At the HealthLeaders Virtual Nursing Mastermind event this week in Atlanta, healthcare leaders discussed the KPIs they're measuring to prove ROI.

Healthcare executives are embracing innovative ideas like virtual care to stabilize a shrinking nursing workforce and boost clinical outcomes, but they need to know what to measure to prove ROI.

Virtual nursing programs are becoming popular in health systems across the country, either as a stand-alone program or, more commonly, as one part of a more comprehensive reimagining of care. And while each health system or hospital is advancing its own strategy, there are common objectives, such as nursing turnover and well-being, administrative tasks, and patient engagement.

Executives from a dozen health systems met in Atlanta this week for the HealthLeaders Virtual Nursing Mastermind program, in a forum to establish common goals, challenges, and successes. The program, which included three virtual roundtables, established a number of key metrics that executives are focusing on as they evaluate their virtual nursing strategies.

Staff turnover and well-being. The initial impetus for many health systems in launching virtual nursing programs is to address a shrinking workforce. Nursing executives are looking for ways to not only reduce turnover, but improve the environment so that nurses want to stay (and others want to join in). Virtual nursing programs create new opportunities for the workforce while revising workloads so that floor nurses are doing less administrative work and spending more time doing what they trained to do: spend time with patients.

While the trurnover rate is a key metric, others include nurse satisfaction (measured in surveys) and time spent on the computer, usually tracked through the EHR platform. While these metrics often are difficult to translate into dollars, Clair Lunt, RN, DHSc, Senior Director of Nursing Informatics at New York’s Mount Sinai Health System, noted they’re seeing a decline in the use of travel nurses and overtime, as well as PTO and even sick time (such as so-called mental health days), all of which significantly affect the bottom line.

The results aren’t limited to nurses, either. Providence is one of seeing a reduction in all-staff turnover, according to Sherene Schlegel, RN, BSN, COO and CNO of Virtual Care and Digital Health. These programs can thus impact all members of the care team, including CNAs and physicians.

As these programs involve, the executives in the Mastermind class noted that virtual nursing can be used as a marketing tool to attract new talent, especially as programs grow to include work-at-home policies.

Patient satisfaction. With the industry’s gradual shift to value-based care, health systems are placing more emphasis on patient experience—and a virtual nursing program can have a profound impact on how a patient feels about the care they receive. Most health systems see these effects in their HCAHPS scores, and some are even tailoring patient surveys to include specific questions on patient interactions with nurses.

It's important to remember that patient satisfaction and engagement do factor into an effective care management plan. Engaged patients are more likely to communicate freely with their nurses, listen to their care teams and adhere to those plans—something that can be measured in medication adherence.

To see those high patient satisfaction scores, health systems need to make sure patients are comfortable with virtual care, including the idea of having a camera in the room, trained on them. Mastermind participants recommended engaging with the patients as soon as they’re settled in their rooms to explain the technology and its uses, as well as designing the technology so that patients know when the camera is off.

Sara Pletcher, MD, MHCDS, SVP and Executive Medical Director of Strategic Innovation at Houston Methodist, pointed out that patients need to understand that virtual care is a routine standard of care, and not an add-on or a luxury. She noted that Houston Methodist now includes virtual care monitoring as part of its consent form, rather than as a separate opt-out.

Patient Throughput. Many health systems are embracing virtual nursing to address patient admission and discharge times, and consequently patient length of stay, all key metrics. But those processes are often complex, involving more than just nurses.

Emily Warr, Administrator of the Center for Telehealth at the Medical University of South Carolina (MUSC), noted that patient discharge is a key pain point in healthcare, one that affects patient satisfaction as well as clinical outcomes, and health systems like Intermountain have a benchmark of three hours from the time a discharge notice is entered to when the patient leaves the hospital. A virtual nursing program is then designed to reduce that time by having a virtual nurse handle as much of the administrative details as possible, including patient education, while the floor nurse manages in-person care duties.

The upshot is that a virtual nurse can oversee those details that a floor nurse would have had to do, reducing time spent and helping the patient get home faster. The same could be said for getting a patient settled into his or her hospital room, with the virtual nurse handling data entry and the floor nurse making sure the patient is comfortable. Both of those processes, as well as any data entry during the patient’s stay, contribute to the overall PLOS.

