Factors such as engagement and leadership development play a larger role in nurse retention, HealthLeaders survey data shows.
Healthcare leaders in the March 2017 HealthLeaders Media Nursing Excellence Survey say that nurse retention (61%) and nurse recruitment (59%) are the top nursing challenges that their organizations are facing. The next level of responses are nurse engagement (35%) and nurse leadership development (33%).
Compensation requirements (26%) falls in the middle of the responses, indicating that money is not one of the main drivers in nurse employment, and that factors such as engagement and leadership development play a larger role in nurse retention.
One driver of nurse retention may involve the length of a typical nursing shift. According to our survey, nearly two-thirds of respondents (62%) say that the typical nursing shift in their organization is 12 hours, and another 29% indicate that the typical shift is eight hours.
Interestingly, the data reveals a correlation between longer nurse shift lengths and higher responses for nurse retention as a challenge.
For example, a greater share of respondents who say shift lengths are 12 hours mention nurse retention as a challenge (65%) than respondents who say shift lengths are eight hours (49%). This suggests that fatigue from longer shift lengths may be partly responsible for nurses leaving an organization.
Survey responses reveal the scope of the retention problem—while almost three quarters of respondents (71%) say that their organizations' RN turnover rate over the past 12 months is less than 20%, one-quarter (25%) of respondents indicate that their turnover rate is 20% or more.
This type of turnover could create difficulties for provider organizations because of the need to be in training mode, which disrupts productivity.
According to Jennifer Gentry, MSN, RN, NEA-BC, chief nursing officer at CHRISTUS Spohn Hospital Corpus Christi - Memorial and CHRISTUS Spohn Hospital Corpus Christi - Shoreline, part of the Texas-based CHRISTUS Spohn Health System with six hospitals and more than 15 medical clinics throughout southeast Texas, there are two main factors impacting nurse retention rates.
"I think that we, as healthcare organizations, need to better align with our schools of nursing. I don't believe that our nurses today are coming out of schools prepared for what the actual role of a professional nurse is. We see that with our nurses in the first year. They get here, they're overwhelmed, they didn't think it was going to be like this; it's a lot of work. They're just not prepared, and I think that's a big piece of losing the nurse in the first year," said Gentry.
"What I found interesting in the survey results, is that nurse leadership development is number four on the list regarding the top three nursing challenges in healthcare organizations."
"If we don't do strong nurse leadership development, then we're shooting ourselves in the foot when it comes to retention, recruitment, and engagement because those frontline nurse leaders, they're the key to all these things," Gentry said.
"They're the ones that are going to create the unit that the nurses want to be on—that strong work environment, those good work relationships, the teamwork, the engagement, the input. And if we're not developing those nurse leaders, then it will be difficult for us to make any improvement in any of those top three challenges."
We asked senior healthcare leaders about the core nursing challenges their organizations face. Here is a highlight from the survey.
According to the March 2017 HealthLeaders Media Nursing Excellence Survey, one-quarter (25%) of respondents indicate that their turnover rate is 20% or more. This type of turnover can create difficulties for provider organizations because of the need to be in training mode, which disrupts productivity. To address this challenge, provider organizations are employing a number of different tactics.
The top four tactics with which respondents say their organizations have had success in improving nurse retention are:
Fexible scheduling (53%)
Communication improvements (51%)
Orientation programs for new nurses (48%)
Salary increases for all nurses (48%)
The majority of responses fall in a relatively tight range between 38% and 53%. This is likely because providers may be implementing a broad array of tactics to improve nurse retention in recognition of the fact that successful retention is driven by an assortment of factors.
Note that several tactics are correlated with financial resources. For example, based on net patient revenue, a greater share of large organizations (72%) than small (51%) and medium organizations (50%) cite flexible scheduling as a successful tactic to improve nurse retention, and a greater share of large organizations (69%) than medium (51%) and small organizations (45%) mention orientation programs for new nurses.
