The healthcare reform law is a source of confusion around insuring diverse populations of hospital employees, making compliance complicated—unless you understand three things.
The PPACA means many things to many people and organizations: controversy, fear, confusion. There are few industries where these reactions resonate more strongly than in healthcare.
Not only does the PPACA transform multiple elements of the American healthcare industry, but for healthcare employers, it creates confusion around insuring diverse populations of hospital employees.
Catherine E. Livingston
"There are no legal…. differences [between healthcare and non-healthcare employers regarding insuring employees], but it may be that hospitals and health systems have a very complicated workforce, composed of everything from minimum wage employees… up to the most highly trained technical professionals," says Catherine E. Livingston, a partner with Jones Daylaw firm in Washington, DC.
"When you have a complex workforce with lots of different categories of workers, working lots of different schedules, complying with the employer mandate becomes very complex."
Here are three things healthcare employers should be aware of regarding the complexity of insuring healthcare employees.
1. Size Matters In the eyes of the US government, being a larger organization means being responsible for insuring employees. "The Affordable Care Act creates an employer mandate—a penalty—that can apply to employers of a certain size that fail to offer good, affordable coverage to their full time employees," says Livingston. "Virtually any hospital or health system is going to be large enough to be subject to that penalty."
The threshold for being required to provide adequate coverage is fifty full-time employees or the equivalent, which even most small hospitals will easily exceed.
Hospitals and health systems must pay attention to the employer mandate, unless they have fewer under 50 full-time employees. To be in compliance, organizations must "offer coverage to avoid the penalty, plan for the possibility of the penalty, and also take account of the new IRS information reporting requirements that apply to all employers," says Livingston.
Healthcare employers might not be very different legally from other large employers, but the variation within a single organization among employee roles, schedules, compensation, and skill levels is fairly unique to healthcare, Livingston says.
2. Seasonal Means Seasonal If your hospital is in an area with a seasonally variable population, such as a resort or college town, seasonal or part time employees such locum tenens physicians, travel nurses, and even temporary employees in non-clinical areas can be a huge relief. One benefit of such arrangements is not having to extend benefits such as health insurance to these workers.
But think twice and ask yourself: does the government consider this employee to be seasonal? "In the regulations that implement the [PPACA] employer mandate, there are specific definitions, including a definition of seasonal employees," says Livingston.
Moving forward, neglecting to offer a regular employee health insurance could lead to facing a penalty under the PPACA. Mistakenly misclassifying an employee as seasonal when she should have been a regular employee is not an excuse the IRS will accept.
The technical definition of a seasonal employee is someone who's annual employment is four months or less. So, if an employee works for your organization more than 120 days yearly, this employee isn't seasonal. Be sure to cap seasonal work at 120 days or the equivalent.
3. The 'Cadillac Tax' is Coming. Get Ready. One of the most controversial parts of the PPACA is the so-called "Cadillac Tax," a payment by employers of a non-deductible tax on high-cost employer sponsored health coverage.
The amount of this tax is currently slated to be 40% of the cost of health coverage that exceeds predetermined threshold amounts. The threshold where the tax is invoked is currently set at $10,200 for individual coverage, $27,500 for family coverage, with some exceptions. These thresholds will be reevaluated in 2018, when the tax takes effect.
Some hospital leaders may decide to delay thinking about the tax until after the next election, but Livingston says this is a risky course of action. "There is no guarantee [it will be repealed], and the tax goes into effect in 2018. In order to prepare to deal with it, you need some lead time," she warns.
Ask your insurer or plan administrator what the projections are regarding whether or not your organization's plan costs will exceed the thresholds, then play out the projections through 2021.
Knowing whether or not your organization is likely to trigger the tax can help both your organization and your insurer to better design plans that will fit your organization's needs, taking into account whether or not the organization is comfortable paying the tax.
"If you think the cost of your coverage is going to cross those thresholds, you have to plan for the possibility that you're not only going to have the cost of the coverage, but the excise tax on the cost of coverage that exceeds the threshold—and 40% is a substantial rate," says Livingston.
But with the election looming next year, no one knows what the future holds for the PPACA. Several candidates have expressed a desire to either repeal it or give it an overhaul. So, anything could happen—which is why it's important to keep an eye on politics and see how things play out in upcoming elections.
HealthLeaders Media Council members cite clinical and business data integration, EHR interoperability, and data accuracy as their top data-related analytics challenges over the next three years.
This article appears in the October 2015 issue of HealthLeaders magazine.
Linda Butler, MD
Vice President of Medical Affairs
and Chief Medical Officer
In our organization, we've seen many IT system changes over the past 18 months. We changed our materials management system to conform to other providers in the Triangle area, and we also switched both our revenue cycle and clinical EMRs to Epic.
