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COVID-19 Conversations: Jeff Kraut at Northwell Health Shares Key COVID-19 Planning Actions at New York’s Epicenter

Bill Klaproth: SHSMD members play a critical role as to the organizations and communities they serve. This special edition of the SHSMD podcast is part of the COVID-19 Conversations Series featuring members stories and resources in an effort to provide insight into how some organizations are managing this unprecedented crisis.

Diane: Welcome everybody. I'm here with Jeff Kraut. He serves as the Executive Vice President for Strategy and Analytics at Northwell Health and is the Associate Dean for Strategy at the Donald and Barbara Zucker School of Medicine at the Hofstra Northwell. Jeff's involved in strategic planning in health policy activities. He works with the provider networks works on mergers and acquisitions and other strategic partnerships and also is responsible for the next generation of business and clinical analytics throughout the health system at Northwell. Jeff is also the chair of the Public Health and Health Planning Council of New York State and served on the AHAs SHSMD board for a number of years and was also our 2017 recipient of the leadership excellence on board. So we're really excited to have Jeff with us today. And Jeff, in your role at Northwell. Tell us about what's going on in your organization, in your community, and kind of what stage you're at, generally speaking with the COVID crisis.

Jeff Kraut: Well, you know, if you think about New York being the epicenter of the COVID crisis Northwell is the epicenter of the epicenter, up until recently. And of course it's spread more. Certainly the communities that we serve in Queens has the most cases. But I'll give you an example is that emergency preparedness, and for large scale bioterrorism events, this is what this health system had planned for as far back as 1999. We realized early on as part of our, it was part of our strategic planning process that we were not well-prepared if there was a large scale public health event. And even before the attack on the world trade center, we had invested in infrastructure warehousing, supply building to take us through these such events. And probably putting aside 9/11, probably during hurricane Sandy, our hospitals were the only ones not to close. You know, at least now that's not true, everybody, a lot of States closed, but we were the ones that were operational because we had prepared.

And similarly here although I don't think we ever drilled for something on this scale, our senior leadership have gone through the hospital incident command structure. We've been the DEMAT team for bioterrorism, for HHS. We have a Nested team here. We have a hundred bed hospital sitting in a warehouse, which we've just recently deployed, and I'll come back to that in a moment. But this has been part of our infrastructure and it was because of that infrastructure that when the COVID outbreak started, our laboratory was out of the gate faster than any other health system, clinical laboratory doing testing. So at the beginning of this, for the first 10, 15 days, there were only three places where you could get tested in New York. That was the Wadsworth Laboratories could do the testing. This is once the samples were collected. The CDC in Atlanta and the Northwell Laboratory. So if you, if you look at March 18th, we had 33% of all the COVID cases in the State, 18% of them in the United States. And by the 31st we then went to about, we represent 9% of the COVID cases in the State. Sorry, 9% of the nation, about 20% in this State and 1.2% in the world.

So our laboratory was kind of the tip of the spear for us in getting to response. And my role, we have a very probably similar to many other health systems, the incident command. So my role works in the area of dealing with the regulatory environment, the government. And obviously the government is playing a major role in it. It's not only responding and trying to shape their requests, but it's also to assist the government in making sure our resources are available, not only to help our own institution, but to make sure that we can help others in a regional effort. And last evening you may have heard the Governor announced that he spoke to the President and the Javits Center, which had been set up with both military and State assets to open about a thousand beds. They've turned to Northwell to manage that on the ground for them. We have the bandwidth to do it, but I'll get into that a little about how maybe we're structured what we've been doing, what I've been doing as a planner, and what I think others should get ready to do. I'll leave it up to you, Diane.

Diane: Yeah, no, that sounds great. So it's definitely in a, still in a state of crisis, but all that planning that you've done has well-prepared you, probably more than most to deal with this. So tell us a bit about your planning team or your planning resources and how they were called upon to assist during the pandemic, whether it was planning execution, how your role actually did shift?

