The Will for Change: Finding Time for this Critical Step

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“What are the necessary and sufficient conditions for improvement in large systems? Will, ideas and execution!” —Tom Nolan, one of the creators of the Model for Improvement.

In a tribute to Tom Nolan, who died on March 19, 2019, pediatrician and founder of the Institute for Healthcare Improvement (IHI) Donald Berwick describes what will, ideas, and execution means:

“Providing will refers to the tasks of fostering discomfort with the status quo and attractiveness for the as-yet-unrealized future. Providing ideas means assuring access to alternative designs and ideas worth testing, as opposed to continuing legacy systems. And execution was his term for embedding learning activities and change in the day-to-day work of everyone, beginning with leaders.” —Milbank Quarterly, August, 2019

Nolan’s three conditions, flow roughly in the following order:

  • Execution cannot lead to improvement without testing
  • Ideas will not be sought out and tested unless organizational leaders make this a personal and organizational priority, an act of will.

It starts with will to improve.

For leaders to decide to make major improvements, fundamentally, we need to challenge the status quo. We must insist on change and provide a vision for a better state that the organization must strive to achieve.

Creating an atmosphere where new ideas can be explored and where strong, independent teams can test these ideas is a central duty of clinical leaders of health care institutions. Yet, it all starts with leadership’s willingness to take risks, communicate a vision of excellence that is achievable, and communicate that the problems of the status quo are unacceptable.

Challenging the status quo is uncomfortable, can be mentally and emotionally draining, and potentially socially isolating.

An alternative leadership style –cherishing tradition and stability– has a certain appeal in the short term. All those staff and stakeholders with an interest in the status quo are happier. There is no need to risk testing new ideas that might fail and make the leader look bad.

When a leader succeeds in upsetting the status quo, particularly in a larger organization, there is significant risk of backlash, which could torpedo the success of the changes. Unless the underlying organizational culture also changes, there is also a probability that improvements will not be sustained and that quality will regress when there is staff turnover.

How do transformational leaders address these challenges? One key tactic is drawing energy from colleagues who are doing the same work in sister organizations. This can help sustain willpower in the face of negative pushback. Another tactic is to develop a group of “true believers” in the quest for quality within different levels of their organization.

Both of these activities require intentionality. They will not naturally happen in the course of our everyday workweek activities. We need to take some time and mental space to build relationships with colleagues outside our organization and with staff within our organization. These relationships must be based on mutual trust, respect, and a shared dedication to lifetime learning. In short, they require some time for reflection, a critical activity that transformational leaders must ensure they do not neglect.

This suggests a causal chain of activities for transformational leaders to be successful at mobilizing the will to improve:

Clinical leaders overwhelmed with patient care and administrative responsibilities lack the time needed to be transformational leaders. The irony is that an improved/transformed health system can use clinician time more efficiently, ultimately giving more potential time for reflection and cultivating relationships. But how can a clinical leader reach this state of improved efficiency if they don’t have time to reflect on the system they are working in?

If the health care system has capacity to add clinical capacity, this can alleviate time pressures for the clinical leaders. This is certainly ideal, if at all possible. Focus first and foremost on recruiting excellent clinicians with a similar dedication to improving quality.

The other options are to work longer hours (which can lead to family stress), or to disappear from everyday work periodically to attend conferences, read books or listen to podcasts, or even complete formal leadership training. This time away can impact patient care in the short term.

Of course, a combination of these three factors –more staffing, longer hours, and disappearing from everyday work– may also give sufficient time for reflective time and building relationships.  Indeed, most transformational leaders have used this combination tactic for their finding time to work on their initial transformational activities.

 

Re-framing POLST Completion as a Procedure

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

Be brave enough to start a conversation that matters.
-Margaret Wheatley

If a surgeon took a patient with a large colon cancer to the operating room against the previously expressed wishes and consent of a patient, they would be subjected to hospital peer review, investigation by the Medical Board, and potential loss of license to practice medicine.

