Recent research shows that the workforce shortage — particularly among registered nurses — is the top issue for healthcare CEOs. While a nursing shortage is challenging for nursing departments, there are a host of systemwide problems that will impact quality and safety of care alongside an organization's ability to grow.
Radio Advisory's Rachel Woods sat down with two leaders from University Hospitals — Chief Quality & Clinical Transformation Officer, Peter Pronovost, and Chief Nursing Executive, Michelle Hereford — to talk about recent data and their experiences navigating the complexity of the workforce shortage. They explore how the shortage is impacting health organizations at large, why organizations can't seem to find a solution, and how addressing tactical issues alone will not solve the crisis.
Read a lightly edited excerpt from the interview below and download the episode for the full conversation.
Rachel Woods: One of the ways that you are joined at the hip is helping to solve the workforce crisis. I want to have a moment of vulnerability with the two of you — there's a lot of talk about what the crisis means, what shortages mean. There's a lot of fear around nursing shortages, workforce shortages starting to impact actual patient safety. Is that something that we should merely be afraid of or is that something that is already happening?
Peter Pronovost: Rae, from my perspective, it's already happening, and the national data is bearing that out. There have been several studies showing that the rates of complications have gone up pretty dramatically. I mean, pressure injuries are up nearly 70% and there's a variety of reasons for that, but without a doubt, both staff shortages, so we have high ratios, and inexperienced staff contribute to that as well as having agency staff who don't know your culture or your protocols.
Michelle Hereford: Rae, it is real. It is real. There was a time that many organizations would not admit that, but this is real. I'm sure it keeps many leaders, many caregivers, and others up at night. I'm proud and happy to say working with Peter is great, but UHN, UH overall has placed a tremendous focus on our workforce. It's not just the things that you probably read about in the paper. It's the needs of our workforce. The workforce has changed, people have changed, and we must change with them.
Woods: We absolutely must change with them. One of the changes that I am so happy that we're starting to see is executives like you coming together and saying, "You know what? This is not just a nursing problem. This is not just a problem for that cost center over there. This is a problem for our entire enterprise. This is certainly a problem for quality and safety. This is something that we need to get the best of our leaders working on together."
So I want you to go into a little bit more depth about the two of you. You've got this shared problem. You've said that you can be joined at the hip together. What does partnership look like for your two teams and for you two personally to start to solve this workforce crisis?
Pronovost: One, it begins with us trusting each other immensely and focusing on the work rather than our responsibility. I'll give you an example with Michelle's managers all the time — we're one team and Michelle meets with the clinical transformation and our care managers as she redesigns care models all the time. We're all aligned around giving the best care possible. Those are I think some pretty concrete examples of how this deep trust between us removes any territorial or hierarchy about, "What are you doing in my space?"
Woods: I love that. No silos.
Hereford: That's the key actually, being able to trust each other, identify that there is a common goal, common concern. The way we work together is definitely a reflection on mutual respect that must exist in any relationship, but it sets an example for the rest of the organization and for those that work directly with us.
One of the things I would also share with you that I think, and I know, actually makes this team — and specifically Peter and I — a great team, other than being kindred spirits, we talk about that all the time, but we both always want to know why. Why has this occurred? Or if there was an event, what are the details?
Woods: Like an actual safety event?
Hereford: Correct. As you continue to peel that onion and it's a continuous peeling, you get to the source of the true why. Not always what we see that is, and Peter and I have the same philosophy around that.
Woods: I think this is how the two of you have come to at least a starting place in starting to work to reduce the staffing shortage, both in terms of number of people, in terms of people that are embedded in the culture, and Peter, as you said, in terms of the right expertise at the right place. I think where you landed is a place that a lot of nurses would be happy about, which is the unbelievable administrative burden that is on frankly all clinicians but is particularly true at the bedside.
We know that a ton of below license work just gets shoveled to bedside nurses. I'm assuming that as you're peeling back the layers of the onion, getting to that why, that's an area of focus for both of your departments where the nurses are suffering and also we're starting to actually see some real safety issues. Is that how you came to that initial first step?
Pronovost: Yeah, Rae, you're so spot on and it's insightful. You know what? Michelle's done brilliant work of retention and paying bonuses and all that great blocking and tackling that needed to be done. But Michelle and I were both aligned with, as you said, a lot of the nursing work that they do doesn't need it to be due. So, we said, "How could we systematically address that?" So I had facilitated a discussion with about 55 of our nurse managers and several frontline staff and asked them a series of questions about, "Which policies do we have does the burden exceed the benefit?"
Then once they listed those, how much time do you spend doing that per patient and how many times per patient day does it need to be done? Then we added, "Is it a CMS policy? Is it a joint commission or DMV, or is it our own policy?" There's a couple stunning things that came out of that was they summed it up to be 60% of nurse's time, six-zero. I mean, it was unbelievable.
The vast majority of them were our own internal policies that we over the years accumulated a whole lot of policies. There were some that were CMS and the team was excited. We arranged calls with CMS leadership that they presented some of the things that they wanted change like the nursing care plan. CMS was highly responsive and it was quite energizing for them. Most of them were around frequency of documentation. We've changed about 70 policies, but those 70 policies were embedded in nearly 2,000 order sets.
So we're now going through each of the order sets to take out that waste of time, but I can tell you the nurses are just energized about this work. I mean, they really are excited about the potential to free up that amount of time for them.
Woods: Well, even back to the idea of the partnership, imagine there's a world where you are sitting down with these 50 nurses, you said there were nurse managers. Even the signal value alone of saying, "I'm here too. I'm the chief clinical transformation quality officer, and we believe that this is actually going to be a quality safety problem and we're also here to help you." Even just that signal value of you coming together I think is an important piece of this story.
Pronovost: After we did this, literally, there was giddy energy in the room when they were buzzing and saying, "Oh, imagine if we do this." One of the managers said, "Peter, this is really strange. We have a policy review meeting every month where we ask about policies that need to be changed and we haven't had any agenda items and now we've just identified 60% of our time." So I questioned them. I said, "So let's unpack that. Why do you think that is?" I think they said once when you work in an environment, you just get used to it the way it is. In safety, we call it normalization of deviance.
The second is we weren't confident that we would get things changed. I think it's probably a universal feeling across nurses, because for too long, their voices haven't been heard. So, signaling that "Hey, you come up with ideas, your voice will be heard," as Michelle and I say, this leadership style that we are implementing is completely moving away from command and control towards unleashing and inspiring people. You come up with ideas. Our job is to knock the barriers down to put those ideas into place.
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