Again, healthcare executives need to understand that these metrics involve much more than just the nursing department, and that one aspect like virtual nursing won’t necessarily move the needle to a large degree. But incremental improvements are just as important, and for health systems engaged in a redesign of the entire care process, this is one vital step in that evolution.

Administrative tasks. Aside from handling admission and discharge processes, a virtual nursing program can also take on most, if not all, tasks which involve putting a floor nurse in front of a computer (a pain point noted in nurse well-being measurements). This could range from virtual rounding to physician visits to surveys for ancillary programs like sepsis detection, wound care, or medication adherence.

Health system executives can measure success here in accuracy of data entry, or in time taken to complete a task. Some executives have noted that floor nurses are often so busy they fail to do all the data entry and paperwork they should be doing. The end result is that care management is more efficient, and in turn leads to better outcomes.

Additionally, in a separate interview, Warr noted that after a while, floor nurses and virtual nurses in their program were so adept at working together that they could handle tasks without stopping to let the other person know. They also felt comfortable jumping in when needed and helping each other with tasks.

A key to success here is the relationship between the virtual nurse and the floor nurse. Health systems must establish clear protocols for both nurses before launching a program, so that each nurse knows their responsibilities. A good collaboration will be seen in efficient documentation, timely care delivery, and nurse satisfaction.

The HealthLeaders Mastermind series is an exclusive series of calls and events with healthcare executives. This Virtual Nursing Mastermind series features ideas, solutions, and insights on exceling your virtual nursing program. Please join the community at our LinkedIn page.

To inquire about participating in an upcoming Mastermind series or attending a HealthLeaders Exchange event, email us at exchange@healthleadersmedia.com.

The longtime leader of Banner Health shares how the role is different now from when he first started.

Since taking the helm at Banner Health 24 years ago, up until his retirement at the end this month, veteran CEO Peter Fine has seen how leading a hospital has changed over time.

As patients' wants and needs have shifted, the CEO has had to follow suit. At a certain point, around 2017, hospitals realized they weren't just dealing with patients, but "customers" because "the public was judging us not on our clinical product, but the ease of usage," Fine told HealthLeaders.

"The focus before was all we have to do is provide a good clinical product and that satisfies everybody. Well, that's not the case," Fine said. "So that causes you to have to change certain things in your style and your approach and the things that you say and do in front of others become way different. Creating that recognition for everybody that you also have to look for opportunities to take away pain points that get in the way of the consumer interacting with us. It's a different approach because how you speak and what you say become way different."

Fine will retire on June 30 after two-plus decades as CEO of the Phoenix, Arizona-based nonprofit health system, giving way to president Amy Perry, who aims to build on his foundation with a technology-forward approach.

Pictured: Banner Health CEO Peter Fine.

As many hospital CEOs are calling it a career, it's contributing to a steady churn at the position that has been exacerbated in recent years due to mounting challenges. According to Fine, the pressure has never been higher and between private equity, relationships with payers, and the growth of Medicare Advantage plans, it's no surprise that leaders are willingly stepping aside.

"COVID took its toll on many, many leaders," Fine said. "Partly because of what we went through for a two-plus year period, but also the change in how you have to lead. I was always used to walking out of my office, walking to one of 10 other offices on the floor there at 4:00 in the afternoon and just sitting down and talking about strategy and the organization. Now everything is a scheduled Zoom call or a Teams call and there's no spontaneity. So for many, they had to learn a new way of leading an organization, figuring out how to be visible and figuring out how to stylistically be out in front of the organization as much as they can."

For Fine, how the CEO role evolved during his tenure was part of the reason why he found the job so intellectually stimulating, causing him to keep tacking on years to the "highly unusual" 47 overall he spent in healthcare.

"It changed and morphed as an organization into a different kind of business today than it was back in 2000," he said. "It was fun and interesting and when something's fun and interesting and intellectually stimulating, in my case, having tremendous governance along the way and board leadership that's very professional, that was advantageous as well. Not everybody has that.

"The idea of watching an organization grow and finding opportunities for an organization to grow made it, quite frankly, a fun job."