However, failure to have a goals-of-care conversation, leading to an incorrectly completed POLST, that then leads to a seriously ill patient receiving unwanted CPR/intensive care, almost never results in a referral to peer review or the Medical Board.

It will take a big culture shift for this to change, but perhaps we can learn something from surgeons: using a systematic process. Surgeons have a standard way of documenting a procedure, which is essentially a checklist reflecting the standard of care:

  1. Procedure performed
  2. Date and time of the procedure
  3. Name of surgeon/assistants
  4. Indication for procedure
  5. Pre-operative diagnosis
  6. Post-operative diagnosis
  7. Anesthesia
  8. Narrative Description of the Procedure
  9. Findings
  10. Specimens
  11. Sponge and needle counts
  12. Drains left in after surgery
  13. Disposition/Status of the patient

A goals of care conversation with a patient and the family should be documented like a procedure, with a few adaptations.

The Physician Order for Life Sustaining Treatment (POLST) was established by AB 3000, passed in 2008, and took effect in 2009. Early on, the California Healthcare Foundation and the Coalition for Compassionate Care of California funded and organized local community coalitions to educate clinicians, emergency medical technicians, and the public, on how to use the POLST appropriately.

For the patient’s wishes around intubation, CPR and artificial nutrition to be honored, the following steps must occur:

  1. A clinician needs to have a goals-of-care conversation with the patient and potentially their family.
  2. When appropriate, a POLST form must be filled out correctly, without missing signatures or inconsistent directives.
  3. The POLST form must be available to any EMS responding to an emergency call.
  4. The family needs to understand and respect the orders expressed in the POLST (or they may hide the POLST or direct the care team to ignore the POLST).
  5. The emergency medical technicians, emergency department physicians and ICU physicians must understand what a POLST is, how to read the POLST, what it means, what the legal requirements are, and agree to following the directives expressed in POLST forms.
  6. The POLST form must be available to the emergency department physician and potentially the ICU physician caring for a patient who is unable to express their own wishes.

A number of organizations in California are piloting electronic POLST forms and POLST registries. One key finding from these pilots is that there are problems with every one of these six steps, such that many patients are not having their wishes honored by one or more providers.

To focus on just the first two steps, which impact you, our primary care providers: Data from the Palliative Care Quality Network shows that PHC contracted palliative care providers in the PHC service area have a high rate of appropriate use of POLST forms.

However, palliative care clinicians often encounter patients who have a POLST form completed by a non-palliative care clinician which have internal inconsistencies or errors, and in which no goals of care conversation is recorded in the medical record.

This sometimes leads to care that is inappropriate and unwanted.

Consider asking your clinicians to document a goals of care conversation like they would document any other medical procedure. See VitalTalk for some resources that can help.

Outcome Disparities vs. Outcome Inequities

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“One’s zip code should not determine one’s health destiny – but in America, it does”

-Robert Ross, CEO California Endowment

Health equity is the focus of much attention recently, with NCQA and DHCS looking for ways to measure and remediate inequities. A major limitation to analysis of health equity in the Medi-Cal population, is that the data available on race, ethnicity, language and gender is self-identified at the time of Medi-Cal application based on limited standardized categories offered by the state. While some providers gather more detailed demographic data, such as gender identity, sexual orientation, or more nuanced ethnicity information, it is not captured in a standardized way and not reported to the health plan or the state, so no analysis based on this more detailed demographic information is possible outside of the provider-level databases. A high priority for making health equity analysis less blunt will be to standardize more detailed race/ethnicity/gender etc. data collected from beneficiaries at the time of application.

Partnership HealthPlan of California (PHC) is able to use the basic member-level ethnicity data we have to evaluate certain clinical data elements that are collected more systematically, as part of HEDIS administrative measures (such as breast cancer screening) or hybrid measures collected as part of the PCP QIP (such as blood pressure control). Outcome data, like maternal mortality or neonatal mortality, is not coded in a way that we can generate accurate rates within our health plan data (county level and state level mortality data is available from CDPH).

