Macro-Environment Issues Drive Innovations for Service Line Introductions, Staff Recruitment, and Retention

Overheard in a hospital corridor…

Cardiologist: I’d like us to expand our services to include PCIs and EP. Our patients don’t want to travel 30 miles to have these types of procedures done.
Administrator: Trust me, I know. Our customer satisfaction scores are getting hammered with all the frustrated patients and their families, but how can we ever do that? For one thing, we don’t have surgical back up. And our staff, well, we only have one nurse with a limited amount of interventional experience.
Cardiologist: Yeah. I get it. But there has to be some way for us to do this...
Administrator: <sigh> Agreed. Let me get back to you, ok?

This conversation will likely seem all too familiar to many community and regional hospital leaders who have struggled with expanding their cardiovascular service lines. The rapid-fire introduction and accelerating pace of new technologies, compounded by our country’s aging population, daunting regulatory environment and evolving protocols to treat heart conditions, is forcing medical administrators and care providers to deal with an endless torrent of challenges. The recognition is clear: “business as usual” is no longer going to suffice if hospitals are going to succeed.

In an attempt to gain a better understanding of market forces that are driving these trends, our organization conducted a comprehensive review of the literature and spoke with some of our hospital customers to better understand the present and future states. The picture that emerges is one that reveals a wide array of environmental issues that have long plagued those working in and managing cardiovascular service lines. These include:

Rising cost of equipment. The cost of acquiring new equipment to treat cardiac disease is astronomical. Take, for instance, the average cost of a bi-plane cath lab system. According to the Modern Healthcare/ECRI Institute Technology Price Index, these systems can set a hospital back $1.1 to $1.5 million¹, with the price of angiography equipment having risen more than 7% in the past year.² When looking at other modalities, such as electrophysiology (EP), the six-year cost of purchasing and maintaining a robotic magnetic navigation for EP cases can exceed $3.9 million.³ Building a new hybrid operating room? Plan to spend $3 to 4 million.⁴

But, despite the expense, hospitals will always find ways to budget for the various tools needed to diagnose and/or treat patients. This comes down to two major factors: physician desire to have available the best means of curing disease and the desire by hospitals to be recognized as being on the cutting-edge of technology that leads to improved care.

Continuing specialty overlap. One does not have to look closely within any hospital to recognize that physicians continue to intersect territories, with interventional cardiologists, and endovascular, cardiothoracic and laparoscopic surgeons all expanding the types of procedures they perform, overlapping more and more. Data from IMV’s Cardiac Cath Census Database reports that the proportion of cath labs being used for non-cardiac cases by interventional radiologists, cardiothoracic surgeons and endovascular/vascular surgeons has increased from 47% to 67% since 2000⁵, with no sign of this pace slowing down. These shifts have workflow and staff-based knowledge issues built in: any facility blending procedures in the same lab needs to consider cross-training staff and/or establishing new worker protocols in these environments in order to ensure efficiency and patient care.

Consumer demand. American users of healthcare are becoming consumers of health services. This distinction is important. No longer are patients relegated to the whims of their physicians or constrained by geography. To be certain, our nation’s healthcare consumers are becoming more discerning and will demand they get the best possible solution to their specific heart ailments. A new study by Randstad Healthcare reinforces this, revealing how health consumers are making the decision to have their services rendered elsewhere when they experience an unpleasant or unsatisfactory level of care from a provider organization.⁶

Endless regulation. Hospitals and providers have always faced an endless barrage of rules and regulations, all enacted to “improve care.” Take, for example, the latest Centers for Medicare and Medicaid Services (CMS) requirement for electronic quality care measure (eCQM) reporting. Facilities must submit four eCQMs for patients discharged in Q3 and Q4 2016 by Feb 2017 as part of the CMS Hospital Inpatient Quality Reporting Program that sets out to provide financial incentive for hospitals to report the quality of their care. A Joint Commission survey of 300+ hospitals regarding this reporting program reveals quite the opposite: less than one-fifth of respondents indicate they are confident these data will accurately reflect “quality of care” they provide. More telling is the fact that only 15% of hospitals surveyed would implement eCQMs voluntarily, and that 88% need to do “some” or “a lot” of work to be ready and comply with this mandate.⁷ These sentiments reflect the ever-increasing administrative burden and costs being forced upon providers, costs that are not improving the direct delivery of patient care.

