Across the country, hospitals continue to be challenged with personnel shortages brought on or worsened by COVID-19. At UAB Hospital, Birmingham, Ala., the highest vacancy rates are among nurses, respiratory therapists, patient care technicians, radiology staff and support services, such as food service, environmental services and patient transport.
CEO Anthony Patterson, FACHE, points to numerous persistent issues contributing to these labor gaps, including the retirement of baby boomer-age staff, the difficulty and distress of caring for COVID-19 patients, and the lure of high-travel agency salaries.
“Our remaining staff have really felt the loss of the people who left,” Patterson says. “Many are suffering fatigue, burnout and stress. In addition, many of our front-line leaders are stretched and feeling significant effects from trying to keep a large hospital functioning at optimum levels.”
Despite these challenges, hospitals have achieved what has seemed at times like an impossible goal: keeping operations as close to normal as possible.
“The fact that we were able to do that during COVID is impressive, given some of the shortages that we experienced,” Patterson says.
Paul Hinchey, MD, is also proud of the achievements and tenacity of hospital staff at University Hospitals, a 23-hospital system that serves Northeast Ohio. “Our people have been working really hard, like they are everywhere in healthcare,” says Hinchey, president, UH Community Delivery Network, and an ACHE Member. “We’ve relied on them to come up with solutions to address labor and operational issues, and we’re proud of the job they’ve done.”
Hinchey, Patterson and other leaders share some of the strategies and solutions their hospitals and health systems have used to optimize operations during this most difficult time for healthcare.
Challenge Assumptions
A key to identifying solutions to personnel shortages is having an open mind. “Probably the biggest thing we’ve learned is to challenge our assumptions about how things work,” Hinchey says. “By asking a series of ‘why’ questions, we can uncover opportunities.”
For instance, University Hospitals was recently short on cardiac catheterization lab nurses, which was impacting the health system’s ability to perform those procedures. To solve the capacity problem, staff identified tasks that catheterization lab nurses typically perform, such as taking vital signs, that could actually be completed by medical assistants, paramedics and other available staff. As a result, the lab continued performing the same number of procedures with fewer nurses.
At UAB Hospital, leaders examined the roles registered nurses filled and converted several to positions that licensed practical nurses now occupy. The hospital also created a student nursing aide position and hired more than 70 students who have completed their basic nursing courses to fill that role.
“We worked with our Alabama Board of Nursing to define the role of these student nursing aides,” Patterson says. “They are not quite patient care techs and not quite LPNs. But, because they are in nursing school, they have a knowledge base that makes them useful team members at a rapid pace.”
The student nursing aides are helping with staffing shortages. “If we only have four of the five nurses needed on a unit, but we’ve got two nursing student aides who are eager to help, it improves the burden on the nurses,” Patterson says.
Rethink Where Patients Go
At Community Memorial Health System, leaders redesigned the organization’s delivery approach to optimize operations during COVID-19 surges. The Southern California system consists of two hospitals: Community Memorial Hospital, a 250-bed facility in Ventura, and Ojai Valley Community Hospital, which includes a 25-bed critical access hospital and a 66-bed skilled nursing facility in the small town of Ojai.
“Our two hospitals worked together and pooled our resources to best serve our community,” says Haady Lashkari, FACHE, chief administrative officer, Ojai Valley Community Hospital, and vice president, Community Memorial Health System.
At the start of the pandemic, leaders established a COVID-19 unit at Community Memorial Hospital, which was better equipped to care for a high number of very sick patients. COVID patients from Ojai Valley were transferred by ambulance to the larger hospital, which is about 30 minutes away.
The health system then used the existing skilled nursing beds at Ojai Valley, as well as swing beds in the critical access hospital. After being discharged from Community Memorial, COVID patients were transferred to Ojai Valley to recover. This helped ensure that patients could get skilled nursing care at a time when communities around the country had a severe shortage of those beds.
At UAB Hospital, leaders recognized the need to increase capacity for essential and complex surgical cases. So the tertiary academic medical center transferred noncomplex ambulatory surgeries to affiliate hospitals across the state.
