BY: ELAINE I. BAUER, M.A., FACHE, and GEORGE F. LONGSHORE
Ms. Bauer is vice president, strategy development, and Mr. Longshore is
vice president, organization effectiveness and human resources, Catholic Health
East, Newtown Square, PA.
Catholic Health East Has Responded to the Nurse Shortage with a Systemwide
Initiative
Warp-speed decision making by a health care system? "In your dreams!"
most health care executives would say. Yet Catholic Health East (CHE), Newtown
Square, PA, a health care system comprising 19 regional health corporations
(RHCs), with 33 hospitals and 44 continuing-care facilities, moved in less than
a year to create, gain consensus on, and begin implementing and measuring the
results of a nursing recruitment and retention program. Even better, the program
was designed to improve nursing models of care delivery and reduce costs
throughout the system.
Before CHE launched the new program, each of its RHCs decided independently
how to meet its staffing needs, including how much to spend on agency nurses.
Some tried revising the roles of nurse managers; some embarked on participatory
management efforts; some stepped up college recruitment efforts. As in most
health care organizations, however, the quickest solution was generally using
agency nurses.
At a time when nurses are aging, often dissatisfied, and certainly scarce,
increasingly heavy reliance on agency nurses is an expensive and unsustainable
remedy. In 2000, CHE spent $22 million to employ staff from outside agencies;
by the end of 2001, the cost had nearly tripled, to $63 million.
Today the goal of the system's various organizations is to control this escalating
expense and to move toward becoming "preferred employers." A ministry-wide solution
called for a dramatic new direction for CHE. As a result of the new program,
the system has changed the way it makes decisions not only regarding nursing
recruitment, retention, and excellence-of-care issues but also in the way it
brings about improvement in other areas.
From the beginning, CHE's leaders realized that solutions to the system's
nursing-related problems were going to be expensive. A major question was: "Can
we, as an organization, afford to throw more money at this?" The leaders decided
that, in reality, they couldn't afford not to invest in the effort.
Although the process that brought the system to successful change was quite
complex, its basic elements are fairly simple. CHE believes that the achievement
of many of the system's objectives in such a short time—especially gaining the
collaborative support of the many entities that make up CHE—is the crux of the
story.
November 2001
CHE began by engaging Cap Gemini, Ernst & Young, a consulting firm, to
bring what it calls its "Rapid Design Process" to bear on the system's efforts.
The overarching intent was to launch CHE's "Blue Ribbon Panel on Nursing Care
Excellence" (BRP), which, in the months to come, would use the meeting's outcome
to develop and implement an accelerated work plan for improving nursing recruitment
and retention and revamping care delivery models.
The Rapid Design Process, which has been used in many industries to develop
swift solutions to strategic problems, generally involves one to three days
of intense discussion facilitated by Cap Gemini consultants, the organization's
leaders, and other personnel. At the end of the discussion, the group reaches
consensus on a number of actions for the organization to take.
A group of 22 people from across CHE's ministries met for a day in November
2001. Involving themselves in a rigorous process of exploration, co-design,
assessment, and decision making, they examined the organization's long- and
short-term goals. They identified current nursing problems, established short-
and long-term objectives, and discussed ways of dealing with the barriers the
system was likely to encounter in trying to achieve its goals.
Robert Stanek, CHE's chief operating officer, told his fellow participants,
"The future of our nursing services rests in the hands of the people who are
assembled here today." He emphasized the importance of the system's core values—reverence
for each person, community, justice, commitment to those who are poor, stewardship,
courage, and integrity—noting that, in the best companies, successful employees
are those who consistently work in accordance with their organizations' values.
March 2002
The BRP held its initial meeting in March 2002. A 45-member, multidisciplinary
team, the BRP included both CEOs and staff nurses. Represented on it were members
of the system's Patient Care Executive Council (the chief nursing officers of
its hospitals, nursing homes, and other components) and executives from its
mission services, human resources, marketing, and administrative departments.