One of our primary goals had been to have everything on one system in hopes that we would be able to run better reports and gain analytic insight in to costs and quality, but we found that this undertaking wasn't quite as easy as just making that transition. We've since realized that we needed a dedicated analytics team to properly extract the data, and then to figure out how to interpret it. Frankly, we're still on that journey.
The ten-year roadmap is similar to the draft released in January for public comment, but clarifies how technical standards are to be improved so that health data can be stored in a manner conducive for sharing among providers and patients.
The Department of Health and Human Services' Office of the National Coordinator for Health Information Technology released on Tuesday the final roadmap for electronic health information interoperability.
ONC officials in Washington, DC, presented the 10-year plan stressing "sameness," standards, and compatibility" via teleconference. "The roadmap is about action. It's not just about talking, it's not just about planning. It's about doing," said Erica Galvez, interoperability portfolio manager for ONC, describing how the federal agency intends the country's goals for health data sharing and interoperability to be achieved.
The document outlines a timeline for three implementation stages, each with its own overarching goal:
2015–2017
Send, receive, find and use priority data domains to improve health care quality and outcomes.
2018–2020 Expand data sources and users in the interoperable health IT ecosystem to improve health and lower cost.
2021–2024 Achieve nationwide interoperability to enable a learning health system, with the person at the center of a system that can continuously improve care, public health, and science through real-time data access.
Karen B. DeSalvo, MD
"By putting out this document today, the federal partners are saying these are the three big overarching commitments that we're making. This roadmap provides more specificity in how we're going to get to that place," said Karen B. DeSalvo, MD, national coordinator for health IT.
The roadmap is similar to the draft released in January for public comment, but clarifies how technical standards are to be improved and offers implementation guidance for priority data domains.
ONC identifies "four critical pathways" it says stakeholders should take toward storing health data in a manner suitable for sharing among providers and patients:
Improve technical standards and implementation guidance for priority data domains and associated elements. In the near-term, the Roadmap focuses on using commonly available standards, while pushing for greater implementation consistency and innovation associated with new standards and technology approaches, such as the use of APIs.
Rapidly shift and align federal, state, and commercial payment policies from fee-for-service to value-based models to stimulate the demand for interoperability.
Clarify and align federal and state privacy and security requirements that enable interoperability.
Coordinate among stakeholders to promote and align consistent policies and business practices that support interoperability and address those that impede interoperability
DeSalvo mentioned the importance of eliminating "information blocking" among vendors and providers, on the call, which she says impedes interoperability. "Different stakeholders across different ecosystems will have to do things in the same way—or in a compatible way." But the phrase appears only once within the 94-page document.
Providers and the Private Sector DeSalvo said that the final version of the roadmap was developed with input from the private sector. "We're going to really call in on the private sector to continue the work they're already doing, and to work hand-in-hand with us."
DeSalvo said providers may expect greater fluidity of data, so that records will be available from any provider a patient has visited. "Anything we can do to unblock data today and address interoperability is the kind of tangible change [providers] will feel, and… we believe that where there is data that can move, it should move."
In a statement issued late Tuesday, Bruce Siegel, president of America's Essential Hospitals, said, "The administration's interoperability roadmap moves us closer to the promise of the electronic health record. We agree with its three core commitments and will review the draft standards closely."
"Essential hospitals care for low-income and other vulnerable patients, who often face social and economic roadblocks to health care access and information: poverty, homelessness, language barriers, and low health literacy, for example," he continued. "It will be important to consider their needs and challenges to their care as we work toward an EHR that improves health care for all people."
Blair Childs, senior vice president of public affairs at Premier, Inc. said ONC's roadmap is "a significant leap forward in the national effort driving toward interoperability…We look forward to working with the administration to advance the technical standards, certification requirements, privacy/security standards and other initiatives that will enable true HIT interoperability. "
The roadmap, said DeSalvo, "describes what the federal partners see needs to happen by when, and by whom… It clearly spells out what we believe we can do." ONC will also ask stakeholders from the private sector to make a commitment to the plan at a public-facing event within the next week.
Don't let confusion around accommodation requests derail your hospital's personnel management strategy. Here are some common questions about workplace accommodations—and answers provided by an attorney.
Few duties are as anxiety-inducing as confronting an underperforming employee about behavioral or performance issues—except when that employee responds by saying they have a disability or health issue and asks for accommodation.
Even veteran HR leaders find disability accommodations to be a challenging, full of potential for missteps, misunderstandings, and abuse.
It helps to have access to a lawyer who can help guide you through the process. I talked with Heather Owen, a labor and employment lawyer with Constangy, Brooks, Smith & Prophete, LLP, which is headquartered in Atlanta. The transcript below has been edited for brevity and clarity.
Heather Owen
HealthLeaders Media: What are some common accommodations healthcare employees ask for under the ADA?
