what works* shortage report.pdf · nurse and physician roles are blurring in primary care, a...

PricewaterhouseCoopers’ Health Research Institute

What works*Healing the healthcare staffing shortage

*connectedthinking

Executivesummary

01 lKeyfindings02 lFutureForces03 lRecommendations04 lAbouttheresearch

05 Background:Businesspolicyissuesaroundthesupplyofnursesandphysicians

11 Thechallengesofinadequatesupply

20 Overcomingthedisconnect

22 Strategiesfordevelopingaworkforcemodelforthefuture

23 lDeveloppublic-privatepartnerships25 lEncouragetechnology-basedtraining27 lDesignflexibleroles31 lEstablishperformance-basedmetrics

35 Conclusion

36 Appendix

Tableofcontents

Executivesummary

Manynursesandphysiciansareamongthebabyboomerswhowillstarttoretireinthenextthreetofiveyears.Thefederalgovernmentispredictingthatby2020,nurseandphysicianretirementswillcontributetoashortageofapproximately24,000doctorsandnearly1millionnurses.Whilehospitalleadersvoicemuchoftheconcernoverpossibleshortages,theimplicationsextendthroughoutthelabor-intensive,trillion-dollarUnitedStateshealthsystem.It’sexpensivetoeducatenewnursesanddoctors.Taxpayer-fundedMedicarespends$8billionayearforresidencetrainingofphysiciansalone.1

WhiletheU.S.hasmorephysiciansandnursestodaythaneverbefore,theyarenotdistributedordeployedefficiently.Shortageprojectionstendtobebuiltaroundtoday’softendysfunctionalsystem,whichmakesthemproblematic.However,whilefutureshortagesarecertainlyworrisome,thebiggerissueforhealthindustryleaderstodayliesinorchestratingcareinanincreasinglycomplexandconverginghealthcarelabormarket.

Shortages,oreventalkofshortages,canmanipulatemarkets,creatingproblemsforhealthindustryexecutiveswhofacethedailyissuesofrecruitingandretainingthebesttalent.Yetbecauseshortageshavealsobeencyclical,short-termsolutionshavewonoutoverlong-termchanges.

Seekingsolutionsmeansunderstandingthatwhilethechallengesconfrontingnurseandphysicianshortagesareverydifferent,theirrolesandfuturesarestartingtoconverge.Healthcareisateamsport:adozenormoretypesofphysiciansandnursescanbeinvolvedinasinglepatient’scare,andtheneedforcoordinationandplanningbecomesmoreimperativeandcomplex.It’snotamatterofdeterminingthemixofnursesanddoctorstodeliverefficientandeffectivecare.Executivestodaymustconsiderwhatkindsofnursesanddoctorsareneeded,whattasksthesecliniciansarebesteducatedtodeliver,andhowtechnologyandlower-skilledworkerscanbeusedtosupplementorreplacethem.

PricewaterhouseCoopers’(PwC)HealthResearchInstitute(HRI)studiedthisevolvingissuewiththeintentofprovidinga360degreeviewofcurrentworkforcechallengesandprovidingaroadmapforanew,moresustainableworkforcemodel.

Keyfindings

Use of temporary nurses is no longer a stop-gap measure but has become a way of life for many hospitals.Reactingtoseveralyearsofnursevacancyratesinthe7%to10%range,hospitalexecutivessurveyedsaidtheyusetempnursesforanaverageof5%ofallnursinghours.Meanwhile,nearlythree-fourthsofhospitalexecutivessurveyedsaidtheirphysiciansareaskingforon-callpay,andtwo-thirdssaidsomeoftheirphysicianswanttobeemployedbythem.Thisdatabolstersthetrendofnursesmovingawayfromhospitalemploymentanddoctorsmovingtowardit.

The process of educating and retaining new nurses is broken.Thenumberofdeniedapplicantsfornursingschoolsisatitshighestever,increasingmorethansixfoldsince2002.Turnoveramongnewlyhiredhospitalnursesishighestinthefirsttwoyears.

Failure to retain nurses is costly and wasteful.Everypercentagepointincreaseinnurseturnovercostsanaveragehospitalabout$300,000annually.Hospitalsthatperformpoorlyinnurseretentionspend,onaverage,$3.6millionmorethanthosewithhighretentionrates.

Hospital leaders are in a state of denial about nurse dissatisfaction. Hospitalexecutivesbelievethatthenurseworkforceingeneralisdissatis-fied,butnotnursesintheirownhospital.Hospitalexecutivessurveyedcitedexcessiveadministrativepaperwork,patientworkloadstrainsduetorisingpatientacuitylevels,andinadequatestaffingasthetopthreefactorsfornursedissatisfactionandturnovers.Inadequatecompensationanddisruptivephysicianbehaviorrankedfourthandfifth,

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respectively.However,hospitalexecutivesmaybeunderestimatingtheeffectsofthesefactorsbe-causemanyofthosesurveyedfailedtorecognizethesecomplaintsasa“verysignificant”problemintheirownorganizations.

A new wave of medical schools could repair the inequity of physicians in underserved areas and specialties.AsmoreU.S.medicalstudentsgraduate,they’lllikelydisplacesomeinternationalmedicalgraduateswhohavebeenfillingthegaps.Aftertwodecadesofthestatusquo,arecordnumberofnewmedicalschoolsareslatedtoopeninthenextfivetotenyears,whichcouldalterthefuturedistributionofphysicians.

Nursing education is stifled by perverse financial incentives.Whilemedicaleducationreceivessignificantfederalsubsidies,thesameisnotnecessarilytruefornursing.Nursingeducationprogramsoftenlosemoneyforcolleges,limitingcolleges’willingnesstoexpandtheirprogramsandraisefacultysalaries.

The workforce is too often a second thought for executives, who are distracted by numerous payment and regulatory issues.Asignificantdisconnectexistsbetweenwhathospitalexecutivesthinkaboutmedicalworkforceshortagesandhowtheyaddressthem.Three-fourthsofhospitalexecutivessurveyedsaidworkforceshortagesarereal.However,whenaskedtoranktheseshortagesasapriorityintheirorganizations,physicianissuesrankedsixthandnursingissuesrankedseventhbehindotherprioritiessuchasreimbursement,governmentregulations,clinicalquality,anduncompensatedcare.

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1 PricewaterhouseCoopers

Theseresearchfindingsindicatethatthecurrentmedicalworkforcemodelisundergreatpressureandinmanycases,isbroken.Therearealsonewforcesonthehorizon,however,towhichhealthcareorganizationsmustbeabletorecognizeandrespond.

Nurse and physician roles are blurring in primary care, a specialty in which lower salaries have dissuaded debt-laden medical students.Three-fourthsofhospitalexecutivessurveyedsaidhospitalsareusingmorephysicianextenders,suchasnursepractitionersandphysicianassistants,andmorethanhalfsaidtheywillusetheminthefuture.Competitionforthesecliniciansisincreasing,particularlywiththeadventofretailclinics,whichheavilyemployphysicianextenders.

Rainmaker roles may change for hospitals. Employmentchangesandpay-for-performancereimbursementmaycombinetofliptheworkforcedynamicinhospitals.Traditionally,physicianswererainmakerswhobroughtinrevenue,andnurseswereoverhead.Throughnew,pay-for-performanceprogramsthatfocusonclinicalqualityandpatientsatisfaction,nurseswillhavesignificantimpactonthekeymetricsthatwilldrivereimbursementupdates.

Schedules trump salary.Organizationsthatfocusonthework/lifebalanceissuesforphysiciansandnurseswillhaveacompetitiveedgeinrecruitingandretainingtoptalent.Medicalstudentssaywork/lifebalanceisatopinfluencerofhowtheypickaspecialty,andnursessaycultureandschedulesarethegreatestinfluencesontheirjobsatisfaction.

Advances in specialization and technology are shifting what is done and by whom.Fromradiologiststocardiologists,todigitaltelemedicineandvirtualcolonoscopies,traditionalrolesanddescriptionsaremorphingandshifting.Thisshiftholdspromiseforincreasedefficiencybutmaycausedisruptionforcertainspecialties.

Futureforces

Whatworks* 2

Giventhesekeyfindingsandfutureforces,PwC’sHealthResearchInstitutehasdevelopedaroadmapforanewworkforcemodelbasedonthefollowingrecommendations:

Develop public-private partnerships.Widespreadshortageshavecreatedanenvironmentinwhichkeyhealthcareplayersmaynolongeroperateinsilos.Rather,thesegroupsmustworkcollectivelytopromotenursingandphysicianprograms,forgingalliancestoprovidenotonlyeducationbutalsorequiredfunding.

Encourage technology-driven training.Improvingclinicaloutcomesrequirestheseamlesscoordinationoftreatmentamongallclinicalprofessionals.Advancesintechnologyhaveenabledcaregiverstoworkinconcertwithoneanother,allowingthefocustoremainonqualitypatientcare.Providers,fortheirpart,mustmaximizeavailabletechnologyandencouragetheadoptionofandadherencetotechnicalinnovationstoincreasetheproductivityofmedicalstaff.

Design flexible roles.Morethanever,physiciansandnursesareplacedinastrongerpositiontodictatethetermsoftheiremployment,andemployersareincreasinglyfindingthatflexibilityiscentraltoattractingandretainingqualitymedicalstaff.Themostsuccessfulemployerswillprovideclinicianswithoptionsandintegrateflexibleworkarrangementsintotheirstaffingmodels.

Establish performance-based metrics. Unlikeotherindustries,healthcarehasbeenabletodelaytheadoptionofperformance-basedstandards.Traditionally,reimbursementdidnotdependonqualityoroperationalefficiencybutratheronlyonthevolumeofservicesdelivered.However,thelandscapeofreimbursementisevolving,withperformancebasedmetrics—suchasclinicalqualityoutcomesandpatientsatisfaction—asitscenterpiece.