“We’ve moved about 8,000 lower-acuity cases to these other sites since 2019,” Patterson says. “Now our staff and recovery rooms are not taken up with cases that can be accomplished in a lower-acuity environment. The university hospital has become a more inpatient-centric hospital.”
UAB Hospital also distinguishes between surgical patients scheduled for less-intensive and more-intensive procedures in order to augment inpatient bed capacity. In the past, all surgical patients stayed on a medical-surgical unit after their operations. Now the hospital places patients with less intensive procedures in the hospital’s pre-operative and post-operative units until they can be discharged. An example of this might be a patient admitted overnight for a cardiac cathererization. This also allows for more timely bed placement for complex high-acuity cases.
“This has helped us to stay open for the kind of essential surgical volume that would be unique to UAB such as transplant, stroke care or trauma volumes,” Patterson says.
Address Staffing and Patient Flow Issues
Since it was established about 10 years ago, UAB Hospital’s Center for Patient Flow has helped ensure that patients get discharged or transferred in a timely fashion and that beds are available for incoming patients. The center is staffed by nurses who oversee bed management. Care management, environmental services and other functions regularly interact with the center.
When COVID-19 hit, the center’s role became even more important. “It was an all-hands-on-deck team effort, but that group was pivotal to keeping patients flowing and keeping up with where all the patients were,” Patterson says.
Marty Sargeant, CEO, Keck Medicine of USC, credits a tiered huddle process with helping the Los Angeles-based academic medical center to manage capacity. Every morning, brief safety huddles are held at staggered times at different levels of the organization to identify problems and concerns. The process begins with meetings on individual nursing units and ends with a meeting of senior executives. Issues that cannot be addressed by front-line staff are escalated up the leadership command.
“Through that tiered huddle process, as well as the technology we use to help with hospital throughput, we can anticipate the demand for resources and compare those demands with trends like employee call-offs,” Sargeant says. “It helps us figure out, for example, how to manage some of the less acute volumes so that we are always available for more acute care episodes.”
Determining how many and what type of staff are needed is a key to ensuring adequate patient flow and capacity. But the traditional way of determining staffing needs, which relies heavily on historical census data, did not work well during the pandemic. “When COVID hit, history became the enemy of the forecast,” says Bryan Dickerson, vice president of workforce, Hospital IQ, an AI-based operations management platform.
To better predict staffing needs during a public health emergency like COVID-19, forecasts need to consider more real-time data such as local COVID-19 trends and acuity levels of patients being seen in the ED, Dickerson says.
Pursue Process Automation
In 2019, University Hospitals created a Process Automation Center. Considered a type of artificial intelligence, process automation entails programming a computer to take over mundane, repetitious tasks.
The center has focused mostly on revenue cycle and finance functions since it launched, reducing the number of staff needed to perform certain back-office tasks such as claims management. “They are focused on automating manual processes and then managing by exception so they only need to chase the outliers,” Hinchey says.
During the pandemic, the Process Automation Center also reduced the documentation burden on nurses, freeing up nursing time by about five full-time equivalents. The process automation solution works in the background 24/7 to process orders that nurses used to have to handle manually. Nurses would have to address 500 to 600 transactions on their computers; now they have 20.
Keck Medicine has also been experimenting with using process automation to assist with back office functions. Looking to the future, the hospital hopes to use artificial intelligence to help reduce the documentation burden on clinicians. “If you ask clinicians, documentation is at the top of the list in terms of what they don’t want to do,” Sargeant says.
Deploy Remote and Virtual Care
University Hospitals has also invested in remote patient monitoring technologies, which is helping with patient flow and capacity issues. The system can now send patients home in a more timely manner with wearable devices, which allows a team of hospital nurses to keep tabs on the their pulse rates, blood oxygen levels and other health indicators.
“Centralized remote patient monitoring really facilitated our ability to better utilize our home-care services to manage volume when that demand was just off the scale,” Hinchey says.