There are two patterns that we find with this approach, illustrated with the following examples:

  • Hypertension control: Note the declining control overall in 2020, due to the COVID pandemic. Additionally, note less control of blood pressure in the Black and male populations. This chart is based on QIP data, the denominator being much larger than for HEDIS data, where only a small sample of the overall population is evaluated. Consequently, while we are not able to find statistically significant disparities from HEDIS data, we are able to see statistical differences in the QIP dataset. Diabetes control exhibits a similar pattern.

  • Childhood Immunization: 10 vaccine series completed by age 2. White and Black children have similarly low vaccination levels, compared to the Asian/Pacific Islander and Hispanic children. Many other clinical measures have a similar pattern, with the health status of white members below that of other ethnic groups.

As this illustrates, not all health disparities are a reflection of inequities. If a socially favored demographic (such as white males) has a worse health status, this disparity would not be considered a reflection of systematic bias or unequal privileges. Such ethnic disparities (in the setting where all groups have Medi-Cal, and so all the comparison groups have low income) may be associated with other factors which could be considered inequities. Examples include, living in a rural area with less access to medical care or having a higher exposure to factors that increase health risk, such as housing instability or substance use.

These examples illustrate the challenges DHCS and NCQA will have as they try to define standardized equity measures that measure performance of health plans. Nonetheless, analyzing the data we have to look for disparities is well worth the effort, to allow a thoughtful contemplation of associations and potential causal factors that we may be able to address.

Remembering the Founder of Community Health Centers

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“The last time I looked in my textbook,
the specific therapy for malnutrition is food.”

-Dr. Jack Geiger

In December, 2020, Dr. H. Jack Geiger, founder of the first Community Health Centers in the United States, died on Monday at his home in Brooklyn at age 95.

In the 1960s, Dr. Geiger was a co-founder, with Dr. Count Gibson, of Community Health Centers in South Boston and in Mound Bayou, in the Mississippi Delta. They provided desperately needed health care but also food, sanitation, education, jobs, and social services — what Dr. Geiger called “a road out” of poverty. The centers inspired a national network of clinics that now number more than 1,300 and serve about 28 million low-income patients at more than 9,000 sites.

Dr. Geiger was a leading proponent of “social medicine,” the idea that doctors should use their expertise and moral authority not just to treat illness, but also to change the conditions that made people sick in the first place: poverty, hunger, discrimination, joblessness, and lack of education.

During his last year of medical school, he traveled to South Africa and worked with two physicians who were setting up a health center in an impoverished, disease-ridden region of the country called Pholela, which was then a Zulu reserve. A key to the center’s success was that local people — its own patients — worked there and helped run it.

For five months Dr. Geiger took care of patients, visiting thatch huts and cattle kraals, meeting traditional healers and seeing the huge improvements — pit latrines, vegetable gardens, children’s feeding programs — that the health center had brought to the region.

In the summer of 1964, he traveled to Mississippi to help care for the civil rights workers who were pouring into the Deep South to campaign for voting rights.

In Mississippi, he saw conditions much like those in South Africa: families living in shacks without clean drinking water, toilets or sewers; sky-high rates of malnutrition, illness, infant death and illiteracy; few or no opportunities for residents to better themselves and escape. He realized that he did not have to travel to Africa to find people in trouble.

Under President Lyndon B. Johnson, the war on poverty had begun and the Office of Economic Opportunity had been created to pay for projects to help the poor. Sponsored by Tufts University, and armed with grants from the opportunity office, Dr. Geiger, Dr. Gibson, Dr. John Hatch and others set up a health center in Mound Bayou, Miss., a poor, Black small town where most people were former cotton sharecroppers whose way of life had been wiped out by mechanization.

The clinic, which opened in 1967, treated the sick, but also used its grant money to dig wells and privies and set up a library, farm cooperative, office of education, high-school equivalency program and other social services.

