Workforce Management Strategies in Times of Uncertainty

Rely on data, technology, policies and processes, people, and patient-centered staffing.

By Karlene Kerfoot, PhD, RN, FAAN

Healthcare rarely experiences a “normal day”; no two patients are alike, and each staff member is unique. However, unexpected events such as pandemics, earthquakes, fires, protests, strikes, and ever-changing government and payor regulations and reimbursements challenge health systems to deliver quality care to patients while protecting and growing staff. Health systems are on the front line of the com- munity’s response to each crisis. They must be adept at quickly and effectively meeting the needs of the com- munities they serve, while respecting and valuing their employees. Well-run systems make themselves crisis-ready by strategically building a long-term workforce management infrastructure to handle small and extreme variations and to care for patients in all types of crises.

Building a stable, data-driven workforce strategy to smooth out variation and reduce chaos when the unexpected occurs is the foundation for resiliency and success and will positively impact patient satisfaction and staff engagement. However, health systems must recognize that workforce management is an ongoing journey; it’s not a one-time initiative.

For all healthcare organizations, five key outcomes— clinical, staff engagement, patient experience, compliance, and financial—help measure success and sustain- ability. Organizational goals should be based on a balanced approach in achieving these outcomes; over- emphasis in one area negatively impacts another. To achieve outcome excellence and balance, an effective workforce management process should include these essential enablers: data, technology, policies and process- es, people, and a patient-centered staffing approach.

Data

Workforce management should be data-driven. Employee, patient, and operational data must all be considered when making staffing and scheduling decisions. Healthcare systems have an abundance of this data, but if it’s not organized into actionable insights, it won’t provide value. Data must enable an organization to make in- formed decisions quickly as demands change.

Technology

Effective workforce management technology bridges the entire enterprise, pulling information together from many systems. Integrated scheduling and timekeeping facilitate productive and cost-efficient workload balance based on data-driven insights. Bridging scheduling to data from the electronic health record (such as nursing documentation and census) helps ensure equitable staff assignments that can flex as needed.

Daily, weekly, and monthly monitoring of automated analytics and dashboards facilitates proactive information use to empower managers to make better staffing decisions and ensures staff can serve their patients effectively. In addition, mobile workforce technologies support staff and manager work preferences and pro- vide for equitable work–life balance.

Workforce technology benefits can be maximized by expanding them to ancillary and support services departments. By going beyond nursing, a health system has better support for streamlining and standardizing across the organization, while containing costs and fostering staff engagement with groups outside of nursing.

Policies and processes

Many health systems have workforce management policies and processes that have been in place for years and have drifted into a state of entropy. New methods may be developed, but the status quo can persist in daily operations, even if it no longer meets the organization’s current needs. Ongoing standardization of policies and processes makes it possible to take a systemic and systematic approach to staffing and provides an opportunity to fix policy or process flaws and update work based on new data and evidence. Workflows can be stream- lined, and policies and processes can be fine-tuned to optimize staff, contain costs, and improve patient care. With variations reduced and processes standardized to best practice, patients can be assured of the same level of care across all facilities and functions in the system.

From a leadership perspective, helping an organization standardize to best practices is an important way
to attain better quality, productivity, and sustainability while minimizing silos. Standardized staffing policy, consistent job descriptions, and continuous cross-train- ing empower staff to confidently provide care outside of their home unit in times of crisis. In addition, with standardized pay and scheduling policies, staff know that everyone is treated fairly and equitably.

People

Everything that happens in healthcare is for people, by people. Every person in a hospital or health system plays a role in achieving clinical and financial outcomes, and all staff impact the patient experience, the bottom line, and the success of the organization.

Workforce management connects human resources, nursing, clinical education, payroll, information technology, finance, nursing informatics, and other clinical disciplines within healthcare organizations. Creating a multidisciplinary ecosystem with a shared oversight and governance structure that spans individual facilities and the system can ensure collaboration. When transparency exists and people are invited to participate in developing processes and finding solutions, more innovative alternatives emerge, resulting in greater support, utilization, and adoption of the workforce management system.

Whether or not an organization experiences a crisis, a clear picture of the entire pool of available staff, their qualifications, credentials, and skill sets regardless of their home unit or facility makes it possible to quickly and accurately match caregivers with patients. An enterprise-wide approach, supported by full transparency, allows qualified caregivers to move from areas of low need to areas of high need, which is both cost-effective and patient-centered.

Patient-centered staffing approach

Each patient is unique and their needs may change during hospitalization, making staffing a complex process. However, that process can be simplified when data, effective technology, people, and processes are integrated. A patient-centered staffing approach delivers more than an acuity or ratio-based approach; it enables health- care systems to deliver excellent patient care in day-to- day and extreme situations.