Heather Owen: In my experience, the most common accommodations revolve around back injuries, like restrictions on lifting less than a certain number of pounds or reaching over head.
A close second is time off as an accommodation. The Family and Medical Leave Act (FMLA) is pretty easy to deal with regarding time off, and everybody knows that they have to give time for FMLA purposes, but when it's exhausted or not available, attendance flexibility is one of the most common accommodation issues.
Of course, my perception may be a bit skewed, as it's related to what I get called to work on. In healthcare, those two are the toughest to deal with. Most healthcare jobs are very physical, and there are a fair number of back or strain injuries that are long term.
HLM: What are common sources of confusion around accommodation requests?
Owen: More often than not, it's not quite clear cut. I had a case in litigation recently where an employee claimed that telling their supervisor that they were "having a difficult time" and needed more time to get tasks done was a request for an accommodation. The employer certainly disagreed that this was a request for an accommodation.
HLM:Can you describe the process for triggering an accommodation? And what should a supervisor do if an employee seems to be having performance problems that could potentially be caused by an illness or disability?
Owen: There as two ways to trigger the interactive process of accommodation. The more obvious is where the employee has brought their health issue to the employer's attention and is requesting some sort of change in their workplace situation to help them deal with it—a fairly direct request for accommodation.
The second is where the supervisor may recognize that the employee is having a problem: it may be attendance, work, productivity, or something else of that nature— and the supervisor should have reason to believe that there is a health condition contributing to the problem.
The example we often give is someone who has been a good employee for many years, but suddenly starts having productivity or attendance issues, and their demeanor changes at work. A manager might not know why exactly, but they usually know something is going on.
You don't want to go up to this employee and ask, 'Is your health OK?' But I do encourage that you be prepared when addressing performance or behavioral issues to begin engaging in the interactive process. Have a meeting with the employee and say to them, 'I've been noticing X, Y, and Z behaviors. Can you tell me what's going on?'
You've left it very open ended. If the employee doesn't say anything, you did your job. But the employee will usually tell you what's going on. 'I'm under a lot of stress.' 'I've been diagnosed with X.' 'I'm having some difficulty.' And that is a trigger for the employer to discuss what accommodations may be available to help them perform or behave in a more appropriate way.
HLM: Mental health conditions seem to be on the rise. What kinds of accommodations are frequently requested by healthcare employees with mental health conditions, and what do HR leaders need to know about this?
Owen: Mental health is something we deal with a lot. It's difficult to lump mental health together; it covers a wide range of conditions. We've been seeing lots of requests for accommodations around ADD and ADHD. Lots of them have been shift requests. Stuff like, "I can only work day shift because my medication works better if I'm consistent with it, so I can't rotate shifts."
And we get a lot of "I can't do overtime, because my medication wears off," or "I can't work weekends," or "I can't be on-call." For obvious reasons, those restrictions are challenging in healthcare.
We've also had some very serious mental health issues where people have made serious errors that may impact patient care. In those situations we've had to provide leave of absence while the organization researches the situation and resolves it.
Here's an example I've seen: An employee suffered a back injury that had occurred outside of work. He was in pain for an extended period of time, and his organization developed a concern that the employee was taking a lot of pain medication and had become addicted.
Not only was the employee not as productive as he had been, but he began disappearing for long periods of time, saying odd things, and staring at his hands. He was generally engaging in concerning behavior not observed in the past—like staring at his computer screen, appearing mesmerized by the colors. His employer responded by removing him from work, because he just wasn't able to perform.
In these situations, I suggest that the employer write a detailed letter to the employee's healthcare provider along with requesting a fitness for duty evaluation. The typical fitness review form is great, and it asks good questions, but you just don't get the information you need because the healthcare provider sees the patient they've dealt with for years and thinks they're fine without recognizing that a problem has developed.
Describe in factual detail the behaviors that have caused this fitness-for-duty evaluation without mentioning that you suspect addiction or making any diagnosis. Ask that the doctor sign the letter and send it back to you.
This has been very effective. About 50% of the time, we never get the letter back—and then, you have grounds to terminate the employee. You do have to give them a couple of chances to get the fitness-for-duty form in, but many times the employee is never able to complete the request.
HLM: More states are permitting marijuana use to treat medical conditions such as Multiple Sclerosis or PTSD. Have you heard any rumblings about people asking for accommodation around medical marijuana?
Owen: Yes, this has been litigated a couple times now, mostly in district courts. So far, the answer is that it's not a reasonable accommodation to make exception to drug testing policy, as marijuana use is illegal under federal law. It's just not reasonable to ask an employer for an exception to federal law.
If there's an October surprise, it may be that the transition to ICD-10 went off without a hitch. For many organizations, however, the surprises will be less welcome and may take weeks or months to reveal themselves.