The clinic “prescribed” food for families with malnourished children — to be purchased from Black-owned groceries — and the bills were paid out of the center’s pharmacy budget.

The governor complained, and a federal official was sent to Mound Bayou to scold Dr. Geiger for misusing pharmacy funds, which, the official said, were meant to cover drugs to treat disease.

“Yeah,” Dr. Geiger replied, “well, the last time I looked in my medical textbooks, they said the specific therapy for malnutrition was food.”

The official, he said, “shut up and went back to Washington.”

(Adapted from Dr. Geiger’s full Obituary in New York Times)

Patient-Centeredness: In the Eye of the Beholder

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“We are guests in our patients’ lives.”

-Don Berwick, MD

April 26-30, 2021 is National Patient Experience Week, a time for health care organizations to celebrate and reflect upon their efforts to improve the way their consumers perceive the care they receive, a time for health care organizations to proclaim that they are “Patient-Centered.”

What does it mean to be patient-centered? The answer depends on who you ask.

The root of the term “patient-centered” goes back to the 1940s with a school of psychological thought that promoted counseling that was centered on the needs of the client: client-centered counseling. In the 1950s and 1960s, Hungarian-British psychologists Michael Balint, Enid Balint, and Paul Ornstein brought a basic psychodynamic approach to primary care clinicians –the “Balint Group” approach now used in primary care medical education around the world. The Balints coined the term patient-centered medicine, which “should include everything the doctor knows and understands about his patient . . . understood as a unique human being,” as distinct from illness-oriented medicine that focuses more narrowly on diagnosis and treatment of localizable pathology.

In 2001, the Institute of Medicine identified being “Patient-Centered” as one of the six aims of health care quality (the others being safe, effective, timely, efficient, and equitable). They defined Patient-Centered as care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring their values help guide all clinical-decisions. This idea of customizing the care to the patient seems consistent with the Balints’ ideas.

Starting in 2007, some larger institutions have appropriated the term patient-centered to have different definitions.

In 2007, all the American organizations representing primary care clinicians (AAFP, AOA, ACP, and AAP) combined the concept of a primary care Medical Home (the 1967 AAP idea of a PCP who coordinates the care provided by specialists), with the idea of patient-centeredness to create the Joint Principles of the Patient-Centered Medical Home. While the goal of this structure is to serve the needs of the patient, this initial conceptualization focused on putting the primary care physician at the center of this care—more of a primary care physician-centered medical home.

Sensing an opportunity, in 2008 the major accreditation agencies (NCQA, URAC, Joint Commission, and AAAHC) launched Patient-Centered Medical Home (PCMH) accreditation and recognition programs. Their focus is on elements of operational and quality infrastructure thought to be good for patients and their outcomes. Moving beyond a narrow physician-centered focus, meeting these elements helps move primary care organizations in the direction of higher quality care, using a compliance with standards approach.

In the meantime, organizations and scholars that were focused on primary care moved in two different directions.

The first of these focuses on relationships between the patient and their clinician who is able to communicate with empathy. This emphasis on relationships is epitomized by the Nuka Model of Care at the Southcentral Foundation in Anchorage, the only health center in the U.S. to win the Baldrige National Quality Award. Health care in the Nuka model is relationship-based and customer-owned. Nuka focuses on understanding each customer-owner’s unique story, values and influencers in an effort to engage them in their care and support long-term behavior change. Note the additional element of community empowerment included in this approach.

The second direction was a focus on more actively seeking input of patients on how to improve the provision of health care, called Patient and Family Centered Care (PFCC). The four fundamental principles of PFCC are treating patients and families with respect and dignity, sharing information, encouraging their participation in care and decision making, and fostering collaboration in care delivery and program design, implementation, and evaluation. The new element here is the idea of moving beyond gathering survey feedback from patients, to partnering with patients to identify service problems and co-design the solutions. “Nothing about us, without us” is their catchphrase.

