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The Balancing Act of Clinician Supply and Demand

 |  By Jennifer Thew RN  
   December 01, 2017

Recognizing there is no one-size-fits-all approach to staffing issues, healthcare leaders across the country are creating customized solutions to meet their organizations' current and future clinician workforce needs.

This article first appeared in the December 2017 issue of HealthLeaders magazine.

And it worked.

At its most vulnerable, the organization had only three physicians and two nurse practitioners.

Today there are five family practice physicians, one ENT surgeon, and six physician assistants.

"We actually don't have a hard time finding doctors," he says.

Key to this model is an emphasis on both domestic and international service work. While it is in a rural area, Kearny County Hospital's surrounding area is culturally and ethnically diverse.

The hospital serves patients from 30 countries, Anderson says, most of whom are political refugees from some of the most challenged parts of the world—Somalia, Sudan, Ethiopia, Eritrea, Burma, and parts of Central and South America.

Anderson says the refugees are a factor in recruitment. "People are coming because of them," he says. "What we're saying is there are people from 30 countries here, and you get to live among them. We'll give you time to go serve people overseas as well."

All physicians are given 10 weeks paid time off to use however they choose, but Anderson says they all use some of their time to volunteer overseas.

The providers, he explains, can be categorized into three groups—senders, goers, and bridgers. Senders are those who intend to spend their entire careers at Kearney County Hospital.

"What [the bridgers have] done for us … is they've stabilized our hospital … because they eliminate our need for locum work."

"They choose to spend some of their time going overseas, which reinvigorates them and encourages them as they serve here locally. It also equips them to serve locally," he says.

The senders are also motivated by the role they play in mentoring, training, and preparing the next group of physicians—the goers—to practice abroad.

Goers are physicians who come out of training and spend three to five years at Kearney County Hospital with the intent of moving abroad.

"[They] commit to coming here to get their loans paid off, to improve their language skills, to mature in their family relationships, and to strengthen their clinical skills so that they may move permanently overseas," Anderson says of this group. "They come here to live among Somalis, Burmese, Sudanese people so that they may move to those places and be better equipped."

The bridgers make six-month to one-year commitments to the organization, work a greater share of hours, and carry a heavier patient load in exchange for a short-term contract.

"What they've done for us, at least previously, is they've stabilized our hospital so that we can recruit goers and senders, because they eliminate our need for locum work," he says.

Anderson says the model has resulted in cost savings from elimination of costly locum tenens coverage. The organization has also seen an increase in operating revenue from $23 million to $31 million annually.

Over the past two years, Kearney County Hospital has added nearly 4,500 new patients, in part, because of the loss of providers in the geographic region. If they stay on pace, the organization may reach up to 360 deliveries this year. In the past, 189 deliveries a year was typical.

Anderson's advice for those who wish to replicate this model is to know your mission, identify your core values, and have a vision for the future.

"It's got to be simple and easy to understand and to articulate," he says. "If you don't know your mission, then the default mission becomes to stay open another day, and I don't know very many mission-hearted, bright medical providers or clinicians that get excited working for an organization whose goal is to stay open another day."

In turn, healthcare leaders should ask recruits what their personal mission and cores values are.

"It really is about understanding each recruit's motivations, and knowing the mission and purpose of the organization, and matching the two," he says. "If they don't match, the person is not going to stay. If they do, it's a very good thing."

International nurses fill a need

At the national level, the U.S. Department of Health & Human Services' Health Resources & Services Administration projects RN supply to exceed demand, resulting in a projected excess of about 293,800 RN FTEs in 2030.

And while Spetz thinks nursing schools will be able to keep pace with nurse supply, there are other factors influencing the nursing workforce supply.

"Overall, I think nursing is graduating the right numbers. There's a distribution problem, just like there is for physicians, and there's a skills problem," she says. "Employers are saying that new graduates don't really quite have the skills we need. We have all these experienced nurses who are leaving their jobs. We need to fill these gaps."