No matter how smoothly the switch to ICD-10 may have transpired, after 36 years of using ICD-9-CM as the backbone for payment data, reports, and diagnosis and inpatient procedure coding, healthcare there are bound to be a few problems, experts say.
Melanie Endicott
"Depending on how prepared the organization or facility is, they could see different issues," says Melanie Endicott, senior director of HIM practice excellence at theAmerican Health Information Management Association (AHIMA). "There are facilities out there that have been doing dual coding for a year or six months or longer. They've had lots of practice, and will be able to jump right in."
She cautions against overconfidence, however. "Some issues that weren't identified will come to light. That's why it's important to get onboard and get everything ready."
Lynne Thomas Gordon, CEO at AHIMA, agrees, and compares the adoption of the new coding system to having a baby. "As any parent would know, the real work begins after you have the baby. Similarly, we need to make sure the correct metrics are in place, see how we're doing with quality, and stay on top of productivity."
Lynne Thomas Gordon
Here are a few post-implementation ICD-10 problems providers may encounter:
Incorrect Code Mapping "The 'gotchas' will be [associated with] legacy systems people were attached to because they got the job done," says Thomas Selva, MD, chief medical information officer for University of Missouri Health Care. He recently oversaw his organization's ICD-10 implementation. For example, the EHR/EMR system may still be mapping to ICD-9-CM codes. "I can guarantee that will crop up." The trick will be to quickly identify whether this is happening and to be able to fix it promptly.
Another problem: Not all reports will generate the same data as before, and may need to be re-built. "It will take at least a year until people have enough data to compare apples to apples," says Gordon.
In the meantime, there may be a period of confusion as organizations adjust metrics from one coding system to the other.
"The best thing you can do is watch all of your reports," says Rhonda Buckholtz, vice president of ICD-10 training and education at the American Academy of Professional Coders (AAPC). "If you usually generate $100,000 daily in revenue, and now it's suddenly $50,000, there's a problem."
Rhonda Buckholtz
She recommends creating new denial codes to track where the problems are, and to expand rejection codes to cover new scenarios.
If incorrect mapping is suspected, contact any vendors involved and alert the IT team; it may take some time and hard work to reconfigure the systems, but it's necessary. If this goes unfixed, it can throw off metrics, billing, and reimbursements.
Denials Will a provider get paid for unspecified codes under ICD-10? This is the million dollar question, says Kerin Draak, director of ICD-10 implementation at Hospital Sisters Health System in Green Bay.
CMS has said it will not audit claims for specificity in the first year. But Draak anticipates a bump in denials around November for many organizations—even organizations where leadership painstakingly tried to cover all their bases with regards to both clinician and coder training.
And she's not alone. "[Physicians] must be careful when [they] code," says Alan L. Plummer, MD, vice president of the Physicians Foundation and professor of medicine at Emory University. "If they do that, they will have fewer denials… but by and large, denials will probably go up."
Kerin Draak
It should be noted that the grace period approved by Congress earlier this year may protect organizations from many errors committed by coders who are still coming up to speed. Denials are the source of real fear for providers, and they are the reason why many organizations have stressed training up until this point, say Gordon and Endicott.
But the training is not over. Even in a perfect world where coders and clinicians have absorbed everything they needed to know prior to implementation, there will be updates to keep up with yearly.
In the meantime, get in touch with payers and try to find out why the denials occurred. If the payer is unresponsive or the situation seems particularly dire, try reaching out to either an organization that is focused on healthcare technology, such as AHIMA, or the CMS ICD-10 ombudsman for help, Endicott suggests.
Productivity Drop For years, critics have opposed ICD-10 in part out of fears of lost productivity—and few deny that this is a valid concern. Many point to Canada's often-cited 67% drop in productivitywhen the country transitioned to ICD-10.
The lack of familiarity will come as a shock to many, says Selva. "If memorized codes were something someone was leaning on, this will cut their productivity… the biggest change will be when coders are reviewing physician notes."
Thomas Selva, MD
There is a concern shared by many that the level of specificity—and the sheer volume of codes—will prevent clinicians and coders from memorizing codes. "It will become much more complicated. There is a lot of fear right now regarding specificity. No one wants to be interrupted [to look something up] over and over again."
There's no easy solution for this one. The general consensus is that some loss of productivity is inevitable. "I think they'll be slower," says Draak.
But Buckholtz is more optimistic. "What we've seen from the coder standpoint is that after being trained for 40 to 80 hours, they do go back to old level of productivity," she says. She points out that coders will no longer have to do dual coding, which should be a relief to many departments.
Alan L. Plummer, MD
Time and practice will help clinicians and coders memorize codes they use frequently, and EHR/EMR systems that auto-populate codes will also help. Now, however, might be a good time for hospital leadership to evaluate staffing levels.