California is the ninth state — after Connecticut, Delaware, Massachusetts, Nevada, New Jersey, Oregon, Rhode Island, and Washington — to set annual health spending targets

By Bernard J. Wolfson

California’s Office of Health Care Affordability faces a herculean task in its plan to slow runaway health care spending.

The goal of the agency, established in 2022, is to make care more affordable and accessible while improving health outcomes, especially for the most disadvantaged state residents. That will require a sustained wrestling match with a sprawling, often dysfunctional health system and powerful industry players who have lots of experience fighting one another and the state.

Can the new agency get insurers, hospitals, and medical groups to collaborate on containing costs even as they jockey for position in the state’s $405 billion health care economy? Can the system be transformed so that financial rewards are tied more to providing quality care than to charging, often exorbitantly, for a seemingly limitless number of services and procedures?

The jury is out, and it could be for many years.

California is the ninth state — after Connecticut, Delaware, Massachusetts, Nevada, New Jersey, Oregon, Rhode Island, and Washington — to set annual health spending targets.

Massachusetts, which started annual spending targets in 2013, was the first state to do so. It’s the only one old enough to have a substantial pre-pandemic track record, and its results are mixed: The annual health spending increases were below the target in three of the first five years and dropped beneath the national average. But more recently, health spending has greatly increased.

In 2022, growth in health care expenditures exceeded Massachusetts’ target by a wide margin. The Health Policy Commission, the state agency established to oversee the spending control efforts, warned that “there are many alarming trends which, if unaddressed, will result in a health care system that is unaffordable.”

Neighboring Rhode Island, despite a preexisting policy of limiting hospital price increases, exceeded its overall health care spending growth target in 2019, the year it took effect. In 2020 and 2021, spending was largely skewed by the pandemic. In 2022, the spending increase came in at half the state’s target rate. Connecticut and Delaware, by contrast, both overshot their 2022 targets.

It’s all a work in progress, and California’s agency will, to some extent, be playing it by ear in the face of state policies and demographic realities that require more spending on health care.

And it will inevitably face pushback from the industry as it confronts unreasonably high prices, unnecessary medical treatments, overuse of high-cost care, administrative waste, and the inflationary concentration of a growing number of hospitals in a small number of hands.

“If you’re telling an industry we need to slow down spending growth, you’re telling them we need to slow down your revenue growth,” says Michael Bailit, president of Bailit Health, a Massachusetts-based consulting group, who has consulted for various states, including California. “And maybe that’s going to be heard as ‘we have to restrain your margins.’ These are very difficult conversations.”

Some of California’s most significant health care sectors have voiced disagreement with the fledgling affordability agency, even as they avoid overtly opposing its goals.

In April, when the affordability office was considering an annual per capita spending growth target of 3%, the California Hospital Association sent it a letter saying hospitals “stand ready to work with” the agency. But the proposed number was far too low, the association argued, because it failed to account for California’s aging population, new investments in Medi-Cal, and other cost pressures.

The hospital group suggested a spending increase target averaging 5.3% over five years, 2025-29. That’s slightly higher than the 5.2% average annual increase in per capita health spending over the five years from 2015 to 2020.

Five days after the hospital association sent its letter, the affordability board approved a slightly less aggressive target that starts at 3.5% in 2025 and drops to 3% by 2029. Carmela Coyle, the association’s chief executive, said in a statement that the board’s decision still failed to account for an aging population, the growing need for mental health and addiction treatment, and a labor shortage.

The California Medical Association, which represents the state’s doctors, expressed similar concerns. The new phased-in target, it said, was “less unreasonable” than the original plan, but the group would “continue to advocate against an artificially low spending target that will have real-life negative impacts on patient access and quality of care.”

But let’s give the state some credit here. The mission on which it is embarking is very ambitious, and it’s hard to argue with the motivation behind it: to interject some financial reason and provide relief for millions of Californians who forgo needed medical care or nix other important household expenses to afford it.

Sushmita Morris, a 38-year-old Pasadena resident, was shocked by a bill she received for an outpatient procedure last July at the University of Southern California’s Keck Hospital, following a miscarriage. The procedure lasted all of 30 minutes, Morris says, and when she received a bill from the doctor for slightly over $700, she paid it. But then a bill from the hospital arrived, totaling nearly $9,000, and her share was over $4,600.