Recommendations


Toprovideresearch-basedinsight,HRIconductedmorethan40in-depthinterviewswiththoughtleadersandexecutivesrepresentinghospitals,academicassociations,nursingschools,andthebusinesscommunity.PwCconductedathoroughliteraturereviewofreportsandguidancefromassociations,regulators,andacademiatogatherinsightsoncurrentchallengesandbestpractices.Publiclyavailabledatawasanalyzedrelatingtoworkforceprojectionsanddemographics.PwCalsocommissionedasurveyofmorethan240hospitalexecutivesfromthroughouttheU.S.inthefollowingcategories:

ChiefNursingOfficer(CNO)

ChiefMedicalOfficer(CMO)

ChiefExecutiveOfficer(CEO)

ChiefFinancialOfficer(CFO)

ChiefOperatingOfficer(COO)

VicePresidentofHumanResources(VP-HR)

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Whilethisreportfocusesonnursesandphysicians,theyarenottheonlyprofessionaloccupationsaffectedbyworkforceshortages.Otheroccupationsincludeimagingtechnicians,pharmacists,labtechnicians,andpatient-careassistants.2Whilethescopeofthisreportdoesnotallowfullexplorationofeacharea,thereissomecommonalityofsupplyanddemanddriversamongthedifferentfields.

TogetthebroadestpossibleinputfromPwC’snetworkofbusinessadvisers,HRIemployedaninnovativetoolcalledthePwCThought-Wiki,whichisbasedonsimilartechnologythatpowersWikipedia,anonlineencyclopedia.ThistoolincorporatedanewlevelofcollaborativeauthoringandknowledgesharingintoHRI’scontentdevelopment.TheThought-WikienabledPwChealthindustrypractitionerstocontributetheirreal-worldknowledgetotheresearch,anditwasespeciallyhelpfulincapturingthecollectiveintelligenceofourclinicians.

HRIalsoenlistedtheaidofPwCSaratoga,aservicethatfocusesonteamingwithexecutivesandHRdepartmentstohelpthemmeasure,manage,andmaximizethevalueoftheirworkforce.

Abouttheresearchh

Whatworks* 4

Registerednurses(RNs)andlicensedphysiciansarethearmsandlegsofthehealthindustry,anditseemsthereareneverenough.Three-fourthsofhospitalexecutivessurveyedbyHRIforthisreportsaidclinicalworkforceshortagesarereal.Asthehealthcareindustrygrowsandnowconsumes16%oftheoveralleconomyintheU.S.,employmentasanurseorphysicianhasdeliveredoneofthemostdependablepaychecksaround.Theneedfornursesandphysiciansinhospitals,nursinghomes,healthplans,pharmaceuticalcompanies,homehealthagencies,andotherhealthcompanieshasexplodedduringthepast20years.

Howmanyisenough?It’sadifficultquestiontoanswer,consideringtheacknowledgedinefficienciesofthesystemoverall.Intermsofglobalbenchmarks,theU.S.hasfewernursesandphysicianspercapitathansomeotherindustrializednations,yetitspendsfarmoremoneypercapita—twiceasmuchasotherindustrializedcountries—onhealthcare.Wouldhavingmorenursesandphysiciansraisecostsevenfurther?Woulditincreasequality?Woulditmakethesystemoperatemoreeffectivelyandefficiently?

Chronic nursing shortages may double after 2010

Thetotalnumberofregisterednurseshasincreasedby75%since1980(Figure1).Talkofnursingshortageshaswaxedandwanedforgenerations.Inrecentyears,atleastadozenstateshaveinitiatedstudiesabouttheshortageofnurses,andinsomeregions,chronicshortagesappeartobegrowing.Forexample,theRegionalMedicalCenterinMemphis,Tenn.reportedin2007itwassoshortofstaffthatithadtoresorttodivertingpatientstootherhospitals—evenwomeninfulllabor.3

Since1999,hospitalshavebeenonaconstructionbinge,heighteningcompetitionfornurses.Hospitalsspentanestimated$30billiononconstructionin2006—a30%increaseinjustoneyear—and83%ofhospitalsreporttheyplantoaddcapacityinthenexttwoyears.4Inaddition,Medicare’scasemixindexforinpatientsstartedtoriseagainin2001,5signalingsickerpatientswhoneedmorecare.ThisfindingwassupportedbyHRI’shospitalexecutivesurveythatrankedincreasedpatientacuityasatopreasonfornursedissatisfaction.Notsurprisingly,registerednursefull-timeequivalents(FTEs)peradjustedadmissionhavebeeninchingupafterdroppingduringmostofthe1990s.6Theneedformorenursestoworkinhospitalsgrew.Althoughhospitalsarethesinglelargestemployersofnurses,theyareincreasinglycompetingfortalentwithnon-hospitalorganizations,suchasambulatorycenters,physicianpractices,healthinsurers,anddiseasemanagementcompanies.Thepercentageofnursesworkinginhospitalshas

Background:Businessandpolicyissuesaroundthesupplyofnursesandphysicians


Whatworks* 6

beendroppingsteadilyovertime(Figure2).Competitionisexpectedtoheatupevenmorewiththeadventofretailandworksiteclinics,staffedbynurses,nursepractitioners,andphysicianassistants.Over300oftheseclinicshaveopened,andanother1,200arescheduledtoopenby2009.7

In2006,direpredictionsabouttheshortageweretemperedwhenpolicymakersobservedaresurgenceofstudentsintheirlate20sandearly30sgoingintonursing.9Inadditiontoenteringtheworkforcelaterthanpreviousgroups,thoseborninthe1970sarenowenteringthenursingprofessioningreaternumbersthantheirpreviouscohortsdid.10

Evenso,thefuturetrendlookstroubling.Forthefirsttimeindecades,thetotalnumberofnursesisprojectedtobegingoingdownafter2010(Figure1).Nurseswillstarttoretireatthesametimethatbabyboomersbeginturning65yearsofageandstartusingmorecare.Currently,forecastsforaregisterednurseshortagein2020rangefrom400,00011tomorethan1million.12Animportantaspectoftheshortageisthatsome450,000licensednursesarenotworkingatthebedside.13Ifby2020allregisterednursesweretobeclinicallyactiveandworking,theshortageestimatefor2020woulddecreasetojustover100,000,mirroringtheshortagetoday.

Predictionsaboutthenursingshortagecouldbecomemoreacutewhencoupledwithnewpredictions

Figure 2. Percentage distribution of RNs by employer

OtherNursing education

Nursing homes/extended careAmbulatory care

1980 1984 1988 1992 1996 2000 20040

20

40

60

80

100

120

Public/community healthHospital

Source:HealthResourcesandServicesAdministration14

Figure 1. Licensed RN supply (past and projected)

1,500,000

2,000,000

2,500,000

3,000,000

1980 2020E1984 1988 1992 1996 2000 2004 2010E 2015E



aboutanimpendingphysicianshortage.Theprospectofclinicalshortagesamongbothphysiciansandnursesmaybemorethantheindustrycanbear.“Thereexistsacertainecologyinthehealthcareindustry.Allofthepiecesdependupononeanother,butthereisnoincentiveorstructuretoviewitasawhole.Wehaveadysfunctionalsystemthatwe’retryingtofixwithsilverbullets,”saysDr.RobertTemplin,presidentofNorthernVirginiaCommunityCollege,oneofthelargestcommunitycollegesintheUnitedStates.

Forecasts of physician supply and demand are more ambiguous than for nursing

Thebasicdemographicforcesarethesameforphysiciansasfornurses:anagingU.S.populationdemandingevermorecareandenmasseretirementsofbabyboomerphysicians(currentlyone-thirdofallactivephysiciansareover55yearsold).15Asprofessionalsonthehighendoftheincomescale,physicianswhohaveplannedaheadfinanciallymaydecidetoretireearlierthannursesbecausetheycanaffordtodoso.Aswithnurses,theabsolutenumberofphysicianshasincreasedsteadilyovertheyears,outpacingpopulationgrowth.16However,thefutureisabitmurkier,complicatedbyspecialization,geographicmaldistribution,andblurringlinesbetweenprimarycarephysiciansandadvanced-practicenurses.Thebestfuturestrategyisanothermatter.Inpart,thismaystemfromstudiesshowingthatmorenursesincreasequality,butmorephysiciansmayaddmorecost.

Maldistributionofphysiciansbyspecialtyandgeographyhasexistedfordecadesbutisnoteasilysolvedbymarketforces.Factorsinfluencingthisaredifferencesinpay,lifestyle,culture,uncompensatedcare,andriskofliability.

Acrossallspecialties,theHealthResourcesandServicesAdministration(HRSA)predictsanetshortageof24,300physiciansby2020usingabaseorcontinuationcase(Figure3).17Thefederalagencyalsomodeledotherscenariosthatincludedproductivityimprovementsandincreaseduseofnurseextenders.Underthosescenarios,asurpluswaspredicted.

Awiderangeofopinionsexistabouttheadequacyoffuturephysiciansupply.AtthehighendisRichardCooper,M.D.,professorofmedicineat

Whatworks* 8

2000 2005 2010E 2015E 2020E

Figure 3. Active physicians: projected supply and demand

30% increasein enrollment

10,000 additionalgraduates in 2020

5,000 additionalgraduates in 2019

HRSA supply HRSA demand

700,000

800,000

900,000

1,000,000

LeonardDavisInstituteofHealthEconomicsoftheSchoolofMedicineattheUniversityofPennsylvania,whopredictsashortageofupto200,000physiciansby2020.18Atthelowendarethosewhoarguethatthemainproblemisoneofefficiencyanddistributionratherthanabsolutesupply.ThemedicalpracticevariationresearchstartedbyJohnE.Wennberg,M.D.,directoroftheCenterfortheEvaluativeClinicalServicesatDartmouthCollege,andcontinuedbyothers,hasshownthatthereisnocorrelationbetweengreaterphysiciansupply(afterarequisitethresholdisreached)andbetterclinicaloutcomes.Therearestillsignificantmedicalpracticevariationsunexplainedbypopulationordiseasecharacteristics.Infact,areaswithhighernumbersofphysiciansdonotnecessarilyimprovepatientoutcomes,buttheydoincreasecosts.19

Arecentpopulation-basedstudydemonstratedlowermortalityrateswheretherearemoreprimarycarephysicians,butnosucheffectwiththesupplyofotherspecialists.21AnotherrecentstudyfoundgreatvariationbetweenacademicmedicalcentersintermsofphysicianlaborinputsusedincaringformatchedMedicarebeneficiarycohortsinthelastsixmonthsoflife.22Thatis,thereweredifferencesinefficiency.Thisdatasupportstheideathatabsolutesupplyofphysiciansisaninsufficientvariableforunderstandingthe“shortage”problem.