Crisis and opportunity

The workforce impacts everything that happens within healthcare organizations. Creating a stabilizing work- force management strategy is imperative in “normal” times and becomes mandatory when chaos strikes. Every crisis gives us the opportunity to re-examine what we’re doing and to reframe our future. Unfortunately, “chasing the next shiny object” can replace strategically “looking around corners” to determine what the organization needs in the near and distant future.

Enabling outcomes

To ensure balance in key outcomes, healthcare organizations must rely on essential enablers—data, technology, policies and processes, people, and a patient-centered staffing approach.

Diana Berkland, PhD, RN, FAAN, vice president of nursing and clinical services at Sanford Health, cautions that innovation should contribute to a positive work- place environment and make the work less complicated. Mary Beth Kingston, PhD, RN, NEA-BC, chief nursing officer for Advocate Aurora Health, notes that innovations must focus on creating a safe clinical enterprise and evaluating performance based on a balanced set of metrics. Berkland, Kingston, and their colleagues share more of their perspectives in the two case studies that follow this article.

Crises ranging from natural disasters to changing government regulations to social unrest will continue to challenge health systems nationwide. Building organizational resiliency through a strong workforce management strategy is mission-critical. One of the most important lessons of crisis readiness is recognizing that best practices are built before the crisis and evaluated after to create new and more efficient practices for the future.

A solid workforce management structure has been a stabilizing force at Sanford Health amid the uncertainty and chaos created by the COVID-19 pandemic. The system, which consists of six large medical centers and 40 critical access hospitals, is located primarily in South Dakota, North Dakota, and Minnesota. A merger in January 2019 with the Evangelical Good Samaritan Society added 158 skilled nursing and rehab sites across 24 states, home health agencies, senior housing, and home- and community-based services.

The region served by Sanford Health is home to several meat-processing and packing plants and long- term care facilities where outbreaks occurred in the early days of the pandemic. Although the numbers of COVID-19 cases have varied across Sanford Health, the system’s data, flexible staffing, enterprise work-

force management, and technology infrastructure have enabled a coordinated and strategic response.

Workforce management success factors

Four workforce management factors contribute to building stability and resiliency and serving staff and patient needs over time.

1. Sanford Health firmly believes that resiliency starts with the care unit directors and managers. They’re viewed as the chief executive officers of their departments with fiduciary accountability and responsibility for maintaining the appropriate staff numbers and skill sets to serve patients.
2. These unit leaders must be committed to cross-train- ing staff so they can be flexible, confident, and comfortable providing care on other units when needed.
3. Central nurse resource pools at the local and regional levels provide flexibility with cross-trained skills that go beyond an employee’s single specialty, whether they work in med-surg, women’s, children’s, or critical care units.
4. The system-wide nurse resource pool provides an internal travel agency for the organization, which spans more than 400,000 square miles and can help local and regional central nurse resource pools when needed.

Underpinning this workforce management infrastructure is a supportive environment that meets the needs of staff in normal times and enhances their ability to perform in emergencies. As a result of actionable and visible data and a focus on staff well- being, the organization has experienced a 12% decrease in agency use and a 2% decrease in RN turnover from 2019 to 2020. (See Using culture to cultivate commitment.)

The role of data and governance

Workforce data are essential to operations. Using sys-

Using culture to cultivate commitment

Sanford Health’s mission is to improve the human condition at every stage of life through exceptional care, spiritual enrichment, innovation, and discov- ery. The system’s operational frame- work is centered on several core val- ues, including calling, courage, family, community, service, resolve, and ad- vancement.

This nursing leadership philosophy—Humanbecoming Paradigm—is based on the work of nurse theorist Rosemarie Rizzo Parse, PhD, RN, FAAN. It creates a “more alike than different” culture that calls on leaders to:

• promote mutual respect and trust
• encourage collaboration
• welcome diverse perspectives
• focus on quality of life from each person’s perspective.

Listening with a “willingness to be influenced” helps new team members feel valued and appreciated when mergers and acquisitions occur.

Leading with respect

Sanford Health nurse leaders believe their success is largely related to operational implementation, adoption, change management, and change leadership within the work environment. To achieve this, they must be committed to a clear vision, and they must support their staff with reverence and respect. A guiding premise for the leadership team at Sanford Health is recognizing that if the staff feels valued and supported in their work, the financial out- comes will follow.