Since the November meeting, Cap Gemini had gathered a large amount of background
data. In March, the BRP put this information to work during its own two-day
Rapid Design Process sessions. Participants focused on identifying patterns
in three areas: recruitment, retention, and patient care delivery. In each of
these areas, a work group was assigned to:
- Accelerate the development of detailed, comprehensive strategies aimed
at helping CHE members become preferred employers of nurses in their local
service areas
- Identify the internal model practices that produce the best results
- Develop easy-to-use tools that would both facilitate and measure effectiveness
in individual CHE facilities and throughout the system
- Maintain local autonomy among facility senior leaders by tailoring solutions
to their particular needs
- Recommend strategies and "next steps" for everyone involved
Recruitment
A BRP subgroup on recruitment was led by Gavin Kerr, CEO of Mercy Health System,
Conshohocken, PA. The group's members, discussing ways to increase the supply
of nurses, focused on how CHE facilities could become preferred employers in
their communities. Other strategies they identified were:
- Determining the difference between what CHE offers nurses from what other
systems offer them
- Enhancing the recruitment experience
- Expanding the candidate pool
- Streamlining the hiring process to facilitate more timely and useful interaction
with job applicants
Citing the 2001 cost to the system of using agency nurses, the subgroup suggested
that by improving the recruitment and retention of nurses, the system could
realize an excellent return on investment (see Box).
The subgroup also prepared an extensive matrix of specific goals in the areas
of candidate sourcing (determining the best places to look for candidates);
"onboarding" (reducing the time between when a candidate is hired and the time
he or she actually begins work); selective hiring (looking for candidates whose
values match the organization's); and infrastructure. A second matrix described
the relative ease of implementation and the probable business impact (e.g.,
a "small payoff" versus a "big payoff") of each suggested strategy. In addition,
the subgroup worked up a full description (including a description of the costs)
involved in establishing relationships with schools of nursing.
Finally, the recruitment subgroup developed a set of tools. One tool, a flow
chart for "onboarding," encompasses the hiring process from the facility's first
contact with the job candidate through the beginning of his or her orientation
as a new employee. A "recruitment measurement tool" has indicators for such
categories as the time elapsed from initial interviews to hiring interviews;
candidate flow; the cost per hire; and the satisfaction, of both the candidates
and the hiring manager, with the process. A third tool is a chart that delineates
the CHE nursing "product" designed to attract prospective nurses.
As the Box shows, this "product" lists factors likely to attract
nursing candidates to CHE, emphasizing life cycle–oriented employment. The system
realizes that an employee's needs vary widely across a lifetime of employment.
Tuition reimbursement, for example, might be an attractive benefit for younger
employees or for older ones with children, but not for older employees without
children. By the same token, work schedules will require changes: New nursing
school graduates might not mind working midnights through the week in order
to have weekends off, but nurses with children may want to stagger shifts in
order to share child-care responsibilities with a spouse. Older employees may
not have the necessary stamina for 12-hour shifts or high-stress workloads.
The Box also shows that CHE's "product" emphasizes choices in
compensation and benefits, support for nurses as caregivers, gain-sharing programs,
and the fostering of leadership skills that can advance the education of those
nurses who choose to come to work for CHE. The "product" specifies opportunities
for growth and development and outlines various attributes of the CHE work environment.
It also encourages candidates to ask themselves whether working for CHE is likely
to match their own lifestyles, missions, and values. In combination, the "product"'s
components provide CHE nursing candidates with highly detailed guidance in making
their decisions. And, of course, these issues are discussed during the candidates'
interview process.
Retention
Studies show that many nurses leave their jobs in the first 90 days of employment,
about half of them because of incompatibility with their direct supervisors.
A BRP retention subgroup, led by Deborah Saylor, senior vice president of nursing,
Holy Cross Hospital, Fort Lauderdale, FL, included among its objectives:
- Considering redesign of the nursing orientation program
- Determining how leadership excellence programs could be implemented to
improve the chances of CHE institutions becoming preferred employers
- Implementing a systemwide exit-interview tool
Like the recruitment subgroup, the retention subgroup created a matrix, in
this case one listing priorities, needs for further development, and a likely
division of labor. Another matrix estimated the ease involved in getting the
jobs done and the probable business impact.
