With Barack Obama's inauguration upon us, policy wonks are itching to get started on an overhaul of the U.S. healthcare system. This roundup presented in the Wall Street Journal's health blog outlines some of the proposals made by Health Affairs.

Everyone knows that tired old saying, "when it rains, it pours." But how did that saying come into existence?

After all, it's not even true. As I'm sitting here next to my window, writing this column, it's clearly raining, but it's definitely not pouring. In fact, it's only a slight mist—some might even call it a heavy fog. Earlier today it rained harder than it's raining now, but even then it wasn't quite pouring. A steady, soaking rain, maybe. So who cares, right?

Well, bear with me, because I think you do. That saying isn't really about rain at all, is it? It's really about bad things that happen to you that are outside your control, and the tendency of such events to group together. Maybe you feel like you could deal with one problem at a time, but when they "pour" on you all at once, you've really got some bailing to do to keep your boat afloat. Sort of like dealing with the current financial crisis, denials, RAC audits, slow payers, no-payers, and other challenges that are affecting healthcare much more swiftly and deeply than they used to.

Now we're getting somewhere.

I've talked to a lot of smart folks over the past few months about what this crisis is doing to healthcare in general and hospitals in particular, and none has used the phrase about rain. But I keep thinking about it as I hear them recite the litany of troubles affecting their professional lives. Like a bad song, it keeps turning over in my head.

Whether you're a CEO, CFO, or anyone else in a hospital leadership position, cash on hand is king with a capital K. One person in the know told me the other day that a hospital CFO she talked to told her his cash on hand dwindled by half in the last days of 2008 as he dealt with a tremendous slowdown in pay speed from commercial insurers and a big increase in denials. It's a vicious cycle. Then hospitals have to lay off staff and slow-pay vendors themselves. It's easy to see how a recession builds on itself. You're dealing with declines in patient volumes due to softening on elective procedures. Your payer mix might be changing. In some areas where the weaker players are shutting down, your Medicaid volumes are likely increasing. You're dealing with contraction of the market in hospital spending. In any case, the status quo is no longer effective and you're making drastic, gut-wrenching decisions.

At the same time, you still have to spend on information systems, productivity measures, and other ways to hold your cash longer and get what you're owed in the door. So in financial terms, the weather's bad and getting worse. I, for one, don't envy your job in this financial climate.

Just keep your wits about you and do your best to stay on top of what this mess is doing to your hospital so that when it's raining, and pouring, you won't be the old man who's snoring.

Last year marked the worst job market since 1945—2.6 million jobs were lost in 2008. The end of last year was particularly challenging—the unemployment rate rose to 7.2% in December from 6.7% in November, and roughly 500,000 jobs were lost in both November and December. The healthcare industry wasn't immune to job market losses, either; during the past few months, the number of hospitals and health systems laying off employees—mostly nonclinical staff—has been staggering.

So I wasn't too surprised to read that leaders at Mercy Hospital Medical Center in Des Moines, IA, were looking for volunteers to switch to part-time status or retire early. Employees have until January 19 to decide. Staff members who do volunteer to resign will receive two weeks' pay for each year they worked at the company along with a bonus week of pay.

I'm just not sure how many employees will actually take the offer. One of the side effects of this recession may be that employees who were planning to retire or work less hours are no longer able to do so. And the uncertainty of the job market may mean that few are willing to gamble on finding work elsewhere. In some instances, this could be good news for healthcare, if it means that physicians and nurses are going to stick around longer. Many regions are still being negatively impacted by work force shortages in healthcare.

And for those employees who are now forced to work a few extra years, having job flexibility will probably be one of their top concerns. If healthcare organizations want to keep these employees happy and remain attractive to new recruits in 2009, developing flexible staffing plans will be essential.

Flexibility is one of the keys to retention, says Jonathan Liepe, director of staffing services at Memorial Health System in Colorado Springs, CO. For example, if you get hired by a hospital as a night and weekend nurse and realize that you are stuck there until a daytime position opens up—which could take years—you probably won't stay very long. "That is where many hospitals have dropped the ball," says Liepe. Employees are more likely to stay in an organization if they can adjust their schedules based on work-life balance, and if they have opportunities to grow their skill sets and advance their careers.

That's one of the reasons Memorial Health has structured its internal staffing agency without too many restrictions. "We are able to garner those nurses looking for more work-life balance—trying to raise a family or getting close to retirement—so it allows them to pick and choose when they are available," Liepe says, adding that they can also choose where they'd like to work. This is different than other hospital internal float pools that force employees to work a specific set of hours and assign the job orders to them. Aside from a small number of nurses who must maintain a certain number of hours to receive benefits, there are no minimum hour requirements, Liepe explains. Employees are expected, however, to work enough hours to maintain their skill sets either at Memorial Health or through other clinical jobs in the community, he adds.

Being able to choose what unit they'd like to work on also appeals to those nurses and employees who like the variety that the float pool can offer by being able to work in different departments and units.

When it comes to staffing efficiency, Liepe has helped transform the three-hospital system's antiquated paper-based staffing process to an automated system that enables the central staffing office, unit directors, and employees to all see what shifts need to be filled and what credentials are required. The system has also helped Memorial Health reduce its reliance on contract labor.

Executives like the system because they can view contract labor costs in real time, rather than being blindsided at the end of the month, Liepe says. In addition, unit managers can also use the system to view the internal or agency candidates and choose the best person based on qualifications, experience working on that particular unit, and cost, which can lead to better quality and patient safety.

The system, from ShiftWise, helped the hospital save roughly $800,000 in 2007 on staffing costs, and it was on target to see similar savings (if not better) in 2008.

The hospital has also started its own internal travel healthcare professional position. It reaches out to professionals who only like to do travel assignments, and hires them directly for the 13-week or 26-week contract. Most of these employees are travelers who have worked with the health system in the past. Summers in Colorado and winters in Florida—it doesn't get more flexible that.