From Every Angle: Workforce

By Erin Cristales, Kayla Green and Randena Hulstrand, Vizient

You hear it all the time: Work smarter, not harder.

But what does that really mean?

When it comes to health systems looking to mitigate workforce challenges, it means considering labor issues from multiple — and often overlooked — perspectives. That involves everything from committing to transformative change in your care delivery process to identifying and addressing the social drivers of health that affect your employees. It means implementing a governance structure in your facility that leads to better security for staff and finding the right strategic partner to help you minimize contract labor expenses. And it means cultivating a healthy, collaborative culture to battle burnout and evolving your pharmacy workforce to ensure top-of-license work.

What we hear repeatedly is there's perhaps no more daunting dilemma for healthcare than labor shortages (and the resulting costs, both financially and operationally). A recent Kaufman Hall report shows that in 2023, staff shortages led to 66% of providers operating under full capacity, with 63% of respondents noting that their organizations struggled to meet demand for patient access to physicians.

In this new series, we aim to discuss some of today's toughest healthcare challenges from numerous perspectives that span the breadth of your organization. From clinical to supply chain to ops and quality to data and analytics, we'll examine potential solutions from every angle designed to help you meet your most important mission.

Sustaining successful labor management.

While recent Vizient nursing workforce indicators are showing a decrease in the use of contract labor, organizations are still struggling with high overtime, rising burnout and elevated turnover levels. And while travel nurse demands have fallen, their bill rates remain elevated above pre pandemic levels. Even though the decreased reliance on contract labor is a positive change, the rising imbalance of workforce supply and demand will continue to drive ongoing challenges. By 2030, we will continue to see an increase in healthcare acuity and complexities and the workforce stats are staggering: 124,000 more physicians are needed by 2034; 800,000 RNs are anticipated to leave nursing by 2027 and the current turnover of staff RNs is 24%.

Healthcare leaders agree on the necessity of long-term change. But Eric Burch, Vizient senior principal leading workforce consulting, said many organizations still struggle with executing future-forward initiatives — such as using data and technology for efficiencies, care redesign and virtual care.

"It is indeed a challenge for healthcare leaders to prioritize their initiatives and maximize return on investment, both in terms of financial outcomes and quality of care," he said. "However, to achieve sustainable success in labor management, organizations must embrace transformational change in the care delivery process."

Sound intimidating? Here are some crucial core competencies to help you get started:

• Aligned governance. First, leverage data to understand what you need to build strategies around and then make sure you have the right key stakeholders as part of your redesign and decision-making process. It's important that the entire team take ownership in helping to prioritize areas to focus on. Then hold each other accountable through transparent communication across the organization about the need for improvement, goals and progress.
• Trusted analytics. To identify and prioritize achievable performance targets for clinical and nonclinical areas of your organization, you must gather the right data that is trustworthy, actionable and believable. It's key to pair quantitative data (such as Vizient's clinical, workforce and operational analytics) and qualitative insights to build a clear story. For example, your data might show high nurse turnover rate in a department that is using a lot of contract labor. More discussion and fact finding could show that your staff are not feeling supported. Is it because they have a new manager who is struggling with leadership capabilities? Is there a way to mitigate these issues that are leading to turnover? Also, when benchmarking against peers, it's important to compare apples to apples of like organizations who are delivering similar kinds of care (e.g., an ED in a small community hospital shouldn't measure against an ED in a large academic system).
• Operational discipline. But how can you turn insights into action? Leverage management systems and high-reliability principles to capture the current state of your practice and understand what you're trying to address through an assessment. Once you identify the need for improvement — such as deficits in the work or inconsistencies in how your departments work — engage key stakeholders. Collectively, you can begin to understand what an improved future state of work looks like and then redesign processes of care together followed by implementation and measuring the new standard of work. For example, one of your units has extra nurses, and another is short. Build a process that allows sharing staff between the units and then measure process metrics (like routine shift staffing huddles) and outcome measures (like a decrease in overtime hours). 
• Leading practices. Developing and reinforcing a systemwide culture of learning, knowledge sharing and recognitionstarts with leadership. It's so important to have engaged leaders who are visible and rounding with staff as they implement redesigned processes. Build a culture of continuous improvement in a non-punitive environment. When process measures aren't moving in the direction you want, call a timeout, see what's not working, go back to redesign and then revise.
  
  

Keeping workers safe.

In October 2023, Dr. Helen Ouyang penned an op-ed for The New York Times titled "Stabbed. Kicked. Spit On. Violence in American Hospitals is Out of Control."