Both the Nuka model and the PFCC move beyond the individual clinician-patient interaction to look at what the organizations that hire these clinicians must do to be patient-centered, in ways that are challenging for standards organizations like NCQA to fully capture.

Jumping up another level above the organizations that provide care, how can health plans like PHC (as well as suppliers and state regulators like DHCS) promote patient-centered care?

  1. Make patient-centeredness a guiding principle—a frame-of-mind—that guides decisions and prioritization.
  2. Ensure consumers of health care have a voice. This includes a process that uses grievances to drive improvement, including consumers in governance and policy-making, and ideally with some joint design activities.
  3. Support providers, especially your primary care organizations, with financial incentives, comparative data, and sharing of best practices around optimizing the patient experience of care.

Becoming truly patient centered, meeting all the different definitions of this term, requires sustained attention from all of us. Thanks for taking a moment on National Health Experience Week to reflect on what you can do meet this ideal.

Challenges Ahead with the Next Phase of COVID Vaccination

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“Wishful thinking is no substitute for careful planning.”

-Steve McConnell

As you are no doubt aware, starting on March 15, adults aged 18-64 with certain medical conditions will qualify for COVID vaccination, based on the clinical judgement of their medical providers. See below for the full list.

Operationalizing this process, coordinating the judgement of the clinician with the actual vaccinators will be challenging if the provider making the judgement is not also doing the vaccination. Even if the provider is doing both, the sheer volume of patients who qualify is daunting and raises many questions:

Do you treat all the groups below equally, or do you prioritize subsets for your first outreach efforts? How exactly does this fit into the patients who sign up through the centralized myturn.ca.gov site? How can myturn.ca.gov possibly know who meets the medical criteria based on their physician judgement? What role will Blue Shield play? The three final options in the list are vague and allow clinician judgement that may not be uniform. How do you interpret that language for your patient population?

While we may wish that these questions will be answered by March 15, it is probable that they won’t be. Each of your health centers, offices and organizations will be expected to use this general guidance to create their own operational plans. This will likely involve using the registry function of your electronic health records to generate lists of potential patients in each group, sub-prioritizing your own outreach activities, and communicating this clearly to your patients. It will also involve ramping up and streamlining your vaccination process, from taking sign-ups, verifying eligibility, checking identity, and auditing for misapplication of the criteria.

These next few months will be even more challenging for primary care. Hope for the best, but plan for the worst. Keep your plans flexible and adaptable to most likely challenges: variable vaccine supply and disconnected communication between the different systems that will need to work together.

Provider Bulletin from the California Department of Public Health:
Beginning March 15, healthcare providers may use their clinical judgement to vaccinate individuals aged 16-64 who are deemed to be at the very highest risk to get very sick from COVID-19 because they have the following severe health conditions:

  • Cancer, current with debilitated or immunocompromised state
  • Chronic kidney disease, stage 4 or above
  • Chronic pulmonary disease, oxygen dependent
  • Down syndrome
  • Immunocompromised state (weakened immune system) from solid organ transplant
  • Pregnancy
  • Sickle cell disease
  • Heart conditions, such as heart failure, coronary artery disease, or cardiomyopathies (excludes hypertension)
  • Severe obesity (Body Mass Index ≥ 40 kg/m2)
  • Type 2 diabetes mellitus with hemoglobin A1c level greater than 7.5%

OR

If as a result of a developmental or other severe high-risk disability, one or more of the following applies:

  • The individual is likely to develop severe life-threatening illness or death from COVID-19 infection
  • Acquiring COVID-19 will limit the individual’s ability to receive ongoing care or services vital to their well-being and survival
  • Providing adequate and timely COVID care will be particularly challenging as a result of the individual’s disability

Focusing Leadership Energy

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“The tragedy of life is not in failure, but complacency.”

-Benjamin Mays

The “Rule of Three” is a principle in writing and public speaking that states that ideas presented in threes are inherently more interesting, more enjoyable and more memorable for your audience. Information grouped into threes will stick in our heads better than other sized groups.