Jeff Kraut: Sure. So one of the things that the government did, the governor issued an executive order suspending most major hospital operations. Our health code really streamlined. It eliminated the need for CON but still required reporting. And so, you're balancing the need for the health system to develop its plans and the need for state and federal authorities to know what's going on so they can assess the situation and bring whatever resources they can. So, that goes into two streams. We had an executive order to increase the capacity of all hospitals in the State by 50%. So my planning group, in addition, we're supporting our operations of people. We're responsible for planning out where are we going to add beds. And our strategy obviously somewhat intuitive was looking, we did not want to leave the walls of the hospital, as the first thing we wanted to first expand within all of our clinical areas, looking where that was possible. And then so beds that we might've made, we might have had four bedrooms, we made two bedded rooms. How do you bring those back up?

Recovery areas, the endoscopy areas, cause we suspended elective surgery. Our lobby, then we moved outside of our clinical areas. And the planning folks help with the operations people about where are we going to go. So for example, one of our auditoriums, a 400 seat, 300 seat auditorium, all fixed seating. We ripped out the fixed seating out of that auditorium to put in beds and supplies and I'll come back to the supply chain. So the planning group had to, on each step of what we did, we had to give the government a surge plan. So each surge plan had multiple levels. If we hit these kinds of volumes, we did, we'd be at level one, level two, level three, level four. Most of our plans went up 10 levels of accommodating incremental volumes. And then we had to notify the State and get permission to approve those plans, which we had to be written up, explain what was happening, what we would be doing. We would submit those plans by notice and the State uncharacteristically, but in the crisis really came through. Sometimes within 90 minutes usually not more than three or four hours, approve those plans.

And then we'd have to monitor their implementation at the same time. So we had a group managing all of this paperwork both internally and externally, the government, and then recognizing the big financial hit we're all taking. You needed to also make sure that all of the sites that you just got approved from the State, to get approved. My group also work with our finance group to file the Medicare 855 forms to permit us and notify Medicare that we'll be billing from those sites. So you know, those are like you say, really in the middle of all of this. Well guys, when you start burning, forget about a million dollars a day. We're probably burning close to 100 million a month. As a system our size, you have to dedicate a team just to collect the information you need to file a claim with FEMA to recover as much of this as possible. And so the planning folks have a role in doing that. The second issue that the planning folks are working on is supplying the data and information to model the surge and the impact. Now in some way, you know, I'm a very practical people who know me. It's very practical. I go, guys, we need more beds. It doesn't matter how many, let's just, you know, I'd rather open up too many than too little.

So the, you know, our surge planning had really was for also to help government understand when those peaks were going to come, but also to help us create demand models for supplies, for ICU use, ventilator use and staffing levels. So there was a group that was put together with our finance people that would use different mathematical models to kind of say, well, here's the impact. And I would just tell go guys, the number one critical variable that was difficult to estimate was the average length of stay of these patients. Since you weren't really discharging people that easily at the beginning. So the discharge, and the ICUs, not that many people were coming out of the ICU. Although we're discharging now 300 people a day to home. We have right now in the hospital Oh gosh, about 5,000 beds filled. We usually have about 4,000 beds, a little under that 3800. And I'm sorry. So we built in about 10 days, a thousand bed academic medical center.

Diane: That's awesome. And you've been pretty skilled and you're mentioning the ICU care. How has the planning team helped with any of the supply or modeling out those supplies and how has that been going?

Jeff Kraut: Well, I would say a lot of this had to be our supply chain people. There are two, there are two areas, and we weren't as intimately involved in that because the supply chain was just all over the world. And as you've heard, you know, it's not only us buying supplies, it's every hospital in New York, New York State, the governments, the local County governments, and the Federal government, all buying a supply chain activities. Now we've gotten a little better. We don't expect to get a lot of stuff out of the national stockpile. You know but we've been fortunate probably our hospital is the only one in New York media that you have not heard patients employees complaining about they don't have access. Part of it is because we had maintained a reasonably large stockpile in general, but like many other places, for a lot of items, you move to a kind of just in time inventory system. And we don't tie up a lot of cash in inventory. We only did it because of the disaster planning capabilities that we had developed.