Source:HealthResourcesandServicesAdministrationandPricewaterwaterhouseCoopers’HealthResearchInstituteanalysis20


International recruitment has filled the gaps but isn’t viewed as a sustainable solution

NurseshavebeenemigratingtotheU.S.formanyyears,especiallyfromCanadaandthePhilippines.By2000,11%ofallU.S.nurseswereinternationalnursinggraduates(INGs).23By2005,13%ofallnewlylicensednurseswereINGs.24

Thepercentagescanbemuchhigherforanindividualfacilityorgeographicarea.MarthaSmith,formerassistantchiefnursingofficeratLaredoMedicalCenterinTexasandcurrentlyCNOatParkPlazaHospitalandMedicalCenterinHouston,describedhowthesituationcanbedifferentwhenlocatedalongtheU.S.-Mexicanborder.“WeoccasionallyreachfullcapacityandsometimescannotopenICU[intensive-careunit]beds.Weactivelyrecruitinternationalnurses—now25%ofourstaff—andIhavepersonallymadetworecruitingtripstothePhilippines.”

Intermsofthephysicianworkforce,internationalmedicalgraduates(IMGs)madeup25%ofallphysiciansinpracticeand26%ofnewgraduatephysiciansenteringpost-graduatetrainingin2005intheU.S.2526GraduatesofU.S.medicalschoolsarevirtuallyguaranteedaresidencyslottocontinuetheireducationtobecomelicensedphysicians.However,whentherearen’tenoughU.S.grads,thoseslots,typicallyinprimarycare,go

Personal story. Code Red in California

Rakeshlikestheexcitementandjobflexibilityoftheemergencydepartment,wherehecanworkasmuchoraslittleashewantsbypickingtheshiftshewantstowork.“IreallyliketheworkbecauseIdon’tknowwhattoexpect.Intheemergencyroomtherearetimesthatcanbemundaneandtimesthatcanbereallyexciting.Itkeepsmeonmytoes,andIseeavarietyofpatients.”

His career

Tenure 5yearsasemergencyroomattendingphysicianandemergencymedicalserviceliaison

Educationalfinancing

Scholarshipsandloans

%oftimeindirectpatientcare 95%

“Mycareerinmedicinestemmedfrommyinterestinthesubjectmatteralongwithmypastexperiencesasavolunteerintheemergencydepartmentandasalifeguard.”

The profession

“Medicinehasgivenmeagreatdeal.Ihavereallygottenalotoutofitandhavemetsomegreatpeople.Ifindalotofdoctorscomplainingandfrustrated,butIfeelthisprofessionisaprivilege.DoctorsinmanycountriesdonotmakeasmuchmoneyastheydointheU.S.,buttheyarepassionateaboutit.”Rakesh’sotherthoughtsabouttheprofession:

Peoplearenotalwaysawareoftheirownhealth

Theemergencydepartmentconceptcanbeabused,especiallybecauseaccesstoprimarycarecanbelimited

Toolittlepreventivecare.“Theemergencydepartmentreallyseestheeffectsofthis.Wefixtheshort-termproblem,butlongterm;theirhealthisnotgoingintherightdirection.”

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Whatworks* 10

toIMGs.Oftheapproximately6,500IMGsenteringU.S.residencytrainingin2005,aboutthree-quarterswentintofirst-yearprimarycareresidencypositions.TheseIMGresidentsaccountedfor42%ofallinternalmedicineslots,37%ofallfamilymedicineslots,and24%ofallpediatricslots.27

However,only23%ofhospitalssurveyedbyHRIsaidtheyhadactivelyrecruitedforeigngraduates.Inaddition,accordingtotheHRIsurvey,only18%ofhospitalssurveyedsaidrecruitmentofforeignnursesanddoctorswasadesirablestrategytocombatfutureshortages.

Criticssaythequalityofnon-U.S.medicalschoolsishighlyvariable,andthatconcernisoneofthereasonstheAssociationofAmericanMedicalColleges(AAMC)hascalledforanincreaseinthesizeofU.S.allopathicmedicalschoolclassesandfornewschoolstobedeveloped.Whilesomeforeignmedicalschoolsareaccreditedbyrecognizedaccreditingagencies,manyhavenoaccreditationoraccreditationwithstandardsappreciablydifferentthanthosedictatedbytheLiaisonCommitteeforMedicalEducation(LCME),whichaccreditsU.S.andCanadianallopathicschools.

Forexample,thequalityofthistrainingisillustratedinthepassageratesontheU.S.MedicalLicensingExamination(USMLE).Passageratesforfirst-timetest-takersonthe2006USMLEStep2examination—whichreflectsfour-yearmedicaleducation—were96%forLCME-accreditedmedicalgraduatesand77%forIMGs;forrepeattest-takers,thesepercentageswere72%and50%,respectively.

Today’sLCME-accreditedallopathicmedicalschoolsintheU.S.reflectboththeartandthescienceofbecomingandpracticingasaphysician,whichgoesbeyondthelicensingexamscores.Anewemphasisoneffectivecommunication,empathy,andunderstandingtheimplicationsofpatientdiscussionsisembeddedintothecurriculum.Itisclearthatphysiciansmustbeabletobothcommunicateeffectivelyandtoartfullyincorporatequantitativeandqualitativeinformationintopatientcare.


Nurses: More than 41,000 qualified nursing applicants were denied admission to nursing school (undergraduate and graduate programs) in 2005.28 This represents a sixfold increase since 2002.

Highvacancyratesandcontinuousturnoverofstaffarestressingthefinancialandculturalfabricofhealthcareproviders.29Itistellingthatnearlyhalfofallnursesdonotworkindirectpatientcare,andthatagrowingnumberofphysiciansareretiringearly.

“Wehaveanagingworkforceandinadequatenumbersofnewnursescomingintothepipeline,”saysAnnHendrich,RN,M.S.N.,FAAN,vicepresidentofclinicalexcellenceoperationsatAscensionHealthSystem.“Staffingdemandsatcurrentlevelsaredifficult.Whenyoucouplethatwiththenewconstructionunderway,it’snotagapbutacrevassethatwillmakeitverydifficulttoavoidshortfallsinaccess,patientsafety,andservice”(Figure4).

Howlargethatgapwillbecomeintheshort-termdepends,inpart,oneducatingnewnurses.In2006,hospitalsnationallyreportedan8.5%nursevacancyrate,accordingtotheAmericanHospitalAssociation.31Aftermultipledropsinenrollmentinthemid-tolate-1990s,nursingenrollmentbeganincreasingagainin2001.Infact,enrollmentsincreasedatdouble-digitratesduringthepastthreeyears.However,there’sbeen

Thechallengesofinadequatesupply

60s

50s

40s

30s

20s

1980 1990 2000 2004 2010E 2020E

Figure 4. Distribution of RN workforce by age group (thousands)

0

1,000

500

500

1,000

1,500

2,000

Age group

Source:AmericanHospitalAssociation30

Whatworks* 12

evenfastergrowthinthenumberofapplicantsturnedaway(Figure5).

Ashortageofqualifiednursingfacultyismostcommonlyblamedforthebottleneck.Asnursingshortagesbegantoappear,salariesbegantoincrease(Figure6).However,facultysalarieshaven’tkeptpace,socollegeadministratorssaytheycan’thiresufficientfacultytoexpandtheirprograms.Yetotherfactorsareatplayhere.Nursingeducationprogramsareexpensive.BrianFoley,actingprovostoftheMedicalEducationCampusofNorthernVirginiaCommunityCollege,states:“Welose$8,000peryearforeverynursewetrain.”Understandably,publiccollegesaren’tanxioustoexpandsuchprograms.Theirtuitionratesaresetbythestate,meaningtheycan’tsimplypassonthehighercoststostudents.Facultyoftenfindtheycanearnhighersalariesoutsideofacademia.Asaresult,thosewhoarequalifiedtoteachoftendon’t.Theaveragenursingfacultyageishigherthantheaverageageoftheoverallnursingpopulation,andthefutureofthenursingeducationsystemwillexperiencesignificantproblemsastheseinstructorsretire.

Anotherproblemforcollegesisthescarcityofclinicaltrainingsites.Overburdenedhospitaldepartmentsandstaffsareoftenreluctanttotakeontheadditionaltaskofteachingstudents.Someareaskingforpayment,therebyaddingtoacollege’seducational

Figure 5. Nursing slots vs. denied applicants

Denied qualified applicants (graduate and undergraduates)Nursing slots

2002 2003 2004 20050

20,000

40,000

60,000

80,000

100,000

Source:AmericanAssociationofCollegesofNursing32


costs.“New[clinicalsites]arenotcomingonlinefastenough,”saysTemplin.“Allocationandutilizationofspacearearchaic.Thesystemisdysfunctional,withindividualorganizationsanddepartmentsoftentakingaparochialviewratherthanasystemapproach.”Compoundingtheproblemisthefactthathospitalsdonotreceivefederalfundingfortrainingnursesastheydoformedicalgraduates.

Physicians: The number of medical school graduates has remained relatively static over the past 25 years.34 The Association of American Medical Colleges has called for a 30% increase in medical school slots to meet shortages forecast by 2020.35

Thedynamicsofthephysicianpipelinearedifferent,buttheyculminateinsimilartalkoffutureshortages.Thetotalsupplyofphysicianshassteadilyincreasedeveryyearsincethe1970s(Figure7).A1980reportfromtheGraduateMedicalEducationNationalAdvisoryCommissionforecastedasurplusofatleast70,000physiciansby1990,apredictionthatwaswidelyacceptedandakeyfactorinlimitinggrowthinthenumberofmedicalschoolslots.36

Evenintothe1990s,physicianworkforcemodelsassumedthatsignificantchangesinpracticepatternswouldbewroughtbytheadventofmanagedcare—thatisagreaterrelianceonprimarycareandmoreefficiencyingeneral.

Figure 6. Hospital nurses' inflation-adjusted median annual earnings and number of hospital nurses

1,100,000

1,300,000

1,500,000

1,700,000

Median annual earningsNumber of hospital nurses

1996 1997 1998 1999 2000 2001 2002 2003 2004$35,000

$37,500

$40,000

$42,500

$45,000

$47,500

Source:InstituteofWomen’sPolicyResearchandPricewaterwaterhouseCoopers’HealthResearchInstituteanalysis33

Figure 7. Number of active physicians

0

100,000

200,000

300,000

400,000

500,000

600,000

700,000

800,000

1970 1975 1980 1985 1990 1995 2000

Source:BureauofHealthProfessions37

Whatworks* 14

AtulGrover,M.D.,Ph.D.,associatedirectoroftheCenterforWorkforceStudiesoftheAAMC,explains:“Webasedeverythingonassumptionsthatthesystemwouldchange.Webelievedthatmanagedcarewasgoingtosweepthecountry,thatitwasgoingtobeembracedbyphysiciansandpatientsalike.We’dallloveit.Itdidn’thappen.”