Patient and provider populations. There’s certainly been no shortage of news or reports about the graying of America and how our nation’s elderly population is going to put a massive strain on the healthcare system. With an estimated 73 million people expected to be 65 or older by the year 2030⁸, there will be demand for more facilities such as hospitals and nursing homes, accompanied by the need for more physicians, nurses, and other healthcare professionals to care for this group. And despite the increase of “active” seniors, this aging population will bring a corresponding 16% increase in the incidence of coronary heart disease over the next twenty years.⁹

The Never-Ending Shortage 

One overarching issue that compounds all of the other items raised earlier is the chronic shortage of physicians, nurses, and allied health professionals that are qualified to treat individuals with cardiovascular disease. This well-documented shortage is exacerbated in a number of ways, including the following:

1. When our population ages, so do our providers. The number of healthcare providers aging in lockstep with the population is significant. For instance, some estimates report that nearly one-third of the current nurse workforce will reach retirement age and leave the workforce in the next 10-15 years.¹⁰ The effects of this phenomenon have already been felt: nursing schools were forced to turn away almost 69,000 qualified student applicants due to lack of faculty, as well as a decreasing number of preceptors, classrooms, and clinical sites, in 2014.¹¹ 
2. It’s going to be expensive. It’s widely understood that workplace attrition, either due to retirement or employee resignations, is a costly proposition. John Zorbini, head of human resources at Milwaukee’s Aurora Health System, pegged this turnover cost to be $85,000 per nurse, as reported in a workforce planning model whitepaper by the American Hospital Association.¹² At that rate, it only takes losing 12 nurses to incur losses that exceed $1 million — a number comprised of many elements, including recruitment advertising, staff time to conduct both interviews and onboarding activities, lost departmental productivity, sign-on bonuses, and overtime for others to cover shift gaps.
3. The knowledge explosion is daunting. Advances in the cardiology industry are occurring at too rapid a pace for any one provider to remain 100% current. Yes, nurses and technologists are required to earn continuing education to maintain their licenses and/or credentials, but the sheer volume of studies and newly launched medicines, matched by a never-ending stream of technology introductions and regulatory developments, only means more demands on the overworked health professional to keep up to date. 

What Are Facilities Doing?

We reviewed some of the ways our organization’s customers have addressed these problems. A few common themes are evident:

• Cardiovascular department directors and administrators are becoming more proactive in addressing some of these concerns, head-on, in new and imaginative ways. 
• Creative thinking is paramount, as is the willingness to explore new types of partnerships and innovative approaches, particularly those that relate to recruiting and retaining invasive cardiology staff.
• Physicians, as they are increasingly choosing to become hospital employees, are demanding their technical and nursing staff counterparts be qualified to handle ever-evolving procedures and new protocols.

Another theme that we found to be common across all of the managers and administrators we spoke with: progressive leaders are taking cues from the corporate community and providing access to focused training and education. Long known to be true by the corporate sector, highly relevant professional development is one of the best retention tools an organization can extend to its team members. Offering education and training demonstrates a commitment to staff that is nearly unparalleled, and the cost to provide training to an organization’s workforce is considerably less than the high cost of turnover. “I’ve seen what a difference educating a clinical team can make in the EP environment, both in terms of morale building and job satisfaction,” says Jeffrey Stiffler, AST, BS, CCDS, CEPS, vice president of electrophysiology at Healthworks. Having taught EP teams across the country, Jeff has seen firsthand the significant impact that an investment in staff training can have. He cites one report from the Advisory Board that found the reduction in nursing turnover from 13% to 10% saved one 500-bed hospital nearly $800,000.¹³

The wide array of benefits associated with quality training for staff goes beyond saving money. Some of these benefits are detailed in a recent article14 by Dean Gesme, MD, a Minneapolis-based oncologist and internist, and include:

Retention. Staff develops a loyalty, knowing that you care about their professional and personal growth.
Staff morale. A culture that encourages learning fosters an engaged and motivated workforce.
Practice efficiency. Orientation and cross-training means a smoothly functioning and stable work environment.
Job competency. Productivity and confidence are increased in those who have undergone job-specific training.
Patient satisfaction. A knowledgeable team directly affects patients, who benefit from the staff’s efficiency and positive attitude.