Texas, according to the HRSA data, is one state grappling with these issues, and by 2025 the state is expected to have an RN shortfall of 15,900 FTEs.

Shannon Medical Center in San Angelo, Texas, a town of more than 100,000 in the western part of the state, is already feeling the pinch.

During the past few years, a local university changed its nursing program from an associate's degree program to a baccalaureate degree program, significantly affecting RN supply at the 409-licensed bed organization.

"There was a lag of supply, and increased demand with retirements and everything else that's going on in healthcare at this point," says Pam Bradshaw, DNP, MBA, RN, NEA-BC, CCRN-K, chief operating officer and chief nursing officer. "If you look at my organization, the average age of a nurse is approximately 48. So as the workforce ages and we have less people coming into healthcare, you're going to end up with this imbalance somewhere. And we don't have the pipeline to backfill it. I will say it does differ based on where you live. In a rural area, it's much harder to recruit and retain than it is if you were in a metropolitan area."

New graduates often head off to larger cities such as Dallas, Austin, or San Antonio in search of big-city experience, she says.

"Realistically, from a complexity and acuity perspective, we provide that same level of care. It's the appeal of the nightlife and the restaurants and the shopping that we battle," Bradshaw says.

Around 2015, in an effort to increase RN supply, Shannon turned to international nurses on long-term contracts through staffing agencies.

"We started relatively small, with about 15," Bradshaw says. "But we quickly realized that in order to accommodate growth, because we are a growing organization, and to accommodate the lack of supply, we really needed more."

Today, 60 of Shannon's over 600 nurses—or 10%—are international nurses on long-term contracts. Additionally, 5% of the nursing workforce is short-term temporary staff.

This is by no means a low-cost solution. Bradshaw estimates the organization spends about $10 million a year on temporary labor.

An agency nurse costs about two-and-a-half-times more per hour than a nurse who is hired directly by the hospital. Some of this cost is accounted for in the annual budget, but at the same time, the organization recognizes the need to evaluate cost avoidance opportunities to stay fiscally on track.

But the investment has enabled Shannon to maintain its quality of care, including a four-star rating by the Centers for Medicare & Medicaid services.

"We have some of the best quality that you'll find anywhere. We're in the top decile [for CMS measures] when you compare us to hospitals across the country. From a quality perspective, there's no issues," she says.

"I think there's no question that we're going to need more physicians than we have been historically producing, but I would agree with the assessment that the solution involves developing care providers across multiple disciplines." 

Bradshaw says the hope is that the international nurses will choose to stay on at Shannon once their two- to three-year contracts are complete.

"They're doing well," Bradshaw says, "and of course our goal is to retain them once we complete their contract."

To help increase the odds of retention, Shannon has created an inclusive culture that treats the international nurses just like its traditional staff nurses.

"If we have any sort of celebration or if we have an incentive that we offer, anything like that, they are eligible just like any other nurse would be. That's one of the ways to integrate them into the culture," Bradshaw says.

For example, a few months ago, an international nurse from the Caribbean won the Daisy Award for Extraordinary Nurses, a recognition that values the clinical skills and compassion of individual nurses.

Meaningful recognition programs are components of a healthy work environment, according to the American Association of Critical-Care Nurses, and research has shown that nurses nominated for the Daisy Award report lower rates of compassion fatigue.

"I'm optimistic that by the time our current contracts are done, we'll either retain those nurses or we'll have improved our local supply, which is something we're also working on," Bradshaw says.

New care models necessary

A 2017 study on behalf of the Association of American Medical Colleges predicts the U.S. will face a shortage of between 40,800 and 104,900 physicians by 2030.

However, a 2014 Institute of Medicine (now the National Academy of Medicine) report on the future of the healthcare workforce notes these projections are based on traditional healthcare delivery systems rather than newer models that include team-based care, advanced practice nurses, and physician assistants.

Spetz has a similar assessment.

"If you look at doctors only, there is a shortage coming, but if you recognize that NPs and PAs can do a lot, and I think they can do more than 25% [of the shortage differential] … there is a lot more they can do to fill the gaps," she says.

