregivers, have demonstrated resoluteness, caring, and
compassion.~ In these unprecedented and uncertain times, each member of
the MD Anderson family, our patients and their loved ones, have all
proven to exhibit extraordinary resilience.

\textbf{~}

\textbf{~}

\textbf{~}

\textbf{~}

\textbf{~}

\textbf{~}

\textbf{~}

\textbf{References}

1\textsuperscript{st} known case of coronavirus traced back to November
in China. LIVESCIENCE. March 14, 2020.
\url{https://www.livescience.com/first-case-coronavirus-found.html},
Accessed April 23, 2020.

\href{https://www.washingtonpost.com/health/covid-19-hits-doctors-nurses-emts-threatening-health-system/2020/03/17/f21147e8-67aa-11ea-b313-df458622c2cc_story.html}{COVID-19
hits doctors, nurses, EMTs. The Washington Post, March 17, 2020.
Accessed Saturday, April 11, 2020.}

\selectlanguage{english}
\FloatBarrier
\end{document}

