Strengthening the
Health Care Workforce

As hospitals address the workforce shortages now and into the future, discussions of how to safely continue services, how to implement different workflows that account for tighter staffing, employing available technology and other approaches to care delivery with fewer team members will be needed.

Some hospitals and health systems experimented with staffing models and team composition out of necessity during the pandemic. While there were numerous iterations, and many likely failed as effective solutions, there is not yet a deep study of the outcomes either for patients or the workforce itself.

• As you think about changes to be made for longer-term interventions, pilot approaches and use of PDSA cycles can help document the advances and potential pitfalls.
• Don’t be afraid to start over. Care delivery models must be shifted with a keen focus on patient care safety and quality, which may not result in the alleviation of burden or reduced expense expected at first. Continue to iterate.
• As you consider different staffing complements, understand the employment landscape to ensure you aren’t creating challenges for other parts of the health care or social service continuum. A market analysis could yield additional clarity on under-employed health care professionals who might not have traditionally supported inpatient care.

As noted in Chapter 5, understanding the work to be done and which team members could perform the work are essential precursors to employing technological supports.

• Too often, technology can be deployed ahead of a full understanding of the work needed and the potential for shifting across teams, causing undue burden or steep learning curves to adapt the people to the technology
• Technological supports also often come with significant investment, so clear understanding of the process and procedure changes that must precede any introduction of technology will be essential.

Finally, understand the current and potential partnerships with community-based organizations that could extend your ability to support patients and your own workforce. Organizations within your community, while likely also straining to find adequate workforce, might be willing to undertake joint efforts that alleviate community needs while balancing workload.

• CASE EXAMPLES
  Community Partnerships to Support the Health Care Workforce

Start by identifying and cataloging approaches taken during the pandemic to address surge capacity needs and other staffing approaches that proved useful in meeting demand. In the review, be sure to identify key factors at the local or unit level, such as team composition, resource usage, or acuity levels, and those provided at an organizational level, such as access to float pools, just-in-time training or technology supports available. Working with local managers to understand what was successful and why will facilitate scaling of effective approaches. As you begin to identify staffing models to test or scale, understand current and recent usage of contract labor for potential savings.

• GUIDANCE The Nursing Think Tank recommendations include detailed suggestions for analyzing need, opportunity and resources needed.

Beyond surge needs, identify data sources and trends that can help you predict future staffing needs to begin cross-training programs and enhance float pools. As you do this work, make sure you understand current configurations of teams and service lines to find those most able to flex, share team members or support capacity needs. Part of this examination, for those with multiple sites or geographic spread, could include internal “travel” opportunities for team members.

As you review approaches that were helpful from the past two years, consider opportunities to bring nontraditional team members into your workflows, expanding roles for those in non-clinical patient-facing positions, and greater use of team-based models to ameliorate staffing shortages.

Identify opportunities to partner with community-based organizations to enhance the reach and ability of your current workforce to support your community. For example, community health workers already involved in chronic disease support could provide additional connections to patients who may have delayed care during the pandemic.

Examine current use of telehealth options, including hospitalat-home, to understand opportunities for non-traditional “bedside” care delivery options for staff. At the same time, identify technological abilities to provide supportive expertise to team members through virtual nursing or other programs that allow those on-site to quickly consult with experienced colleagues who may be remote-based.

As you consider which staffing models and workflow changes to pilot, spend time refining the opportunity with front line leaders and team members to ensure changes aren’t happening too fast or there aren’t pitfalls at the local level. Utilize PDSA cycles to evaluate changes and gather feedback from the full team. Part of your evaluation should include patient and family input as well as studies of relative costs and quality and safety outcomes.

Consider using national and local surge capacity trainings, examples or resources as starting points in piloting or refining models beyond pandemic needs.

• WEBINAR
  Nursing Surge Staffing example and Unique Models to Support Well-Being
• GUIDE
  Society for Critical Care Medicine Preparing Your ICU for Disaster Response includes communications plans, how-to guide for building surge capacity, understanding ethical decision making and more.
• RESOURCES
  University of Washington Critical Care Training for Non-Critical Care-Trained Providers: Now What Do I Do?

