Surviving Harvey: Disaster preparation issues for medical practices hit by hurricanes Insight Article - December 3, 2018 Disaster Planning Policies & Procedures Sign in to save Jennifer Myers MBA, CPA, CGMA, FACMPE Editor's note: This article is adapted from a Fellow paper submitted for fulfillment of the requirements of Fellowship in the American College of Medical Practice Executives. Learn more about Fellowship: mgma.com/acmpe. Hurricane Harvey, a Category 4 hurricane, hit the Texas Gulf Coast on Aug. 25, 2017, dumping about 60 inches of rain1 around Port Arthur and causing an estimated $126 billion in damages.2 The 130-mph winds left more than 308,000 homes without power.3 The subsequent weeks of media coverage of the damage and suffering often spotlighted the extensive damage done to the area’s hospitals. For instance, East Houston Regional Medical Center received such extensive damage caused by six feet of floodwaters that administrators decided not to rebuild the 40-year-old, 131-bed hospital,4 resulting in layoffs for the hospital’s entire 479-employee workforce.5 At least 16 hospitals were closed because of complications caused by flooding, and about 1,000 patients were moved to other facilities throughout the state. In one evacuation effort, residents of a Port Arthur nursing home facility waited in flooded hallways for up to 24 hours before U.S. Coast Guard personnel and volunteer assistants helped transport them from the flooded facility. In some instances, family members transported their own relatives from the facility with boats they brought from home.6 Texas Gulf Coast medical practices were also adversely affected by Hurricane Harvey yet received minimal press coverage of their damages. The Texas Medical Association surveyed its physician members in September 2017, revealing that 65% of physicians temporarily closed their practice and 35% reduced their hours or services.7 The experience with Harvey revealed to many Texas practice leaders that their plans and preparations did not adequately guide them through the ordeal of the storm’s aftermath. In interviews about 10 months after Harvey with a diverse group of practice administrators representing cardiology, nephrology, OB/GYN and primary care, all of them recognized that their practices’ current hurricane preparation plans needed at least some modification. All respondents indicated a need to improve communication with staff, patients and other constituents. Other recommendations involved data storage, insurance coverage review, inventory tracking, availability of temporary accommodations and facility restoration services. A few respondents indicated a desire to create more detailed disaster planning documents in which the occurrence of predetermined “trigger points” would automatically evoke appropriate action. Several detailed disaster planning documents were suggested as possible resources for practice administrators to consider. Disaster plan documents Practice administrators were asked to identify elements of disaster plan documents that helped or hindered them: One practice has a disaster preparation plan document that is reviewed annually and used in coordination with a corporate office in Florida, where dedicated staff ensure that practices are compliant with it and elements such as HIPAA security during a disaster. Before hurricane season, the corporate office sends out a “hurricane bucket” that contains a preparation checklist. It also has a national partner ready to supply them with sandbags and plywood. Another practice had a disaster plan written into the employee manual, but it lacked specific action steps and was largely focused on the lab, for which a plan was mandatory for certification requirements. The practice did not conduct rehearsal sessions for a hurricane scenario. One practice administrator noted that the organization’s disaster preparation plan document was more than 20 years old and employees did not practice the hurricane plan. Another medical practice had a formal disaster preparation plan document, identifying four phases of hurricane readiness. The practice conducts an in-service training session every year in May before the beginning of hurricane season. Team leaders are charged with knowing the possible evacuation plans of subordinates, and essential personnel are notified that they will need to stay. When considering closing the office, they discuss their decision based on hurricane watches and warnings. They have an automated way of notifying patients who are scheduled for appointments that the office will be closed due to weather. Preparation makes the difference All of the medical practices consulted for this study had done some earlier preparation on their disaster plans, which paid off during Harvey: One practice moved equipment, patient records and lab notes into interior offices without windows, as well as covering computers with garbage bags. By design, expensive computers were not placed on the first and third floors, where flooding or roof leaks would do the most damage, and the server was covered with a tent. Another practice effectively downsized the clinic from 23,000 square feet to 2,000 square feet by creating half-day shifts in limited areas of the facility. Some patients were seen by physicians on site, and phone work was transferred to a remote location. Another practice estimated how long it would be without electricity and used this to protect temperature-sensitive items, some of which were sent with physicians to locations with generator power. The practice also sent lab specimens out to the reference lab rather than doing the work in house. One practice sent providers and the office manager home with laptops. If it had power, staff took calls from an answering service, filled prescriptions and managed patients remotely. The damage done All medical practices consulted for this study endured damage. The main factor in the degree of damage suffered was the facilities’ locations in relation to the storm path. At one time the storm path was projected to hit Corpus Christi directly. However, the hurricane changed direction at the last minute, taking a northeasterly path, eventually landing on the Texas Gulf approximately 30 miles northeast of Corpus Christi in the city of Rockport.8 Damage to facilities and equipment. A medical practice in downtown Corpus Christi experienced significant water damage at its main office, which closed the entire medical building for two weeks. The practice shifted its physicians and necessary staff to its satellite office, which experienced less or no physical damage. It was not able to provide the normal level of care but was able to carry on with some basic services. Another practice had a roof leak at one location, damaging everything underneath. By the time officials were able to enter the facility, mold had become widespread. Some exam tables were ruined; others were salvaged. The building was not reopened. The practice’s main office was only closed for one day, in light of hurricane preparedness efforts: Employees knew what to do, such as taking items off the wall, pushing equipment into interior rooms and covering everything with tarps, allowing operations to resume sooner. Another practice suffered no damage to its building but was forced to close for half a day because of staffing shortages, another day because