Coronavirus COVID-19: Key Challenges and

Core Measures for DSOs to consider Vs 4.0 March 18, 2020

Petra Rumpf
EVP Head DSO StraumannGroup
 Content

1 COVID-19 Facts and Typical Chain of

events (Europe, China)

2 COVID-19 DSO - Check-List

3 Challenges and Measures during chain of

events (European experience)

2
 COVID-19

• COVID-19 is, first and foremost, a humanitarian challenge.

• While quarantines and mobility restrictions are not
infallible, China’s early experience with the virus
demonstrates the importance of “maximum containment”
strategies to prevent health care system break-down.
• Simply “slowing” the pace of infection is important to any
effective public policy response and the likely one chosen
• The document is based on the learnings from Chinese and
European DSOs and insight from financial advisors, and
management consultancies
• Aim is to help DSO decision-makers to prepare for the
crisis, learn from each other and elevate from of the crisis
stronger

3 Source: 2020 MCK, Deutsche Bank, Interviews

 Protecting the Healthcare System from Breakdown is the
Ultimate Goal of COVID-19 Government Measures

Core WHY?
assumption • If infection goes too fast, the health
Ultimate Goal: care system will break down
Maximum containment • Affecting the ability to treat COVID-
70% of the of population to slow 19 emergencies (pneumonia)
population and provide critical hospital
will get down the pace of care (emergency care,
infected infection and prevent intensive/post-op care, chronical
health care system diseases, cancer, birth,..)
break-down • Especially endangered: Elderly
Drivers and people with chronic diseases
• Low social immunity
that need periodic hospital care
• Rapid transmission rate
• Long incubation • Issue accelerates over time as
period/being infectious doctors/nurses get infected and
• Often mild symptoms have to go on quarantine
4 Also check: https://www.washingtonpost.com/graphics/2020/world/corona-simulator/
Through imposing drastic mobility measures, China
was able to slow down the pace of infection
China: Drastic people mobility
measures reduced the pace of China: Mobility limitations
infection and allowed health are slowly being eased
care systems to recover

RoW: Accelerating infection

rates in more than 141
countries. Risk of healthcare
China: Most cities in a systems to collapse if
Lock-down mode infection pace is not
contained

The earlier and the more drastic

the measures taken, the shorter
the duration
In China almost 60 Mio people were placed under Lock-
down in Hubei province alone, most factories in the
province are expected to remain shut until March 20. The
economic costs are enormous with a large % of small
businesses running out of cash

5 Johns Hopkins CSSE, WHO. NY Times, As of March 14, 2020.

«Social Distancing» also affects dental office traffic. In
Europe patient traffic down up to 90% within two weeks

Based on what you

know about the
coronavirus, are you
currently more or
less likely to do the
following?

6 Source: Morning Consult. Poll conducted Feb. 28-March 1, 2020, among 2,200 U.S. adults, with a margin of error of +/-2%. Figures may not add up to 100% due to rounding.
 COVID- 19 Attributes feeding more rapid Transmission

While COVID-19 is often casually described as a “bad flu”, many of its core attributes have combined to facilitate rapid transmission globally.
In summary, the illness is “contagious enough” to spread quickly, and “deadly enough” to be concerning and cause “social distancing” that
exacerbates global demand and supply shocks.

7 Source: Deutsche Bank Research (1) WHO; Dr. Michael Edelstein (Epidemiologist, Department of Immunization, Public Health England). February 25, 2020.
 Comparative Mortality Rate Estimates
COVID-19 may be characterized as having a higher transmission rate, longer incubation period, and higher mortality rate than the “seasonal” flu. The
novelty of the virus has also not allowed the population to develop stronger immunity over time. Given the high transmission rates, and containment
challenges in densely populated high income regions (i.e., Europe), public policy responses may need to shift more in the direction of mitigation and
treatment (versus closing borders and quarantines, etc.).