Asaresult,thenumberofmedicalschools(125)andslotsinU.S.allopathiceducationhasremainedrelativelystableformorethanadecade.Evenasthepopulationgrew,fewerstudentspercapitalwereenteringmedicalschool(Figure8).38’

Thedynamicsofmedicalschoolenrollmentarenowstartingtochange.Thefirstnewschoolin20years—FloridaStateUniversityCollegeofMedicine—graduateditsfirstclassofstudentsin2005.40Moreschoolsareunderdevelopment(Figure9).Mostofthenewschoolswillbebuiltinareaswithhighpopulationgrowth,andgraduatestendtolocatenearwheretheyaretrained.

Whiletherearestillplentyofapplicants(2.2applicantsforeveryslot)seekingentrytothisverylongtrainingpipeline,thenumberofmedicalschoolslotshasbeenrelativelystaticformanyyears.Asinnursing,thereareworriesaboutolderdoctorsretiringandseniorsneedingmorecareafter2010.Recognizingthelongpipelinetobuildschools

Figure 8. First-year MD enrollment per 100,000 population

4

5

6

7

8

1980 2020E1985 1990 1995 2000 2005 2010E 2015E

Source:AssociationofAmericanMedicalColleges39

Source:AssociationofAmericanMedicalCollegesandPricewaterwaterhouseCoopers’HealthResearchInstituteanalysis41

Alaska

Hawaii

Florida

Louisiana

MississippiGeorgia

Alabama

South CarolinaArkansas

Texas

North CarolinaTennessee

New Mexico

OklahomaArizona

Kentucky

Virginia

MarylandDelaware

KansasMissouri

West Virginia

Colorado

New JerseyIndiana Ohio

Nevada

Utah

California

Rhode IslandConnecticut

Pennsylvania

Illinois

Massachusetts

NebraskaIowa

Wyoming

New York

Vermont

New Hampshire

Michigan

South Dakota

Oregon

Wisconsin

MaineNorth Dakota

Idaho

Montana

Washington

Minnesota

Figure 9. Medical school enrollments & forecasted medical school additions by state, 2006

University of California(Merced & Riverside)

Arizona State University & University of Arizona(Phoenix)

University of Texas(El Paso)

Texas Tech University Health Sciences Center(El Paso) University of Houston,

Methodist Hospital, & Cornell University (Houston)

University of Central Florida (Orlando)

Florida International University (Miami)

University of North Carolina & Carolina Medical Center(Charlotte)

Virginia Tech University & Carilion Health System (Roanoke)

Mercer University(Savannah)

Touro University(Florham Park)

Beaumont Hospital & Oakland University(Auburn Hills)

Northeastern Pennsylvania Education Development Consortium (Scranton)

University of Washington (Spokane)

300-399200-299

600-699400-499

Over 1,000800-899

100-1990-99

Number of matriculates


andthenumberofyearsrequiredtoeducateandtraindoctors,theAAMCin2005calledfora15%increaseinmedicalschoolslotsandthenoneyearlaterdoubledthatcalltoa30%increase.42

Amongthoseinterviewed,opinionsdifferedonphysicianshortages.Certainlytherearegeographicandspecialtygaps,suchasinneurosurgeryandinhospital-basedspecialties,suchasradiology,anesthesiology,andpathology.Andthere’salwaysbeenregionalmaldistributionofphysicians.Forexample,MassachusettshastwiceasmanyphysicianspercapitaasMississippi,and20%ofAmericansliveinaprimarymedicalcareshortagearea,asdesignatedbyHRSA(Figure10).4344TheNationalHealthServiceCorpsisdesignedtoaddressshortagesthroughtuitionreimbursementincentives,butithasbeenregardedaschronicallyunderfunded.Studentsrecruitedfromunderservedareasaremoreapttoreturntothoseareasandpractice.Suchstudentsaremorelikelytobefromminoritygroups,yetblacksandHispanicsstillconstituteonly4%eachofthephysicianworkforce,withsimilarratiosseeninnursing.45

Not a HPSA

Full primary care HPSAPartial primary care HPSA

2002 County HPSA status

Figure 10. Primary care health professional shortage areas

Source:AmericanAcademyofFamilyPhysicians46

Whatworks* 16

Theerosionofinterestinprimarycare,however,remainsthemostcriticalproblem.ThenumberofU.S.medicalgraduateschoosingtheprimarycarespecialtiesoffamilymedicineandgeneralinternalmedicinehasplummeted50%inthepast10years.47Only20%ofinternalmedicineresidentsnowchoosegeneralinternalmedicine—thatis,primarycareinsteadofa(higherpaying)subspecialty.48TheAmericanAcademyofFamilyPhysicianshascalledfora39%increaseinfamilymedicinephysiciansbasedonitsassessmentoffutureneed.49Amajorunknownfactorinanyforecastofprimarycarephysicianneedistheextenttowhichsub-specialistsprovideorwillprovideprimarycareserviceswithintheirownpractice.

Physicians and Nurses: Financial pressures influence education, career paths, and staffing.

Whilemanyentermedicineforaltruisticreasons,moststudentsalsolookatreceivingareturnontheirinvestment.Theerosionofstudentsgoingintoprimarycaremaybelinkedtosalariesthathaven’tkeptpacewiththerisingcostofeducation(Figure11).Theaverageeducationalindebtednessfor2006medicalschoolgraduates(includingpre-medborrowing)hasballoonedtoapproximately$130,000.50In2006,theaveragedebtofgraduatingmedicalstudentsincreasedby8.5%comparedtothepreviousyear.51

Personal story. Frontier medicine

KateworksinPresidioCounty,Texas,oneofthelargestandpoorestcountiesintheU.S.“Ifyouliveinafrontierarea,youbetternotgetsick.Therearehardshipsjusttogetthebasicneedsmet.Iftheoneambulanceisoutonarun,youhavetoimprovise.Manypeoplearebornhere,andtheydon’twanttoleaveorcan’taffordtoleave.Thisisaplacewhereyouhavetodrivethreehoursjusttogetyourteethcleaned.”

Tenure 9yearsasRN,11asnursepractitioner

Educationalfinancing Loans


Her career

“IdecidedtobecomeanursepractitionerbecauseIwasfedupwiththesystem.Nursinghasstruggledtobeascientificprofessionbecauseofthebasicnursingprocessofnotdiagnosingortreatingbutfollowinganursingcareplan.Thatwastoolimiting,andIfeltlikeIwasalwaysworkingwithmyhandstied.”

The profession

“Weneedtohaveclinicianscollaboratemoreasteamsandclearlydefinethedifferentjobsandroles.Nursesoftenshootthemselvesinthefootbynotdifferentiatingbetweenthedifferentlevelsofeducationthatprepareyoufordifferentjobs.Butmostimportant,weneedtochangethewholesystemandgeteveryoneaccess.”Kate’sotherthoughtsabouttheprofession:

Professionalnursesshouldhaveaminimumofabachelor’sdegree

Internationalmedicalgraduatesareessentialtoruralareas;theyareincrediblymotivatedandhighlytrained

Shegetsfrustratedwithphysicianswhodonothaveaholisticapproachtohealth

•

•

•


Asdebtreacheshigherlevels,thereisagreaterinfluenceonspecialtychoice.52Graduatesself-reportthatotherfactorsdrivetheirspecialtychoice.53

Whilepayranksthirdasanursesatisfier—behindworkingconditionsandscheduling—aroughcorrelationhasbeendemonstratedbetweennursepaylevelsandnumbersofnursesintheworkforce.55Nurseshortagesresultintheuseofagencynursesatahigherrateofpay.Tominimizeagencystaffingandensurecoverageandviabilityovertime,executivesareaddressingpayissuesfornursingstaff(Figure12).

Physiciansaremorefrequentlydemandingon-calllevelsofcompensationorareoptingoutofemergencydepartmentandtraumacoveragecompletely.Theyarealsoincreasinglyseekingemploymentarrangements.Thisdatademonstratesthegrowingdesireofyoungergenerationsforwork/lifebalanceaswellasameansofensuringadequatecompensation,whichtrackscloselytooverallworkforcetrends.

Source:AmericanAssociationofMedicalCollegesandPricewaterwaterhouseCoopers’HealthResearchInstituteanalysis54

Figure 11. Monthy physician debt obligations vs. monthly income (before taxes)

$12,000

$12,250

$12,500

$12,750

$13,000

Monthly debt obligationsMonthly income

2002 2003 2004 2005$800

$900

$1,000

$1,100


Figure 12. Actual and real average annual salaries of full-time RNs

$10,000

$20,000

$30,000

$40,000

$50,000

$60,000

1980 1984 1988 1992 1996 2000 2004

Actual salary (dollars)Real salary (dollars)

Whatworks* 18

Inthesub-specialtyarena,somephysiciansarechallengedwithrisingcostsanduncompensatedcare.Asaresult,someobstetrician/gynecologistshavedroppedobstetrics;somephysicianshavemovedtostateswithliabilitycaps;andsomeareseekingadditionalreimbursementthroughstatesandothersources.JamesF.Caldas,presidentofWashingtonHospitalCenterinWashington,D.C.,says,“Weoperateinaverychallengingmarketforhealthcare—onethatisparticularlyharshforobstetricians.Inresponsetotheskyrocketingmalpracticepremiums,manyoftheprivatepracticeobstetriciansinthismarkethavelefttheDistrictofColumbiabecausetheysimplycouldnotaffordtheexorbitantcostofinsurance.Wehaveexcellentobstetriccoverageatourhospitalonlybecauseweemploythephysiciansdirectly.”

Hospitalexecutivesalsovoicedconcernaroundotherspecialties—suchasneurosurgery,generalsurgery,andorthopedics—forcoverageintheemergencydepartment.Theriskofliabilityanduncompensatedcarehasbecomesogreatinsomeareasthatitisdifficultforhospitalstofindsuchcoverage.Thisisaggravatedbyrisingutilizationanddiminishedcapacityinemergencydepartmentsnationally.57Thesephenomenawilldrivegeographicandspecialtydistribution,perhapsevendrasticallyinthefuture.