Further, a greater share of large organizations (62%) than medium (44%) and small organizations (36%) cite tuition reimbursement for advanced education and certification programs as a successful tactic to improve nurse retention, and a greater share of large organizations (64%) than medium (51%) and small organizations (35%) mention shared governance.
One of the tactics with the fewest responses is retention bonuses for new nurses (14%). This either indicates that providers may have difficulty funding bonus programs, or that they find retention bonuses ineffective in improving retention over the longer term (or both). Evidence supporting the case for financial resources constraints as a factor can be found in the following data: based on net patient revenue, a greater share of large (21%) and medium organizations (19%) mention retention bonuses than small organizations (10%).
This article first appeared in the April 2017 issue of HealthLeaders magazine.
The steady march of merger, acquisition, and partnership (MAP) activity shows few signs of abatement, and the long list of factors contributing to healthcare industry consolidation—healthcare reform, the move to value-based care, and provider needs for greater scale and geographic coverage, to name just a few—continue to reshape the industry landscape.
However, unlike with last year's HealthLeaders MAP survey, we can no longer say that there are no mitigating factors with the potential to slow MAP activity. With a new administration in Washington promising to make significant changes to the healthcare industry, notably to repeal and replace the Patient Protection and Affordable Care Act, substantial change appears to be in the wind, and has the potential to bring a pause in MAP activity as providers await greater clarity from the administration.
According to the 2017 HealthLeaders Mergers, Acquisitions, and Partnerships Survey, for example, more than half (54%) of respondents say there are no changes to their organization's MAP plans because of the incoming Trump administration. Another 19% say they are putting some things on hold until they know more, and 9% are revising and updating some plans. No respondents (0%) say that their organization is making extensive changes to its plans.
"I don't think there's enough clarity out of the administration on the healthcare front to be able to pivot yet, and it's been such a short period of time that I'm not surprised to see people waiting to know more before reacting," says Kevin Griffin, MBA, senior vice president of financial planning and analysis at Novant Health, a nonprofit integrated healthcare network with 2,655-licensed beds, 14 medical centers, and approximately 1,500 physicians in more than 500 locations, based in Winston-Salem, North Carolina, and the lead advisor for this Intelligence Report.
Case for continued MAP growth
While 19% of respondents in our survey say they are putting some things on hold until they know more about the Trump administration's plans, several other survey data points reflect little if any diminishment in MAP appetite.
For example, 87% of respondents say that their organization's MAP plans for the next 12–18 months involve either exploring potential deals or completing deals underway, or both. The breakdown: 40% of respondents say that their organization will be both exploring potential deals and completing deals underway, 34% say they will be exploring potential deals, and 13% say they will be completing deals underway. Only 13% of respondents say they have no MAP plans, which is down 12 percentage points from 25% in last year's survey. These results indicate a continued positive trend for MAP activity.
Further, 61% of respondents expect their organizations' MAP activity to increase within the next three years, and 32% expect this to remain the same. Only 6% expect MAP activity to decrease, indicating that the overall trend will likely continue for some time. These results are nearly identical to last year's survey results, which were increase (63%), remain the same (33%), and decrease (3%).
A close examination of the data reveals that a greater share of physician organizations (67%) than health systems (61%) and hospitals (56%) expect MAP activity to increase, and a greater share of hospitals (41%) than health systems (30%) and physician organizations (27%) expect this activity to remain the same.
In addition, based on net patient revenue, a greater share of large organizations (72%) than small (55%) and medium organizations (54%) expect MAP activity to increase, and a greater share of medium (42%) and small organizations (37%) than large organizations (19%) expect this activity to remain the same.
Interestingly, there are some regional differences in expectations for MAP activity. For example, a greater share of respondents who say they expect MAP activity to increase are from the West (82%) than from the South (57%), Midwest (53%), and Northeast (53%), and a greater share of respondents who say they expect this activity to remain the same are from the Midwest (47%) than from the Northeast (37%), South (35%), and West (12%). Note that a greater share of respondents who say they expect this activity to decrease are from the Northeast (10%) and South (9%) than from the West (6%) and Midwest (0%).