Source: Deutsche Bank. (1-2) WHO; Dr. Michael Edelstein (Epidemiologist, Department of Immunization, Public Health England). February 25, 2020
8 https://www.imperial.ac.uk/media/imperial-college/medicine/sph/ide/gida-fellowships/Imperial-College-COVID19-NPI-modelling-16-03-2020.pdf
.
 COVID-19: Typical chain of events
Declare Shut down Limit hospital Controlled
Social distancing/ Close down
State of schools, access & put Time release of
Limit public Cities/ ?
Emergency, restaurants, highest priority mobility
gatherings Countries
close borders bars,.. on emergency limitation

• Ban all events • Allows government • Closing of schools • Control hospital • Highly affected areas/ • Controlled release
>1’000 people to limit people • Encourage home office access (people can counties/cities are closed of people mobility
(sports-events, mobility and to for all corporations only access down stop once infection
trade-shows, access crisis • Encourage people to emergency after • People asked to stay at rate (# of new
business resources (loans stock-up and stay at phone consultation) home (application & infections) is under
gatherings,..) for small home • First consultation approval needed to leave control and hospitals
• Social distancing businesses, • No visitors accepted in of patients in the house e.g. Italy) have empty capacity
campaigns financing of paid hospitals, elderly parking lot (fever • Policing and fining when • Rate of release
(discourage people leaves,..) homes, nursing homes measurement, people are out without (policies) dependent
to go to restaurants • Provide financial • Significant slow-down in COVID-19 symptom permission on healthcare
bars,..) support and cheap dental patient traffic 75- check,..) • Corporations to enforce capacity (doctors,
• Encourage tele- loan capacity to 90% (start of dental • All non-emergency home office. Strict shift nurses, beds) in
conferencing for all s/m businesses to office closure) care clinics concept in manufacturing respective region
meetings >10 avoid economic • Final Stage: Close all requested to send all • Controlled supermarket and number of new
people break-down restaurants/ retail surgical masks, and pharmacy access infections
• Public Hygiene • Close borders to except pharmacies sterilization liquid etc (limited # of people
Campaigns (wash affected areas and groceries (China, to hospitals allowed to enter at same
hands, disinfect) Italy, Spain, France, • All dental offices time)
partially US…) closed (Italy, CH,
Denmark,..)

China
Italy
Spain, Germany, CH, France, Denmark, …
9 USA
 Content

1 COVID-19 Facts and Typical Chain of events

(Europe, China)

2 COVID-19 DSO - Check-List

3 Challenges and Measures during chain of

events (European experience)

10
 COVID-19 Response Workflow

Integrate via Nerve Define, align leadership team on potential scenarios and their impact
Center Define Central Nerve Center Network
Run financial stress test for all scenarios

Protect & Give Run table top exercise for tough decisions

Purpose Define, communicate & monitor clear policies & guidelines for staff and clinics
Cross
Ensure transparent two way communications
Functional
Create “single source of truth” about headwinds (Changes in official policies etc)
COVID-19 Stress-test
Response Financials Monitor issues on near-time basis, and act fast

Team Plan and ensure critical processes sustainability in all scenarios

Map exposure of critical suppliers (surgical masks, sterilization liquids,…)
Stabilize Supply &
Operations Ensure supplier stability, act on rationing, inventory, logistics for critical items
Build pro-active patient engagement and communication plan
Map out post-crisis opportunities (acquisitions,,…)
Actively Engage
Equip for on-line learning opportunities for doctors and staff (during Lock-down)
with Patients
.
Source: McK, Internal Team, Expert interviews
11
 Integrate via Nerve Center Organization
Example Nerve Center Organisation Integrate via
Nerve Center Clinical
CEO Directors
…
• Multiple semi- Business
…
autonomous cross- CEO
Policy
Surveill-
Develop- Medical Call Center
ment Director
functional teams ance CFO Engage Mgmnt
Protect & with
working Give Purpose
Doctor
patients
Committee
Communicate Patient
HR Practice
• Agility enabled by Mgmrs Communi-
cation
clearly articulated Clinical
Internal
Comm. Doctors
values Directors
CEO
• Simple meeting/call Head
Procure-
cadence and radical ment CFO
Stabilize Stress
transparency (all Supply & Ensure test
Critical
working materials Country or financials
Regional Operations Private
available to everybody) Mgmt Equity/ …
Clinical Owners
Practice Directors Financial
Mgmnt Advisors