Morris called the Keck billing office multiple times asking for an itemization of the charges but got nowhere. “I got a robotic answer, ‘You have a high-deductible plan,’” she says. “But I should still receive a bill within reason for what was done.” She has refused to pay that bill and expects to hear soon from a collection agency.

The road to more affordable health care will be long and chock-full of big challenges and unforeseen events that could alter the landscape and require considerable flexibility.

Some flexibility is built in. For one thing, the state cap on spending increases may not apply to health care institutions, industry segments, or geographic regions that can show their circumstances justify higher spending — for example, older, sicker patients or sharp increases in the cost of labor.

For those that exceed the limit without such justification, the first step will be a performance improvement plan. If that doesn’t work, at some point — yet to be determined — the affordability office can levy financial penalties up to the full amount by which an organization exceeds the target. But that is unlikely to happen until at least 2030, given the time lag of data collection, followed by conversations with those who exceed the target, and potential improvement plans.

In California, officials, consumer advocates, and health care experts say engagement among all the players, informed by robust and institution-specific data on cost trends, will yield greater transparency and, ultimately, accountability.

Richard Kronick, a public health professor at the University of California-San Diego and a member of the affordability board, notes there is scant public data about cost trends at specific health care institutions. However, “we will know that in the future,” he says, “and I think that knowing it and having that information in the public will put some pressure on those organizations.”

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

Reducing span of control will allow for leadership development, this nurse leader says. 

HealthLeaders spoke with Rudy Jackson, senior vice president and chief nurse executive at UW Health, and HealthLeaders Exchange member, to find out how leaders can lower span of control for nurse managers to improve workforce development without adding additional cost. Tune in to hear his insights.

Click here to read the accompanying article. 

Health systems are brainstorming new ideas for how to build and improve virtual nursing programs.

The Virtual Nursing Mastermind program participants are meeting in Atlanta, Georgia, to discuss the ins and outs of implementing virtual nursing programs.

The program consists of CNOs and other nurse and technology leaders from 12 health systems across the country who are all at various stages in their virtual nursing journeys, and who are innovating with new technologies and solutions.

Implementation

One of the biggest hurdles for virtual nursing is program adoption and implementation. The participants discussed how to gain buy-in from the other C-suite members, particularly the CFO and CIO, and how to introduce the program to the nursing workforce.

There's also a call for defining terms, which the participants say will help with buy-in. The participants were clear that "nursing" needs to come out of "virtual nursing." The tasks being done virtually, like certain documentation functions, do not necessarily need to be completed by a nurse. Health systems should be looking at other departments or positions who can complete those types of processes. This new technology will also enable many other departments in the health systems to also use the platforms for their various needs.

The participants also shared how they have operationally set up their virtual nursing programs. Many have centralized hubs with dedicated buildings where their virtual nurses are based, and others have virtual nurses working from home. The participants noted that they believe virtual nurses need to be at least technologically proficient to take on the position and that those working from home have a private space they can use with a reliable internet connection.

Lessons learned

ROI and improved clinical outcomes are a crucial piece of the puzzle. The participants spoke about what outcomes and efficiencies they are seeing so far and the metrics they are using to track progress. Some of the top metrics include timely discharges, turnover rates, incremental overtime, HCAHPS, and other nurse sensitive quality indicators.

Every health system is going to have different needs and different ways to measure ROI, so according to the participants, it is important to start with a metric like timely discharges. Leaders should look at traditionally "soft" ROI metrics and assign dollars to them so that the rest of the C-suite will get on board with implementing virtual care programs. Additionally, if a system is going to launch a virtual care pilot, it should directly address the chosen ROI metric that will solve the problems that the health system is focusing on.

The participants said the possibilities are endless with virtual nursing technology. The programs are set to expand well beyond just documentation and more into patient monitoring, nurse mentorship, and into more forms of digital care. The ultimate goal is to leverage virtual technology to create sustainable care models of the future.