Increases in MAP dollar value
Another indicator of MAP activity is the cumulative total dollar value of the mergers and acquisitions respondents say their organizations will be exploring over the next three years . While this year's results are relatively comparable to last year's survey, there appears to be a slight shift toward lower cumulative total dollar value. The shift becomes apparent when you aggregate some of the results, with the less than $50 million range being eight percentage points higher (61% versus 53%) than last year, and the $50 million and more range being eight percentage points lower (39% versus 47%).
However, while cumulative total dollar spend may be declining slightly, the survey results also indicate that the majority of respondents (55%) expect that the size of the merger and acquisition deals their organizations will pursue within the next three years will increase. Approximately one-third (34%) expect the dollar value to remain even, and only 12% expect the dollar value to decrease.
Looking into the data further, a greater share of physician organizations (68%) than hospitals (48%) and health systems (48%) expect the dollar value of the mergers and acquisitions their organization will be pursuing to increase, and a greater share of hospitals (44%) than health systems (35%) and physician organizations (25%) expect the dollar value to remain even. In addition, a greater share of health systems (17%) than hospitals (8%) and physician organizations (7%) expect the dollar value to decrease.
Based on net patient revenue, a greater share of small organizations (61%) than large (48%) and medium organizations (46%) expect the dollar value of the mergers and acquisitions their organization will be pursuing to increase, and a greater share of medium (46%) and small (34%) organizations than large organizations (22%) expect this to remain even. In addition, a greater share of large organizations (30%) than medium (8%) and small organizations (5%) expect the dollar value to decrease.
MAP organizational preferences
Survey responses indicate that the top three entities involved in respondents' most recent MAP activity are health systems (27%), physician practices (27%), and hospitals (20%), which represents 74% of the total MAP activity.
Interestingly, responses indicate that providers favor MAP activity with a provider from the same or a similar setting. For example, a greater share of health systems (35%) than hospitals (26%) and physician organizations (10%) say that their most recent MAP activity is with another health system, and a greater share of physician organizations (48%) than health systems (25%) and hospitals (16%) mention activity with physician practices. Further, a greater share of hospitals (37%) than health systems (17%) and physician organizations (7%) cite activity with another hospital, and a greater share of physician organizations (21%) than health systems (5%) and hospitals (3%) mention activity with another physician organization. These responses appear to indicate that providers have a preference for increasing scale along similar lines of business, and that increasing infrastructure diversity throughout the care continuum is currently a secondary strategy.
Looking forward to the next year, more than half of respondents (59%) say that their organization has a high interest in pursuing a physician practice through a MAP. The response for this type of entity is followed by a second tier of tightly clustered responses, including physician organization (30%), health system (27%), and hospital (26%). The strong response for physician practices is likely because primary care physicians are a key component of the continuum of care, and will play an increasingly important role in population health management and clinical integration efforts in the years to come.
Griffin suggests that, besides population health management and clinical integration efforts, there is another factor behind the high levels of physician organization interest in pursuing physician practices and other physician organizations.
"My hypothesis is that physician practices that wanted to be affiliated with health systems have largely happened by 2015 or 2016 in major markets, and I think the physician groups that are left are ones that generally don't want to be part of health systems. They value their independence, but my guess is they may not have the scale to compete against other physician groups or against the employed physician groups in the health systems. So these independent groups are starting to band together to build scale against the health systems in order to be able to compete with them.
"I think the low-hanging fruit for the healthcare systems has probably been harvested by now, and so the folks that are left and potentially able to do deals are probably fiercely independent. I would guess these are largely specialty groups as opposed to the primary care folks."
Objectives of MAP activity
Respondents indicate that the range of objectives driving their organizations' MAP planning or activity is exceptionally broad in nature. For example, nearly three-quarters of respondents (74%) report that the primary objective of their organizations' overall MAP planning or activity is both financial/operational and clinical/care delivery equally. Sixteen percent say that the primary objective is financial/operational and only 8% say that it is clinical/care delivery.