12 Source: McK, Internal Team, DSO interviews

 Financial Stress Test
Have you completed a scenario analysis for stressed liquidity scenarios and availability
1
of undrawn bank lines?
Integrate via Nerve 2
How long do your existing sources of liquidity hold up in a prolonged stressed
environment (i.e. reduced patient flow, Lock-down period*, stress in funding markets)?
Center
Have you taken all measures to reduce running costs, limit cash out-flow, maximize
3 cash in flow (Hiring freeze, cost containment/reduction, accelerated billing and
invoicing, prolongation of accounts payable,…).
Protect & Give Have you reviewed your liquidity positions to determine how pockets of liquidity could
Purpose 4
be used to finance/optimize liquidity needs in areas?
Cross For any near term maturity or large pending transactions in the next 3-4 months, have
5
Functional you developed a contingency plan for funding and risk management?
COVID-19 Stress-test 6
Are you ready to move quickly during “pockets of stability” to opportunistically raise
debt capital or lock-in rates at historically low levels?
Response Financials
Have you examined supply chain finance exposures and potential disruptions for key
Team 7
suppliers and/or financing needs for them in case of default?
Have you checked all available government support and applied for access (cheap
Stabilize Critical 8
loans, support for paid leave during Lock-down)?
Operations 9 Have you re-examined potential cash acquisitions for lower target valuations?
Does your set-up/situation provide a weakness that could precipitate unwanted interest
10
Actively Engage or attacks from competitors?
with Patients Have you done a detailed review of pre-COVID-19 capital allocation plans for a new
11
. environment of higher economic uncertainty and volatility (capex, debt pay down, etc.)?
Source: Deutsche Bank, DSO interviews
13 * Take worst case assumption on the lock-down period (3 months anticipated in
most of Europe)
 Example measures: Protect & Give Purpose
Issue and over-communicate policies around safety/ hygiene & precaution in a
Safety 1
Integrate via Nerve simple and readable format, make sure people understand the “why”
Policies &
Center Communi-
2
Apply COVID-19 Sterilization guidelines to all clinics. Provide hand sanitization upon entry
into the building. Potentially monitor temperature of employees, and of incoming patients in
cation
isolated room/parking lot, call patients before appointment to check on health

Protect & Give 3

Consider to send care packages to employees (fever, thermometer, vitamins,
sanitizers,..), stay in touch with employees during quarantine and shut down
Purpose
Encourage open communication to ensure employees can speak up if they feel
Care 4
unsafe, stay in touch through SMS/whatsaop if employees do not have e-mails
Revise policies to ensure non-punitive measures taking “days-off” due to being ill.
Cross 5
Define deputies for core functions to enable operability during quarantine
Functional Stress-test Delay all non-essential travel. Cancel gatherings and events and restrict non-
6
COVID-19 Financials Travel
patient/third party visitors. Keep meetings virtual
restrictions
Response 7
Quarantine employees who recently visited highly affected areas or commute from
highly affected areas
Team
Office: Offer employees the flexibility to work from home. Make sure their home work-place
8
Stabilize Critical is fully enabled for eventual Lock-down period (Computer)
Clinic: Define clear guidelines and rules for doctors & clinical staff. Composition of shifts,
Supply & 9 how to protect against infection, what to do when infected etc. Stay recent and adapt to
Operations Ways of local regulations (shut down etc). Define, communicate shut down procedure
working Assign shift concept for clinical personnel to allow for parents to be at home with
10
kids (in areas of school closures). Optimize doctor availability between clinics
Actively Engage 11
Ensure critical roles (e.g. patient data, booking, rescheduling etc) are fully equipped
to work from at home (computer and access) in case of office closure
with Patients
14 .
Source: McK and DSO input
 Example Supply Chain & Operations actions to
consider Map all critical processes (e.g. patient booking, patient communication etc.) and
Critical 1
ensure operability during Lock-down (Computer/System access at home etc.)
Process
inventory Evaluate technologies available to monitor patients from at home, e.g. Dental
Integrate via Nerve 2
Monitoring via iPhone*. Provide emergency phone that is operable during shut down
Center Determine truly critical items and understand the risks of suppliers (origin, financial
3
capacity of supplier,…) – masks, gloves, …
Under-
Identify origin of supply (e.g. Korea, China,..) build risk map and define inventory
stand 4
Protect & Give Exposure
buffer and locations. Assess how fast supply can be scaled-up