What has stayed with me most, Dr. Ouyang wrote, is not the near miss of a thrown computer or a slur a patient used but a medical student saying to me after he witnessed a violent episode, "I learned today that I don't want to go into emergency medicine." The field is seeing a steep decline in applicants. Who will tend to waiting patients?

There's perhaps no more sobering question. The same article cited startling statistics: A 2022 American College of Emergency Physicians survey of ER doctors found that 55% said they had been physically assaulted, with a third of those resulting in injuries. The risks were even higher for ER nurses, with over 70% reporting they had sustained physical assaults at work — and only 15% of surveyed hospital nurses said they would continue in the same job in one year.

It's cliche to say there are no easy answers, but there are people committed to pinpointing possible solutions. That includes Kat Kemper-Kelly, a Vizient senior consultant in food, environmental services, security and healthcare technology management, who has spent the bulk of her career as a leader in hospital risk, safety, security and emergency preparedness.

"If employees aren't safe," she said, "they can't provide care to patients, which is every hospital's No. 1 business."

What are some steps hospitals can take to boost safety?

• Security risk assessment. Step No. 1 is to focus on three main areas: people, systems and buildings. By understanding all risks — including workplace violence, technology vulnerabilities and natural disasters — health systems can better mitigate them. For instance, active shooter is top of mind for risk and many hospitals have installed metal detectors to prevent entrants from bringing weapons into the building. It's also advisable to limit access points — some facilities have up to 100 entrances, so it's important to ensure those aren't open to everyone to minimize the risk of weapons entering the facility.
• Culture. Your organization should embrace open communication, including encouraging employees to report any red flags they see. Additionally, it's important that the person who leads your security team directly reports to the C-suite, whether to the chief operating officer or chief nursing officer. Essentially, your security team should no longer roll up under facilities but should instead be positioned in a more operations-focused role as their scope has expanded from securing facilities to securing employees, patients, assets, information, medication and utilities. And senior executives who want to learn more about developing a safer hospital environment can access educational resources through organizations like the International Association for Healthcare Safety and Security.
• Threat management team. If you haven't already established one in your hospital, make it a top priority. The team should include representatives from security, human resources, risk management, the emergency department and social services, along with anyone else the leadership team thinks appropriate. The group should meet at least once a month and any time a risk is found.
• Proactive, not reactive. Understand the Joint Commission standards for identifying red flags (such as general agitation like clenched fists and a raised voice), as well preventative tips offered by OSHA. De-escalation is often the key to avoiding violence, as well as consistent communication. If a patient shows signs of aggression, especially around issues such as long wait times, quickly let them know what is happening and why. Employees who are dealing with personal issues such as domestic violence should let their supervisor know as soon as possible so they can alert the security team.
• Technology. AI-enabled cameras make it easier to locate suspicious individuals within your hospital and listening technologies screen for escalating voices. But central to increased safety is integrating all your security technologies together — from access control to metal detectors to cameras to mass communication, the combined power of these devices is immense. The use of technology should supplement security personnel, which ensures security staffing can be maintained at lower levels and is focused on needed response. For instance, one southwest-based hospital created a workplace violence code that immediately alerts senior leaders that an event has occurred and initiates a checklist for accountability and follow up.
  
  

Meeting employees' SDOH needs.

Through her work with the patent pending Vizient Vulnerability Index™, Heather Blonsky is a pro at pulling social drivers of health data down to the zip code level. That's a big benefit for hospitals looking to better serve the needs of their patients — if you see lack of transportation affects huge swaths of your community, standing up locations within high-needs neighborhoods could be one solution, as could partnering with rideshare services to ensure patients make it to their appointments.

What's easy to forget is that in many cases, your employees are faced with the same SDOH challenges as your patients, especially those who work in jobs like environmental and food services, janitorial, landscaping — pretty much anyone whose pay grade is in the lowest quartile. For instance, a 2022 study published in Health Affairs found that 19.7% of healthcare support workers reported experiencing food insecurity in the prior month. To keep your workforce, you must address their needs too. After all, if they live in a zip code that's a transportation desert, it's no easier for them to get to the hospital than it is for a patient.

So, where to start?