The following real-world examples illustrate how progressive hospitals are leveraging their investment in training and education, detailing what some cardiovascular leaders have done to expand service lines, solve recruitment challenges, and build high-performing invasive cardiology teams, all offering a significant return on education investment.

Midwest Expansion

A 300-bed anchor hospital in a regional health network in Ohio was undergoing construction to build a new, integrated healthcare campus that leveraged partnerships and technology. The goal was to offer the community a unique blend of medical services, health career education, specialty child care, and a senior housing complex. Within the new facility, the cardiology unit was slated to expand to three labs from its single cath lab, adding both a new EP lab and an interventional lab. Management had set a target goal for each lab to function with cross-trained teams of one nurse and two technologists, with a total of approximately 17 full-time workers. 

The challenge was multi-faceted: the hospital had to recruit for new allied health staff with interventional experience, and train the existing team of nurses and technologists, all while attempting to keep the existing diagnostic lab volume uninterrupted during the construction. To address this issue, the first step that cath lab management took was to deploy a comprehensive teaching program that included an intense instructor-led training for all existing staff to ensure they had the required interventional knowledge. They also offered this program to new recruits. 

In order to minimize disruption of patient cases and workflow, the management decided to use a team of Healthworks nurses and technologists to work in their lab while the hospital’s new recruits and existing personnel attended the instructor-led coursework. This contingent staff group was comprised of a number of individuals who ultimately precepted the hospital’s workforce during the second, hands-on portion of the training. The benefit of this approach was evident, seeing the preceptors were now very familiar with the physicians’ preferences and protocols, and were able to train the hospital’s new recruits accordingly. This facility has earned the highest rating for treatment of heart failure by a national quality measurement organization for three years in a row.

Creating High-Performing Teams

Today, Philadelphia’s largest teaching hospital, the Hospital of the University of Pennsylvania (HUP), has five electrophysiology labs and is overseen by one of the specialty’s most influential thought leaders, Francis Marchlinski, MD. During 2008, the hospital, part of the UPenn Health System, was rapidly expanding from two to five EP labs. A significant number of existing staff were leaving for industry jobs or other EP positions, forcing the facility to embark on an aggressive recruitment campaign for nurses and technologists. 

The dichotomy of this situation was not lost on their management. “We knew we had to do something to positively impact this turnover and get many new hires up to speed quickly during the expansion,” said EP lab manager, Tanya Smith, MMS, PAC-C, CEPS, CCDS. “We worked closely with Healthworks’ vice president of electrophysiology, Jeffrey Stiffler, to implement a new three-month electrophysiology education program, which we eventually dubbed ‘EP Boot Camp’.” During these intense sessions, all HUP staff, those recently hired as well as existing EP team members, were exposed to accredited, instructor-led training, accompanied by guided preceptorships in a specially-designated lab fully staffed by a team of Healthworks EP specialists. Boot camp participants took part in ongoing quizzes, and every nurse and technologist was required to take a final competency exam, ensuring they all had a critical understanding of the various EP fundamentals. 

This solved two problems. First, it allowed the hospital to rapidly onboard its new recruits. Moreover, the three-month program ran twice, giving Smith six months to build her own education program for future hires. Smith, who oversaw the entire effort, said, “Our turnover was significantly reduced, and the team’s motivation improved greatly. Everyone benefits from education — the doctors, management, and staff, and most of all, our patients.” Victoria Rich, PhD, RN, FAAN, then chief nursing officer at HUP, recognized the importance of such a program and noted at the time, “the hospital is committed to a culture of continual improvement while providing the highest level of care, and a highly educated workforce is a key component of this care strategy.” 