Emory's Plummer suggests pairing struggling physicians with practices coders to help them adjust to the new system. "If coders are available to work with them, that's the best thing—tell them, 'don't ask another physician, they probably don't know any more than you do.'"
Perhaps most importantly, very few experts believe patient care will be impacted by the move to ICD-10. "I can rest assured that at our facility, patient care is our chief concern. We'll do everything around that as our focus. Our quality won't go down," says Draak.
Most organizations have done their homework and have spent many resources training employees and preparing, and most of them can expect a fairly smooth transition, says Gordon. "I think people are ready."
Attending the American Society for Healthcare Human Resources Administration's annual conference is a reminder that professional conferences provide a platform for collaboration, which itself can lead to change, growth, and progress.
"Collaboration" has become a bit of a buzzword. Sometimes it feels as though it's presented as a magical secret ingredient that, if said frequently enough, will cause organizations to become resilient, creative, and successful overnight.
I can't offer any promises regarding the results of collaboration, knowledge sharing with colleagues, or teamwork, but I can say that there's nothing magical about it.
Alex MacLennan, PHR
Here's one example of how collaboration can help get an organization off the ground: many well-known companies including Facebook, Microsoft, Google, and Warby Parker were conceived while their founders were in college or graduate school. College campuses are popular birthplaces of companies because they bring together groups of people with similar interests and values, in an environment where there is lots of unstructured time.
Many students use this time to discuss ideas—their future goals and aspirations, attempts to solve common problems, and new ways to share ideas.
Think of professional events as a brief return to the college mindset. You are, if only for a short while, revisiting a situation where you are surrounded by others with similar interests to your own, with some unstructured time during which to exchange ideas.
I attended the American Society for Healthcare Human Resources Administration's annual conference in Orlando last week. In addition to the planned sessions and events, I discovered a potential hotbed for problem solving and creativity.
Here are a few things I observed about collaboration:
1. It Can Rekindle Excitement About HR and Healthcare "I come to [the ASHHRA conference] to be inspired," Alex MacLennan, PHR, Human Resources Director of the Tahoe Forest Health System in Truckee, California, told me during the Sunday morning keynote.
Becky Rauen
While MacLennan says he's never received a solution to a problem "out of the box" by attending a conference, he has developed ideas and learned more about problems other organizations are encountering, and how they've handled them.
MacLennan says he is reinvigorated after several days of collaboration at a conference, which, he says, "helps [him] to inspire and motivate [his] management team."
Becky Rauen, Director of Human Resources at Maple Grove Hospitalin Minnesota, says her time at ASHHRA served as a reminder about what's really important to her. "There are many ways attending this conference benefits us," she says, "but I think it's really about getting back to basics. Let's get back to the why—the purpose of what we do—that we're here for our patients."
2. It Leads to Problem Solving Gary Pastore, MSL, Director of Human Resources at Honor Health in Scottsdale, AZ, says he was surprised to learn during a forum at the conference that many organizations were facing similar challenges around managing physicians—and the solutions those organizations found for managing these issues. "I think I learned a lot about how we need to behave moving forward."
And it wasn't just him. Several attendees I spoke to said they encountered solutions to problems they had been mulling for months or years.
Gary Pastore, MSL
"I learned that we're not the only hospital facing the issues and problems we face," says Lisa Halley, MSHRD, SPHR, vice president of human resources at Holzer Health System in Gallipolis, OH. She believes she'll be able to apply information she learned in sessions and from other HR leaders at the conference.
3. It Creates Opportunities to Help Others Some of the most valuable time at conferences is simply time spent getting to know others in your field and comparing notes, says Jeremy Rogers, HR manager with Intermountain Healthcare in Provo, UT.
"I used to understand networking as, 'how do I get a leg up?' But it's really about helping each other, about mentoring and giving others in this profession opportunities, as others have given me," he says.
Rogers says he's met HR professionals at events he has later been able to introduce to management teams looking for new candidates. Through these connections, he was able to help both an organization find a top-notch candidate and help a colleague find a placement where he knew they would be happy.
Jeremy Rogers
"This kind of networking is about being able to reach out to others; it's about being able to refer others to opportunities."
Rogers took advantage of a session on emergency preparedness to get ideas for his hospital's emergency management program and generally compare notes with other HR leaders. "It's nice to be able to reach out to another HR professional sitting next to you and say, 'have you ever done this before?'"
There's no need to wait until the next national conference to take advantage of these kinds of activities; there are local chapters of professional organizations, groups on social media networks, and other opportunities available to meet with other HR leaders who will be able to relate to your interest and excitement around HR-related topics. If you're really craving the opportunity to spend time with other HR professionals, you could even look into creating a local meetup.
Chances are, someone else in your area will be grateful for the opportunity to network. "Sometimes, it's just being able to turn to the person next to you and know that they understand [when you] say, 'this is hard,'" says Rogers. "And then, being able to say, yeah, it's hard, but you can do it."