Enabling staff to achieve work-life balance is key to helping them feel appreciated. Unit managers and directors must be well versed in the work- force technology to enable consistent staffing with minimal chaos. Calling staff every afternoon to work without foresight is a failure of leadership that may compromise their well-being; it’s a form of leadership malpractice. The staffing and scheduling committee is called the “Work-Life Balance Committee” to emphasize its importance.

Critical to that work-life balance is creating a solid and detailed succession

plan, and giving everyone opportunities to grow. Providing positive coaching and extensive competency training, along with having crucial conversations, creates the stability needed to ensure staff success in providing excellent patient care.

Proof of concept

Proof of the positive impact of this leadership philosophy can be seen in staff engagement and patient out- comes.

• One hospital within the system has successfully achieved four Magnet® designations and another has achieved three.
• In organizations that receive Magnet designation, nursing staff engage- ment, as measured by the Practice Environment Scale, indicates staff experience at or above the mean for comparable organizations.
• Nurse-sensitive indicator outcome data indicate low numbers of falls, pressure injuries, central line infections, and catheter-associated urinary tract infections.
• Clinical comparative data indicate a statistically significant improvement in overall rankings in most domains for the past 18 months.

tem-wide workforce technology* provides information to local managers and directors, resource pools, and executives to ensure leading practices are in place throughout the organization.

A holistic approach to workforce management re- quires that all disciplines (not just nursing) use the same platform. Integrating information—such as predictive and descriptive analytics based on volume, turnover, length of stay, leaves of absence, and other metrics—completes the holistic picture. We created dashboards in response to COVID-19 and the accompanying medication, medical supplies, and personal protective equipment (PPE) supply chain challenges. This allowed us to be nimble and accurate with sup- ply-and-demand calculations. These data were instrumental in allowing leaders to make data-driven decisions to ensure patient and staff safety.

Workforce management governance is comprehensive and takes two forms: the system workforce governance structure and the nurse executive council.

System workforce governance

The system workforce governance structure includes all stakeholders and content experts, such as payroll administrators, finance officers, nursing informatics staff, nursing officers, and information technology staff. This group provides oversight and monitors the workforce management system, ensures standardization of nomenclature and system technology, decides which disciplines and units will use the system, and determines implementation timelines.

The system workforce governance structure also decides the best use of workforce management technology and has oversight for ensuring one consistent, leading practice standard throughout the organization. Staffing and scheduling software is used in areas other than nursing, so everyone must be represented as the technology is designed and developed.

Nurse executive council

The nurse executive council’s respectful, appreciative, trustful model ensures that everyone has a voice and consensus is obtained. The council determines staffing standards, skill sets, and hours per patient day across the organization and aligns these standards within the workforce management technology.

Sanford Health currently has five workforce management optimization projects: predictive/prescriptive data analytics (which includes several interactive calculators), staffing standards, governance, position control data standardization, and workforce management technology. The goal is to create an environment in which people can do the work they’re called to with the re- sources they need to accomplish it.

Coming together during the pandemic

In early 2020, staff needed to feel valued, safe, and supported as Sanford Health navigated the turbulent first weeks of the COVID-19 pandemic. Guidance about the virus changed frequently and required clear, concise communication and trusted leadership. This was accomplished, in part, via existing modalities, including the nursing governance structure, the nursing senate, various nursing governance councils, daily safety briefs, and short weekly surveys to all staff. In addition to these regular interactions, the enterprise and regional incident command structure provided daily standardized, succinct, and transparent communication (including vertical and horizontal communication from point-of-service staff through executive leadership) to ensure proper information flow.

The organization quickly posted a Facts over Fear page on the intranet, and daily Town Hall sessions were recorded so all shifts could hear the most current information from leaders. In addition, weekly Face- book Live sessions, hosted by leaders, were well at- tended by thousands of team members. Guiding this work was a philosophical belief that point-of-service staff needed to feel safe and secure while providing care. To that end, a PPE and supply-chain dashboard was created to allow leaders to make data-driven decisions based on supply and demand. (Learn more about how to support staff at myamericannurse.com/?p=68570.)

The cross-training that’s been in place at Sanford Health’s flagship hospital in Sioux Falls, SD, for 20 years provided a foundation for ensuring staff training, education, and competency when caring for patients with COVID-19. In addition, the system’s well-established local and enterprise float pools consist of staff who are enthusiastic about floating and confident in their skills.

Early in the pandemic, when patient volume in some units (including ambulatory care) was low, San- ford Health used the time for training and advancing skills and competencies to ensure staff could confidently take on challenges and be even better prepared

for the future. Expert nurses were paired with novice nurses as volume surge plans were implemented, and upskilled ambulatory nursing personnel were prepared to work with expert nurses to ensure enough skilled staff would be available for the projected surge in patients with COVID-19.