Going Back to School in the Southwest

A medium-sized facility in New Mexico was struggling to build and maintain a fully qualified cath lab team, having been forced to use a large number of rotating travelers for a number of years. At one point, the entire cath team was comprised of contingent nursing and per-diem technical staff, with one exception: a full-time working lab supervisor. New Mexico mandates technologists working in invasive cardiology environments be certified and registered radiologic technologists [RT(R)s]. Based on these regulations, we partnered with the management team to create a hospital-sponsored training program whereby the facility would offer invasive cardiology education to RTs interested in working in the cath lab, at no charge, in exchange for formal work commitments. 

This hospital then reached out to the various in-state schools and colleges with RT programs, ultimately identifying four RTs that took the facility up on their offer. These RTs were joined by two nurses recruited from within the hospital, and all successfully completed the education program that included extensive precepting. The program was so successful that the hospital reduced its reliance on travelers, and subsequently repeated the program six years later.

Hanover Hospital: A Case Study

Located in rural south-central Pennsylvania, Hanover Hospital is a 93-bed community hospital that was looking to introduce PCI (percutaneous coronary interventions) without on-site surgical backup, a highly regulated procedure by the state’s department of health. In 2013, the hospital’s management indicated the facility had worked with a consulting company to build a business plan to best understand the potential and outline a market approach. They had a significant interest in pursuing this service line.

According to Kathy Miller, RN, BSN, MHA, Administrative Director of Hanover’s Heart and Vascular Center, the hospital’s community health needs assessment found that the incidence of heart disease and diabetes was on the rise. Coupled with high cost and risk of transporting patients to other facilities that offered PCIs, “we also learned that patients and their families were less than satisfied in being forced to leave the community for care,” said Miller. “More importantly,” she added, “we knew that eliminating this transit time and keeping patients close to home would mean saved lives.” Ultimately, the consultant’s report was encouraging — there was a market for this offering — and a goal of 200 PCIs was set for the program’s first year.

In order to offer this new service line to the community, the hospital knew that having the requisite physicians to perform PCI was not a problem. Recruiting and deploying a capable and qualified staff in order to support the physicians conducting these interventions, however, would be, since the hospital was in a remote location without big-city wages to attract experienced allied health professionals. There were other challenges, too, including the lack of a dedicated post-procedure recovery area for this patient group.  Dr. David M. Gilbert, an interventional cardiologist and board-certified specialist with the American Osteopathic Board of Internal Medicine, voiced an additional concern: “Hanover has a great cath lab staff, all who are energetic and hardworking professionals. But when you expose people to new procedures, and ‘start at the beginning,’ their ability to be on the lookout for potential complications is not inherent.”

During the summer of 2014, the hospital began its recruitment efforts in earnest, while partnering with Healthworks to supply experienced interventional cardiology nurses and technologists to staff the lab. In addition, the hospital was advised on a variety of items such as patient workflow, interventional equipment, and inventory recommendations by Healthworks team members. 

In September of that year, the facility successfully conducted its first PCI, with Hanover relying on Healthworks’s continued provision of contingent staff to support the cases, having had no luck recruiting the necessary number of full-time employees. By year-end, Hanover’s Miller decided she needed to shift recruitment strategies. “It was obvious we had to do something different,” stated Miller. “It was time to grow our own.” She set her mind to identifying internal candidates who would be interested in working in the cath lab, offering them access to invasive cardiology-specific training and precepting. By March 2015, four nurses and two technologists had agreed to participate, each taking the Essentials of Invasive Cardiology program taught by Healthworks. 

After the first year, 340 PCIs (92 of which were ST-elevated myocardial infarction [STEMI]-related) were performed, well ahead of the defined business plan target. There was a halo effect, too. According to Miller, the number of diagnostic cath procedures doubled, and their peripheral and vascular ultrasound scans grew 25%. Now they are also averaging more than 20 transesophageal echocardiograms per month. “I didn’t expect that amount of growth so quickly,” she said, “and now we are aggressively recruiting for additional non-invasive allied health staff.” 

Shannon Hiestand, RN, a long-time nurse for more than 20 years, including five years in the emergency room, who is one of the internal recruits, shared her sentiments about the training, “I’ve certainly seen my fair share of STEMI patients from the ED view, but learning it from the cath lab side was like being a brand-new nursing school grad.” Hiestand felt the Hanover-sponsored education was extremely valuable, and that by playing out ‘what-if’ scenarios presented by the faculty, she and her colleagues learned to think ahead. The benefit translated well to the real world. “One month ago we had a patient code in the lab,” said Hiestand, “and every Hanover team member knew exactly where to go and what to do.” In reflecting on the program, Dr. Gilbert agreed: “We avoided any complications that could have readily derailed this program.”

