July 30, 2020

Q&A: How Ascension mobilized nearly 10,000 nurses for Covid-19—in less than 2 weeks

Daily Briefing

    Amy Wilson serves as Senior Vice President of Clinical Operations for Ascension, a system with over 150 hospitals in 20 states. In this role, Wilson oversees Ascension's nursing enterprise and care delivery models. She recently connected with Steven Berkow, Advisory Board's VP of Provider Research, to discuss how her system mobilized nearly 10,000 nurses to deliver Covid-19 care in different care settings—and other lessons learned for transforming care delivery.

    What nurse leaders can do today to prepare their frontline for Covid-19

    Question: Thanks for speaking with me today, Amy. Since the outbreak of the pandemic, system executives have increasingly shared with me how Covid-19 has been driving or accelerating systemness. How has Ascension, which is such a large system, leveraged its size to address the pandemic?

    Amy Wilson: As you know, we started coming together as One Ascension about six years ago. Before we were a holding company.  But we've now been working together for years to standardize processes and protocols at the enterprise level whenever it makes good sense, while still making room for local flavor. This journey, combined with our adoption of Agile learning, put us in a far better position to respond quickly to Covid-19.

    Question: Let's narrow our focus to nursing. You oversee more than 60,000 nurses. How did you leverage Ascension's expansive nursing resources and capabilities to respond to Covid-19?

    Wilson: In the beginning, we were most concerned about staffing during a system-wide surge. We worried about all our markets being hit hard at roughly the same time. So, we leaned on the reach of our system to speed up learning and evolution of a team-based Covid-19 staffing model. For example, we already had some team-based model pilots running in our Jacksonville market. We also incorporated insights about tiered staffing models shared by nurse executives in the first Covid-19 hot spot, Seattle.

    Question: So what did this model look like in practice?

    Wilson: We ultimately took that tier-based approach and went a step further to develop two different RN roles within the team: Deputized RNs and Functional RNs. The deputized role is for RNs who already have needed specialized skills and can be quickly cross-trained for a more acute Covid-19 unit. For example, PACU nurses are strong candidates to serve as Deputized RNs in the ICU.

    In contrast, Functional RNs don't have all the clinical competencies required to independently deliver care in the more acute setting but do have much needed universal nursing skills—for example, med-surg nurses redeployed to that ICU. By delineating these two roles in the early days of the epidemic, we built confidence among our nurses that they wouldn't be asked to deliver care above their competency level.

    It was so successful we quickly incorporated respiratory therapists and CNAs into the model as well. Within a week and a half, we had cross-trained almost 10,000 nurses, respiratory therapists, and CNAs—all across the country—to flex in a surge.

    Question: Let me slow down a bit here, because 10,000 employees trained in less than two weeks is quite an achievement. With such a limited amount of time, where did you focus your training efforts?

    Wilson: We were most concerned about ICU staffing at first, so we focused on ventilator skills, proning, and other critical care skills. We also trained staff on team-based behaviors key to a high-performing ICU and weaved in self-care, such as trauma recovery, to prepare them mentally and spiritually for the journey ahead.

    But very quickly we realized that med-surg was also going to see a surge. So we adopted a similar program for the med-surg area, identifying OR circulators, Ascension Medical Group nurses, and nurse practitioners who typically work in the outpatient setting for Deputized or Functional roles and training up as many as feasible.

    Question: So it sounds like you created something of a conga line to leverage your workforce here, pulling in your PACU providers to help in the ICU, and then tapping some of your outpatient nurses to pitch-in on med-surg units. But given social distancing requirements, what training modality did you use?

    Wilson: We shifted all classroom-based trainings to virtual. We used the Google Classrooms platform to create an interactive virtual experience. And then we would conduct very small simulation check-offs—with just 10 people or fewer present.

    And the nurses loved it! In fact, one of our lessons-learned going forward is that we should be doing more virtual trainings. Nurses love the flexibility. They don't have to drive into work to participate; they can do it from anywhere.

    Question: Once they're trained, how do you deploy these staff? Do they flex within just their hospital, their region, or broader?

    Wilson: Originally, we were thinking about it at a regional level—a radius that people could drive to. Then Detroit, a big area for us, got hit significantly. Even with heightened RN flexibility and surge staffing plans in place, we didn't have enough nurses to cover the volumes. At the same time, we had facilities in northern Michigan that were not hit.