For lexophiles, there are two single words for the Rule of Three.

The first is tricolon, derived from the Greek tria (three) and kolon (clause or member). The idea is old; Aristotle described it in his book Rhetoric. The three words or phrases have different meanings but are grouped together for a common purpose.

Some medical examples:
Airway, breathing, circulation
Oriented to person, place and time.

The second word is hendiatris, derived from the Greek hen dia treis (one through three), in which three words are used to convey a single concept. For example, Shakespeare’s Julius Caesar says:

Friends, Romans, Countrymen, lend me your ears.

Why does this rule work so well? One theory is that our minds naturally organize information into patterns so that they can process and retain information. The smallest number in a pattern is three, hence the Rule of Three.

Leaders throughout history have used the tricolon to communicate, inspire and motivate those around them. There is another variation on the Rule of Three used by leaders to focus their strategic energy and achieve success on what matters most. To be effective, we need to regularly decide what our top three priorities are for focusing our discretionary energy. Write them down, talk about them, and remember them when you can take a break from the myriad of busy tasks (email, meetings, patient care) that take up so many hours each day.

Focusing on your top three priorities requires discipline to defer lower priorities to later, or perhaps delegate them to someone else. This discipline also forces us to be clear on the criteria for prioritizing the highest priorities, a process sometimes called “remembering our north star,” the guiding light in the darkness which is steadfast, and present, night after night.

So take a moment to remember the principles that guide you, and set your top three priorities for the next week/month/year. Then, as you seek to inspire others to work on these priorities, consider how rules of three can help you.

Effective Promotion of COVID Vaccination

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“For he who has health has hope; and he who has hope has everything.”
-Owen Arthur

The first step to encouraging our patients to take advantage of the opportunity and privilege of being vaccinated against COVID-19 is to understand and communicate some core facts on vaccine development, efficacy, and safety. Here are some examples that may be helpful.

Have you ever seen a home makeover TV show, where they build a sturdy beautiful home in a week? New homes typically take months to build. How is this possible?

  1. By having prefabricated parts ready to assemble rapidly. Don’t build everything from scratch.
  2. By pouring resources (workers and money) into the building process, and working long hours.
  3. Wherever possible, by doing different parts of the project simultaneously, instead of sequentially.

These same three steps have been the key to developing highly effective COVID vaccines with thorough safety testing:

  1. Re-purposing a vaccine platform that has been proven effective and safe on other similar infections, adapted to the specific genetic code of the COVID-19 virus.
  2. Getting up-front funding for the final product, allowing people and facilities to be re-purposed to produce the vaccine on a large scale, quickly.
  3. Do all the usual steps in testing a vaccine for effectiveness and safety without unnecessary delay between steps, WHILE large scale production is already going on, in case it works well.

Efficiency, while assuring quality. No corners were cut!

I heard you can still catch COVID after being vaccinated. If that’s the case, why should I get vaccinated? Do COVID vaccines protect against COVID infection?

The COVID-19 vaccines are amazingly effective against both serious COVID-19 infection (close to 100%) and symptomatic COVID infection (95% for two doses of the two mRNA vaccines, 72% for a single dose of the Johnson and Johnson vaccine, when available in the US).

Importantly, protection against asymptomatic infection is probably in the ballpark of 50%, so vaccinated individuals can still carry infection home to their family and friends who are not vaccinated. Because of this, it is very important to continue to diligently use masks, physically distance and avoid indoor gatherings with individuals outside of your COVID bubble. This won’t last forever. We need many people to be vaccinated AND little COVID to be circulating in the community before we consider easing up on other protective measures.

I’m worried about the side effects of the vaccine. Could I catch COVID from the vaccine? Can’t the RNA in the vaccine become a part of my own DNA, causing problems down the road? What about long-term side effects?

First and foremost, COVID vaccination cannot cause COVID-19 (about 30% of Americans believe this, so it is important to address this up front). No COVID virus was used in production of the vaccine. The messenger RNA in the vaccine codes for just one protein of the virus. This messenger RNA was manufactured from chemical building blocks in vaccine production facilities.