Purpose 5
Conduct scenario planning to understand financial and operational implications of
Cross prolonged shutdown because of supply shortage (surgical masks,…)?
Functional 6
Look to ramp up immediately on alternative sources, potentially change mode of
transportation to accelerate and reduce exposure to be ready after lock-down
COVID-19 Stress-test
Take action
Act on rationalization of supply, shifting & optimization within entire practice network
Response Financials to address 7
Reschedule patients proactively in case of supply shortage of critical items
shortage
Team Make sure you are ready to ramp-up clinics quickly after shut down (ensure sufficient
8
Stabilize Critical stock on critical items e.g. masks, clinical stock)

Supply & Evaluate suppliers and review alternative sourcing options for all critical materials.
9 Assess if suppliers have faltered during pro-longed shut down (make sure you are
Operations ready after shut down)
Mid term
optimization Establish a supply risk analysis and convert war room into a reliable risk management
10
Actively Engage process

with Patients 11 Post-crisis, determine possible geographies and review supplier shortlists (risk map)
.
15 Source: McK and DSO input
* https://www.straumann.com/content/dam/media-center/straumann/en/documents/brochure/product-information/dental-monitoring-brochure%20Doctor%20-%20EN.v.2.0.pdf
 Actively engage with patients
Actively engage with doctors during COVID-19 and crisis management. Make sure
1
Actively they are part of the nerve system and active crisis management at clinic level
engage and Develop emergency working/shift plans in case of individual doctors need to go into
enable 2 quarantine or need to stay at home (e.g. schools close). Possibly align with adjacent clinics
Integrate via Nerve Doctors to to allow flexibility in shift plan and patient rescheduling
engage with
Center patients
Ensure home connectivity of critical staff and doctors (computers, access to patient contact
3 data) and access to on-line learning in case lock-down occurs over longer period (up to 3
months in China, Europe)

Proactively communicate with patients. Offer open-line and emergency line (via smart
Protect & Give 4 phone/e-mail) in case of questions and emergency situation (show empathy and comfort).
Consider to send care packages (thermometer, masks, vitamins, sanitizers) to patients
Purpose
Cross 5
Generally offer patients possibility to reschedule appointments (call all patients day before
treatments, check on health and avoid no-shows in case they have infection concerns).
Functional Proactively contact and reschedule patients before Lock-down.