When asked what advice she might offer colleagues considering expanding into new cardiovascular service lines, Miller told us, “there was lots of pressure to ensure the success of the PCI program. I hired the manager of the lab about one month after the project.” Miller admits that putting a manager in place before embarking on the PCI program would have been much better. The recruiting process was longer than anticipated, and Miller shared that she would have started the recruitment process for cath lab nurses much sooner, too, not realizing how difficult this would be at the onset. “Start very early is what I learned.”  Finally, Miller endorsed the investment in education: “Growing our own was a solid strategy. Our hospital’s investment in training our staff generated close to an 8-fold return.”

Today, Hanover has 5 technologists and 6 nurses on their cath lab staff, and recently opened its brand-new Heart and Vascular Center. The new area includes new state-of-the-art equipment, a 16-bed holding area, and their success in this new service line area is proudly featured in the hospital’s 2015 annual report. The nurses have begun to learn to scrub in for cases, as this will give everyone a greater appreciation for and an understanding of what each role requires. One of their electrophysiologists has started providing EP education as well. Better still, the facility is averaging a door-to-balloon time of 69 minutes and keeping patients in their community for this critical care procedure. 
The best part? They are, indeed, saving more lives.

References

1. Lee J. Prices of cardiac imaging systems fall—for now. Modern Healthcare. February 7, 2013. Available online at https://www.modernhealthcare.com/article/20130207/NEWS/302079965. Accessed October 24, 2016.
2. Technology Price Index. Modern Healthcare. Available online at https://www.modernhealthcare.com/section/technology-price-index. Accessed June 29, 2016.
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4. Hybrid Operating Rooms with a focus on Endovascular Hybrid ORs. Planning guidelines, pricing, and procurement trends powered by ECRI Institute’s SELECTplus® Market Analytics. ECRI Institute, 2015. Available online at https://www.ecri.org/Resources/Whitepapers_and_reports/MS13084_HybridOR_Market_Analytics_Snapshot.pdf. Accessed October 24, 2016.
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6. Healthcare Workplace Trends Guide, 2016. Randstad Healthcare. Available for free download at https://www.randstadusa.com/workforce360/workforce-insights/randstads-workplace-trends-guide-executive-summary/301/. Accessed October 24, 2016.
7. Pioneers in Quality, eCQM Voice of the Customer, Division of Healthcare Quality Evaluation. The Joint Commission, 2016. Available online at https://www.jointcommission.org/assets/1/6/eCQM_survey_March__2016_Results_Slides.pdf. Accessed October 24, 2016.
8. Ortman JM, Velkoff VA, Hogan H. An aging nation: the older population in the United States, current population reports, P25-1140. U.S. Census Bureau, Washington, D.C., 2014. Available online at https://www.census.gov/prod/2014pubs/p25-1140.pdf. Accessed October 24, 2016.
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10. Grant R. The U.S. is running out of nurses. The Atlantic. Feb 3, 2016. Available online at https://www.theatlantic.com/health/archive/2016/02/nursing-shortage/459741/. Accessed October 24, 2016.
11. 2014-2015 Enrollment and Graduations in Baccalaureate and Graduate Programs in Nursing. Nursing Faculty Shortage. Scope of the Nursing Faculty Shortage. American Association of Colleges of Nursing. Available online at https://www.aacn.nche.edu/media-relations/fact-sheets/nursing-faculty-shortage. Accessed October 24, 2016.
12. Developing an Effective Health Care Workforce Planning Model. September 2013. American Organization of Nurse Executives and American Society for Healthcare Human Resources, both operating units of the American Hospital Association. Available online at https://www.aha.org/content/13/13wpmwhitepaperfinal.pdf. Accessed October 24, 2016.
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Keith R. Chamberlain, MBA, MA, can be contacted at (610) 385-1227 or via kchamberlain@healthworksonline.com.