"Obviously, they're both critically important," says Griffin. "But I'm not surprised to see financial/operational a little bit more important right now, because it's always staring you in the face every day. Everyone is aware of the transition to value-based care and population health, but they're not living in that world every day yet, at least to the same extent that they're dealing with the fee-for-service, financial/operational, blocking-and-tackling world."
Looking at financial objectives specifically, respondents say that increasing market share within their geography (67%) is the top financial objective of their organizations' overall MAP planning or activity. However, there is a large group of responses in the second tier, suggesting that no single objective is responsible for driving MAP activity. This second group includes expanding geographic coverage (58%), improving financial stability (58%), improving position for payer negotiations (54%), and expanding position in care continuum (53%).
It probably comes as no surprise that a greater share of health systems (75%) than hospitals (62%) and physician organizations (59%) say that increasing market share within their geography is the top financial objective of their organizations' overall MAP planning or activity. Note that, while this is the top activity for health systems and hospitals, improving financial stability (74%) is the top activity for physician organizations.
Further, a greater share of health systems (70%) than physician organizations (53%) and hospitals (49%) mention expanding geographic coverage as being among the financial objectives of their organizations' overall MAP planning or activity. While this is the second-ranked activity for health systems, the second-ranked activity for physician organizations (68%) and hospitals (58%) is improving their position for payer negotiations.
According to respondents, the top three care delivery objectives of their organizations' overall MAP activity are improving position for population health management (69%), improving clinical integration (66%), and improving position for care delivery efficiencies (64%).
Griffin says that Novant Health is currently fine-tuning its strategy to focus on tactics other than just market share acquisition and building scale. "We're moving to things such as expanding geographic coverage. This would probably be our No. 1 goal in getting into other markets—while we do want to take market share in our markets, M&A is not necessarily going to drive that. But getting into expanded geographic coverage for diversification purposes, for population health purposes, that's going to be really important for us."
Notably, a greater share of health systems (75%) than physician organizations (68%) and hospitals (64%) mention improving their position for population health management as among the care delivery objectives of their organizations' overall MAP activity. Further, based on net patient revenue, a greater share of medium organizations (76%) than large (71%) and small organizations (64%) mention improving their position for population health management. Last, a greater share of nonprofit organizations (75%) than for-profit organizations (57%) cite this as well.
MAP activity type
Respondents were asked to describe the nature of their most recent MAP activity. The top responses are an acquisition of one organization by another (37%), a contractual relationship, but not M&A (33%), and a merger of two organizations into one (10%). Only 14% of respondents say that their organization has had no activity. Note that non-M&A partnerships are expected to grow over the next few years because it is typically less expensive than traditional M&A and doesn't require an exchange of assets or a change of local governance.
"I do think health systems and hospitals understand that they need to do something but don't want to give up control and financial flexibility at this time," says Griffin. "For example, we have a shared services division that provides management services and other services for about eight or nine hospitals around the Southeast, and I think those folks know they need some help but aren't yet ready to raise their hand and lose local control. And I think many health systems and hospitals have started going down that road a little bit by creating soft relationships maybe to position themselves for what they may need to do but aren't ready to pull the trigger on yet."
Interestingly, M&A activity based on the acquisition of one organization by another is correlated with organizational size. For example, based on net patient revenue, a greater share of large organizations (50%) than small (36%) and medium organizations (31%) mention this kind of activity. Organizational size is also correlated with a merger of two organizations into one, with a greater share of large organizations (18%) than small (7%) and medium organizations (7%) citing this activity. This is likely because larger organizations have the necessary financial resources to support such transactions.
Among respondents who mention a contractual relationship, but not M&A, the top responses for contractual relationship types are affiliation, collaboration, or alliance (47%); joint operating agreement (21%); and professional service agreement (17%). Other joint venture (8%) and joint venture with change of ownership (6%) complete the list of responses.