The hospital also launched a service called Hospital@Home in March 2021 to increase hospital capacity and continue to care for patients who need intermittent observation but not round-the-clock care. The service essentially brings hospital services to the patient using a combination of telemedicine, remote monitoring and in-home or virtual visits by care team members, including physicians, nurses, pharmacists and physical therapists. In addition, a paramedic from the health system’s EMS Institute visits every day.
“Hospital@Home is a huge patient satisfier, and it’s helpful for throughput,” Hinchey says. “It’s a win-win all-round.”
Other hospitals are also reporting multiple benefits from deploying various types of virtual approaches to care. For instance, Community Memorial Health System implemented a tele-sitter program that has reduced the number of patient sitters needed. “Patient sitters are a difficult position to fill,” Lashkari says. “After putting 360-degree cameras in our patient rooms, one tele-sitter can now monitor 12 patients at a time.”
The system provides two-way communication so the tele-sitter can coach patients about fall prevention or alert unit staff to any safety issues in patient rooms. In addition to easing staffing issues, the tele-sitter program has reduced falls by 50 percent at Community Memorial Hospital.
Boost Recruitment and Retention
Labor is tight across the country, which is driving up wages in many markets and making hiring that much more difficult for the healthcare field, according to Hospital IQ’s Dickerson.
For example, for UAB Hospital, a new employer in town has increased the area wage rate for entry-level jobs, such as food service, patient transport and other support services. Amazon opened numerous warehouses and fulfillment centers in Birmingham, Ala., creating thousands of well-paid entry-level jobs.
To compete, UAB Hospital raised wages for support staff and other front-line employees. The hospital is also looking into issuing paychecks in a more timely fashion, such as after every shift versus every two weeks.
Community Memorial Health System is betting on its “grow-our-own” strategy to help keep itself staffed into the future. The health system developed a physician residency program, and currently has 88 residents across five specialties. In addition, it offers residencies and internships for newly graduated nurses, clinical lab scientists and registered dieticians.
“It gives them an insider view of our health system and our culture,” Lashkari says. “By the time they finish their internships, many students want to continue on their careers with us.”
One way Keck Medicine is competing for—and retaining—staff is by emphasizing the potential for growth and development within their organizations. Sargeant points to several employee success stories there, including one who started as a central sterile processing technician and is now an RN in the post-anesthesia care unit.
“When someone starts at our hospital, we tell them what their possible career pathways are and then pull all the levers for them,” Sargeant says.
Prioritize Culture
Amid the challenging personnel shortages that hospitals are facing, Sargeant sees an opportunity he calls “The Great Realization.” “The pandemic has heightened our employees’ desires for something bigger and better,” he says. “They want worthwhile work. They want flexibility and respect. They want a sense of purpose.”
By building a culture that addresses these employee desires, hospitals will naturally address many recruitment and retention challenges, Sargeant says. “If we don’t have a culture that engages staff and gives them a sense of purpose, we’re going to be chasing compensation and turnover. And that’s not where we need to spend our time. My focus is on building a culture of purpose that values human beings.”
Engaging front-line leaders in culture work is critical, leaders stress. To that end, UAB Hospital is implementing an accountable care team framework across its nursing units. Units are led by a triad of managers: a physician, a nurse and an operational leader. The managers engage all unit staff in weekly process improvement meetings that focus on improving patient outcomes, discharge efficiency and other aspects of care and operations.
In employee surveys, staff on units that have adopted accountable care teams report greater feelings of autonomy, resilience, community and teamwork.
The framework is a type of “psychological PPE,” Patterson says. “It helps to convey a sense of teamwork and that you are all in it together.”
Maggie Van Dyke is a freelance writer based in the Chicago area.
Inside the Air Traffic Control Function of a Florida Hospital
It’s 7 a.m., April 13, 2022, at Sarasota (Fla.) Memorial Healthcare System, and an overflow unit is opening as planned. Based on data reviewed the night before, Susan Grimwood, APRN-C, knew that the health system would not have enough beds to care for all the cardiac patients who were projected to be admitted.