Personal story. The lure of specialty medicine

Specialistsliketobeonthecuttingedge,takingcareofcomplicatedcases.Daksha’scareerstartedinacademiatobeclosertotheresearchandspecializedequipment,butvolumeswerenothighenough.“Theacademiclifewasgood,buttherewasnotenoughworkspecifictomypractice.”

Tenure25yearsasob-gyn;4yearsasreproductiveendocrinologist

Educationfinancing Personalfinancing


Her career

“Iwanttohelpdiagnoseandtreatpeoplewithraremedicaldisorders—oratleastsupportthemwhenIcannottreatthem.Ilikethechallenge.”Dakshatreatsproblemsrelatedtothereproductivesystem,suchashormonaldisorders,menstrualproblems,pregnancyloss,infertility,andmenopause.

The profession

“Ithinkthatwiththeadvancementoftechnology,physiciansmustbemoreproactiveaboutlearning.”Daksha’sotherthoughtsabouttheprofession:

Dealingwithinsurancecompaniescanbefrustrating

Sometimescurrentinsuranceguidelinesdonotmeettheclinicalneedsofpatients

•

•


Regulationcanimpactshortages.Forexample,inCaliforniain2004,thelegislaturemandatednursestaffingratiosinhospitals.Thevastmajorityofhospitalshadbeenincompliancewiththeratiospriortothelaw,butthosethatweren’thadtoscrambletocomply.Unfortunately,themandatewasnotaccompaniedbyanyinitiativestoenhancethenumberofgraduatesthroughadditionaleducationalfundingorothermechanisms.Asaresult,manyhospitalscontractedwithagencynursesathigherexpense,ortheyeliminatedotherstaff,suchaspatientcareassistants,topayforadditionalnurses.RickMartin,seniorvicepresidentofpatientcareservicesandCNOatHoagHospitalinNewportBeach,Calif.says:“Whileourfacilityabsorbedthecostsofmaintainingourpoolofnursingassistantsinthefaceofthemandatedratios,manyfacilitiesdidnot.Thecostburdenofthesemandateswillincrease,andthesituationwilldeterioratefurtherwhenthestatutoryratiofortelemetryunitsincreasesfrom1:5to1:4.Thischangewillfurtheraggravatethenursingshortageandstaffingchallengefacedbymanyproviders.”

Source:PricewaterhouseCoopers’HealthResearchInstituteSurvey58

Figure 13. Involvement with initiatives (all respondents)

75% 80% 85% 90% 95% 100%

Quality improvement

Information technology

Patient safety

Recruitment & retention (nurses)

Operational process improvement

Recruitment & retention (physicians)

Consumerism

Facility construction (new or expansion)

Joint venture

Whatworks* 20

Overcomingthedisconnect

Afterseveralyearsofnursingvacanciesthatrangedfrom7%to10%,hospitalexecutiveshavelearnedtosustainoperationsbysupplementingwithtemporarynursesasnecessary.Astheworkforceshortagecontinuestogrow,thenumberofsupplementalRNsandlicensedpracticalnursesisprojectedtogrow57%by2012.59AccordingtotheHRIsurvey,hospitalsareusingtempstosupplementabout5%ofnursingworkhoursonaverage,resultinginalowvacancyrate.Dependingontheorganizationalculture,executivesmayperceivethisscenarioasasustainablesolution.

Hospitalexecutivesareexperiencinginitiativeoverload.RecruitmentandretentioninitiativesmustcompetewithmanyotherhospitalprioritiesaccordingtoanHRIsurveyofhospitalexecutives(Figure13).

Accordingtothesurvey,workforceissuesareprioritizedlowerthanallothercomplexissuesexceptformanagedcarecontracting(Figure14).Thisdisconnectseemstoindicatethathospitalexecutivesdonotyetfullyappreciatetheimpactofworkforceissuesonotherstrategicinitiatives.Considerationoftheavailabilityoffinancialresourcesasaninputtoplanningiscommonplace;however,humancapitalisnotalwaysgiventhesameconsideration.Failuretoconsiderhumanresourceconstraintscanleadtofaultyplanningandaninabilitytoimplementkeystrategies.Inaddition,hospitalexecutivesarenotalignedregardingprioritization.CNOsandvicepresidentsofnursingandhumanresourcesprioritizenursestaffingandclinicalqualityhigherthandohospitalCEOs,CFOs,andCOOs(Figure15).


Inaddition,nursingleaderspointtoseriousfracturesinthesystem.Onestudyshowedthat40%ofU.S.hospitalnursesreportedjobdissatisfaction,andmorethan43%demonstratedhighlevelsofburnout.62Nearly23%ofU.S.nursessaidtheyplannedtoleavetheircurrentjobwithinthenextyear.63Fornursesunder30yearsofage,thatfigurewas33%.64Almost55%wouldnotrecommendtheprofessionasacareerchoice.65Acommonlyheardphraseis“lovenursing,hatethejob.”

Manyhospitalsarerecognizinganeedforchangeinthecaremodelinvolvingbothnursesandphysicians.OfthehospitalexecutivessurveyedbyHRIforthisreport,oneinthreesaidtheywereintheprocessofimplementingnewnursingmodels.

Manynursesgraduatebutdonotpursuenursingasacareer.Ofthosewhodo,halfleavetheirfirstemployeraftertwoyears(Figure16).Thiscanindicateseveralthings:nurseeducationprogramsarenotproperlypreparingstudentsregardingwhattoexpectonthejob;organizationsarehiringnursesintoaninflexiblemodelthatdoesn’taccommodatewhatyoungnurseswanttoputintoandgetoutofnursing;andtheproblemsthatcreatedissatisfactionamongnursesaren’tbeingaddressedsufficientlybyhospitalleadership. Source:PricewaterhouseCoopers’HealthResearchInstituteSurvey61

(1 is the least important 5 is the most important)

1

2

3

4

5

Figure 15. Prioritization of complex issues among healthcare organizations

CEO, CFO, COO

Government reimbursement

Clinicalquality

Governmentregulation

Nurse Staffing

Physicianstaffing

Managed carecontracting

CNO, VPs of Nursing and HRCMO

Figure 14. Hospital executive rankings of hospital issues/priorities

Ranks Overall rank

Reimbursementfromgovernmentpayers 1

Clinicalquality 2

Governmentregulations 3

Reimbursementfromcommercialpayers 4

Uncompensatedcare 5

Nursestaffing-generalorspeciality 6

Physicianstaffing-generalorspeciality 7

Managedcarecontracting 8


Whatworks* 22

TheHRIsurveyshowedadisconnectonnursedissatisfaction.Whenaskedaboutcommonfactorsthatdrivedissatisfaction,hospitalexecutivessurveyedsaidnoneofthosewereamajorfactorintheirorganizations(Figure17).

Anyfuturenursingmodelshouldaddresstheprimarydissatisfiersthatdrivenursesoutoftheworkforcetoday.Manyofthefeaturesmaybegroupedundertheheadingofprofessionalautonomybutalsoincludeaspectsofpracticestandardsandtechnicalinfrastructure.Takenasawhole,theydescribeamorehighlytrained,effective,andautonomousprofession.

Strategies for developing a workforce model for the future

Ourresearchindicatesthathealthcareorganizationsneedtodesignasustainableworkforcemodelthatincorporatessolutionsfromtrainingtoretaining.Tothisend,PwChasdevelopedfourkeystrategies—detailedinthefollowingpages—thatassistinprovidingablueprintforanimprovedmedicalworkforcemodel.

Source:NationalLeagueforNursingandPricewaterwaterhouseCoopers’HealthResearchInstituteanalysis66

Annual applicants for basic RN programs

Annual admissions into basic RN programs

New nurses leave first job within 2 years

Pass licensure exam

Annual graduates from basic RN programs

320,000

145,410

~52%

74,327

78,476

Figure 16. The system is leaky


Figure 17. Factors for nurse dissatisfaction/turnover

1.0 1.5 2.0 2.5 3.0

Excessive employee cost sharing for benefits

Scheduling; mandatory overtime

Reliance upon agency nurses

Unpleasant or inefficient physical environment

Not enough direct patient care activity

Lack of information technology support

Inadequate preparation/training

Disruptive physician behaviour

Inadequate compensation

Workload too heavy due to inadequate staff

Workload too heavy due to acuity levels

Excessive administrative paperwork


Inmanyregions,providersandeducatorshavebandedtogetherinvariouswaystoaddressthenurseandphysicianshortagesthroughprivateandpublicfunding,loanerinstructors,promotionalcampaigns,flexiblework-studyprogramsforadvanceddegrees,andleadershipinterventionsthatpromotethevalueofnursingandteaching.Communityoutreachprogramstohighschoolsandevenmiddleschoolscaninfluencestudentsatayoungage.TheRobertWoodJohnsonFoundationcampaignwascitedbymanyintervieweesashavingapositiveimpactontheimageofnurses,aswellasprovidingscholarships.Innovativecurricularapproachesarebeingtestedtospeeduptheeducationaltimeline.

Bettercommunicationbetweenhealthcareorganizationsandkeystakeholderssuchasgovernmententities,schools,andthebusinesscommunityiscritical.Dualappointmentscaninjectmoreclinicalfacultyintotheteachingenvironment,dominatednowbyanagingfacultyoftenlongremovedfromthebedside.Somestatesareprovidingloanforgivenessfornursingstudentswhopursuegraduateeducationandlaterteachnursingundergraduatesinstateschools.Forexample,Tennesseelauncheda$1.4millionpublic/privatepartnershipinwhichapproximately$1millionwasprovidedbythehealthcareindustry.69

AnumberofstateshaveenteredintotheNursingLicensureCompact(NLC),whichallowsanursetohavealicenseinonestateandtopracticeinanothercompactstate—subjecttothatstate’spracticelawandregulation.70Theseagreementsallowformorerapidtransferoflicensednursesacrossgeographicareas,whethertorespondtochangingdemandfornursingservicesortoreactintimesofcrisisornaturaldisaster.

Intermsofphysicians,themedicalschoolsnowonthedrawingboardreflectstrongregionalpartnershipsdirectedatlocalneeds.Physiciansoftenprefertopracticeneartheirresidencies.Becauseofthedroughtinnewmedicalschoolsoverthelasttwodecades,regionswithhighpopulationgrowthhavenothadacorrespondingincreaseinmedicalgrads.That’schanging,thankstoeffortsinhigh-growthstatessuchasFloridaandTexas,wherethere’salsoashortageofHispanicphysicians.