• Data. Tools like the Vizient Vulnerability Index™ allow you to objectively assess the social drivers that most affect your employees. Sure, you can conduct internal surveys, but many workers don't want to share personal information — and certainly not hardships — even if promised anonymity. Geographic data, combined with engagement and retention data, can give you a true window into what support employees need.
• Community partnerships. No one knows your employees better than the organizations that are based in their neighborhoods. Join forces with local nonprofits that focus on food insecurity, housing assistance, transportation needs, education, environmental issues and public safety to figure out innovative ways to address those issues. And some institutions even use grant money to provide employee assistance, including for car repairs — after all, $200 to replace a flat tire costs a lot less than being short an FTE for an entire shift.
• Internal resources. Many of the resources required to address SDOH exist within your hospital. Instead of disposing of leftover food at the end of the day, package it up and send it home with high-needs employees (and patients) — a win for both health equity and sustainability. Consider setting up on-site daycare, or better yet, sick-child daycare. And what better place than a hospital to provide free or low-cost preventative and urgent care to employees and their families?
• Employee pipeline strategy. Incorporate health equity measures to support employee growth and development, especially as the current labor market has made recruiting and retaining nonclinical workers a particularly challenging task. One option is to support education opportunities for employees in terminal services so that they can eventually rise to clinical or administrative positions within your org.
  
  

Cultivating culture and battling burnout.

Burnout is the leading cause of healthcare worker turnover globally — and it's only getting worse. That's why cultivating a healthy culture is critical to mitigating workforce challenges. A healthy and robust culture improves workplace environment, team member engagement and clinical safety. It's also foundational to financial sustainability and growth. 

"An organization's cultural health determines its ability to achieve and sustain excellence," said Katerie Chapman, Vizient senior principal, high reliability consulting. "To fulfill the mission to care for patients and serve communities, there must be an intentional focus on, and explicit nurturing of, a healthy culture and environment where team members deliver care."

When team members aren't supported with healthy environments, processes and systems, they experience significant burnout, and the healthcare organization faces attrition, inefficiencies, low productivity and medical errors.

Engaging in cultural performance improvement is intentional and perpetual work and requires constant learning, but it doesn't have to be daunting. Below are some tips and tools to get you started.

• Review data and benchmark. It's important to assess the wellbeing of your teams through data analysis and benchmarking. While many hospitals evaluate their team engagement and culture of safety, few use the insights gained to inform learning and performance improvement. Vizient's SCORE survey — accredited by Leapfrog and ANCC Magnet — measures and provides insights into psychological safety, wellbeing and engagement, and enables a strong understanding of the workforce and the interventions providers can implement to reliably drive meaningful cultural improvement. It also provides interventions and next steps for providers to create an action plan around and immediately start implementing. To date, SCORE has been used to survey more than 15% of the U.S. healthcare workforce, making it the largest benchmark on burnout and resilience in the country.
• Embrace clear communication. When it comes to fostering a healthy culture, there's nothing more important than clear and transparent communication. Tools like Vizient's LENS board — a web-based visual management platform — enable hospital leaders, managers and frontline teams to increase transparency and simplify communication to grow community, manage work, and consistently deliver high reliability healthcare by eliminating barriers and closing the loop on day-to-day ideas, tasks and concerns. At The Queens Health System on Oahu, Hawaii, implementing LENS into their day-to-day activities helped them rise from the 60th percentile for the Bar Code Medication Administration (BCMA) scanning rates to the 95th within a matter of months.
• Engage in leader rounding. A recent study revealed that effective leader rounding can show up to a 34% increase in areas like teamwork, burnout reduction, local leadership, work-life balance and learning. To be effective in leader rounding, leaders must listen openly and actively close the loop on the feedback received. "It is the best way to say, 'I see you, and I care,' Chapman said. "It builds trust and deepens the relationships between those directly serving our patients, and their leaders and managers. Effective leader rounding also helps facilitate psychological safety, encourages team members to speak up and enhances staff engagement in operational goals."
• Invest in leader training. Equipping leaders and teams with the necessary skills, activities and behaviors needed to drive cultural transformation and operational and clinical excellence is key to improving workplace culture. An effective leader knows how to give feedback in positive and empowering ways while also promoting a culture of continuous learning and improvement. Vizient data also show that for every 10-point increase in the leadership domain of the SCORE survey, the odds of burnout in that team are reduced by 28%.
  
  

Streamlining contract labor.

Call it selective memory: Though many think of COVID as the origin of the contract labor crisis, temporary staffing levels were an issue long before.

"The pandemic," said Kerry Poole, Vizient principal, indirect spend advisory, "just threw a match on it."

Four years later, there is some good news — contract labor rates have dropped, and utilization is at an all-time low (a relief, considering an American Hospital Association analysis found contract labor expenses for hospitals and health systems surged 258% from 2019 to 2022). Still, the temporary staffing landscape is often seen as the "wild west," with some hospitals contracting with as many as 30 vendors at various price points with little to no guardrails in place.

