Managing Workforce Challenges: Cost/Benefit Intervention Considerations

(Companion document to: Leader Dialogue Podcast Session #66)

Authored by: Leader Dialogue hosts - Charles Peck, MD, FACS and Ben Sawyer MBA, PT, OCS, LBB

Workforce challenges in the post COVID world have become colossal. This blog, in alignment with the Nov 16, 2021, Leader Dialogue podcast seeks to provide some helpful context for health system leaders faced with addressing these challenges from both a recruitment/retention standpoint, and also from a workflow orchestration/process standpoint. Some of the cost benefit considerations inherent in such decisions are also discussed.

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By way of context, a survey from executives participating in a recent HMA Industry Briefing event, reported that the top two (2) challenges they are facing are: 1) Workforce issues, and 2) Operating as one (systemness). Both are related of course, as the rapid increase in contract labor impacts colleague engagement and organizational effectiveness. The Baldrige performance excellence criteria as summarized in the Visual Baldrige: Organizational Hierarchy of Needs (see image below), represents why.

The Baldrige criteria are an evidence-based, validated set of characteristics of high-performance organizations which focus on business results. Almost 50% of the Baldrige framework contents are predicated on a balanced set of outcomes. The criteria are non-prescriptive and adaptable. They don’t tell you what to do, rather focus attention on the drivers of success to guide leaders through their own assessment of what’s important and how to address those areas of concern.

Delivering differentiated patient and consumer value necessitates all of the Baldrige criteria to function in synchrony, as represented in the Organizational Hierarchy of Needs.

Organizations are able to leverage the different facets of their organizational hierarchy of needs to gain success in addressing workforce challenges. Let’s look first at the challenges of recruitment and retention strategies within the milieu of the pandemic, which correspond directly to the seven (7) Baldrige Categories:

  1. Leadership: Providing a compelling shared vision, and encouraging persistent learning.

  2. Strategy: Preparing for the future, including the goals, objectives, and key initiatives to align people with purpose to achieve exceptional results.

  3. Customers: Listening to, satisfying, and engaging patients and other consumers in accommodating changing demands.

  4. Measurement, Analysis, and Knowledge Management (MAKM): Determining how to secure and use reliable data and information to make effective organizational decisions.

  5. Workforce: Engaging all members of the workforce, to ensure roles and responsibilities are clear and that they are empowered and supported in the discharge of their duties to the benefit of the patient, consumer, and organization.

  6. Operations: Designing, managing, improving, and innovating healthcare services and work processes to improve operational effectiveness to deliver value to patients, other customers, and to achieve ongoing organizational success.

When these categories are fully integrated and in balance with each other, leaders are able to comprehensively address all of the different aspects of their organizational hierarchy of needs and drive exceptional organizational results along four dimensions, which answer the following questions.

  1. Approach: How do you accomplish your organization’s work? How systematic and effective are your key approaches?

  2. Deployment: How consistently are your key approaches used in relevant parts of your organization?

  3. Learning: How well have you evaluated and improved your key approaches? How well have improvements been shared within your organization? Has new knowledge led to innovation?

  4. Integration: How well do your approaches reflect your current and future organizational needs? How well are processes and operations harmonized across your organization to achieve key organization-wide goals?

Category 7: Results – Precipitated from this ADLI dimensions perspective includes:

  • 7.1: Healthcare and Process Results

  • 7.2: Customer Results

  • 7.3: Workforce Results

  • 7.4: Leadership and Governance Results

  • 7.5: Financial, Market, and Strategy Results

What are Some of the Key Workforce Recruitment / Retention Challenges?

Turning our attention to the workforce recruitment/retention challenges then, there are several we want to focus on in the blog and in the Nov 16th podcast.

1. Cultivating organizational resilience

This means showing a commitment to provider and staff welfare and providing meaningful emotional support to them during the pandemic transitions. In other words, letting them know without any question that you have their back.

2. Culture over messaging

There were issues that were already percolating up to the surface prior to COVID, particularly with nursing staff and some of the other caregivers, such as: bullying in the workplace, workplace violence and incivility. Those are still issues that need to be addressed. And, those issues are very important issues to today’s workforce, and in many instances are causing workforce departures.

3. Opening all lines of communication and being totally transparent

About where the organization is and what the vision is going forward for the organization.