The HealthLeaders Mastermind series is an exclusive series of calls and events with healthcare executives. This Virtual Nursing Mastermind series features ideas, solutions, and insights on excelling your virtual nursing program. Please join the community at our LinkedIn page.

To inquire about participating in an upcoming Mastermind series or attending a HealthLeaders Exchange event, email us at exchange@healthleadersmedia.com.

The new simulation lab will use new technologies and interactive labs to train healthcare workers on care management for pregnant women and their children

Stanford Medicine Children’s Health is launching a new innovation lab aimed at improving care for pregnant women and their children.

The Stanford Medicine Children’s Health Simulation Innovation Center will use AR, digital health-enabled mannequins, and other tools and technology to give healthcare workers a more hands-on education on a wide variety of health concerns, from difficult births to neonatal care.

“The Innovation Center is … a tool for enhancing care delivery, research, and quality improvement initiatives,” Kristine Taylor, DNP, executive director of the Innovation Center and Center for Professional Excellence and Inquiry, said in a press release. “By analyzing simulation data and outcomes, healthcare teams can identify areas for improvement and implement evidence-based practices to enhance patient care.”

The 4,900-square-foot center is one of several innovative projects being launched across the country to address the nation’s high maternal mortality rate and significant care gaps in children’s health. The maternal mortality rate in 2022 was 22.3 deaths per 100,000 live births, according to the U.S. Centers for Disease Control and Prevention; that’s down compared with 32.9 per 100,000 in 2021, during the height of the pandemic, but still high compared to other developed nations.

[Also read: NYC Targets Maternal Health Care Gap With Mobile Program.]

Healthcare leaders at Stanford Children’s say the new center and technology will help train healthcare workers of all levels, even social workers, in an interactive learning environment that includes debriefing rooms, where they can go over what they’ve learned and discuss new ways of delivering care.

“We are able to enhance our critical thinking, decision-making, and communication skills, ultimately improving patient care outcomes without putting actual patients at risk,” Emily Tomich, RN, a triage nurse and labor and delivery nurse educator, said in the press release. “This is especially important in high-stress situations where clear communication is critical, from basic procedures to complex surgical techniques.”

Gerard Phillips, the health system’s Senior Director of Nursing, explains in this week’s HealthLeaders podcast how UCSD Health is improving patient safety--and where they expect to use the technology next

UC San Diego Health has avoided more than $10 million in healthcare costs since adding remote video monitoring to its telesitting program in 2012.

In this week’s HealthLeaders podcast, Gerard Phillips, DNP, MBA, RN, the health system’s Senior Director of Nursing, says the bidirectional cameras placed in patient rooms enable specially trained video monitoring technicians to monitor patients and communicate with them around the clock.

The 24/7 monitoring program is designed for patients deemed at risk of falling, wandering, or causing harm to themselves by pulling out attached lines and tubes. The health system now has 30 cart-based cameras stationed across five healthcare sites, monitored by three technicians, who are trained CNAs, at a central video monitoring hub.

Phillips says the program not only has allowed UCSD to “maintain a higher level of safety [for] our patients,” but enabled the health system to use those savings to invest in other areas of the organization.

He also says UCSD envisions using remote video monitoring in a number of areas, including virtual nursing, staff safety and home-based care management. And they’re embedding AI technology into the cameras to help monitors spot visual cues of signs of concern with patients.

Listen to Phillips and learn how the health system is making the most out of its virtual telesiting program here.

CNOs and CFOs must learn to speak each other's language, says this nurse leader.

On this episode of HL Shorts, we hear from Katie Boston-Leary, director of nursing programs at the American Nurses Association, about how CNOs and CFOs can better communicate with each other. Tune in to hear her insights.

A new report shows that lowering nurse manager span of control improves clinical and financial outcomes.

Amid high burnout and turnover rates, nurse leaders should take a closer look at a key piece of the workforce puzzle: nurse managers.

Nurse managers need time and support from leadership to complete their tasks. According to a report published by the American Organization for Nursing Leadership (AONL) and Laudio, this could be accomplished by lowering span of control.

Span of control refers to the number of employees that nurse managers are in charge of supervising. According to the report, the median span of control for nurse managers is 46 employees, but 25% of all inpatient nurse managers have spans of control higher than 78.