    So that's when we stood up the Ascension travel program. We voluntarily mobilized nurses who lived two, three, four hours from Detroit, paid them a travel rate, and hoteled them nearby. That went so well we started doing it across state lines. We've been able to do some of that through the Nurse Licensure Compact, but I also have to thank our advocacy teams in Michigan and Illinois, which were two non-compact license states where we needed the most help initially. The advocacy teams worked with the governors to create reciprocity on an expedited basis.

    We're continuing the Ascension travel program across state lines today. In fact, soon after Texas was hit hard, I got a call that Austin needed additional nurses. Michigan nurses were so thankful for how Texas, Kansas, and several other ministries came to help them when Michigan was surging that many welcomed the chance to help their sister hospitals in Texas.

    To date, we've had over 400 nurses, respiratory therapists, and nursing assistants travel from low-volume areas to high-volume areas—and we haven't had to hire any nurses. These are all Ascension staff members meeting patient demand where it's at.

    Question: And with some non-surging areas struggling to get non-Covid patients to come back in for care, I'm guessing some of them probably need the hours?

    Wilson: Correct. And there are other benefits. Going back to your question about systemness, it propels the idea of One Ascension. We get to share learnings across the organization at the grassroots level, very differently than we do through our affinity group process.

    In fact, this has gone so well that we're standing up a permanent travel program within Ascension. We will have clinicians who will be dedicated to the travel program in the future. But we're still going to allow our full-time associates who don't travel to have some type of sabbatical or exchange program where they can exchange jobs with another associate.

    Question: The training program, the internal travel agency—you have led a ton of needed change in a very small amount of time. It makes me reflect on how many systems still don't have a system-level chief nurse executive. Do you think that hampers their ability to replicate some of the things you've done?

    Wilson: Absolutely. The system-level nurse executive brings a critical perspective to the C-suite in several ways. Most obviously, more than 60% of a health system's workforce is nursing or nursing support. So just from a workforce planning perspective, there's ample work for a system-level CNO.

    But perhaps more important, health care is now very much a team sport. We need our physicians and nurses working in lockstep to deliver high value care, but right or wrong, physicians and nurses have different motivations and start points for addressing challenges. If you're not set up to bake in the nursing perspective from the outset and how best to secure nurse buy-in, your organization is going to struggle to advance most strategic initiatives. Again, over 60% of your workforce is nursing or nursing support.

    Question: I want to switch gears for a few minutes to talk about another challenge facing system executives: convincing patients that it's safe to come back to the system and get care. How have you been tackling this?

    Wilson: It's important to remember all the channels and people you already have in place to help here. That's where we turned first. More specifically, we've been repurposing our patient surveys and focus groups to better understand what patients need to feel safe. We're now taking that data and working with our Marketing and Communication team along with a mix of clinical leaders to develop care and communication protocols to meet these needs. And we're tapping our national Patient Family Advisory Council to pressure test these plans and provide feedback.

    Convincing all our patients it's safe to come back is going to require a multi-prong effort. But what we're finding is most important is those one-on-one conversations and phone calls with patients.   

    Question: For a system of Ascension's size, standardizing one-to-one conversations is a tall order. How do you ensure your frontline providers are on message?

    Wilson: We do it by cascading information. Once protocols are developed, they go out to all executives in the organization. After that, it's communicated to the specific people whose work is impacted, all the way to the front line. We also provide standard flyers and messaging across the system, so no matter which facility you walk into across the country, you're going to hear and see the same message on social distancing. You're going to hear and see the same message about universal masking.

    Question: I want to give you free reign over our last few moments. Is there anything else you want to share with your health system peers?

    Wilson: I want to address staff burnout. Many have focused on the trauma and emotional exhaustion experienced by clinicians caught up in extreme surges. This is exceedingly well deserved. But I want to encourage my peers to remember that Covid-19 has impacted everyone. We have nurses who are feeling guilty because they happen to live in a market that didn't surge. Others are struggling to adjust to working virtually. And others are struggling with Covid-19 challenges outside of work.

    I also want to remind my peers that safeguarding time for self-care and well-being has not been a strength of health care professionals. We're really good at telling others how to take care of themselves, and we're really bad at caring for ourselves. But ultimately, we will not have the capacity to provide care for others if we're not caring for ourselves, particularly amid a historic pandemic.

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