The messenger RNA is quickly digested by our bodies back into these building blocks, just after it instructs the protein factories within cells to produce the COVID spike protein in large amounts, so your body can learn to react against it in the future. Messenger RNA does not become part of your body’s DNA. Your DNA is safely located in the nucleus of the cell, away from the protein factories where the messenger RNA does its work.

In the past year, about 1 in 700 Americans have died of COVID. In comparison, the major risks of the vaccines are exceedingly rare: 4 hospitalizations per million doses of the current vaccine for either anaphylaxis or low platelet count (immune thrombocytopenia). Longer term side effects affect about 5-10% of those infected with COVID-19 (sometimes called “long haulers”), while no long-term side effects have yet been described for the vaccine (at least 42 million doses given so far, in just the United States).
Short term side effects of the vaccine include arm pain, muscle aches, headache, fever, and fatigue. These minor side effects are quite common, and usually last no more than 24 hours.

Framing the Conversation
Frame COVID-19 vaccination conversations with messages that resonate. Here are three ways of framing recommended by the Ad Council COVID Collaborative:

  1. Moments Missed. Reference things your patients miss the most. With many feeling COVID-19 fatigue, missed moments (especially human connections that we took for granted like visiting family and friends) serve as a powerful reminder of the ultimate end goal: vaccination as a pathway to the possibility of regaining these moments (don’t use the term “return to normal” though as this overpromises and may lead to unsafe behavior after vaccination).
  2. Protection. Emphasize a shared goal of “protecting yourself, loved ones and those in your community” (rather than “coming together as a nation”).
  3. Positive tone. Be inviting and respectful as opposed to demanding. Start with the assumption that the person would want to be vaccinated. If they say they don’t want the vaccine, then acknowledge “the choice is yours to make” which connects with the deeply rooted American value of liberty. Trying to harness fear of COVID can backfire, leading to fear of the vaccine.

In this pandemic, all of us in the health care community have the privilege and the responsibility to be public health ambassadors, for our patients, our families and our communities. As ambassadors, to be most effective we must be energetic, committed and diplomatic.

New Information on Highly Infectious COVID-19 Strains

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“The tragedy of life is not in failure, but complacency.”

-Benjamin Mays

In the past week, there has been a flurry of new information about different COVID-19 strains. With large-scale community transmission, new strains can spread widely, and the most infectious strains will become more prevalent than less infectious strains over time. New information will continue to become available in the days and weeks ahead. Here is a summary of highlights:

CAL.20C: California has its own highly infectious strain of COVID-19, called CAL.20C which first appeared last summer in Los Angeles, but spread steadily since November, accounting for 30% of cases three weeks ago, and 50% of COVID-19 isolates two weeks ago in Los Angeles. This strain has now been found throughout California, including the Bay Area. Kaiser has identified it at all of their hospitals in Northern California.
This strain was incidentally discovered when California scientists began looking for the highly infectious British strain.

A laboratory director in Napa noted last week isolates of COVID-19 from community testing have much higher load of viruses in the samples than seen before in Napa. This is consistent with the mechanism for higher infectivity of these strains, which is that more virus is shed when people are infectious. Sequencing confirmation is pending, but this suggests that a more infectious strain is rapidly spreading in Northern California in larger numbers. This means that we may be looking at accelerated spread in our region in the month to come.

In the next few weeks, we will learn steadily more about this CAL.20C strain and its role in the notable big surge in COVID-19 cases in California, Arizona, and Nevada, starting in November. Specifically, we need data on mortality rates, effectiveness of vaccines, degree of increased infectiousness, and pattern of spread through the state.

