Resiliency: an owner's perspective to running a business during the pandemic
On March 16, 2020, I hit “send” on an email that shook my life to the core. I was overwhelmed with trepidation, nausea and utter disbelief. In my volunteer role as president of the Saskatchewan College of Physical Therapists (SCPT), I had engaged legal counsel prior to suggesting that every licensed private physical therapist in our province had 6 days to contact their patients- with high likelihood the government would be mandating closure of the doors of private practice clinics. I followed the science and statistics, I watched as the world shuttered their doors, and I made the educated guess that our profession would follow suit. The SCPT executive committee and I acted as quickly as possible, to allow our professionals time to contact their caseloads and plan for the unknown. The backlash was unbelievable, as that email made physical therapy the first health profession in Saskatchewan to formally recognize to its membership that the world as we knew it was changing. The requirement to pause practices became imminent when the state of emergency became official two days later on March 18, 2020.
Just because the pandemic hit, it did not mitigate or erase our patient’s pain. Their mental health concerns were not solved, and their post-operative wounds did not immediately heal. Yet, our doors were soon to be shuttered. Our appointments were canceled. The next day, I processed payroll for 30 people early, and handed out R.O.E.s. The R.O.E.s had an unknown date of recall. I was physically sick and emotionally in shock. I knew I had staff that were not great with managing their finances. My clinic was in a precarious position, as I was in the midst of significant building renovations. I put the renovations on hold to create a fund for any of my staff that might struggle making ends meet while we paused and attempted to ‘flattened the curve’.
A health clinic closed during a medical pandemic? Unheard of! I finished university with two of my current colleagues. We were students during the SARS outbreak. We donned PPE and still worked. We still provided care. The day before I locked the doors in March of 2020, we sat in shock, trying to process what was happening, feeling fearful and overwhelmed with uselessness. For the first time in our careers, we truly believed we were letting our patients down.
The days went on, but the fixed business expenses didn’t stop.
Quitting was simply not an option. Failure wasn’t a remote possibility. When people trust you to guide them in health, abandoning them when they need your skills the most could not happen. When I was a solo practitioner, my patients were my priority. As my business grew, I provided financial security for other practitioners and administrative staff. Those practitioners had patients that were their priority. My responsibility multiplied from my patients, to the livelihood of the practitioners that trusted me to provide them with a facility which allowed them to feed their families and support themselves, as well as care for their respective patients. I quickly understood that it was no longer about me, but about all of the staff, associates and patients that depended on my ability to keep the business afloat and the clinic functional (virtual and physical).
Our doors had to re-open. May 4, 2020, they did.
I am incredibly proud of my contribution to the groundwork to allow private health practices in Saskatchewan to reopen (while overseeing building renovations and transitioning to virtual care as much as possible). The groundwork didn’t just affect my business, it helped all private allied health clinics in our province. There were 2 components needed, clarification that we provided emergent essential services, and guidelines to reopen as safely as possible.
When the initial Provincial Health Order was dropped in March of 2020, it indicated that essential health services could provide limited emergent patient care. But, our province had no definition, list or criteria to establish which profession or service was deemed essential. They also had not defined emergent care. I saw this as my opportunity to be useful, and one of the the only ways to save my business. I dove headfirst to work in an area I was completely unfamiliar with. Through the SCPT, as President, I requested that our lawyer draft a definition of what essential emergent care was. I had our Executive Director provide this definition to the Ministry of Health, and distribute our draft to all regulated health professions that were members of the Saskatchewan Network of Interprofessional Regulatory Organizations (NIRO). We simply requested that they approve the definition presented to them in a timely fashion.
At the same time, I knew some of our services couldn’t happen virtually over a computer, and the services did not fit the definition of emergent. But they were still important to our patients. I began research into what Quebec had done (as their physiotherapy clinics were open) as well as what was happening in some of the American States. I drafted the provincial reopening guidelines for Physical Therapy Private Practice. The SCPT Executive Committee edited, proofed, and clarified those guidelines, along with our newly created Pandemic advising team. I am proud to say that we had the Guidelines ready to provide to our entire provincial membership on the same day that the Ministry of Health agreed that our profession was able to resume limited care. I gave the guidelines to all of NIRO, and to the Executive Directors of the other regulated professions that worked in my clinic. I gave the guidelines to the Physio clinics that requested them in BC and Ontario when they heard they had been compiled. I gave them to personal care homes in the city, and anyone and everyone that asked. While the guidelines were admittedly far from perfect, they were something. They were a start. They were the groundwork for a path- some sort of direction for other clinic owners to follow to begin to provide patient services again.
My clinic partially re-opened for essential emergent care through the professions that were approved. The day that I unlocked the front door, I did my best to hold back tears that were a mixture fear, gratitude and joy. I had staff that were afraid, and chose not to work- we couldn’t test our patients for the virus, and we are in close contact with each patient for a prolonged amount of time. We quickly navigated and adapted virtual platforms to provide care via video. Some of our mental health practitioners were able to provide support over the phone. It wasn’t how we ‘used to do things’, but it worked. We provided free mental health online support groups for people experiencing Pandemic Anxiety. I had staff that mentally needed to be in clinic to work- they even added clinic cleaning and disinfecting to their job descriptions. We screened patients for those that were emergent (their new injury or chronic pain would otherwise take them to the hospital) and got back to providing some care. At that time, the provincial modelling had suggested a completely overwhelmed capacity of all hospitals. The goal at my clinic was to see any patients where our skills could try to circumvent a hospital visit and be cared for in a private community space.