AnotherleadingmodelthataddressesunderservedareasisinWashington,Wyoming,Alaska,Montana,andIdaho,wherethemedicalschoolinWashingtondrawsonremotetrainingsitesintherespectivestatesformedicalstudents.71Thisarrangementisviewedasmoreeconomicalthanbuildingnewmedicalschools,anditaddressestwobasicissues:offeringeducationalopportunitytostudentsinstateswithoutmedicalschoolsandplacingtraineesinunderservedareas,therebyincreasingthechancetheywillpracticethere.Oregon,Kentucky,andotherstatemedicalschoolsareexpandingremoteplacementoftraineestothissameend.

Developpublic-privatepartnerships

Casestudy.NorthernVirginiaHealthcareWorkforceAlliance

Whatworks* 24

NorthernVirginia,whichincludessomeofthenation’sfastestgrowingcounties,createdtheNorthernVirginiaHealthCareWorkforceAlliance(theAlliance)tofacilitatearesponsetothegrowingshortageofhealthcarepersonnel.TheAlliancecomprisesproviders,businesses,academicinstitutions,economicdevelopmentagencies,workforceinvestment,andcommunityleaders.72Allianceleaderssaytheeffortwasoneofthefirsttimestheproblemhasbeenaddressedbyabroadrangeofinvolvedparties.

Todate,theAlliancehashelpedobtain$1.2millionfromthestatetoenhanceeducationalcapacity,andthosefundsarebeingmatchedbylocalhospitalsandhealthsystems.Inaddition,theAlliancefacilitateda$1.2milliongrantfromtheU.S.DepartmentofLaborfortrainingimagingpersonnel.NorthernVirginiaCommunityCollege,asaresult,hasexpandeditseducationalprogramstoreachnewgraduationgoalsfor2009.TheAlliancealsoisdevelopingamethodtoquantitativelymeasureitssuccessinproducingnewgraduatesandreducingtheclinicianshortage.

Inhealthcare,asinmostindustries,itisrareforcompetitorstocollaborate.However,inthiscase,leadersfromlocalhealthsystems,thebusinesscommunity,highschools,communitycolleges,anduniversitiescametogethertoaddresstheintertwinedproblemsandsolutionscontributingtotheshortage,suchascredentialingandclinicaltrainingsites.ManyoftheAlliancemembersalsonowserveontheGovernor’sHealthReformCommission,sharingtheirknowledgewithotherportionsofthecommonwealth.

Thegroup’sfirstgoalsincludedobtainingobjective,quantifiableinformationoncurrentandfutureworkforcechallenges,identifyinggapsinthecurrenthealthcareworkforce,andseekingprovenbestpracticestoclosethegaps.TheAlliancestudiedtheregionalmarkettounderstandthedynamics,includingpopulationtrends,economicfactors,educationallevelsofthepopulation,currentandfuturehealthcaredeliverychangesincludingconstructionandexpansion,anddiversityoftheworkforce.Aprimarytrendwasthehighcostofshort-termincentives.Providershadbeenaggressiveinconfrontingthestaffingchallenges;however,thecostsinherenttothisactionweredeemedunsustainableovertime.

TheAlliancealsonotedthatwhiletheregionfaceddemographicchallengescommontootherareas,uniqueregionalcharacteristicscompoundedtheproblem.Forexample,theregionhashigheconomicgrowth,ahighlyeducatedpopulation,lowunemployment,ahighcostofliving,andadiverseandimmigrantpopulationthatisnotcurrentlyreflectedintheworkforce.73

Basedontheresearch,theAlliancedevelopedsolutionsthat:

Recognizetheimpactofshortagesontheregion’slong-termeconomicandbusinesscosts

Acknowledgetheneedtotapintothediverseimmigrantpopulationinthearea

Developleadingretentionpractices,suchascareerladders

Partnerwithareaemployers,theeducationalsystem,andbusinessestointroducehealthcarecareerstoyoungstudents

•

•

•

•

Recommendations

Collaborate across a region.Educationalinstitutions,healthsystems,andbusinessesmustworktogethertodevelopandimplementincentives—suchasflexiblescheduling,loanforgivenessorstipends,andfaculty-specificbenefits—toenticenursesintofacultypositions.Considerationshouldalsobegiventoeasethetransferofresourceswithinaregion,particularlyasitrelatestolicensurerequirements.

Seek understanding. Buildinggoodpartnershipsrequiresthatpartnersspendtimelearningtounderstandeachotherandacknowledgeeachother’sprioritiesandhowtheyworkonaday-to-daybasis.Bringingtogetherallofthestakeholderswhoshareintherisksandrewardsofthisissueisfoundational—andcanbechallenging.Partiesmaywanttobringinoutsidefacilitatorsinregionswithahistoryofcompetitionorconflict.Thepayofffortheseeffortscouldbelong-termsustainabilityoftheentireregionalsystem.

Operationalize the strategy. Recognizethateffectiveandsustainablepartnershipsneedtoworkatboththestrategicandoperationallevels.Toprovidethedesiredresults,allhigh-levelplanningandstrategyneedstobefollowedbycomprehensiveandfocusedplanstooperationalizethestrategyandachievethevision.High-levelplanningneedstobebackedupbysoundoperationaleffectivenessandsolidexecution.

Adapt as needed. Continuouslyreviewandmonitorthepartnershipandresultstoensurethatthecollaborationremainsfocusedonthevisionandisachievingitsdesiredmission.Thismaymeanchangingtackwhereitappearsappropriate,adaptingtochangesinthemarketplace,andevolvingwithregulatoryandotherchanges.Allpartiesshouldworktogethertoensurethattheeducationandcertificationrequirementsareadaptingtothechangingclinicalenvironment.

Measure results. Assesstheinitialstartingpointasthecollaborationcommences,anddevelopperiodicmeasurementstomonitorprogressandresultsachieved.Establishingeffectiveanddata-drivenperformancemeasuresforthepartnershipwillhelpensurethatthevisionisachievedandallowforadjustmentstobemadeasnecessary.


Whiletherehasbeensomeinnovationintheeducationalenvironmentfornursesandphysiciansovertheyears,progresshasnotkeptpacewithtechnology.Thetransferofclinicalknowledgeandcognitionisgenerallyexcellent,buttheskillsrequiredtothriveinthenewworldofhealthcarearenotalwaysbeingimpartedeffectively.Graduatesneedtobepreparedforthatworldviarelevantlearningexperiencesandtechnology.

Patientsimulatorscanprovideclinicaltrainingscenariosthatmimicaparticularpatientpathologybyusingcomputersimulationmonitoringsystemsthattrackclinicianperformancegradesagainstinstitutionallyestablishedbestpractices.Remotedistancelearningcanbeusedtoexpandeducationalprogramstounderservedareas.Interdisciplinarymodelsandroleplayingcanbeusedintheclinicalyearsoftrainingtofosterteamwork,communication,mutualrespect,andpartnershiponsuchinitiativesasclinicalqualityandpatientsafety.Clinicalexpertiseofnurses,pharmacists,nutritionists,andrespiratorytherapistsmustbebroughttothebedsideassharedresourcesinconcertwithphysicians’work,asopposedtoeachspecialtyfunctioninginseparatesilos.Consumerismcreateddemandforamedicalworkforceeducatedinthebasicsofcustomerfocusandhowtorespondtotheincreasinglyinformedpatient.“Hospitalsthathaverespondedtothatconsumermind-sethavereapedtherewardsofincreasedpatientsatisfaction,”indicatesWilliamPowanda,vicepresidentofGriffinHealthServices,aDerby,CTbasedhospitalsystem.

Recommendations

Integrate technology into new educational models.Newtechnology,suchaspatientsimulators,allowsstudentstopracticewithvariousclinicalscenariosanddeveloptheirdiagnosisandtreatmentskills.Thiscanresultingreateraccuracyandincreaseexposuretovariedclinicalencounters,leadingtoimprovedoutcomes.

Embrace consumerism. Virtualroleplayingshouldbedevelopedandincorporatedintothecurriculumandusedasameansforstudentstogainpracticeincommunicatingwithbothpatientsandotherpractitioners.Itwillhelpstudentsimprovetheirbedsidemanner,adopttransparencyfordealingwithincreasinglyeducatedpatientsandcolleagues,andlearnandutilizeeffectivecollaborationskills.Theseeffortswillimprovetheirconfidencewhentheyencountersimilarexperiencesintheclinicalsetting.

Make information technology competency a requirement.Nursesshouldaccepttechnologyasameanstobecomemoreeffectiveandefficientwithnon-patientcareduties.ThroughtheuseofelectronicmedicalrecordsandWeb-basedtools,paperdocumentationisminimized,transparencyisincreased,turnaroundtimescanbedecreased,andcontinuityofcarebecomesamoreseamlessprocess.Inordertobeofutmostvalue,however,technologyapplicationsmustbefullyembracedandintegrated.Effortstoeducateandinvolvetheclinicalstaffinimplementationcanimproveacceptanceofthesenewtechnologies.

Encouragetechnology-basedtraining

Casestudy.Nursingeducationmeetsthestarshipenterprise

Whatworks* 26

Traditionally,nursingschoolshavereliedonusedmedicalequipmentdonatedbyhospitalsandthedidacticteachingtechniquesassociatedwithatypicalclassroom-styleeducationprogram.Today,nursingeducationleadersarepushingforchange.ElizabethPoster,deanattheUniversityofTexasatArlingtonSchoolofNursing(UTASN)says:“Wecan’tjustdothesamethingforeverandexpecttohavedifferentoutcomes.Thetraditionaleducationthatwe’veallseenoverthelasthundredyearsneedstochange.”

UTASNisoneofthelargestnursingschoolsintheU.S.andgraduatescloseto200B.S.N.studentsannuallywitha99%passrateontheNationalCouncilLicensureExaminationforRegisteredNurses(NCLEX).Theschoolisnowinphasetwoofathree-phaseSmartHospitaldevelopment.Whencompleted,itwillincludemorethan100,000squarefeetand60bedsofteachingspace.TheSmartHospitalisalaboratoryofvirtuallearningandsimulationthatleveragestechnologytosupplementfaculty.Ineffect,technologybecomesafacultyextender.“Wearemovingawayfromthe‘Ilecture,youlisten,Itestbypaperandpencil’approach.Bygettingthestudentsmorecomfortablewiththepsychomotorskillsfirst,whichwecandoinsimulation,thenthehourswedospendinthehospitalaremuchmoreproductivehours.Aftersimulationtraining,theyreallycanhitthegroundrunning,andtheycanbemoreperceptivetopatientandstaffneeds,”saysBethMancini,UniversityofTexasatArlingtonassociatenursingdean.