Note that affiliation, collaboration, or alliance likely receives a high response because this type of agreement is simpler, more flexible, and requires less commitment than a joint operating agreement or joint venture with change of ownership.
Why MAP deals fall apart
When providers enter into MAP negotiations, there are no guarantees that a formal agreement will be concluded. In fact, there are a number of ways that a potential deal can be derailed.
For example, approximately one-quarter (23%) of respondents say that concern about assumption of liabilities is the top financial reason that a MAP involving their organization was abandoned before or during the due diligence phase Note that the full extent of a target organization's financial liabilities may not be apparent until the due diligence phase is completed, which may explain why this important aspect plays a major role as a deal-breaker.
Rounding out the top financial responses for abandoning a deal were concern about price (20%) and regulatory issues (18%). It is worth mentioning that 18% of respondents report that their organization did not abandon the negotiations.
Respondents say that the top operational reasons that a MAP involving their organization was abandoned before or during the due diligence phase was concern about governance (30%), incompatible cultures (27%), mistrust between parties (23%), and concern about the operational transition plan (21%). Only 9% of respondents say that their organization did not abandon negotiations.
Digging into the data reveals that a greater share of physician organizations (58%) than health systems (25%) and hospitals (17%) mention shared governance, and a greater share of hospitals (37%) than physician organizations (29%) and health systems (22%) cite incompatible cultures. Further, a greater share of physician organizations (38%) than hospitals (17%) and health systems (16%) mention concern about the operational transition plan.
Importance of an aligned culture
While there are many financial and operational challenges to overcome during any MAP negotiation, perhaps the most important aspect during the due diligence phase is determining whether alignment exists between the cultures of the respective organizations. Without alignment, a MAP will be destined for failure.
Griffin outlines some of the key considerations. "One, is the management team compatible and do they think about delivering care, which, in our case, we call 'delivering the remarkable patient experience.' Do they believe in that every day? And second, is everyone aligned in what we're trying to do? That, at the end of the day, we're a not-for-profit mission-driven organization just like they are."
Senior healthcare leaders surveyed about their top nursing challenges shine a spotlight on the unique dichotomy of nursing staff responsibilities.
According to the March 2017 HealthLeaders Media Nursing Excellence Survey, healthcare leaders say that nursing staff performance is measured using tools that are both clinical and nonclinical in nature, demonstrating the unique dichotomy of nursing staff responsibility.
Survey respondents indicate that the primary method of tracking and measuring nursing staff performance at their organizations is HCAHPS or other CMS surveys (76%). This is followed by post discharge phone calls (50%), in-house survey activity (non-CMS) (46%), and Press Ganey (45%).
Note that the top two responses are used mainly to track nurse performance in terms of patient experience and satisfaction, compared with the more clinically oriented measurement offered by the National Database of Nursing Quality Indicators (NDNQI) (42%), which falls in the middle of the response range.
"In our organization, we measure compliance with the bedside shift report, purposeful rounding, as well as the things we measure through the nursing domain of HCAHPS," says Jennifer Gentry, MSN, RN, NEA-BC, chief nursing officer at CHRISTUS Spohn Hospital Corpus Christi - Memorial and CHRISTUS Spohn Hospital Corpus Christi - Shoreline, part of the Texas-based CHRISTUS Spohn Health System with six hospitals and more than 15 medical clinics throughout southeast Texas.
But she acknowledges that HCAHPS is flawed in terms of nursing's clinical mission, and that it is viewed mostly as a patient satisfaction survey by her staff. For this reason, CHRISTUS Spohn Health System also relies on the NDNQI tool.
Survey responses reveal that organizational size is correlated with how organizations track and measure the performance of their nursing staff.
For example, based on net patient revenue, a greater share of large (85%) organizations than medium (76%) and small (69%) organizations mention HCAHPS or other CMS surveys as ways to track and measure the performance, and a greater share of large organizations (59%) than medium (49%) and small organizations (49%) cite postdischarge phone calls. Further, a greater share of medium (56%) and large (56%) organizations than small (37%) organizations mention Press Ganey, and a greater share of medium (53%) and large organizations (51%) than small organizations (31%) cite the NDNQI.