But we've been holding our own, we're barely staying ahead of the burn rate for the supplies. And it's all the obvious things and then it's some, a lot of the other obvious things. There's now, you know, shortages developing for the pharmaceutical support that you need to keep people on, ventilators, Propanol, other medications that are the non COVID related medications and stuff. But we'll see. And they're doing amazing thing, after the supply chain or I would say in parallel with it, it's the staffing. You know, we had people exposed at the beginning, people had to go out on furlough. The amount of time people are doing, and folks in just the sheer number of people that are dying each and every day in the hospital. The mental health toll it's taking on the workforce. I mean, we all know this is going to redefine healthcare this moment.

We're all going to be redefining, you know, my career is 40 years in this business. It'll probably be defined by that moment. And the people that are just starting out in planning in their twenties, they'll probably have this moment and redefine it. And I'm hoping, you know, we're very optimistic because we know we're going to come through it. We know we're going to do better and we think the lessons we're going to learn are going to improve healthcare in the future. We think we'll get rid of some of the regulatory burdens that add very little value to providing care. And I think from a planning you're also seeing, I think the benefit of health systems, what they can do. And, you know, it's interesting, we've been bashed as an industry for the last couple of years for a variety of very good reasons, right? We know there's room for improvement, but when there's a crisis, this room, we keep reminding it through the AHA. You know, at the crisis, you may think hospitals are not needed, but when there's a crisis, they're the only things that are needed by a community to keep it healthy. And you don't hear the insurance companies managing care. You don't hear all these pop up companies, Apple, Google, Amazon, you know, providing care and organizing things. It's us. We are the boots on the ground. We are the first line of defense of America’s healthcare. And I think everybody's going to remember that after this is over.

Diane: Absolutely. Absolutely. There's quite enough outpouring of respect and appreciation in almost all communities for what hospitals are doing right now. So, and thank you for what you and your teams are doing. Tell me what a day in the life is right now. So you've gone through this phase of you're building capacity, you're helping with the modeling and the forecasting, which I'm sure you're still doing. But what does today hold? What is your short planning shifting to right now?

Jeff Kraut: Let me give you an example of the two or three things I'm dealing with today. Our, one of the local County Departments of Health just sent us a notice saying they are no longer going to pick up our bodies. They want all of the bodies double bagged. We don't have enough body. I mean, I called them and I said, guys, we don't have enough body bags. Why all of a sudden this, you know, so I have to now get somebody got it in their mind that this should happen. They sent out a regulatory notice. This is a local community, a Commissioner of Health and I have to, I have to spend like an hour and a half kind of having this discussion, reminding them when we had the aids epidemic, you didn't ask us to do it, when we had SARS. You didn't ask us to do it, but we had H1N1, you didn't ask us to do it. Why now? You know, tell me. Then we've had other inquiry. So I deal with these like ridiculous. Like when my staff, when our staff can't deal with some regulatory or some requests, cause there's an uncoordinated amount between State DOH and local counties.

And we're in about five different counties. They all have authority from Public Health or, not over the hospitals. They're all asking for information, which is redundant. And we even have County epidemiologic nurses calling, asking to speak to a nurse that took care of a patient because we followed that patient was COVID positive, wanting to interview them, the nurse. And we said, guys, we're not pulling anybody off the floors. So a part of my day is dealing with what I would say well-meaning but misdirected initiatives that are initiated by government. And everybody's, once you get to it, you do it. The second thing that I'm doing is I'm bringing up an alternative care sites. So we have for the last two or three days located a gymnasium in a local college where we want to bring up a site for low acuity kind of discharge planning. We're having some problems. We have some families that have refused to take their family members back when they're ready for discharge from the hospital out of fear because they have an elderly parent or something there.

So we need now alternate sites where we might be able to take care of people. Our big problem is staffing. So we're working with a local community and ambulance volunteer Corp that are going to get us volunteer paramedics, community, some volunteer doctors, some voluntary medical staff, nurses who are going to staff this. And we're bringing up how to, how to bring up this particular site and make it available for the next, at least for the next two weeks, just to keep the pressure valve out of the hospitals. And then we would also augment it with a kind of enhanced urgent care for non COVID related issues. You know, we're still getting MRIs, we're still getting stroke. People are ignoring those symptoms and we want to encourage that they should feel safe that there are sites in the community, they can come into. So that's another issue I'm dealing with. And believe it or not, I'm interviewing a potential candidate for a chairmanship of one of our, you know, business has to go on.