Many models employed during the pandemic looked at ways to expand roles or bring team members from traditionally outpatient and ambulatory roles into the inpatient or even virtual space. These types of approaches can be facilitated by a centralized structure for scheduling and deployment that allows for flexibility across settings. These models also benefit from increased training, just-in-time resources to support new assignments and strong communication skills from front-line leaders.

• WEBINAR
  Restructuring Staffing Models to Enhance Value — highlights cross-training, non-traditional roles for clinical team members and opportunities to share staff across departments.
• CASE EXAMPLE
  Nurse leaders at Yale New Haven Hospital used alternate staffing models to grow and retain their nursing workforce during the COVID-19 pandemic.

Organizations with larger geographic spread can also consider internally organized traveler opportunities to offer desired flexibility and new experience while retaining team members.

• SUMMARY OF EXAMPLES
  Team-based Models of Care highlights approaches used throughout the COVID-19 pandemic to bring teams together to provide care.

Consider expanding roles for non-clinical patient-facing team members where they can enhance your clinical team’s ability to support care delivery. Consider working with your patient and family advisory councils to identify other opportunities to engage with families for additional support.

• CASE STUDIES
  Capitalizing on Relationships to Drive Coordinated Care — identifying non-traditional roles for all team members to facilitate patient care.
• GUIDE
  Building A Community Health Worker Program: The Key to Better Care, Better Outcomes, & Lower Costs
• GUIDE AND PODCASTS
  Engaging PFACs in Care Delivery

Organizations have greatly expanded technological solutions to reach patients, such as hospital-at-home, telehealth and other digital approaches, but it is important to understand how these efforts can provide opportunities and challenges for care delivery and impact the well-being of the care team. Ensuring sufficient training and comfort levels with using technology to care for patients and understanding needed adjustments in workflows are key to success.

Programs that use technology can provide options for team members to work in less traditional settings and shifts, allowing for greater retention. But these arrangements can significantly change the team dynamic or available support, so clear understanding, training and expectation setting of the work needed is essential.

• ISSUE BRIEF
  Creating Value by Bringing Hospital Care Home
• CASE EXAMPLES
  Hospital-at-Home
• PODCASTS
  Atrium Health Virtual Hospital During COVID

Virtual nursing programs that provide backup to those on the front lines, such as e-ICU or other modalities, as well as remote access to specialists or consults through telemedicine can greatly expand the reach and support felt by the care team. However, many of these programs require significant investment and infrastructure to put in place. Bring together a team to evaluate the potential of these programs and again, consider pilot approaches.

Managing change is not an innate skill. Make sure your team leaders and front line managers have the appropriate training and support to lead their teams through care model design piloting, testing and implementation.

As you identify and prioritize models to pilot, ensure sufficient resources of time, energy and analytics capability across the right teams to accurately study and then scale effective models.

Opportunities to share lessons learned across divisions and departments may require protected time for leaders to observe and learn from each other from the front lines to the senior levels. Invest in opportunities to share successes and key metrics.

Many care model shifts that took place during the COVID-19 pandemic are too new to have deep study or proven outcomes for patients or their caregivers. In many cases, as changes were made rapidly to accommodate surges, there are not data on quality, safety or other metrics to understand what was successful and where changes are needed. As you move through piloting different interventions and models, ensure you invest in data collection and review to evaluate these metrics.

Creative approaches to the care model can offer opportunities for recruitment and retention of team members with different needs, abilities and approaches, potentially increasing team diversity. Ensure that as you evaluate new models they do not impede equitable access to care, particularly those using digital supports.

As you identify new roles for current team members or opportunities to bring team members from different settings to your care delivery model, ensure that you are not leaving other care settings with shortages they cannot sustain.

New care delivery models may require different configurations of support teams across the organization. As you evaluate pilots, ensure you are creating feedback loops that include information technology, facilities, finance, operations, communication, human resources, and all relevant colleagues.

• American Organization for Nursing Leadership
• AHA Physician Alliance