TheSmartHospitalfeatures:

Full-bodypatientsimulatorsthatincludeinfant,child,adult

Birthingmannequinsandhigh-fidelitymannequinsthatreplicatephysiologyfunctions

Virtualintravenousdevices

Simulationsoftwaretoconductrealisticscenariosandrole-playingactivities

Monitoringandrecordingequipmentthatenablesmultiplesimulationsandwhat-ifscenariosforfacultyreviewandevaluationaswellastimeandmotionstudies

•

•

•

•

•

Butcantechnologyandsimulationincreasethesupplyandhelpnursesre-entertheworkforce?Itisestimatedthatapproximately500,000nursesaren’tworkingintheprofession.74Mancinisaysyes:“Therearenursesoutthereinthecommunitythataren’tworkinginhospitals,andwewantthemback.Soweneedtohelpthemacquiretheknowledgeandskillstheyneedinamannerthatfitstheirschedulesandpreparesthemtoworkatthebedside.CanweputtheminourSmartHospitalandgivethemthecompetenciestheyneed?Absolutely—notaproblem.”

Posterconcludes:“Simulationandcomputerizedmannequinsgivethefacultymorecontroloverwhatstudentsseeandexperience,sowhentheygraduatethey’remoreconfidentandmorecompetent.Thiscansignificantlychangethelearningtimelinewhen,forexample,inthehospitalsetting,insteadofhavinganinternshipforsixmonthsorayearandcosting$45,000to$70,000,maybethatdoesn’tneedtohappenanymore.”


Lifestyle,notsalary,isatopreasonthatmedicalstudentsciteforselectingtheirspecialty,accordingtothe2006MedicalSchoolGraduationQuestionnairepublishedbytheAAMC.75Eventoday’sphysiciansarechoosingbetterwork/lifebalance;studiesshowthatphysiciansareworkingfewerhoursonaveragethaninthepast.BeverlyJordan,vicepresidentandCNOatBaptistMemorialHealthCareCorp.inMemphis,Tenn.relatesaconversationshehadwithasecond-generationphysicianwhorecentlycompletedtraining:“Thisyoungdoctorindicated:‘Mydadpridedhimselfonhowmanyhoursheworked.WhenIwasgrowingup,myfatherdidn’tknowwhetherIhadabike.Iwanttoteachmychildrentoridetheirs.’”

Dr.CarySennett,seniorvicepresidentofstrategyandcommunicationsattheAmericanBoardofInternalMedicine(ABIM),relatesthestoryofastudentwhosays:“IreallyappreciateMotherTeresa,butthat’snotme.”Sennettsaysthatstudentsareweighingthedebtburdenandlifestyleissues.“StudentslookatthevalueequationofhowmuchamIgoingtoearnversushowmuchoutofmyhide?”

Employmentmodelsforphysiciansandnursesarechangingasmorephysiciansareaskinghospitalstoemploythem—atleastpart-time.“Systemsmoreandmorehavetosupplementaphysician’sincome[thatis,payingforon-callhours],”saysLeisaMaddoux,vicepresidentofoperationsatCenturaHealthinDenver.“Withashortageofcertainspecialists,physiciansareunwillingtotakedaysanddaysoncall.Emergencydepartmentcoverageisdifficultbecausedoctorsdon’twanttoexposethemselvestosignificantlyhighlevelsofuncompensatedcare.”

Technologyischangingjobdescriptionsforphysiciansaswellasnurses,creatingtheneedforflexibility.Radiologistsarenowdoingsomeoftheworkthatcardiologistsdid,utilizingdiagnosticcomputerizedtomographyscansofthecoronaryarteriesinsteadofinvasiveangiography.Likewise,cardiologistsarereplacingsurgeonsinsomeproceduresasmorepeople

chooselessinvasivetreatments,suchasstents,toaddresscoronarybypassconcerns.Interventionalradiologiststreatcerebralaneurysms,whichwasoncethedomainofneurosurgeons.Virtualcolonoscopiesmayeliminatetheinvasiveprocedureasnowperformedbygastroenterologists.DigitaltelemedicineisallowingX-raystobereadovernightinIndia,psychotherapytobeconductedremotely,andmammogramstobescreenedautomaticallythroughdigitalscanning.Thisexplosionoftechnologyapplicationsholdsnotonlythepromiseofmoreefficientandmoreeffectivelydistributedcarebutalsothepotentialforsignificantdisruptionforcertainmedicalspecialties.

Toolsthatcanreducenon-patientcaredutiesfornursescanimproveefficiencyandsatisfactionwhencoupledwithprocessimprovements.Thegoalistousetechnologyeffectivelyandmaximizepatientcaretime.Asnursesadopttechnology,thereis“areducedtimeofshiftchangeandinturnincreasedfacetimewiththepatient,”saysPamHudson,vicepresidentofKaiserPermanenteHealthConnectTM.“Thepatientexperienceswarmerhand-offsbetweennurses,andthenursesexperienceimprovedwork/lifebalancewithreducedovertime.Patientsaremoreinvolvedintheircareastheyareabletoviewtheirchartandlabinformationonin-roommonitors.”TheprimaryfunctionalareaswhereITtoolscanbeimplementedforbesteffectare:

Documentation,suchasbedsidewirelesstrans-missiontomonitorsandelectronicmedicalrecords

Medicationadministration,suchascomputerizedphysicianorderentry,barcoding,androboticdelivery

Locationandretrievalofpatients,suppliesandequipment—suchasbarcoding,radiofrequencyidentification,andelectronicpatientprogressiontracking

Communications,suchasone-and-donecalls:immediateresponsesfromattendingphysicianversusmakingmultiplecalls

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Designflexibleroles

Whatworks* 28

Withopportunitiesforclinicianstoworkwithambulatorycenters,healthplans,andpharmaceuticalcompanies,hospitalsmustfindtheircompetitiveedge.“Nursesleavebecauseofculturalissues:theyareleavingthecultureoftheorganization,”saysLilleeGelinas,vicepresidentandCNOofVHAInc.“Moneyisthenumberoneattractor,butthenumberoneretentionandemployeeengagementfactorisstateoftheculture.”Somehospitalshaverespondedbyusinginternalregistriesandothertoolsthathelpnursesfeelmoreincontroloftheirworkandpersonalschedules.Asmorephysiciansseekemployment,thesameissuesfacingnurseretentionmaybecomeanissueforphysicianretention.

Manyviewtheprospectofadvancedpracticenursesandphysicianassistantsasfillingorsupplementingprimarycarerolesatalowersalarycostandtrainingrate(Figure19).“Giventheever-growingexpectationsforpreventiveservicesandchronicdiseasemanagement,itmaynotbehumanlypossibleforprimarycarephysicianstodoallthatweareaskingofthem.Therearewaysthatpracticescanbeorganizedandleveragedthatcouldincreaseefficiency,butmostphysiciansaren’tusedtothinkingabouthowtomanageworkflowandoptimizesystemsforpatientcare,”saysABIM’sSennett.

Thepotentialfornon-physiciansubstitutionbyextendersorothertypesofhealthcarepractitionerscanprovideaboostforclinicalproductivity.Ononehand,physiciansmayhavetorelyincreasinglyoncollaborativeworkwithadvancednursepractitioners.77Ontheotherhand,convenientandwidespreaddiagnosticandtherapeutictechnologyincreasesconsumerdemand,puttingfurtherpressureontheworkforce.

Technologyadvancesmayyieldnewdeliverymodelsaswell.“Deliveringcarefromadistanceisamodelthatwillcome.Wecanargueaboutthetiming,butitwillmaterialize,”predictsRobertPearl,M.D.,executivedirectorandCEOofthenation’slargestmedicalgroup,thePermanenteMedicalGroup.“Our6,000physiciansallutilizeelectroniccommunicationswiththeirpatients.Asanexample,patientscansendtheirphysiciansasecuree-mailwithaquestionrelatedtoaproblemthatisnotamedicalemergency.Thephysiciancanrespondlaterthatday,andtheinformationisavailableanywherethepatienthasInternetaccess.Asaresult,medicalcareisprovidedinawaythatisconvenientforboththepatientandthedoctor.Additionally,inKaiserPermanente,patientscanrequestprescriptionrefills,scheduleappointments,andreviewtheirlaboratoryresultsonline24hoursaday,sevendaysaweek.Thisapproachisoptimalinorganizationsthatareprepaidfortheirservices,butovertime,allpaymentmodelswillneedtorecognizethisservicetofacilitatewidespreadadoption.”

Source:BureauofLaborStatisticsandPricewaterwaterhouseCoopers’HealthResearchInstituteanalysis76

Figure 19. Comparison on 2004 salaries

Registered nurse

Physician'sassistant

Nursepractitioner

Family/generalpractitioner

0

$30,000

$60,000

$90,000

$120,000

$150,000

$180,000

Generalinternists


Recommendations

Develop a range of physician compensation models.Asphysiciansbecomemorecloselyalignedwithhospitalsandlooktohospitalsasemployers,hospitalsneedtodevelopcompensationoptionsthatrewardthemforperformance.Thesemodelsneedtointegratenewpaymenttriggerstocompensateforperformance,quality,andintegratedcare.Themodelsalsomayneedtobecustomizedforphysiciansindifferentspecialtiesandindifferentstagesoftheircareers.