Models of Care
A models-of-care subgroup, led by Kathy Brodbeck, vice president of patient
care services for St. Peter's Healthcare Services, Albany, NY, sought to define
strategies that would:
- Support participative management and shared governance
- Explore various nursing care delivery models
- Establish agency management principles and guidelines
- Set forth common measures supportive of, and aligned with, desired CHE
behaviors
This group suggested that, as its five main strategies, CHE should:
- Adapt a software tool providing e-Bay–style Web site bidding for nurses'
services
- Develop a balanced scorecard for management of agency staff use
- Improve management of agency staff use
- Develop models of care delivery
- Offer shared governance/participatory management (which is widely seen
as a key to preferred-employer status)
The models-of-care subgroup divided each of these strategies into specific
actions and, like the other subgroups, arranged them in matrix form according
to priority. The subgroup also reviewed nursing care paradigms, choosing one
particular model of care for CHE. This model includes guiding principles, measurements
of success (outcomes in the clinical, financial, satisfaction, and operational
areas), and the infrastructure needed to support the model.
"Next Steps"
Finally, at the end of the meeting, the BRP outlined seven "next steps." CHE
would, the group decided:
- Determine the initiatives' priorities and take them to the various CEOs
for endorsement
- Identify the infrastructure required to carry out the BRP's recommendations
and continue its work, both at the corporate level and in member facilities
- Define "next steps" for the BRP's subgroups and their leaders (decide,
that is, whether to continue or restructure the subgroups)
- Complete business plans based on the CEOs' endorsement of strategies and
estimate the likely return on investment from such plans
- Review and refine timelines for each recommendation
- Establish a formal system for tracking, measuring, and sharing internal
"best practices" (that is, corporate support for member facilities' efforts)
- Develop an overarching communications plan
June 2002
After the March BRP session, Elaine I. Bauer (one of this article's authors)
was assigned to coordinate the findings and advance action on all fronts. Between
March and June, CHE's senior leadership team (including the RHC CEOs and the
system's senior management team) first studied and then approved the BRP's recommendations,
even though doing so without knowing every detail and possible ramification
of the work to be done required a considerable leap of faith.
Two meetings in June put implementation of the BRP's recommendations in motion.
One, chaired by Bauer, was a joint meeting of the system's Patient Care Executive
Council (composed of its chief nursing officers) and the Human Resources Council
(composed of its human resources executives). Because the nursing recruitment
and retention program is a joint effort of human resources, nursing, and other
departments, bringing all those involved together to discuss implementation,
timing, and division of labor made sense and saved time. The participants were
asked to take back to their facilities those ideas that seemed likely to work
and to start making changes accordingly.
The second meeting, facilitated by The Studer Group, another consulting firm,
used a modified Rapid Design Process. The Studer Group has correlated health
care systems' remediation of problems in patient satisfaction, employee satisfaction,
and quality of care, with improved clinical, financial, and operational performance.
The meeting, attended by a cross-section of people from throughout CHE, discussed
how the system could use the Studer concept and principles to pursue both service
excellence and putting CHE's values into practice.
As a result of the June meeting, CHE developed its "Values in Practice Program,"
which—encompassing as it does the system's culture, programs, and methods of
achieving excellence—provides an overall framework for excellence in service
to all of CHE's constituencies. Values in Practice uses the Studer principles,
customized to CHE needs, to drive a culture of service excellence throughout
the system, as was recommended by the BRP retention subgroup.
From June 2002 to the Present
Values in Practice provides some of the tools for improving nursing recruitment
and retention that were identified in CHE's nursing care excellence work plan.