B.1.1.7: On Friday, the UK government announced that early data suggests that the British variant (B.1.1.7), already known to be about 50% more infectious, may have a 30% higher mortality rate than the previous COVID-19 circulating in the UK. In the UK, this means an increase in overall mortality rate from about 1.0% to about 1.3%, still far below the mortality of coronaviruses that caused SARS in 2003 or MERS in 2012.
Early studies have confirmed Moderna vaccine effectiveness against the B.1.1.7 variant.

501Y.V2: This strain, circulating widely in South Africa, has decreased cross-reactivity to convalescent plasma and monoclonal antibodies. Today, Moderna announced that the immune response to their vaccine was somewhat less strong against 501Y.V2 than the original Wuhan strain that their vaccine is based on. We don’t know how much less clinical effectiveness (in terms of actual prevention of infection) that this translates to, but Moderna has developed a new version of their vaccine targeting this strain that it is planning on testing as a booster dose, after the original 2 dose series is completed.

P1: A new strain with over 20 mutations has been identified in Manaus, Brazil has exploded in December, 2020, even in a community which was devastated by a 60-70% infection rate in April, 2020, enough that should have generated herd immunity of the original COVID-19 strain. This raises concerns of widespread re-infection when strains of COVID-19 are sufficiently different, and makes it more likely that vaccines will be less effective against this strain. It will be weeks before we know more details.

Implications of Increased Infectiousness of COVID-19: France and Germany decided that cloth masks are not sufficient to counter spread of more infectious strains. Germany is now requiring N95, KN95, FFP2, or surgical masks, and specifically not cloth masks, for people interacting in public (like grocery stores and public transit). The original push for homemade cloth masks came from a desire to save scarce N95 masks and other masks for doctors, nurses, paramedics, doctor’s offices, etc. It is doubtful that the global supply chain for N95 masks can meet the demand to have the entire population wear them, but KN95 masks are more readily available. Absent these medical grade masks, some are calling for wearing two cloth masks, one on top of the other, to decrease risk of infection.

To increase protection against these more infectious strains, in addition to possible future changes in mask recommendations, the CDC may alter their recommendations around physical distancing. In the meantime, it might be prudent to consider a higher standard (such as 9 feet and 5 minutes instead of 6 feet and 15 minutes), in your health care settings.

Scaling Up COVID Vaccinations: Reflections on the Science of Implementation and Spread

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“Nearly every problem has been solved by someone, somewhere. The challenge is to find out what works and scale it up.”

-Bill Clinton, former U.S. President

In spite of several months of planning, the scaling up of the COVID vaccine has been challenging. Often, the scaling up of successful pilot programs and improvement projects encounter problems. Successful large scale implementation is a skill set not necessarily associated with good intentions, innovative thinking, or the size of the organization.

Stephen Dubner offers a nice introduction to this challenge in a Freakonomics Radio podcast, from early 2020.

In the last 10-15 years, a new social science concept called “Implementation Science” seeks to explain the factors leading to implementation challenges and how to overcome them. Several of these frameworks on how to increase the success of large scale implementation were combined into a Consolidated Framework for Implementation.

Here are a few major reasons that scaling up of successful pilots may fail:

  1. The pilot did not actually work (look at the actual data, not the hype).
  2. The people studied in the pilot are not representative of the general population.
  3. Efforts to scale up implementations cut corners and no longer follow key aspects of the pilot program.
  4. Scaling up does not account for limited supply of qualified staff and other inputs.
  5. Scaling up assumes the “build it and they will come” theory; that demand for the intervention will spontaneously be high. An insufficient marketing plan is included.

Over the course of our careers, as we experience or witness failed implementations, it is too easy to develop a sense of fatalism about many proposed expansions. In the case of mass COVID vaccination, our society, health care delivery system, and economy, demand that we have a different mindset. Successful implementation is hard, it is a skill-set, but it importantly reflects a “can do” mindset, not a “can’t do” mindset. It means tackling challenges head on, seeking new solutions to problems encountered, including the key challenge of vaccine hesitancy.

We at PHC thank you, and your staff, for your work on promoting COVID vaccination among your staff and in your community, in the weeks ahead.