Note that the one exception to the organizational size correlation is for in-house survey activity (non-CMS) where, based on net patient revenue, a greater share of small organizations (55%) than medium (43%) and large (28%) organizations mention it as a way to track and measure nursing staff performance.
This is likely because small organizations, due to their smaller footprint and lower nursing staff levels, may more easily track nurses using in-house staff than larger organizations that have more locations and higher nursing staff levels.
How do you track and measure the performance of your organization's nursing staff?
Source: HealthLeaders Media Intelligence Report, Nursing Excellence: Leadership Development, Culture, and Retention; March 2017.
A tug-of-war between nonclinical and clinical nursing requirements exemplifies one of the core nursing challenges—delivering improved outcomes to satisfied patient-consumers.
In the HealthLeaders 2017 Annual Industry Outlook Survey, senior healthcare leaders were asked about the challenges their organizations face as they transition to value-based care.
To successfully execute on their mission, provider organizations must run at optimal levels. This is an especially complex organizational undertaking given the industry's transition to new care delivery and payment models and an ever-changing regulatory environment.
However, the good news according to the January/February 2017 HealthLeaders Media Annual Industry Outlook Survey is that respondents generally report positive reviews of the overall organizational performance of specific groups and individuals in their organizations.
Organizational performance excellence starts at the top, and 43% of respondents rate their CEO's performance as very strong, making CEOs the top performing group/individuals.
The result is up four percentage points over last year's survey (39%). Thirty percent of respondents rate the leadership team's performance as very strong, giving it the second-highest response.
The groups receiving the lowest responses for very strong are data analytics staff (10%) and IT staff (15%). While only 6% of CEOs and 11% non-CEOs say data analytics staff performance is very strong, 46% of CEOs and 26% of non-CEOs indicate that performance is strong, leading to an overall rating of 28%.
Last year, the response for data analytics for very strong was just 8%, indicating that progress in this important area has been slow in coming.
In a similar vein, while only 17% of CEOs and 15% of non-CEOs say IT staff performance is very strong, 46% of CEOs and 35% of non-CEOs indicate that performance is strong, leading to an overall 36% rating for strong. Last year, the response for IT staff for very strong was 11%, four percentage points lower than in this year's survey.
Looking at organizational performance more broadly, nearly three-quarters (71%) of respondents say that their prospects for growth are very strong or strong, with responses for fiscal management (67%), collaboration/relationships with providers (62%), and strategic planning (61%) following closely behind.
A greater share of CEOs (80%) than non-CEOs (70%) say their organization's prospects for growth are very strong or strong, and a greater share of CEOs (80%) than non-CEOs (65%) rate their organization's fiscal management as very strong or strong.
The area receiving the lowest response for very strong or strong is price transparency (33%), which continues to be a challenge for the industry. Based on net patient revenue, a greater share of small organizations (37%) than medium (28%) and large (26%) organizations say price transparency is strong or very strong.
And a greater share of rural organizations (44%) than non-rural organizations (14%) say this.
Along with managing the transition to value-based care, provider organizations must focus on enhancing care coordination, optimizing financial performance, and driving organizational performance in order to remain viable.
Download the free full report, Annual Industry Outlook: The Road to Value-Based Care, to read the results and a detailed analysis from our senior research analyst, Jonathan Bees.
Leadership development and engagement empower nurses for professional success.
This article first appeared in the March 2017 issue of HealthLeaders magazine.
Nursing is an exceedingly demanding profession, typified by long hours and a high-stress work environment as nurses provide care and respond to a multitude of patient needs. But while their role is mostly clinical, increasingly it is also part care coordinator, social worker, therapist, teacher, customer service professional, and executive.