This work plan, created and updated monthly, is extremely detailed. Each major
goal area—nursing recruitment, retention, models of care, and communication—involves
specific initiatives taken from the BRP subgroups' recommendations. The retention
goal area, for example, incorporates exit interviews, orientation, and methods
of getting to the preferred-employer level. Every initiative is assigned:
- Specific strategies
- Responsibility (local or CHE)
- A "champion"
- Detailed actions to be taken (e.g., "evaluate options/vendors")
- A deadline for completion of each action
- A brief status report on each recommended action (e.g., "Software was demonstrated
5/20/02. Reviewed several options with Patient Care executives and the Human
Resources Council 6/11/02; reviewed them with CEOs 7/9/02. Negotiations with
vendors will proceed.")
Bauer and the local Patient Care executives coordinate the efforts of the
local facilities, making sure that everyone stays on track. In addition, Bauer
chairs meetings of the Corporate Project Team, which are attended by Diane Denny,
vice president for quality and patient safety; Jack Hueter, vice president for
information technology; Sal Foti, vice president for marketing and communications;
George F. Longshore (this article's coauthor), vice president for organization
effectiveness and human resources; and Stanek.
Bauer and Stanek make quarterly half-hour conference calls to nurse-executives
in each CHE facility (some 30 to 40 in all), discussing both successes and obstacles.
Since June, the nurse-executives have been busy gathering information about
what's working and what's not working, facilitating changes, and networking
with other nurse-executives in local institutions.
Accomplishments
Between June and the end of September 2002, most deadlines in the work plan
were met. By early in the fourth quarter, when the first "scorecard" was issued,
CHE's leaders could see that the changes undertaken had made a measurable difference.
For example, five of the regional ministries showed significant and steady declines
in their agency staff use; by August, three CHE organizations had cut their
spending on agency nurses to nearly zero.
Four of the system's RHCs have adapted software developed and licensed by
St. Peter's in Albany, NY, a member hospital, to put RNjobs.com the e-Bay–style
bidding site for nurses' services—on the Web.
The system is actively developing preferred relationships with hospital-associated
nursing schools, as well as with colleges with nursing programs. CHE plans to
start on-campus recruiting at the end of students' junior years, using high-tech
methods of iýterviewing. The system has also partnered with Drexel University,
Philadelphia, to develop an online program that helps licensed practical nurses
for advancement, trains registered nurses to earn bachelor's of nursing science
(BSN) degrees, and helps BSNs to earn master's of nursing science degrees.
Realizing that a large proportion of nurses leave their employers because
of conflict with supervisors, CHE has put together for its nurse managers a
new first-line supervisory training program that will be implemented in all
of its hospitals. A new section on CHE's Web site will have links offering sample
job descriptions, policies, and practices for recruiting and retaining nurses.
For CHE, this was the first time corporate and local staff had come together
in such an intense, focused, and collaborative effort to address a strategic
challenge. The nursing shortage is a problem at which many hospitals have simply
thrown money in the form of signing bonuses and dramatic wage increases—but
with only limited success. Through CHE's process, its leaders came to the realization
that successful nursing recruitment, retention, and quality-of-care modeling
are complex and multifaceted. Still, one fact remains: Patient quality of care
comes first. CHE believes that if it is a preferred employer for nurses, a higher
quality of care and patient satisfaction will follow.
In sum, CHE has learned that:
- It cannot afford to do things the way it has always done them.
- There is no magic bullet for solving nursing problems; a combination of
efforts is needed, and combined resources can meet more needs for more RHCs
than can the resources of a single organization.
- To offset the stress of their work, nurses need personal and professional
rewards, including clear, consistent communication and constructive feedback—and
some fun, too.
- To appeal to today's professional nursing workforce (which, after all,
has employment options besides acute and long-term care institutions) the
traditional organizational culture (and the tools it provides for doing a
good nursing job) have to change.
Return on Investment: CHE Wide Savings Opportunity
- Savings Opportunity
| Reduce Time to Hire by 20% | $13.4M |
| Reduce Turnover by 1% | $3.7M |
- Increased Patient Satisfaction
- Improved Quality of Care
- Improved Employee Satisfaction
- Improved Sustainability for the Mission
