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Temporary Nurses Are a Stopgap Solution

 |  By Chelsea Rice  
   July 08, 2013

With dozens of staffing contracts and hundreds of vacant nursing positions, Scott & White Healthcare in Texas faced a business expansion that outpaced its staffing resources. Here's how the HR department recovered.

Nursing is the largest sector of the healthcare workforce. As hospital leaders look ahead to masses of newly insured patients about to walk through their doors, they risk overburdening nurses and the negative impacts that can have on patient safety.

Whats' more, when exhausted nurses walk out the door, those vacancies can't last long without impacting the rest of the staff and affecting the quality of patient care. Under the pressure to fill positions, may hire less-than-ideal candidates.

When Keith Minnis arrived in 2008 to Scott & White Healthcare in Temple, TX, as the director of recruitment and retention, the health system had 6,500–7,000 employees. Today, the large multi-specialty practice employs 14,500 at its 12 hospitals. From 2008 to 2011, the system more than doubled its nurse workforce from approximately 2,000 nurses to over 4,000, and in 2011 the system had anywhere from 200 to 400 open nursing positions.

"We were actively recruiting for [nurses], but we couldn't meet the demands of the growth of the organization. We grew so big so fast with opening clinics, service lines, and hospitals, we literally outgrew our workforce marketplace here to support the 30,000 square miles we serve," says Minnis, now the vice president of human resources.

A nonprofit, multispecialty academic medical center, Scott & White owns a dozen hospitals and 60 primary and specialty care clinics spanning central Texas in the triangle between San Antonio, Houston, and Dallas. But with many facilities in rural areas, Minnis says, in 2008 they were already struggling to find nurses. Then Scott & White began to expand its footprint and take on additional providers and payers. With the growth in patients as well as facilities came a need to staff nurses quickly. As an academic medical center operating a Level I Trauma acute care hospital, the additional challenge was to recruit experienced, high-quality candidates, says Minnis.

In recent years, many of the organization's nurses went mobile or moved closer to the cities. In 2008, more than 150 travel nurses supported the system's staffing needs, but Scott & White also maintained up to 70 staffing agreements with various vendors to help them manage the demand. Demand continued to grow, and by 2011, Scott & White faced one of the worst nurse staffing shortages in the country.

It was time to examine their overall staffing strategy, stop using stopgaps, and build lasting solutions, Minnis says.

A shift to permanent employees

"It was really important to understand where our bottlenecks were and understand the challenges we were experiencing. If you have broken processes, you're going to just keep re-creating the same holes to dig yourself out of," he says. "You really need to look at what are the challenges for recruitment, because continuing to staff with temporary staffing really is a short-term solution."

The small volume of qualified, experienced nurses Scott & White was finding presented a challenge common to most healthcare systems. Although recent graduates and interns applied in decent numbers, they didn't have the two to three years of experience S&W needed for the complexity or acuity of patients they treat, says Minnis. From locums to per diems to travelling staff, contracted nurses come with a premium, not to mention the administrative costs of organizing all of the service contracts.

A little over a year ago, S&W stopped hiring traveling nurses and began hiring and training recent graduates as permanent employees. Although Minnis says he still doesn't feel that the organization has "arrived" at an ideal recruiting/retention solution, he considers the shift away from relying on travelers "a success story."

"I would point to the literally millions of dollars shaved off the bottom line that resulted from getting contracted labor shaved off the organization," says Minnis.

Some of that money saved has been invested back into the nursing workforce future. The human resources department and nurse leaders went on a campaign to bring on nurse interns and recent graduates during the summer and in January, so that they could train with residents and fellows and see the benefits to working full-time at Scott & White. A few weeks ago S&W hired more than 150 recent nurse graduates, and expects another 100 in the next month.

Hire to keep, retain to save

Time-to-hire is the most costly challenge for hospital human resources. In the United States, nurses average a 20% turnover rate, and the nursing workforce is aging along with the patient population. Those valuable nurses with decades of experience are growing closer to retirement, and the challenge remains to attract a workforce that has so many opportunities.

"They really do have a lot of choices, and a nurse can literally get a job in a day. It's critical to have them highly engaged and involved in their workplace," says Minnis. "Nurses first and foremost care greatly about the patients and the quality of care. If they feel like that's not being delivered, they can vote with their feet and move to another hospital or facility really easily."By shifting away from temporary employees, Scott & White was able to reduce costs for staffing solutions by 29% for its 12 hospitals and still increase retention, he says.

The key driver of shifting S&W's recruiting strategy was the opportunity to improve hiring from a quality and regulatory perspective, says Minnis.

"We didn't have the quantity or a good depth in the pool here in central Texas, so we needed someone to help us navigate and funnel those experienced nurses to us, but we were working with so many different vendors," he says.

Managed service programs (MSPs) manage staffing companies and contracts as well as talent pools, recruitment, and onboarding. This single-source style of staffing solution began outside of healthcare around 20 years ago but has become increasingly more popular in healthcare in the past 10 years. S&W found this service in AMN Healthcare, which was previously helping the health system with contracted nursing staff solutions.

 "It really was looking at how can we manage one relationship as opposed to numerous relationships, and how can we ensure that we have the standard practice from completing background checks to onboarding," says Minnis. "When you can manage one price point and manage a standard process, your ability to manage a vendor and deliver in a certain way increases. We weren't on the cutting edge of this, but we were probably in the front of the pack."

Through its MSP, Scott & White was able to drive down the price points and reduce spending on contingent labor while also maintaining the level of quality for patients through more full-time employees.

The goal from the beginning was for AMN to "work themselves out of a job," says Minnis, because the health system was actively reducing its contingent labor needs. "It was a temporary solution with the goal that we would work towards recruiting and training our own."

Hospitals today can't afford to be short-staffed and have low engagement scores or high turnover. Nurses have a wealth of opportunities available to them nationwide, and each time a hospital loses a nurse, it impacts quality and patient experience.  But by reducing the dependency on temporary nurses, building a talent pool from the ground up, and streamlining recruiting services, hospitals can put their recruiting problems to bed and improve the quality of patient care.

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Chelsea Rice is an associate editor for HealthLeaders Media.
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