COVID-19 Stress-test Engage 6

Evaluate and engage in remote patient monitoring options for treatments that need
continuous monitoring e.g. ClearAligners via Dental Monitoring on iPhone*
with
Response Financials Patients
Provide continuous communication via the doctor/staff to the patient during lock-
Team 7
down. E.g. provide COVID-19 advice via patient web-page, social media etc to
provide comfort and care to patients. Allow them to call staff in emergency.
Stabilize Critical Schedule on-line “break-fast” meetings via Zoom with doctors/staff
Supply &
Brainstorm with doctors and staff on how to keep patient engagement and comfort
8
Operations during possible office closure and define roles & responsibilities
Keep active communication with referrals. Provide advise on emergency plans,
Actively 9 hygiene rules etc. stay tuned in with their opening hours and support in case of
Actively Engage communi- supply issues, shut down.
with Patients cate with
Brainstorm ways to best engage with referrals during crisis to provide best support
referrals 10
. to patients
16 Source: McK and DSO input
* https://www.straumann.com/content/dam/media-center/straumann/en/documents/brochure/product-information/dental-monitoring-brochure%20Doctor%20-%20EN.v.2.0.pdf
 Prepare for Post-COVID-19 Offense
Assess opportunities offered Prepare for “Bounce-back Anticipate changes in patient
by the crisis after the crisis behaviours after COVID-19
List bold strategic opportunities that the crisis • Reschedule patients before shut • Anticipate sustainable shift in patient
offers such as down to ensure strong start behaviour and demands (e.g. China saw a
• Take advantage of historically low interest • Keep in touch with patients during large surge in telemedicine *)
rates to finance organic and external growth Lock-down if any possible • Anticipate significant surge in competitive
• Define M&A opportunities and road-map post • Actively use lock-down period for campaigns after lock-down
COVID-19 online training for staff and • Plan own patient campaigns & re-engage
• Optimize the supplier portfolio to better hedge doctors (Patient communication, with the patients fast after the crisis to drive
against supply risks in the future practice management, clinical traffic and capture postponed treatment
training, ClearAligner, **…) to surge
• Accelerate recruitment of doctors that have increase post-lock-down success
financially faltered during the crisis • Assess treatment portfolio most relevant
• Monitor macro-developments and after lock-down (e.g. emergency, check-ups,
• Take bold decision on portfolio or service trends that give indication on time cleanings,…) and proactively promote
investments that anticipate changing patient and intensity of comeback through multi-channel
needs (Telemedicine, patient home
monitoring,..) • Ensure sufficient stock of critical • Build scenarios on how you can differentiate
items to ensure strong return or beat competition in different economic
• Make sure balance sheet is robust enough to situations (e.g. recession)
create resilience against hostile approaches • Sustain team agility built during
crisis in critical processes (invest • Mobilize impactful post-COVID charitable
in tools for long term) engagement
.
Source: McK, Bain, DSO interviews
17
*https://www.economist.com/business/2020/03/05/millions-of-chinese-cooped-up-and-anxious-turn-to-online-doctors
** Contact Straumann as we offer free sign-up for ITI online training platform https://www.iti.org/ during COVID 19 shut downs
 Content

1 COVID-19 Facts and Typical Chain of events

(Europe, China)

2 COVID-19 DSO - Check-List

Challenges and Measures during chain

3 of events (European experience)
18
 COVID-19: In Europe, each phase posed multiple
challenges and measure
Social Declare Shut down Limit hospital Controlled
Close down
distancing/ State of schools, access & put Time release of
Cities/ ?
Limit public Emergency, restaurants, highest priority mobility
Countries
gatherings close borders bars,.. on emergency limitation

Challenges Measures
• Social distancing campaigns result in • Call patients day before treatment. Check symptoms and offer option to reschedule
patient no-shows (50% not uncommon) (provide comfort, avoid no-shows and ensure patient traffic post crisis)
• Office and clinical team get infected (need • Stock up and monitor supply on highly critical items (masks, gloves,..)
for quarantine, relocation of doctors • Implement and monitor strict COVID-19 hygiene and sanitization procedures in office and
between clinics) clinic (policies and training)
• Infected patients spread virus to team • Equip employees with any needed sanitary or personal protection. Consider screening
• Stock-outs (masks, gloves, sterilization employees for symptoms (temperature, etc.) and sending home staff that display signs of
liquids,…) limit the ability to treat patients illness. Put infected team members in quarantine
• Encourage team to comply with hygiene rules at home and avoid unnecessary social
contact in private (restaurants, …), discourage business- travel for all employees
• Introduce shifts in clinic if feasible (split in two teams, if one team gets infected, you have
still one team)
• Measure fever and check symptoms of all patients before entering waiting room
• Stay close to government policies and financial support for quarantine & sickness-leave of
staff for COVID-19
19
 COVID-19: In Europe, each phase posed multiple
challenges and measure
Social Declare Shut down Limit hospital Controlled
Close down
distancing/ State of schools, access & put Time release of
Cities/ ?
Limit public Emergency, restaurants, highest priority mobility
Countries
gatherings close borders bars,.. on emergency limitation