OhioHealth, the faith-based, not-for-profit health system in Columbus, has 11 hospitals, numerous ambulatory sites, and more than 200 physician offices serving a 47-county
service area in central Ohio.

"I describe a lot of the work we're doing as, ‘How do we try to get some of the work that needs to be done for our patients out of the exam room?'" says Hugh Thornhill, president of the
OhioHealth Physician Group, which employs over 700 physicians. "I'm trying to get a lot of that load off the physicians' shoulders, to have them move into a care team coaching role, plus taking care of our sickest of the sick patients."

Team-based care is essential to achieving this goal.

"More and more, our physicians are providing leadership for teams or providers that include folks from a variety of healthcare disciplines," says Bruce Vanderhoff, MD, MBA, senior vice president and chief medical officer at OhioHealth.

OhioHealth is achieving this, in part, by embracing the patient-centered medical home model. The organization has 39 primary care practices that are qualified for Comprehensive
Primary Care Plus (CPC+) under CMS.

"It is indeed a model of multidisciplinary care, but one that really enables our medical staff, our primary care physicians, to focus appropriately on their patients' care where their expertise and advanced knowledge is most needed," Vanderhoff says.

Additionally, OhioHealth is working to prepare physicians and other providers in this model of care through a partnership with Ohio University's Heritage College of Osteopathic Medicine. In 2014, the first group of 50 medical students began courses at the college's Dublin extension campus. The partnership expanded clinical, residency, and fellowship opportunities in central Ohio and through the OhioHealth system.

"They are a medical school whose history has been to support primary care, so we've worked very closely with them," Vanderhoff says. "Simultaneously, as we've worked to grow and expand the medical school class, we've worked with them to also develop training of some of
their advanced practice providers, very specifically, their physician assistant school."

The two organizations are also exploring similar work with the school's nurse practitioner program.

"The pipeline is a very important part that we have invested in. I think there's no question that we're going to need more physicians than we have been historically producing, but I would agree with the assessment that the solution involves developing care providers across multiple disciplines," he says.

OhioHealth hopes its commitment to team-based care will appeal to the providers who have trained in this collaborative care model.

"As we're going down the patient-centered medical home and the CPC+ journey, [we want to] hardwire that experience for our physicians through their residency training directly into our practices," Thornhill says. "If I'm finishing as a resident, and I know how it works in my residency program, I know if I go to another practice in OhioHealth, it will feel like that. It will have the same resources available."

Grow your own

Healthcare leaders at Fairview Health Services, a nonprofit health system with 11 hospitals and 56 primary care clinics in Minneapolis, recognize that investment in the clinician pipeline is essential to meeting the organization's needs.

"My point of view is there is both a skills shortage and a people shortage. What we're having to do to fill critical shortages—what we have to do to pipeline people in—it's a different game now," says Laura Beeth, system vice president of talent acquisition at Fairview. "We have to really balance our short-term recruitment with looking at incentives and sourcing, but we have to augment that with pipelines of really thought-out career pathways and academics."

At Fairview, this means prioritizing training for positions such as medical assistants, surgical techs, psychiatric associates, and nurses. The organization is doing this through registered apprentice programs, dual training, career pathways, local hiring strategies, and internship programs.

In 2015 and 2016, Fairview received two awards totaling $1,225,000 for apprenticeships grants from the U.S. Department of Labor to support 245 nurses and other healthcare workers to advance their careers, including moving from an ADN to a BSN.

To be recognized as a registered apprentice program by the DOL, programs must meet certain criteria such as 2,000 hours of on-the-job training, a progressive wage scale, and a specific number of hours of safety and training in addition to an academic credential.

"It can't just be they're learning something on the job. It has to be that they're getting a formalized credential, either a degree or something that has a test behind it, or a one-year program credential that's recognized nationally," explains Beeth. "We map out the competencies, and those competencies have to equate to that higher level of learning, higher level of wages, higher level of experience."