A healthcare economist's prescription for retaining RNs includes creating mentorship positions for older nurses and investing in employee development programs.
High turnover is undesirable in any department, but the pain can be especially when nurses leave. It's the nurse at the bedside that the patient remembers, and nurses often bring with them decades of versatile experience and wisdom that follow them out the door when they depart.
Since the beginning of the recession in 2008, nurse hiring has been a buyers' market with hospitals being able to demand higher credentials and more experience from nurse job candidates, says Peter McMenamin, PhD, senior policy fellow and healthcare economist with the American Nurses Associationin Silver Spring, MD—but that's about to change.
Peter McMenamin, PhD
"You used to see ads [for nursing positions] that said 'new graduates need not apply.' You don't see them as often anymore," says McMenamin. This is because 40% of practicing nurses are over the age of 55, with many reaching retirement age. Many of these nurses have been delaying retirement, but they can't hold off on retiring forever.
While the market seems to be in the process of correcting itself with more students graduating from nursing programs annually over the last few years, it will take time for those nurses to come up to speed and gain experience. In the meantime, there is a nurse shortage that will get worse before it gets better, and hospitals need to try hard to retain good nurses.
McMenamin has an unusual prescription for doing this.
"Although many hospitals have very narrow or negative margins, the hospital industry banks $15 billion per quarter because revenues are that much higher than expenses. That money is put into a financial reserve, and is often spent on acquisitions or building projects. I think a good idea is to consider many hospitals setting up a human capital reserves," he says.
Here are some areas to consider investing both financial and human capital in to cut back on turnover and improve retention.
Invest in Employee Development
Nurse retention is highest in hospitals that focus on developing nursing staff, McMenamin says; internal training and investing in employee education are sure-fire ways to keep employees engaged.
Employee development programs have gained popularity in recent years as increasing numbers of healthcare employers have realized the benefits of growing a nursing staff internally and the high cost of education has made college unreachable for more fulltime workers.
Another benefit of an internal program is that it's safe to say workers are a good cultural fit for the organization—plus, on-the-job investment in employee education is a strong mechanism for keeping staff on-board.
Create Mentorships
As older nurses leave, they take decades of nursing experience with them. Their replacements may have technical knowledge and book smarts, but lack hands-on, clinical experience. But there's are strategies for developing experienced nursing teams, says McMenamin.
He suggests that HR departments hire a few more newly-minted nurse graduates than they normally would. At the same time, nurses that are preparing for retirement should shift into roles that primarily focus on mentoring.
"This will extend some nurses' careers. They might not do as much at bedside, but they will still be valuable to your organization. As you hire on slightly more new grads 'than appropriate,' allow the older nurses to mentor them and pass their experience along. In just a few years, you will grow an experienced workforce."
Focus on Staffing Ratios
"If I feel beat up at end of shift, I won't feel good about myself, my job or my employer," says McMenamin. Staffing ratios are still an area of contention between nurses and hospital administration: some states, such as California, have passed laws ensuring a higher nurse-to-patient ratio, but many others allow this to hospital management's discretion.
For McMenamin, the choice is obvious.
"Better hospital staffing gets better results," says McMenamin. "Studies show higher nurse-to-patient ratio numbers have better results, fewer fines from CMS, lower readmissions, and hospital mortality goes down. There are statistically significant differences showing that more nurses equal better results. But, more pertinent to this topic, it also leads to higher levels of job satisfaction among the nurses."
Many nurses who work in environments with lower staffing ratios say they feel regret over not being able to better care for patients because they had too many, he says. "They often say they feel they could have done more," he explains. Conversely, when the staffing ratios are more appropriate, they report that they feel respected and engaged at work.
Of course, hospitals must weigh the benefits McMenamin mentions against the risks. Data shows that under mandated nurse-patient staffing ratios, patient safety benefits have not been clearly demonstrated. In California, where a similar law has been in effect for 11 years, hospital operating expenses have risen.
Ultimately, the key to hanging on to these in-demand employees is for HR departments is to make sure nurses feel valued, says McMenamin. "That kind of treatment will make a nurse want to work at that specific organization."
In our April 2015 Intelligence Report, healthcare leaders cited clinical and business data integration, EHR interoperability, and data accuracy as their top data-related analytics challenges over the next three years. HealthLeaders Media Council members discuss ways to improve analytics performance.
This article first appeared in the October 2015 issue of HealthLeaders magazine.
Linda Butler, MD
Vice President of Medical Affairs
and Chief Medical Officer
Rex Healthcare, Raleigh, NC
In our organization, we've seen many IT system changes over the past 18 months. We changed our materials management system to conform to other providers in the Triangle area, and we also switched both our revenue cycle and clinical EMRs to Epic.