So I have an interview today with, a phone interview with a potential candidate for one of our service line leaders. And later I'm planning out, I have a board meeting that I have to schedule to keep our board informed. And it's seven o'clock tonight, I'll do a, we'll be hosting an update for our board of trustees, all of our advisory groups, subsidiary boards, major donors and community leaders to give them an update of not only where we are, but what we see happening with COVID. And my day starts at about seven. It'll usually end nine or 10. I have conference calls with my colleagues, zoom, most of them is Microsoft Teams, and our group's been going seven days a week. It's really, I had to actually up ventilators on Sunday from a site that no longer needed them and we just didn't have transport. So I said, I'll go do it and I went and volunteered, got in the car.

Diane: Well we're so grateful for all the work you're doing, and I don't know how you stay resilient during these times, but please keep healthy and keep your teams healthy and we'll be thinking of you. Is there any lesson learned that you'd like to share with other planners out there as we?

Jeff Kraut: Well, you know, I think there's going to be a lot of lessons here, and you know, whether it's done through the planning office or the operations office, I just think that you know, we're going to be, when you think about the future that's going to happen, we're now have seen the value of tele-medicine. You know, so when you are thinking about primary care and you know, you might've thought, you know, the community's not ready, doctors are not ready. It's been a proven tool here. And we just actually had a discussion this morning about rethinking our primary care strategy and how we incorporate in tele-health in a much more aggressive model that that's been going on. The other issue I think is the whole notion of how we're going to, you know, what's going to happen. You not only have to plan for the crisis, you have to plan for what happens after the crisis occurs. So we are going to be starting on Friday, a group about how do we take ourselves out of this, and so we've delayed all elective surgery.

So we're just doing some planning on how do we staff and get our operating’s rooms back up to speed but going seven days a week and then doing surgery on Saturdays and Sundays full schedules, we do a light Saturday usually. Now we're going to go full bore because a lot of our clinicians want to have all that backlog. So how are we going to metabolize the bolus of patients that have been delayed waiting to see and how do we try to regain, you know, the financial benefit of that. But also what I would suggest to you if you haven't, each community is different. A lot of communities have gotten involved with equity back purchases of physician practices. They made those decisions. If you have noticed a lot of those equity back purchases of the doctors have been notified that they're reducing their pay or not, because it was all based on their revenue. So I think we're going to have some great opportunities out there after this is over to think strategically about how we build up our business, our relationships. Cause everybody's going to want to be connected to a hospital and it's not hospital care. It's Health systems, ambulatory, all that stuff. So I shouldn't be hospital centric. I just happened to be right now. That's it Diane.

Diane: All right Jeff, thank you so much for taking time with us today.

Jeff Kraut: I'm sorry one more thing. You are hearing all these things that are bouncing and all these pinging’s that are going on in the background. So that is all of my hospital. That's the planning office communicating with each other and in order to keep them together we've had weekly meetings. I've actually sent them all gift cards to order in food for lunch cause we usually sponsor lunch at the meeting and they are, they're not only keeping each other informed right now, they're also the, each one of them has responsibility to do a joke of the day, a brain teaser of the day. And so you have to think about how do you keep your people connected when they're not physically located. And that's again, that's all the, everything that you are seeing, all the emails that are all the messages that are popping up as I'm speaking or from my medical staff, from my planning staff, communicating with one another. It's a great tool.

Diane: You need that kind of distraction and uplifting moments in the day.

Jeff Kraut: Alright. And everybody still, listen in the fall, we're all going to be together at SHSMD. We are not going to cancel that. Okay. We're hoping we're going to be there. We're hoping to see everybody. There will be a little more distance. We'll still be there together. Okay.

Diane: Thank you Jeff, have a great day.

Jeff Kraut: All right. Take care Diane. Bye. Bye.

Diane: Bye bye.

Bill Klaproth: Thanks for listening and know that we are thinking of you during these unprecedented times. For general updates and resources on COVID-19 head to AHA.org/COVID19 and visit SHSMD.org for a collection of specific COVID-19 resources for strategists.