Concern about the financial impact of a disaster tends to dominate in stressful times. Examining how decisions about finance affect patients, caregivers, and the success of the organization is important. San- ford Health takes a balanced approach to measure success, with a focus on clinical outcomes, financial metrics, patient experience, and healthcare worker experience.

Innovations for the future

Innovation is important for healthcare systems, but it should add to, rather than detract from, the workplace environment. Innovations should be viewed through the eyes of the staff. For example, mobile workforce management technologies are important because this is how millennials operate and we need to work with- in that world. These technologies include applications that are available via mobile devices and functions such as work schedules, available shifts, and time card corrections and approvals that can be completed remotely.

Data analytics and artificial intelligence should be aimed at taking work out of the system and providing support for leaders and end users, not making work more complicated. As innovation occurs, everyone on the team should acquire the skills needed to ask the right questions and extract meaning from the data.

Sanford Health has achieved consistency, excellence, and equilibrium amid many chaotic events. We’ve used a sophisticated workforce management system to synthesize technology and the work environment to balance staff and patient needs. Leaders are responsible for creating a workplace environment that engages competent staff who can provide excellent patient care.

Thanks to a rich and robust professional nursing culture, clear vision, and solid succession planning, San- ford Health is nimble and well-positioned for future tidal waves of change. AN

*Workforce Management Solutions by API Healthcare, now a part of symplr

Diana Berkland is vice president of nursing and clinical services and Meghan Goldammer is chief nursing officer at Sanford Health in Sioux Falls, South Dakota.

Developing a robust, flexible nursing workforce over the past 6 years has positioned Advocate Aurora Health (AAH) to proactively manage uncertainty in

an everchanging environment, particularly during the COVID-19 pandemic. By improving staffing processes, the system’s leaders have developed workforce management strategies to respond to change and build powerful organizational resilience. These qualities, in turn, have provided a stable foundation throughout the crisis.

AAH is one of the 10 largest not-for-profit integrated health systems in the United States, serving nearly 3 million patients annually in Illinois and Wisconsin across more than 500 sites. The system’s purpose is to “help people live well” during times of crisis and calm, fully embracing a whole-person health focus and commitment. Leaders have leveraged the size of the system while moving with speed and agility to navigate the changes created by the pandemic.

Workforce management: A foundation for organizational resilience

Improving patient health, safety, and satisfaction while also improving team member satisfaction and ensuring an optimal work environment have been key AAH goals. To meet them, leaders have implemented best practices, developed a robust infrastructure, and identified tools to help plan and deploy clinical labor resources to best meet patient needs.

One initiative is the Effective Staffing Vision, which is driven by a commitment to get five key things right: the right nurse, at the right time, with the right competencies and credentials, at the right cost. Three critical success factors for achieving this are shared governance, metrics, and standardization. (See Ecosystems unite stake- holders in staffing decisions.)

Responding to COVID-19

With a strong workforce management strategy already in place, AAH was positioned to quickly and effectively respond to the COVID-19 pandemic. The creation of a virtual system labor pool command center was a key workforce strategy. Co-led by the vice president for talent acquisition and nursing, the command center includes team members from human resources (HR), HR analytics, ambulatory, and the system float pool, along with a project manager and the contingent labor director. Working closely with each site’s labor command team, the command center developed a 24/7 online process for sites to request and reassign staff. The system command center team helps optimize the use of all available, qualified staff. Success strategies include:

• allowing team members to volunteer for reassignment
• hiring more than 100 zero-assigned nursing students; nurses; and respiratory therapy, environmental services, and hospitality staff (all managed through the system labor pool) to support site needs
• partnering with contingent labor companies to hire and onboard agency nurses
• leveraging the relaxation of licensing requirements at the state level to send nurses between state lines
• reassigning more than 5,000 team members to new roles
• matching prior work experience with work-from- home or furloughed team members to meet site needs
• conducting twice daily system calls to address immediate and anticipatory staffing needs
• redeploying team members with medical restrictions to nonclinical areas, such as managing department of health data requests
• creating a database of all available team members for potential staffing support.

This collaborative approach to meeting patient care needs was highlighted in the system’s response to a surge in patients requiring extracorporeal membrane oxygenation (ECMO) at one of the hospital sites. To simultaneously support up to 30 patients on ECMO at a single facility, highly qualified staff from throughout the system stepped up to help, with some staff stay-

Ecosystems unite stakeholders in staffing decisions

Advocate Aurora Health (AAH) uses two key strategies to ensure effective staffing: ecosystems (multidisciplinary and interdisciplinary teams) and engaged frontline nursing teams. The ecosystems are used to create structure, change processes, develop sound staffing plans, and track key metrics at the system and local site levels.