4. Burnout

Which is an overarching umbrella theme to all of the other workforce challenges in the post-COVID environment. Note that this is about the workplace more than it is about the people. Some think of burnout as an individual problem, and try to address that problem with individual solutions, but it's much more complicated than that preliminary intuition. The case for burnout is less about the employee, and more about the milieu in which the employee is working in their everyday life. There are some staggering statistics associated with this.

From Stanford University:

  • Workplace stress: Impacts health costs and mortality in the US to the tune of $190B in spending – 8% of national healthcare outlays and nearly 120,000 deaths per year

  • Suicide rates: Among caregivers are 40% higher for men and 130% higher for women than the general population

From the American Psychological Association:

  • At high pressure firms: Healthcare costs are 50% greater

  • Workplace stress is estimated to cost: The US economy more than $500B

  • Each year: 550 million workdays lost due to stress on the job

  • Burned out employees: Are 2.6 times more likely to seeking different job, 63% more likely to take a sick day, 23% more likely to visit an ED

For further information please refer to the Harvard Business Review (HBR) article here.

So clearly, burnout has to be addressed head-on. When asking employees about what it is that's causing them to feel burnout, there are five (5) reasons that employees often point to.

  • i. Unfair treatment at work;

  • ii. Unmanageable workloads;

  • iii. Lack of role clarity;

  • iv. Lack of communication and support from their manager; and

  • v. Unreasonable time pressures.

We need to ask ourselves as leaders the following questions at minimum, and also dig into the data, as the Baldrige framework suggests, to find answers.

  1. What is making my staff so unhealthy?

  2. Why does the work environment here lack the conditions for them to flourish?

  3. What would make work better for them?

  4. What, specifically, is causing them to be stressed?

  5. What is it that's causing them to leave the organization?

  6. What are some things we might be able to do to reverse those trends?

Reducing Workforce Stress: Are there Workflow Orchestration / Process Opportunities?

As we consider the questions associated with the workforce / retention challenges let’s also consider what can be done from a workflow orchestration / process standpoint to reduce staff stress and burnout.

By way of example, let’s start with the workforce stressors inherent in the patient throughput processes within an acute care hospital setting. Depicted below are some of the associated bottlenecks, and the related optimal flow opportunities.

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1. Inefficient Transfers

Referencing the diagram above, let’s consider the transfer process first. There is often a lack of role clarity and extensive manual effort associated with the transfer process. As a result, transfers become inefficient, compromising the patient experience, adding workforce stressors, and resulting in patient leakage as referring facilities/providers select other tertiary care options. In other words, if an organization is unable to accept a patient, that patient will go somewhere else. The root causal factors seem to be the manual processes, the lack of clarity as to the on-call providers for rapid acceptance, the lack of visibility of staffed beds available, and associated real-time reporting gaps,

So, when one considers the workforce stressors from a transfer process standpoint, there are some optimal flow opportunities to consider. One is the investment in a seamless access and orchestration hub. The result is setting up in advance very predictable role accountabilities, clear technology enabled processes, and best practices to optimize the transfer operations while reducing workforce stress. This approach can provide a much-needed augmentation to the EMR, with composable solutions effectively addressing workforce workload and process gaps to order to maximize performance results.

For those readers unfamiliar with the term composability, it is an IT system design principle that deals with the interrelationships of components. A highly composable system provides components that can be selected and assembled in various combinations to satisfy specific user requirements. In the acute care hospital example, a composable solution approach helps with patient throughput optimization, beginning at the front door.

2. Highly variable / delayed discharge planning

The result of highly variable and delayed discharge planning are excess/avoidable days. There is an authorized LOS approved by the payor based upon the presenting condition of the patient reflective of the patient’s severity of injury/illness and intensity of services required, known as the SI/IS.

Once the patient is admitted, the providers and staff are expected to continue to confirm and manage the estimated date of discharge (EDD) through to discharge, documenting the necessary patient disposition information and making care progression adjustments as necessary. However, what if the providers and staff do not have all of the necessary tools, capacity, or time to focus on this timely and efficient care progression for each patient? The result, which is often seen in acute care settings, are care progression interruptions and delayed patient discharges.