One of our primary goals had been to have everything on one system in hopes that we would be able to run better reports and gain analytic insight in to costs and quality, but we found that this undertaking wasn't quite as easy as just making that transition. We've since realized that we needed a dedicated analytics team to properly extract the data, and then to figure out how to interpret it. Frankly, we're still on that journey.
There's a real challenge around data accuracy. When you're running a report, you need to put the right parameters in to get data that is meaningful. If you don't have the information entered correctly, then everything downstream will also be incorrect. We've found that when workers were inputting certain data fields, it was easy for them to make a mistake. Sometimes, they didn't understand the consequence of that mistake—the incorrect data feeds into other screens, into orders, and creates other data accuracy problems as well.
Marlene Weatherwax
Vice President and CFO
Columbus (IN)
Regional Health
We recently formed an accountable care organization with Schneck Medical Center in Seymour, Indiana, and are trying to clinically integrate all of our facilities. So far, both hospitals have their own separate electronic medical records, and the physician practices within our Columbus organization are also using an assortment of records systems. We've been trying to find a common data warehouse or repository that can track the clinical indicators that we want to focus on.
Our greatest challenge to improved data quality and analytics is that, currently, EMRs don't talk to each other. You have to implement something that interfaces with them and can accept information from disparate systems, and you have to work with various software vendors to get it, which is expensive to do.
I believe that improved analytics will enhance the care continuum. Our organization is starting this process with the employees of our own hospitals as we try to gather this information. As we see improvement among them, we're hoping we can go out and get other insurance companies and employers interested in using this network, as we'll have a proven track record in helping patients to manage most chronic diseases.
We're hoping that analytics will help us identify patients we see more frequently, or who would benefit from being paired up with a health coach to change some of their practices, and that we will be able to encourage them to live a healthier lifestyle.
Bobby Olm-Shipman
Vice President, Planning
and Project Management
Saint Luke's Health System
Kansas City, MS
The endgame is that we're all moving toward becoming value-based providers. I believe all of our analytics activities are really aiming toward various strategies to achieve that overarching goal.
Analytics and related programs fall in to three buckets: First, we're trying to get a better handle on our data across our enterprises. That includes across the continuum; we want data from hospitals, physician practices, other nonacute locations like ambulatory and retail centers. We're looking to get a good sense of data and a snapshot of what's going on clinically, financially, and around utilization from the entire continuum of care.
The second bucket is that of market intelligence. Historically, we have had a lot of good data relative to inpatient hospitals. But more and more, care is not delivered in the inpatient setting. To understand how many patients are seeking, say, diabetic care in an ambulatory setting or a physician office, that's becoming increasingly important as we craft our population health strategies.
Third—from an analytics perspective—is that we're really trying to turn the massive amounts of data into good useable, meaningful information in the right format that allows the execution of this overarching strategy of transformation. The goal is to use all of this information, which is fantastic, and get it to the right people so they can actually do something with it.
Bill Fenske
Chief Financial Officer
Rice Memorial Hospital
Willmar, MN
On interoperability: Organizationally, we're looking at how we can share clinical data with providers who may not be located at our physical location. As we send our patients out to tertiary care providers, we want to know they're ready to take care of the patient immediately upon arrival. I think one of the most important points of this process is to be able to improve the interoperability and accessibility of medical data as the patient moves across systems.
On resources: Interoperability is a significant challenge for a couple different reasons, and both are related to resources. The first is around having the proper tools to extract clinical data. The second is finding human resources with the ability and time to be able to learn to do that—and to be able to translate it into meaningful information.
On population health: I think there will be population health benefits of improved clinical data, but I believe those benefits are years down the road. But we've identified the need to integrate clinical and business data in analytics. What options might there be in terms of getting over further hurdles? How do we start working together to jointly understand clinical and business analytics related to a specific care delivery or population health model? It will be interesting to watch this develop.
Four senior healthcare executives open up about their searches for contractual relationships ranging from mergers and acquisitions, to partnerships and joint ownership agreements.
When providers engage in contractual relationships, they primarily fall in the merger and acquisition model. But other types of arrangements, such as joint ownership agreements and partnerships are not uncommon.
The path toward identifying the right business arrangement can take time and a great deal of effort. Four senior healthcare executives recently discussed their experiences the HealthLeaders magazine.
"Each acquisition gets easier than the last," said Robert Shapiro, executive VP and CFO of Northwell Health (formerly North Shore-LIJ Health System) in Great Neck, NY. "After you've done this enough times—the due diligence, the partnering, bringing two organizations together—you develop a sense of what we need to look at. There are fewer surprises down the road."