This tug-of-war between nonclinical and clinical requirements exemplifies one of the core challenges facing the nursing profession—delivering improved outcomes to satisfied patient-consumers. A quick look at nurse performance measurement is revealing. Notably, 76% of respondents in our survey say HCAHPS or other CMS surveys are the top nurse performance measurement tools used at their organizations, measuring mostly nonclinical nursing activities. Given that nurses typically remain dedicated to the clinical side of providing care, it is somewhat surprising that a tool such as the National Database of Nursing Quality Indicators (NDNQI) (42%) finishes in the midtier of responses.
Top nursing challenges
Respondents in our survey say that nurse retention (61%) and nurse recruitment (59%) are the top nursing challenges that their organizations are facing. The next level of responses are nurse engagement (35%) and nurse leadership development (33%). Note that compensation requirements (26%) falls in the middle of the responses, indicating that money is not one of the main drivers in nurse employment, and that factors such as engagement and leadership development play a larger role in nurse retention.
Survey responses reveal the scope of the retention problem—while almost three quarters of respondents (71%) say that their organizations' RN turnover rate over the past 12 months is less than 20%, one-quarter (25%) of respondents indicate that their turnover rate is 20% or more. This type of turnover could create difficulties for provider organizations because of the need to be in training mode, which disrupts productivity.
According to Jennifer Gentry, MSN, RN, NEA-BC, chief nursing officer at CHRISTUS Spohn Hospital Corpus Christi - Memorial and CHRISTUS Spohn Hospital Corpus Christi - Shoreline, part of the Texas–based CHRISTUS Spohn Health System, with six hospitals and more than 15 medical clinics throughout southeast Texas, and the lead advisor for this Intelligence Report, there are two main factors impacting nurse retention rates.
"I think that we, as healthcare organizations, need to better align with our schools of nursing. I don't believe that our nurses today are coming out of schools prepared for what the actual role of a professional nurse is. We see that with our nurses in the first year. They get here, they're overwhelmed, they didn't think it was going to be like this; it's a lot of work. They're just not prepared, and I think that's a big piece of losing the nurse in the first year.
"What I found interesting in the survey results is that nurse leadership development is number four on the list regarding the top three nursing challenges in healthcare organizations. If we don't do strong nurse leadership development, then we're shooting ourselves in the foot when it comes to retention, recruitment, and engagement, because those frontline nurse leaders, they're the key to all these things. They're the ones that are going to create the unit that the nurses want to be on—that strong work environment, those good work relationships, the teamwork, the engagement, the input. And if we're not developing those nurse leaders, then it will be difficult for us to make any improvement in any of those top three challenges."
Tactics to improve nurse retention
The top four tactics with which respondents say their organizations have had success in improving nurse retention are flexible scheduling (53%), communication improvements (51%), orientation programs for new nurses (48%), and salary increases for all nurses (48%). The majority of responses fall in a relatively tight range between 38% and 53%. This is likely because providers may be implementing a broad array of tactics to improve nurse retention in recognition of the fact that successful retention is driven by an assortment of factors.
One of the tactics with the fewest responses is retention bonuses for new nurses (14%). This either indicates that providers may have difficulty funding bonus programs, or that they find retention bonuses ineffective in improving retention over the longer term (or both). Evidence supporting the case for financial resources constraints as a factor can be found in the following data: Based on net patient revenue, a greater share of large (21%) and medium (19%) organizations mention retention bonuses than small (10%) organizations.
"I have to say that this has been my own experience," says Gentry. "I have two emergency departments that report to me. Texas is not a certificate-of-need state, and we had stand-alone, freestanding ERs popping up all over town over the last couple of years. And they can pay more than I can even think about paying. And so we offered retention bonuses as a counter to try to keep those nurses with us, and it came with a two-year commitment.
"What I found ironic is one of my EDs was a very stable ED and had little turnover for years—great teamwork, great work environment, good working relationships with the physicians, good relationships with patients. Everybody took the retention bonus, and the only people who didn't stay for their two years had circumstances that were completely beyond their control. Now, the other ED, which was not mine at the time, had only about half the nurses accept the retention bonus, and out of those that accepted the retention bonus, only about half of those even stayed for the two years. And the reasons they cited for leaving were all of the reasons [cited in the HealthLeaders Media survey] except the retention bonus. So that money made absolutely no difference to them—they wanted other things to be fixed for them to stay."