Currently, there are 126 employees in Fairview's apprenticeship programs.

"The idea of, ‘What are we doing to prepare for the future?' is really critical," says Carolyn Jacobson, chief human resources officer at Fairview. "The shortages right now are really challenging for our operational leaders. [We need to be] thinking about how we create programs and processes to continually build our talent pool so that our time to fill is as short as possible [to] lessen the impact on our operational areas."

This requires looking not just at the number of clinicians but their skills and experience as well.

One example of this is operating room nurses.

According to the 2014 Association of periOperative Registered Nurses Salary and Compensation Survey, approximately 13% of the 3,437 respondents were at least 60 years old; 38% were in their 50s; 27% in their 40s; and only 23% were under age 40. Of the perioperative nurses surveyed 64% planned to retire by 2022.

"In nursing, we're seeing some of the same trends, where you have older nurses in the operating room, older nurses in behavioral, older nurses in PACU," Beeth says.

That is why the organization has developed an internal program to train nurses in the perioperative specialty so that they can fill critical perioperative nursing vacancies within Fairview.

As part of the perioperative program, the cost of each nurse's education is paid and nurses earn a salary while they learn. The program includes classroom, lab, and clinical practicum and lasts about six months. Those who complete the program commit to working in an accepted position for a minimum of two years.

"Ninety percent of the nurses hired in our periop areas come from our internal operating room program," Beeth explains. "We run that program proactively several times a year, because as an aging workforce, people are exiting, but we're also training all year long on that. In addition, perioperative skills are not part of the prelicensure nursing curriculum while they attend college, so it is critical we have pipelines in place to teach these additional skills."

Beeth advises leaders not to overlook nursing students or new graduates as potential employment candidates.

"As the workforce ages and we have less people coming into healthcare, you're going to end up with this imbalance somewhere."

"Ideally everyone wants an experienced nurse—baccalaureate or above—but you have to be open to absolutely looking at new grads," she says. "You're not going to get out of this challenge without doing some work to invest in the new grad's journey to become a nurse," she says.

Last year, Fairview converted about 600 students, in nursing and other fields, to new hires.

"Those numbers are because you're working with them, people are familiar with them, and they want to hire them," she says.

This familiarity occurs in a few ways. Fairview has a formal summer nurse internship program for all newly hired nurses, in which nurses earn both academic credit and pay. Those students are also given conditional job offers a year in advance.

"That last year they're in school, we continue to place them in their clinical experience, and a high percent of those people are placed on the unit they're eventually going to work on," Beeth says.

All told, 46% of the students are hired in the same unit in which they interned.

The organization also tries to place students completing their capstones in an area of interest.

"Those are all deliberate attempts to place them here, and actually do it in a way that makes sense," Beeth says. "What we're seeing is a 50% decrease in cost for onboarding when those students are hired."

Once they begin working as fully licensed RNs, new nurses with under two years of experience are automatically enrolled in Fairview's nursing residency program.

Beyond nurses, Fairview collects its own data on 38 different healthcare job classes and compares it to other health systems in the state.

"We can see risks, we can see retention, we can see age bands, all those kinds of things," Beeth says.

In collaboration with her HR strategy leader, Beeth is also gathering information on how much is spent on contingent workforce, succession information, internal turnover, or days to fill a vacancy to better help other leaders understand what the workforce and its issues look like at Fairview.

"It is something that we talk about at our regular senior operations team meetings," says Jacobson.

The group discusses how many roles are open, what the organization is doing to make sure those openings are filled, how to best recruit candidates, and what is the mixture of experienced staff versus new staff.

"The balance of making sure we do have the appropriate workforce, both in the future as well as on the ground, and that we're keeping our retention high and our voluntary turnover low, is really what we're trying to work through across the whole system," she says. "This is the nuts and bolts of what our operations are dealing with, and in order to be a great HR partner, we need to make sure we're providing the right people, data, information, programs, and processes so our leaders can do their jobs."


Jennifer Thew, RN, is the senior nursing editor at HealthLeaders.

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