the hospital in which it is located was evacuated and another day after power was lost. No damage to practice records. None of the practices lost patient or other records in the hurricane. They all had the foresight to back up their records on the cloud or at remote locations. One practice with an off-site backup has since decided to move to cloud-based backups. Another practice had a backup but was not able to immediately work from it. Were they covered? Disaster preparedness means more than just actions taken ahead of an adverse event; it also includes having proper insurance coverage for when disaster strikes: One practice held interruption of business and general liability insurance coverage. When their building was closed, the distribution from their interruption of business claim helped during that difficult financial period. Another practice did not carry hurricane insurance coverage through its general liability policy; rather, its coverage was through a windstorm policy and it did not include interruption of business coverage. One practice filed a claim through a general liability policy for a satellite office in a building it did not own. The policy, for $15,000, did not cover all damages. Another practice that is part of a large, national organization had a general liability policy. The practice administrator contacted the corporate office, told them what happened and asked them to contact the insurance provider. He did not have to worry about policy numbers, insurance agents’ numbers and other such details. Lessons learned All medical practice administrators consulted readily acknowledged that their hurricane preparations were not complete or perfect: One practice leader said the practice would be more proactive about supplying patients with durable medical equipment (DME), refills and supplies and extra oxygen before a storm. They also realized that calls stopped forwarding to the answering service when the building lost power. In the future, phone forwarding will have to occur directly with the phone carrier and bypass the local system. Another practice leader said that communication with employees suffered, and that in the future, the practice would designate specific channels for messages, such as a private Facebook group, group texts or phone calls. Conclusion Many of the medical practices interviewed for this study intimated that they need to make improvements in drafting a functional if not highly effective disaster plan document. Several admitted that they “flew by the seat of their pants” in getting through Hurricane Harvey. In hindsight, the administrators offered several suggestions on what they would like to accomplish: Data stored on the cloud. All of the practices had their data backed up off site. In spite of the benefits of off-site data storage, they still faced limitations in retrieving their data remotely. Storing data on the cloud should help them in retrieving data remotely and more quickly. Insurance policies review. Administrators should review their insurance policy to ensure that the practice has adequate coverage. They should be certain that policies provide replacement coverage. There is a difference between actual cash value and replacement costs. Actual cash value is the cost of repair or replacing the property less depreciation. Depreciation is the loss in value of the property due to time and wear and tear. Replacement cost is the cost that an entity pays to replace an asset. Interruption of business insurance coverage. All practices had some type of insurance coverage. Those that were protected with interruption of business insurance coverage all said they were very grateful to have the funds to get them through a period when they would have otherwise had no funds to operate. Inventory practice property. The practice administrator should inventory the practice property in advance and have that list available if it becomes necessary to file a claim. It becomes problematic trying to file a claim on property that floated away from the building. Restoration company on retainer. One of the administrators recommended having a restoration company on retainer. If a hurricane produces significant water damage, the practice would be able to make immediate contact with the restoration company for water cleanup and other services. Rather than waiting in line behind other companies needing water damage restoration service, the practice would have already established a relationship that should move them to the front of the line. Improved communication. All practices consulted mentioned that they thought they could improve communication. Patients, physicians, staff and the public need to be kept informed on closings and reopenings. Some firms relied on manual phone tree systems, while others were using automatic phone tree systems. Several firms mentioned they would like to rely on social media platforms more in the future. More detailed disaster planning documents. Several administrators mentioned the desire to “tighten up” their disaster planning document with more specificity on when and how to respond to certain disaster conditions. Several administrators mentioned the idea of using “trigger points” that would direct them to the specific action to take when certain “triggers” or events occur. For example, if a hurricane reached a certain wind speed or location within the Gulf, that would trigger a predetermined list of actions. Review available sample disaster plans. A well-crafted disaster preparation plan requires considerable time and effort. It is wise to consult templates or completed plans from other offices in the same industry to get an idea on how to start. Preparing medical practices for potential disasters is not a pleasant task. However, not preparing for them may be a devastating decision with terminal consequences. Additional resources Do you understand CMS emergency preparedness requirements for Medicare and Medicaid participating providers and suppliers? Learn more from an MGMA subject-matter expert and access a member-benefit MGMA Emergency Planning Checklist. Find more disaster plan templates from: Emergency Preparedness for Healthcare Practices (MedPro) Disaster Preparedness Planning (McKesson) Long-term Care Organizations Template (Mather LifeWays) Notes: 1. Samenow J. “60 inches of rain fell from Hurricane Harvey in Texas, shattering U.S. storm record.” Washington Post. Sept. 22, 2017. Available from: wapo.st/2OAV3f8. 2. “NHC estimates Harvey damage at $125 billion.” Occupational Health & Safety. Jan. 29, 2018. Available from: bit.ly/2NXwpYV. 3. Frosch D, Ailworth E, & Gold R. “Hurricane Harvey slams Texas with devastating force.” The Wall Street Journal. Aug. 27, 2017. Available from: on.wsj.com/2QP33dQ. 4. “Houston hospital won’t reopen after flood damage from Harvey.” The Associated Press. Nov. 10, 2017. Available from: bit.ly/2QMha3K. 5. Deam J & Ackerman T. “Harvey-damaged East Houston Regional Medical Center will close.” Houston Chronicle. Nov. 10, 2017. Available from: bit.ly/2Dt8sFd. 6. Christensen J. “Some hospitals hang on as others close amid Harvey’s floods.” CNN. Aug. 31, 2017. Available from: cnn.it/2DiJVSZ. 7. Texas Medical Association. TMA Hurricane Harvey Survey. Available from: bit.ly/2pnfKAh. 8. National Weather Service. “Major Hurricane Harvey – August 25-29, 2017.” Available from: bit.ly/2rGAbtp.