Considering the financial implications, it's critical for healthcare organizations to forge a more modern frontier for the future of contract labor. How to start?

• Strategic partnerships. Hospitals should work with a managed services provider (MSP) — Vizient, for example, has a partnership with Vaya Workforce — that can help them build internal flow pools and develop a design solution that sets clear policies and procedures. For hospitals that want to manage contract labor themselves, look for a partner with a technology platform that can serve as your one source of truth. But, Poole cautions, don't try to run before you can walk. The right partner can help you get a program in place and then aid you in building your own program if that's your goal.
• Speaking of technology ... It's the cornerstone of any successful contract labor approach. An effective strategic partner will offer an advanced technology platform that provides transparency into a hospital's spend as well as regional and national market intelligence to help set realistic rates and drive permanent placements. Look for a partner with a customizable dashboard that can show you anything from the number of open positions to upcoming renewals. At the end of the day, you want a platform that can help you adjust pricing and drive cost reductions and efficiencies.
• Flexibility. Contract nurses want more flexibility in their schedules, including working shorter shifts and varying assignments. It's important for both providers and vendors to embrace that flexibility, whether in shift design or contract length.
• Stakeholder engagement. Contract labor isn't just a supply chain issue: It needs to be a top concern for executive leadership. Stakeholders from across the organization — including HR, nursing and nonclinical (such as environmental services and food and nutrition services) — should discuss internal operations, challenges and areas for improvement. Also consider developing an executive stakeholder group, which would ideally include the CFO and COO, to drive engagement and provide strategic direction.
  
  

Evolving pharmacy.

Like with physicians and nurses, hiring and retaining a pharmacy workforce is a significant challenge. In a recent McKinsey survey of 80 health system pharmacy leaders, 81% of respondents reported an understaffing of pharmacy technicians, 41% indicated a shortage of acute clinical pharmacists and 34% said they were short on ambulatory clinical pharmacists and acute pharmacists. With pharmacy school applicants decreasing by more than 60% in a decade and new disruptors entering the market, the industry is facing more shortages than ever.

"These issues are complex and multifaceted, and they have a cascading effect," said Bruce Leavitt, Vizient assistant vice president of pharmacy consulting. "We're going to have to rethink our operational approach if we want to successfully navigate challenges."

So, how can providers do that?

• Utilize data and analytics. Start measuring your performance now with internal benchmarking. Empower team members who do the work every day to identify key metrics that can help track progress and identify areas of improvement in operational areas. "Internal benchmarking is continuous quality improvement while external benchmarking identifies best practices. The challenge with external benchmarking is that peer groups are very diverse," Leavitt said. "I've never been in two hospitals that perfectly aligned in terms of the work they were executing in their enterprise. External benchmarking is directional, at best."
• Put your people first. How we invest in our people impacts our recruitment and retention of talent. Historically, there hasn't been a promotional path for pharmacists; however, some academic medical centers have advanced clinical tracks that offer additional opportunities for pharmacists along with added compensation. For pharmacy technicians, training and allowing for top-of-license work may be key. There's a growing sentiment that the role and responsibilities of pharmacy technicians need to evolve into a more defined career pathway that requires formal training and education with an increased salary potential. The American Society of Health-System Pharmacists recently launched a pharmacy technician training program to bridge the professional development gaps contributing to the current nationwide shortage of pharmacy technicians. Vizient also launched a tool last year to help train entry-level technicians and provide clean room competency modules on sterile and non-sterile compounding. Expanding the responsibilities of pharmacy technicians helps retain team members and frees up pharmacists to work at the top of their licensure.
• Restore trust in leadership. Pharmacists need to trust their leaders. Traditionally, hospital pharmacies have been looked upon as a cost center or ancillary unit, but given its rapid growth over recent years, it's simply no longer the case. Healthcare systems estimate that at least 25% of overall system net revenue is attributed to pharmacy, which means that it could easily make or break a hospital's margin. So, when it comes to restoring trust in leadership, it's crucial for pharmacists to have a strong advocate, such as a Chief Pharmacy Officer, in the C-suite who can listen, give voice to the team, understand the department's needs and close the loop on feedback received.
• Be more flexible. When looking at the pharmacy's organizational structure, consider alternative opportunities wherever possible, especially when looking to attract and retain talent. If it's not possible to hire a new full-time position, job sharing may be the answer. Different shifts, staggered hours, flextime or condensed work weeks also may be an option for pharmacy departments.