As we navigate through our third year of the pandemic, some things have become clear.
Our world has changed. And healthcare has finally started to change. It is beginning to shift into what I have hoped it could someday become. After working in the healthcare systems of 6 different countries, I will be honest, I did not look forward to moving back to Canada. Fourteen years ago, I had aspired to create something different. The adaptations required to navigate this pandemic are a mere start towards initiating change. The wheels have been set into motion to open our minds to possibilities of what health is, and how healthcare services can be delivered.
In my opinion, it all comes down to patient ownership, aided by flexibility and choice. When I founded my clinic in 2009, I tried to provide those options. We were the first to provide online booking- the patient could book the date, time and practitioner that the patient felt was the best fit instead of being told whom to see and when. I added our mental health division in 2016, and tried to normalize attending counselling. It is my belief, and that of my staff, that we don’t care if it is your ankle, brain or shoulder that you are seeking help with. While this seems reasonable, it wasn’t at that time. Although we have come a long way, we still aren’t there. Brownstone Health will continue to try to help people be as comfortable as possible- whatever their need may be. We do this by the way I designed the physical layout of my facility, the scripted wording I have given to my administrative staff, colour coded instead of labelled waiting areas, the options and choice through online booking and payment. In 2019, the Midlife Women’s Centre was added. We are now trying to break down barriers to women’s healthcare. Again, providing flexibility and choice- this time in realm of women’s needs for care as their bodies adapt through life. We are offering a multitude of options for treatment, as the patient chooses and directs, based on what the she needs. The pandemic forced our hand into the world of virtual care. It works! We will continue providing these options, without looking back.
At the end of the day, my goal is to meet the patient where the patient is at. I do not want my team to try and force the patient to be in a certain place or stage or belief. I want my team to help our patients figure out what they need, and how they would like to best move forward. The pandemic has reinforced that we are on the right track.
I try not to compare my clinic to other clinics, as healthcare isn’t a market which benefits from direct competition, it benefits from diversity. What I do try to do is listen to what people need, and grow my business to provide that service. I had my staff and associates take time during the lockdown to reflect upon where we were at, and what we could become. I had them work on goal setting and explore areas of practice to expand upon, both while we were in a restricted practice mode and for our future.
I went above and beyond all regulations to have the clinic be as safe as possible, I adapted the way patients traveled through the facility, implementing ‘directional traffic flow’. The mechanical systems and air exchangers were rerouted and upgraded, the space was electrostatically misted and deep cleaned several times per day. I had purchased our own equipment. We did our best to follow the science for infection control measures, day in and out. We did everything possible to help our patients feel safe and comfortable during treatment.
While we were on a mission to decrease our carbon footprint and become as environmentally respectful as possible pre-pendemic, we sadly reversed course and returned to single-use disposable everything.
When we could, we transitioned to virtual care. I had to ensure that our video platform was HIPA compliant and safe, with end-to-end encryption, yet user friendly.
When it was best practice, we measured and recorded temperatures of all people entering the facility. We have hand washing stations by the door, as well as in waiting areas.
We didn’t qualify for healthcare worker vaccinations (my staff and I wrote letters to the Ministry, MLAs, Covid-19 business team, and started a social media campaign for inclusion), or the ability to test our patients for Covid-19 before working with them, so I purchased full Personal Protective Equipment (visors, masks, gloves and gowns) for all administrative staff and practitioners to wear when there were patients present in the clinic. So far, the clinic has spent approximately $38 000 on PPE alone. I justify this expense in several ways.
1.Humanity: at the time of this post, we are the only clinic that I am aware of that has not had one single staff or associate contract Covid-19 from a workplace exposure. We have had staff and associates contract the virus, but not due to work. We have had numerous known exposures in the clinic. Every patient we treat becomes a potential close contact. To treat, most practitioners physically touch the patients, and we risk contracting the virus from an asymptomatic carrier multiple times per day. The psychological weight of transmission of the virus to a child or grandparent of a staff member from to a workplace exposure would be too much for me, personally, to bear. Therefore, I have absorbed the full cost of the PPE, and made it clinic policy to be donned during several of the waves, depending on case counts (when we had them).
2.Reputationally: how can we expect our patients to trust us if we have to constantly notify them of clinic outbreaks? How would that reflect upon our infection control guidelines?
3.Financially: We operate most services on 90+% fill capacity, often booking weeks in advance. For one staff member to cancel a day of work, we have the administrative expenses of changing appointments, if we even have a place to move that appointment. We often don’t have room in schedules to reschedule a patient, so we have the cost of the cancellation.
4.Respect: people don’t like appointments being changed or rescheduled.
This is a work in process. Times are tough, margins are tight, but our doors our open. After the rollercoaster ride we've all been on, we graciously welcome you as part of our journey.
Daysha Shuya, clinical director