Washington's COVID-19 hospital czar is cautiously optimistic

When the coronavirus outlook got scary and hairy in mid-March, Washington Gov. Jay Inslee recruited an outsider to join his crisis management team. He convinced a retired vice admiral to temporarily move cross-country to serve as Washington state's COVID-19 hospital "czar." Dr. Raquel Bono says she is now cautiously optimistic the state's health care system can handle a surge of ill patients.

When the call came, Vice Admiral Bono was six months into retirement after a long career in military medicine and health care administration. She was at home in Alexandria, Virginia, in mid-March watching the coronavirus outbreak unfold.

"I was like, 'Oh, I know what we need to do here,' Bono said in an interview. "On the other hand, I was relieved that I was not in charge of that military health system."

Then her cell phone started buzzing with texts and calls. She learned through a friend and former mentor that Washington state's governor's office was looking for someone to take charge of hospital surge capacity. It wasn't long before Gov. Jay Inslee himself dialed the trained Navy surgeon to close the deal.

"I asked the governor, 'Sir, when do you want me?' Bono recalled. "And he said, 'If I had my way, I would ask you to pack a small bag now.' That was like Friday midmorning. Then I was on a plane on Sunday and I started the following Monday."

Gov. Inslee's chief of staff David Postman said the whirlwind, word-of-mouth recruitment stemmed from a realization that the state needed a "hospital czar." It had to be someone who could command power and respect to coordinate disparate hospitals and long-term care companies, testing sites and possible field hospitals.

"It just became very clear that it was a massive endeavor to try to manage our hospital systems sort of as one piece," Postman said. "They are all independent operators."

"It took some socializing on all sides," Postman said in an interview Monday. "We wanted to make sure that hospitals were going to be OK with this idea, labor would be OK with it and our own agencies needed to be OK. And everybody was."

The retired vice admiral Inslee enlisted for this health system czar role is an outsider. Bono had never lived in the Pacific Northwest before. She was not previously acquainted with her new state government coworkers or many of the hospital CEOs she would be dealing with.

Bono said her military experience helped her dive in.

"I think my training as a trauma surgeon has really taught me that remaining calm in all types of crises is the first order of business," Bono said. "Being in the military, I think what that has taught me is there is an orderly way you can approach most problems and create a series of solution sets."

Bono was thrown into many different, challenging situations over her 36-year Navy career. After completing medical training at Texas Tech, she went on to manage casualty receiving at a field hospital in Saudi Arabia during the first Gulf War. Years later, she was assigned to straighten out Naval Hospital Jacksonville, which had been hit with a slew of medical malpractice lawsuits.

Her final posting was to oversee the complex consolidation of military hospitals and clinics under the new Defense Health Agency. During the time she directed that agency, she also earned an executive MBA degree entirely online from Washington State University.

"We could not be more proud of her," said Chip Hunter, the WSU Carson College of Business dean, in an emailed statement.

A 2016 profile in Positively Filipino magazine noted that Bono emerged from a family of high achievers. Her grandfather joined the Army infantry in the Philippines in World War II, eventually serving as both a colonel and a civilian obstetrician. Bono's father, a surgeon, served in the Navy Reserve after immigrating to North America. Bono's brother, Anatolio Cruz III, graduated from the Naval Academy in Annapolis and rose through the ranks like his sister. For a time, Bono and Cruz were the only sister-brother admiral pair in the Navy until Cruz retired in 2013.

Bono said in her new role she works closely with the state Emergency Operations Center and the state Department of Health to evaluate what hospital surge capacity is needed and then to marshal resources to meet it. Her focus has broadened from the initial job conception of coordinating hospital beds and staffing to encompass increasing virus testing and managing protective equipment and ventilator distribution.

After her first two weeks on the job, Bono said she's "cautiously optimistic."

"As we're looking at what the modeling shows and what our current numbers for capacity show, we feel that collectively across the state we have enough beds to take care of those patients that we are projecting may need hospitalization," Bono said Friday. "Reassuringly, we also appear to have the right number of ventilators."

The University of Washington’s Institute of Health Metrics and Evaluation produces one of the primary models of the future course of the pandemic that Bono said she looks at frequently. In the latest model run on Tuesday, the peak of COVID-19 hospitalizations in Washington state is shown as happening a few days ago. As of Tuesday, hospitals statewide had 341 intensive care beds available for COVID-19 patients of which only 190 were needed, according to the model.

Bono was joined Tuesday on a media briefing call by state Health Secretary John Wiesman and State Health Officer Dr. Kathy Lofy. Lofy said it is hard to know if the state has truly reached the peak strain on the healthcare system without two to three weeks of additional data showing declines in infection rates and hospitalizations, "which we haven’t seen yet."

The UW-IHME model projected the state would need about 165 ventilators to handle the peak demand of seriously-ill COVID-19 patients this week. On Tuesday, the governor's office shared a list of pending procurement orders for various types of medical equipment in high demand. That list showed the state has 752 ventilators on order that have not yet been delivered at a cost of more than $17 million.

Oregon officials, by the way, are also increasingly confident they can handle their expected surge of COVID-19 patients. Oregon's governor did not appoint a coronavirus czar, like her neighbor did.

Washington State Hospital Association leadership met with Bono on her first day on the job and have talked with her often since. Hospital association president Cassie Sauer said Bono made a good first impression and then made some hard asks. Improving data reporting, for one. Returning ventilators to the national stockpile for use by harder-hit states was another. And most recently, to conserve personal protective equipment.

"If she's directing, we will follow because she is excellent at getting input from a broad variety of people, synthesizing that information and then setting a course that we can believe in," Sauer told public radio on Monday.

Sauer and some folks in the governor's office have gotten comfortable enough with the new czar on the block to address the retired vice admiral by her nickname, Rocky.

"When most people hear that Rocky Bono is coming, if they've never met me, I tend to surprise them when I walk through the door. I don't think I'm the prototype for a Rocky," said the 63-year-old Filipino-American mother of three with a laugh.

When her husband or daughters ask when Bono will return home to the East Coast, she answers that she is planning to stay "for the duration," whatever that is.

Postman said the state of Washington has recruited a few more high-level outsiders to lend their expertise to aspects of the coronavirus crisis response. He said an Amazon.com senior manager is lending distribution prowess to get personal protective equipment to the front lines and a Microsoft executive is helping with procurement.

Unlike in Bono's case though, neither of those two were appointed to the governor's staff on contracts with full-time pay.

Bono said one of the details she asked the governor to clarify before she accepted her czar position was what kind of authority she would have. Only a handful of reassigned staffers work directly for her.

According to Bono, Inslee offered to delegate the governor's power to command through executive authority under his February 29 declaration of emergency, if she needed it.

"I have not had to revert to the governor's authority at all," Bono said. She said she learned from past experience that if you have to revert to "positional authority" to get your way, you need to try harder to understand the situation and why people hold on to the positions they do.