"I believe that there are more opportunities for regional collaboration than there have ever been in the past," said Jerry Birk, VP of Business Planning and Strategic Development at Rideout Health in Yuba City, CA. "The underlying premise is that we all have issues and problems, but often they are shared problems"
For Ministry Health in Appleton WI, a catholic organization freestanding Catholic hospitals in its lineage, "Cultural fit has always been the most important element of selecting partners for us," says Larry Sobal, VP of care transitions.
The job of HR and leadership is not to drive employees, says the manager of Vanderbilt University Medical Center's EAP; it's to support them and enforce work/life balance so employees can focus on what matters: patient quality and safety.
Emails sent after midnight with the expectation of an immediate response. Marathon conference calls on Thanksgiving Day and Easter Sunday. Employees crying at their desks from the relentless pressure. It's not a scene from a sensationalistic movie about Wall Street; it's day-to-day life in one of America's most beloved companies.
Last month, the New York Times exposed Amazon.com's grueling work environment, where employees are routinely pushed to their limits. Amazon's leadership defended its culture, saying it encourages innovation. But in healthcare, the Amazon approach would do much more harm than good, says Jim Kendall, manager of Work/Life Connections, Vanderbilt University Medical Center's Employee Assistance Program.
Jim Kendall
"When I read that article, it made me feel like that was the kind of place I wouldn't want to work," says Kendall. He believes an Amazon-like environment would be detrimental to getting a job done right just about anywhere, but would be especially toxic in a healthcare organization, where patient quality and safety is paramount, even as the needs of patients could easily keep a dedicated physician or nurse on duty 24 hours a day.
Vanderbilt's approach toward work/life balance has been to create a "culture of resilience," says Kendall. His department focuses on helping employees find solutions to problems (including some problems outside work), being emotionally fulfilled, and remaining healthy. The idea is to create a workforce that is relaxed, engaged, and emotionally ready for the challenges they might face at work each day.
Here are three lessons to take from Vanderbilt's model.
1. What Can We Do For You?
Anything administration can do to simplify its employees' lives will have a huge impact on morale and resiliency, says Kendall.
Vanderbilt offers on-site early childhood education services on its Nashville campus for the children of employees and faculty. It also offers a concierge service that helps connect workers with many different needs, including elder care, banking, and financial services. Kendall once got a referral from the concierge to have his wedding ring resized.
Vanderbilt's concierge also maintains a collection of gift cards to pass out to hospital staff if they forget a birthday or otherwise need a gift on short notice. Target, Walmart, and popular chain restaurants are all well represented in the gift card supply.
"It may not sound significant, but for some of these workers, knowing that they have somewhere [on campus] to go when they have a last-minute need like a gift card can be a really big deal," Kendall says.
Another service Vanderbilt offers its employees is an odd job board where students and staff who are willing to run errands, babysit, or walk pets, can offer help, or those who need services can create a post requesting them. Frequently, Kendall says, he refers stressed-out workers to the board when they begin talking about having too much on their plates.
The idea, Kendall says, is helping these busy workers to streamline their lives so they can focus on what matters.
2. Vacation is Sacred In the New York Times article, numerous former Amazonians recalled feeling pressured to work remotely during their vacations. That wouldn't fly at Vanderbilt—and should be a complete no-no everywhere, says Kendall.
"It's very important to make it clear that [healthcare workers] need time away from the hospital, away from their patients, and away from their cell phones and laptop computers… Healthcare workers will enjoy time off much more when they're really off."
Recently, Vanderbilt changed its PTO policy to feature a "use it or lose it" clause, which prohibits rolling over more than a certain amount of time to the next year. While controversial with workers, this policy actually encourages them to take vacation, says Kendall.
"We all know the guys who save up vacation, year after year," he says. "They have a bunch of time on reserve, but they never actually go on vacation." The new policy discourages hoarding vacation time.
HR and managers should intervene when a worker refuses to go on vacation, says Kendall. "Find out what's going on—they should be taking their vacation time," he says.
3. Staging an Intervention Some organizations are happy to watch their workers become workaholics, but in healthcare that can negatively impact quality of care, says Kendall.
"People become more irritable. They become less effective but spend more time at work. They start spinning their wheels and forget that living is what we do."
If an employee seems to be losing productivity while spending more time online or at the workplace or answering emails, managers should say something, says Kendall. "Sometimes it takes manager to give the worker a nudge to take day off."
Leaders should model the behavior they hope to see in workers, such as taking time off, not responding to emails sent after hours, and actually leaving their desks for lunch, suggests Kendall.
HR's role is to remind workers that work-life balance is "about life. It's about not compartmentalizing, and not segmenting your life," he says.
Workers aren't truly living when they can't take a vacation without worrying whether they will be able to find a Wi-Fi connection "just in case" they have to sign on and get work done; they aren't truly living if they're competing to see who logs more hours on-duty, says Kendall. "We need to grant our employees permission to set boundaries."