To avoid silos, AAH has standardized staffing and scheduling practices across the system, creating consistent job descriptions for all flexible staff and staffing offices, and synchronizing scheduling time frames. Scheduling software* has been leveraged to implement optimal care models. In partnership with finance, nursing budgeting principles have been developed, and both site and system multidisciplinary teams have been formed.

Shared governance and an infrastructure to support collaboration between the system and individual sites paves the way for creating a multidisciplinary group to anticipate equipment, resources, and staff needed for patient surges. The system and site labor command center teams met twice daily to respond to staffing demands; the system is now developing a standard approach to any new surges based on lessons learned. A database of furloughed, newly hired, and volunteer staff is instrumental in helping with reassignments, including new roles such as visitor and staff screeners or site-based testers.

Ensuring nurses have the support they need for reassignments is a priority. The system-based nursing education and professional development team provide support from the system and site perspective. From the system,

the team developed a virtual surge orientation staffing and critical care program that focuses on helping furloughed nurses from the OR, post-anesthesia care unit, and clinics return to the med-surg unit or ICU bedside for clinical re- assignment. Over 3,500 nurses participated in these online programs. The nursing department also moved the orientation and new graduate residency program to a virtual format for more than 3,000 nurses. The system team created COVID-19 educational videos, which have been viewed over 37,000 times, and regularly updates personal protective equipment (PPE) guides, which have been downloaded 35,000 times.

The site-based teams help share new daily information and updates, provide support for proper PPE donning and doffing, and, in many cases, provide direct care staffing or are reassigned to areas of high need such as employee health. An educational program sup- ports implementing a team-based nursing model and helps reassigned nursing education and professional development staff feel comfortable in their new roles. In partnership with nursing practice, these staff have implemented more than 300 practice changes to cope with the pandemic’s unique challenges.

In addition to standard communication processes, daily communication updates provide information about quickly evolving practices, policies, and procedures. Site metrics and issues are shared through daily huddles. Precise, targeted communication, along with robust, innovative educational and clinical support systems, are essential for taking care of staff during these very difficult times.

The Effective Staffing Vision provides the infra- structure for creating the resiliency needed to quickly manage the pandemic in two states with very different challenges at different times The ability to expeditiously share knowledge and resources, as well as move patients and staff quickly to different care sites, makes it possible to meet everyone’s needs. (See Balancing metrics, meeting goals.)

Strength for the future

The system and site leadership team plans to make the most of the lessons they learn during the pandemic. In- stead of narrowly focusing on the pandemic’s financial impact, a balanced workforce management strategy that leads to excellent patient care and staff engagement has been maintained. AAH’s response to COVID-19 requires a flexible workforce, and staff experiences are being evaluated for ongoing implementation, especially regarding a system approach to labor pools. Leaders also are identifying opportunities to sustain new skill sets learned during reassignments. The more than 300 practice changes that have been implemented during the cri- sis reflect the importance of listening to frontline staff and inform the next steps in implementing change. The shared governance structure in inpatient, ambulatory, and home care assists in gathering this important feedback.

The pandemic response also has helped strengthen relationships with staff, providing an opportunity for leadership to show they care and reinforcing the priority of nursing career development. In reassigning staff, nurse leaders are listening to clinical nurses and considering their skills, interests, and educational needs. Nurses in every area are welcoming to those orienting to different care settings and respectful of their current skills and expertise. Leaders and educators are coordinating the process and are instrumental in building trust, ensuring that clinical nurses have the training and support re- quired for new assignments. Providing excellent care during the pandemic is a unifying goal, and nurses in the inpatient setting appreciate their colleagues’ help.

In addition to the system labor pool and clinical

nursing support, special innovative payment models have been initiated by creating two different COVID-19 pay models:

• Continuity pay. This is identified by trigger factors such as census and COVID-19 prevalence in the community. If the triggers are met, team members receive an increase in hourly rate based on role.
• COVID-19 pay. This applies to the emergency department and units where more than 50% of patients have COVID-19. An increase in hourly rate is pro- vided based on role.

Feedback from the nursing team is that the combination of staffing initiatives, pay incentives, and transparent communication are essential elements supporting nurses during this challenging time. Ongoing innovation during the pandemic has fostered resiliency and will position the organization for other unexpected challenges in the future.