Tactics to improve shift coverage
It perhaps comes as no surprise that one of the drawbacks of high nurse turnover is shift coverage problems caused by nursing staff shortages. The top tactic that respondents say their organizations use to successfully address shift coverage problems caused by nursing staff shortages is overtime (78%), followed by flexible scheduling (55%) and internal float pools (49%). The use of agency nurses (42%) and travel nurses (32%) round out the list of tactics.
Impact of value-based care
The majority of respondents (54%) expect that the impact from the transition from fee-for-service to value-based care at their organization will either have a major positive impact (18%) or a minor positive impact (36%) on nursing performance. A far more modest number (20%) of respondents expect that this will have a major negative impact (6%) or a minor negative impact (14%). Another 12% say they expect it will have no impact, and 13% don't know.
The importance of organizational culture
Nearly one-third (32%) of respondents say that difficulty changing organizational culture is the biggest stumbling block to creating an effective nursing program at their organization.
To Gentry, creating a good nursing culture begins with providing a professional career path for nurses. "It begins with really working on professional development of the nurses. Our nurses understand their professional responsibility and accept that professional responsibility. It's that the nursing profession is not just about a job; it's not just about coming in and clocking in and out. They have a responsibility to their profession, to their license, to excellent patient care, to improving outcomes, to process improvement, all of those things. And we try to balance that professional expectation and professional development with the limitations of the current financial landscape."
HealthLeaders' Annual Industry Outlook Survey asked senior healthcare executives about the challenges of transitioning to value-based care, about their care continuum and financial strategies, and about organizational performance.
Healthcare leaders see value in both informal and formal relationships as they develop organizational strategic plans for the care continuum, according to the January/February 2017 HealthLeaders Annual Industry Outlook Survey.
When asked about care continuum and postacute care organizational plans, survey respondents mention looking to develop stronger relationships (67%), followed by looking to partner with providers (55%) and looking to acquire providers (22%).
The responses are inversely correlated with the level of commitment required by their organizations, indicating that respondents see value in more informal relationships and recognize that care continuum and postacute care plans don't necessarily require spending financial resources or entering into complex agreements.
"This shows that folks understand that to move to value you have to have better handoffs, better coordination of care, but the other thing is, you don't have to own everything," says Mark Laney, MD, CEO of Mosaic Life Care, a St. Joseph, Missouri-based health system with more than 60 clinical facilities serving a 23-county area of northwest Missouri, northeast Kansas, and southeast Nebraska. "It's a great realization that there's a lot of ways to provide seamless care and you don't necessarily have to own all of it."
Financial resources, however, may also play a role in the degree to which respondent organizations seek to acquire providers in the care continuum.
Based on net patient revenue, more large (31%) and medium (27%) organizations than small organizations (17%) say they are looking to acquire providers. And financial resources also impact the degree to which respondents say they are looking to partner with providers, with more large organizations (69%) than small (57%) and medium (51%) organizations saying this.
Interestingly, respondents who cite looking to acquire providers indicate they have a greater share of value-based net patient revenue (27%) than those who mention looking to partner with providers (19%) and those looking to develop stronger relationships (18%).
Respondents who say care continuum and postacute care plans are not a significant part of their business have the lowest value-based net patient revenue percentage (7%).
This indicates that as providers make increasingly greater commitments to value-based care, such as owning parts of the continuum associated with postacute care, there is a corresponding increase in value-based net patient revenue.
As the healthcare industry continues its steady metamorphosis from a fee-for-service to value-based model, the stakes keep getting higher for those lagging behind. Along with managing the transition to value-based care, provider organizations must focus on enhancing care coordination, optimizing financial performance, and driving organizational performance.