The problem

According to Rudy Jackson, senior vice president and CNE at UW Health and a HealthLeaders Exchange member, nurse managers often have to perform many different duties. As a result, they’re often stretched thin.

"We put so much incredible pressure on our nurse managers to manage finances, culture, patient experience, quality, [and] keep turnover rates [and] length of stay down," Jackson said. "Yet we have all of these things that we put on their shoulders before they're able to get those things done."

Jackson said UW Health is making a significant investment in reducing span of control for nurse leaders. They’re looking at metrics like total headcount per nurse manager vs. how many pilots they are working on, as well as workforce diversity.

Jackson said a recent study has helped the health system understand what “we can eliminate off their plate” to make their jobs easier.

High spans of control also impact turnover rates.

According to the report, managers with higher spans of control face more turnover costs and incremental overtime.

Nurse managers are often swamped with busy work, leaving little time for job development. Jackson said that with more time, nurse managers could develop relationships with their teams, improve quality outcomes, improve the patient experience, and ultimately reduce costs, turnover and vacancy rates.

"What I need are leaders," Jackson said, "and reducing that span of control is going to allow us to move those individuals into a leadership role where they're truly able to guide their teams." 

The solution

The ultimate goal of lowering span of control is to give time back to nurse managers while also keeping costs down.

The report says that a financial case can be made for reducing span of control, when possible, even if it means splitting larger departments into smaller ones. According to the report, leaders should consider reducing or reallocating administrative tasks to offload the nurse manager's burden, while leveraging technology.

Additionally, the report says that giving more time to nurse managers to meaningfully interact with staff lowers RN turnover rates, which in turn lowers hiring costs.  

To Jackson, the answer to this issue will vary depending on the size of a health system and its resources.

"When you look at the control data for an organization like UW Health and you compare us to others, we do have a lot of resources that support our managers," Jackson said.

"It's a matter of trying to understand what exactly are those individual things that are impacting our leaders," Jackson continued, "and how can I leverage technology to offset some of that burden?"

UW Health developed a nurse manager council so that nurse managers have a venue to voice innovative solutions, questions, problems, and concerns. Jackson said UW Health will soon be conducting time studies with managers across the health system to better understand where nurse managers are spending their time.

"One of the solutions I heard recently from a CNE was [that they] give [their] managers a day off once a week, and … in theory, that would work pretty well," Jackson said. "The reality is that the work doesn't stop."

"As CNEs, we need to start thinking about innovative solutions, leveraging technology, offering the appropriate support," Jackson said, "but [doing] so in a manner that doesn't add additional cost to organizations that already exist on razor thin margins."

What about assistant nurse managers?

According to the report, the assistant nurse manager plays a critical role in this strategy.

The study found that 56% of nurse managers are supported by at least one nurse manager. Of that number, 4% of nurse managers have all team members reporting to the assistant nurse manager and 18% share the direct reports, while 78% have all team members as their direct reports, without including the assistant nurse manager.

The report says that RN turnover is lower when assistant nurse managers are part of high span of control teams, which ultimately reduces costs. However, the data also shows that too many assistant managers can become counterproductive and lead to high turnover, possibly because roles are less clear.

Jackson has experienced working in environments with and without assistant nurse managers, and UW Health is now trying something new.

"What we've challenged our team with is start looking within," Jackson said. "What resources do we have internally that can allow us to start to decrease that administrative burden to those managers so that we can get them out of their office and elevate the roles of some of the others?"

UW Health deploys full-time charge nurses called care team leaders (CTLs). Jackson said they are looking at how CTLs can help offload the burden from nurse managers.

UW Health is also leveraging technology to help with administrative burdens.

"We're looking at technology to remove the burden of scheduling," Jackson said. "We've got to be able to put pressure on our IT departments to find those solutions that help nurses and help the organization make our leaders more efficient, [and] support our nurses even better."

In health systems where creating new roles is not possible, Jackson recommended making existing roles more supportive to the nurse managers.

"I think there's a lot of different ways to utilize the assistant manager role," Jackson said, "but I don’t think we need to be stuck with the solution that the assistant manager is the only way we're going to fix the manager span of control."