Challenges Measures
• Children are at home. Grandparents • Introduce shifts and home office policy for office staff wherever feasible (ensure
should not be engaged in child care to accessibility, computer and data access from home)
avoid exposure to virus • Extend shift concept to clinical team to allow parents to take care of children/ move
• Doctors/nurses, office team need to take doctors and nurses between clinics in same area where possible
care of children • Check possibility and financial feasibility to keep the clinic open for Emergency treatments
• Significant reduction in patient traffic (75- only (relate to the guideline from NADG on treatment spectrum and necessary approvals –
90% in Europe) as people are different by state)
discouraged from socializing • Develop and share procedure and protocol for office closures (incl. communication and
roles & responsibilities for time after closure)
• Check and secure government funding on unpaid leave
• Get prepared for Lock-down stage (possibly relocate critical HQ functions to lower affected
areas in case there is less risk of complete shut down)

20
 COVID-19: In Europe, each phase posed multiple
challenges and measure
Social Declare Shut down Limit hospital Controlled
Close down
distancing/ State of schools, access & put Time release of
Cities/ ?
Limit public Emergency, restaurants, highest priority mobility
Countries
gatherings close borders bars,.. on emergency limitation

Challenges Measures
• Office and practices are closed as care is • Anticipate liquidity challenge and be prepared early (see financial check-list)
limited to emergency only – dental often • Access government support (paid leave support, low interest loans,..) to support paid
not considered as emergency leave of employees (differs greatly between country of operation)
• Dental offices are asked to send all items • Offer on-line learning opportunities for doctors and staff (clinical, patient
(Masks, sanitization tools,…) to the public communication,…)* to keep engagement and ensure strong restart.
hospitals for deployment • Keep close to employees and patients during Lock-down (provide comfort). Anticipate that
• Sustained cash management issues some employees might get affected or one in their family will. E.g..organize weekly on-line
(need to pay salaries, rent etc) for “Zoom” Breakfasts by clinic
undefined period of time) • Enhance social media communication and posts to patients and staff (e.g. WhatsApp
• Shut-down period in China (3 months) in groups by clinic, Health line, psychological coaching hot-line), if possible provide care
Europe between 5 weeks (initially packages (vitamins, masks, fever thermometers, hand sterilizer etc)
announced in G, CH) and 3 months • Possibly consider to what extend your doctors/nurses can support the community health
(Denmark, Norway) care system on voluntary basis. Likely that healthcare system will operate beyond capacity
at this moment
• Prepare for post-crisis opening (See: Prepare for Post-COVID-19 Offense)
21
** Contact Straumann as we offer free sign-up for ITI online training platform https://www.iti.org/ during COVID 19 shut downs
 Summary
• The impact of the COVID-19 crisis is unprecedented in the modern era.
The shock itself has multiple dimensions and feedback loops: public health,
supply & demand, manufacturing & services, funding & liquidity markets.
• Given the rapid spread of COVID-19 to date, DSOs should consider a set
of actions: Protect and provide purpose to employees, stress-test
financials, stabilize critical functions, engage with patients, leverage on-line
training, and integrate all these efforts under a central Nerve Center.
• We encourage you to remain calm, install strong central project
management, stay close to government policies, always be ready for the
next phase, and continuously stay close to your employees and patients!
• COVID – 19 provides an opportunity to demonstrate a people driven
culture that truly cares for its employees, their families and most
importantly for the patients.
• As you will demonstrate the necessary agility enabled by the right set of
values you will not only manage the crisis well, but definitely come out
stronger!

Above all: Be well and be safe!

22
 For Updates on Check-lists and
experience sharing

North American Dental Group in the USA (part of Jacobs Group) provides
continuously updated repository of clinical guidelines, procedures, policies
etc.)
https://nadentalgroup.com/covid19/

Straumann:
https://www.straumann.com/group/en/discover/covid19.html

23
We care for you

Petra Rumpf
[email protected]
+41 (0) 79 4685 626
https://www.straumann.com/
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UNITED FOR EXCELLENCE

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Committed to supporting our customers in achieving profitable growth
and successfully navigating through COVID-19

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