The optimal flow opportunity then is to initiate discharge planning upon admission. Doing so, involves consistently using the estimated date of discharge (EDD) and the related disposition intelligence within the daily multidisciplinary round (MDR) as a key focus to make sure that there is a coordinated multi-disciplinary action plan for each patient. This alignment of staff roles with tech-enabled efficient processes reduces the staff workload and results in improved patient experience and LOS performance.

3. Tedious to manage and resolve barriers to care

There are patient flow barriers that come up frequently in the acute care management of patients. They included diagnostic service delays, consulting provider delays, and care transition delays, to name a few. These delays stress the workforce as they have to work around the impediments.

An optimal flow opportunity is to prioritize the barriers and orchestrate centrally the disparate efforts across the ancillaries to resolve barriers and use artificial intelligence and machine learning enabled process flows to identify those rate limiting steps and promote the most efficient care path for each patient.

4. Post-acute care (PAC) access and transportation impediments

PAC impediments gain significance the later in the patient’s LOS. This means that the post-acute impediments can be substantially reduced if discharge planning begins upon admission and is managed effectively during the daily MDR’s. Doing so, enables PAC planning to commence as early as possible in the patient care journey.

An optimal flow opportunity is an orchestration hub combined with technology enabled processes to ensure that the patient’s PAC provider options are clear and available for early scheduling. This includes having an already curated PAC provider network and being able to leverage that within the orchestration hub so that PAC decisions can be completed early on in the process.

All four (4) of the previously described workflow orchestration/process opportunities are examples of how workforce stressors can be reduced, while simultaneously driving an improved patient care experience and results.

Cost/Benefit Implications

As the diagram below demonstrates, if we cross-map the above workflow orchestration / process opportunities into the following five (5) steps, leaders are able to attach an estimated dollar value to each step and understand how to get things done right and avoid penalties for getting things wrong.

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Let’s start with the inpatient stay progression as described in the image above.

1. Optimal Transfers

Represent an average contribution margin opportunity of approximately $10,800 for each new patient admitted. Success means being able to accommodate the patient transfer within a 30-minute window, enabling patient assignment to a readily available on-call provider, assignment to the best available staffed bed determined from system-wide visibility, and the coordination of computer-aided emergency transport dispatch when necessary.

2. Discharge and care progression planning starting upon admission

Represent a $1,500 per patient revenue opportunity, based upon achieving a timely and effective discharge within the authorized length of stay (LOS) window. The objective is that the final observed to expected (O/E) ratio for that patient upon discharge is < 1.0 with the facilitation of a rapid bed turn to accommodate the next new patient.

3. Effective management and resolution of barriers to care

Are able to reduce excess /avoidable days at an average cost of $1,000/day, thereby freeing up capacity and better balancing patient demand with a ready supply of staffed beds.

4. Post-acute care (PAC) access and transportation

PAC pre-planning, including transportation reservation, can also efficiently and effectively support patient and family decision making as to the best care provider needed at the conclusion of the acute care stay. Potential revenue opportunity is $1,424 if placement occurs within the health system’s network, represented as an average 17.8% of the Medicare spend per beneficiary (MSPB).

5. Reduction of readmissions

Represents an opportunity to reduce readmissions at an average cost of $14,400 per patient. According to the literature, most root causes for readmission are disease-related (46%), followed by human (healthcare worker)- (33%) and patient- (15%) related root causes.

  1. Nearly one-half of readmissions are considered to be potentially preventable.

  2. Preventable readmissions predominantly have human-related coordination opportunities such as:

  • i. Interventions designed to improve communication among healthcare teams and focus on the care transition from hospital to the PAC environment, such as within a well-managed MDR;

  • ii. Starting these care transition interventions early in the hospital upon admission, and continue after discharge rather than starting at the time of, or after, discharge;

  • iii. Enhancing patient empowerment and disease monitoring, and providing ample support for patient self-management, during and after the acute stay.

Summary

This blog discussed, and recommends, a Baldrige organizational hierarchy of needs blended approach that includes: 1) Proactive staffing strategies to improve staff recruitment/retention, and 2) Technology enabled process improvements designed to reduce workforce stressors and maximize performance.

The cost/benefit implications of doing so are well worth the time and investment. The diagram below represents a graphical representation of this blended approach supporting an integrated system of care.

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