Personalize scheduling.ShiftbiddingisanInternet-basedprogramusedbyhospitalstofillopenshifts.Thesystemworksbyallowingnursestobidonopenshifts;thenursewhoplacesthelowestbidonashift,withthebidamountstillgreaterthannormalwages,winstheshift.Shiftbiddingwasoriginallycreatedasameanstoenhanceorsupplementnurseschedulingmethodsbuthasevolvedintoaprimary-shiftschedulingprogram,asitcanbetailoredtofithospitalpoliciesandprocedures.78Thecostsassociatedwithashift-biddingsystemaregenerallylowerthanwithtemporarystaffingagenciesandprovideagreateramountofefficiency.Asanaddedbenefit,theshift-biddingsystemcanincreasenurseautonomywhileboostingoverallemployeemorale.Manyhospitalshavereportedanincreaseinretentionasaresultofutilizingtheshift-biddingsystem.St.PetersHospitalinAlbany,NewYork,hasbeenusingashift-biddingsystemsince2001andclaimsasavingsofmorethan$1.7millionandadropinnursevacancyratefrom11%to5%.SpartanburgRegionalHealthcareSysteminSouthCarolinareportsthatshiftbiddinghasdroppeditsnursevacancyratefrom20%to7%.UseofthissystemhasenabledSpartanburgRegionaltocutnurseoutsourcingbymorethan90%,resultinginasavingsof$10,000to$20,000perweek.79Suchefficienciesarepromptingsomehospitalstoprovideincentivesforemployeestousethebiddingsystem,suchasearlypaymenttothoseemployeeswhoscheduletheirshiftsthroughtheWeb-basedsystem.Additionally,organizationsshouldconsiderotherflexiblestaffingoptions,includingjobsharing,offeringoptionstoretiredorretiringstaff,uniqueshiftopportunities,andotherinnovations.

Use internal registries and eliminate supplemental staffing.Internalregistriesfunctionsimilartoahospitalownedandoperatedstaffingagency,inthatthehospitalcreatestheregistry’spoliciesandproceduresandhascompletecontroloveritswagesandbenefits.Theseregistriesallowhospitalstoeffectivelyreacttoarangeofvariablesthatrequireadditionalstaff—suchascoverageduringvacationandsicktime,leavesofabsence,andbedopenings—withouthavingtodependonanexternal

staffingagency.Withaninternalregistry,ahospitalcaneliminatesupplementalagencyfeesandinsteadpaycompetitivewagestotheregistryemployeeswhilestillensuringasavings.80Temporarystaffingcanharmstaffcohesion.AnInstituteofMedicinestudyreportsthatincreaseduseofagencynursesisassociatedwithalackofcontinuityofcareandcreatesvulnerabilitytoqualityproblemsanddiscontentonthepartofphysiciansandnurseswhomustworkwithtemporarystaffunfamiliarwiththeworksetting.Thisinturncausesdisruptioninateamculture.81Temporarynursesareoftencompensatedathigherlevels,withthebasicper-diemmark-uprangingfrom25%to40%abovetheaverageemployee’swage.Thistranslatesinto$250,000to$400,000thatthehospitalispayingjustforanagency’sserviceandoverheadcostsforevery$1millionspentonsupplementalstaffing.82

Consider going through the Magnet Recognition® Program process. Thejourneytowardthiscertificationprovidesvaluableprocessimprovementsforhospitals.TheMagnetRecognitionProgram,developedbytheAmericanNursesCredentialingCenter(ANCC)torecognizehealthcareorganizationsthatprovidenursingexcellence,hascertified242nursingorganizations.83Whilethecredentialitselfmaybeeffectiveinrecruitingnurses,intervieweessaidthattheprocesstowardMagnetstatuswasbeneficialinforcingtheorganizationtoexamineitsstructureandprocessesrelevanttothenursingworkforce.Giventhesignificantcostofobtainingthedesignation,eachhospitalshouldweighthecostandbenefitindividually.ThemanagementinterventionstiedtoMagnetstatuscanhaveapositiveimpactonnursesatisfactionandretention.Featuresofrecognizedhospitalsaresharedgovernance;focusonsupervisoryeffectiveness;schedulinginnovation;performancemeasurementandfeedback;qualityimprovement;andinterdisciplinaryworkingrelationships.ThecreationofaMagnetculturealsohasbeenshowntoimprovepatientqualityoutcomes.84

Measure the organizational fit.Somehospitalsareusingtoolsthatgaugeanapplicant’sfit.Dr.RosemaryLuquire,formerseniorvicepresidentandchiefnursingandqualityofficeratSt.Luke’sEpiscopalHealthSysteminHoustonandcurrentseniorvicepresidentandCNOatBaylorHealthCareSysteminDallas,says:“Ourutilizationofanorganizational-fithiringmodel,whichhelpsensureagoodmatchwithnursingingeneralaswellasspecialtyareas,hasprovedtobeofgreatvaluetooursystem.Oursuccesswasobviousduringthefirst18monthsfollowingimplementationasourturnoverratesdroppedsignificantly.”Evenpriortoemployment,clinicalpreceptorshipscanbondtraineestotheorganization.

Whatworks* 30

Think ergonomics.Ergonomicdesignsregardingthephysicaldemandsoflifting,otherrisksofinjury,excessivewalkingorstanding,andinadequatevisualdisplayareunderstoodtobesignificantfactorsinretainingworkforce,especiallyforthosewhoareaging.DonStubbs,vicepresidentofhumanresourcesandriskmanagementatSt.Joseph/CandlerHealthSysteminSavannah,Georgia,summarizesthechallenges:“Asthepopulationandourpatientscontinuetogetheavierandheavier,we’redevelopingwaystodealwiththeseissues.We’recurrentlyjustoverayearintoaprojectwherewehaveprovideduser-friendlyliftingandhandlingequipmenttoassistnurseswithpatientcare.Werecentlyhadapatientforwhomstaffneededequipmentjusttolifttheindividual’sleg,whichweighedover120pounds.Wecannotexpectournursestomeetthisneedwithoutassistance.”

Walk the walk.Settingthetoneatthetopcanchangethecultureofanorganization.ThomasE.FitzJr.,FACHE,ispresidentandCEOofSt.Mary’sHealthCareinAthens,Georgia,afacilitythathasreceivedrepeatedrecognitionforqualityandwasnamed2006LargeHospitaloftheYearbytheGeorgiaAllianceof

CommunityHospitals.Hesummarizesthephilosophytheyemploy:“WehaveintentionallycreatedacultureatSt.Mary’s.Peopleunderstandtheyaregoingtoworkhardhere,buttheyenjoyworkinghere.WehaveborrowedthemottofromSouthwestAirlines:‘Nowhiringhardworking,fun-lovingindividualswhowanttomakeadifference.’Thisphilosophyhaspaidoffforusinmanyways,includingsignificantimprovementsinretention.Inonedepartment,wehad75%annualturnoverjustafewyearsago;thatdepartmentnowhasawaitinglist.”Thechangesdidnottakeplaceimmediatelyandrequiredmanyinnovativeactions.Theyincluded:

Implementationofadedicatedandstructuredleadershiptrainingprogramforallmanagementstaff

Committedtransparency,includingfrequentcommunicationsandbulletinboardsoneveryunitwithfinancial,quality,andstaffingmetrics

Dailystand-upmeetingsintheCEO’soffice,whereallexecutivesmeeteachdayforaveryshortperiodtoallowforimmediateactiononpriorityissues

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Personal story. Quality of life

Likemanyclinicians,Lauriemadehercareermovesbasedonherabilitytobalancefamilyneedswithworkschedulesandcareeradvancement.“Ihavetakenpaycutstoworkinaprivatepracticesettingandinautilizationandcasemanagementrole.Atonepoint,Ileftthehospitaltogoworkinprivatepracticeforacardiologist.Ihadtwoyoungchildrenandwantedmorepredictablehours.Iammotivatedbyfamily,andthatmeansmoretomethanmoney.”

Tenure 25yearsasRN(8inprivatepractice;restascasemanagerandinformaticist)

Educationfinancing Loans


Her career

“Iwaskindofpushedintonursingbymyfamily.Mystepmotherandfourofmysistersarenurses.TherewereloanforgivenessprogramswhenIwenttoschool,andthisplayedheavilyinmycareerdecision.WhenIbeganmycareer,itseemedtobemorepatientcenteredthanitistoday.Manytimespeoplenowseemtobemoremotivatedby‘What’sinitforme?’”

The profession

“Ourprofessionisverydatadriven.Myjobasaclinicalinformaticististoperformclinicalandqualityreportingforourhospitalfacilities.IsupervisetheCMSqualityindicatorreporting.”Laurie’sotherthoughtsabouttheprofession:

Nursingisagreatprofessionbecauseyoucanworkanywhereinthecountry

Shegetsfrustratedbyphysicianswithbigegos

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Establishperformance-basedmetrics

Beautyisintheeyeofthebeholder,andqualityisviewedthroughtheeyesofthepatient.Qualityisincreasinglybecomingthedriverbehindpay-for-performancereimbursementbyMedicareandcommercialhealthplans.Qualityisbeingmeasuredbyclinicaloutcomes,processmetrics,andpatientsatisfaction.Nursesareaboutthreetimesmorenumerousthanphysiciansandarekeylinksinthequalitychain,ensuringthatroutineproceduresareperformedcorrectly,patientsaremonitored,dataarerecorded,medicationsaredeliveredcorrectly,andpatientsarecomfortedintheirdailyneeds.

Understandingthelinkbetweencaregiversandpatientsatisfactioniscriticalforearningbonusesundernewpay-for-performancemethodologies,saysWilliamPowanda,vicepresidentofGriffinHealthServicesCorp.GriffinisalsotheparentorganizationofPlanetree,a125-hospitalorganizationcommittedtohumanizing,personalizing,anddemystifyingthehospitalexperiencebycreatinghealingenvironmentsandengagingpatientsintheircaretreatmentandwell-being.GriffinistheonlyhospitalnamedbyFortunemagazineasoneofthe100BestCompaniestoWorkForforeightconsecutiveyears.“Wehaveadoptedthephilosophythatprovidinginformationforpatientsallowsthemtoparticipateintheirhealthcareinwaysthatwillimprovetheiroutcomesandsatisfaction.Weprovideinformationforpatientsabouttheirmedicalproblemandthetreatmentandcaretheywillreceiveinanumberofways,includingdiagnosis-specificpatientpathways.Weallowpatientsfullaccesstotheirmedicalrecords,tests,andanyinformationthatmaybenefitthem.Themodelisattractivetopatientsandstaff.Ourpatientsandstaffaremoresatisfied.Wehavebecomethehospitalofchoiceforthecommunityserved,andourattractivenessasanemployerisextremelyhigh,withover7,200applicantsforour160openpositionslastyear.”

Beginningin2008,thefederalgovernmentplanstopublishpatientsatisfactionscoresonindividualhospitals.Morethanhalfofthepatientsatisfactionsurveyfocusesonthequalityofcareprovidedbynursesandphysicians.Questionsinclude,“Duringthishospitalstay,howoftendidnursestreatyouwithcourtesyandrespect?”and“Duringthisstay,howoftendidthehospitalstaffdoeverythingtheycouldtohelpyouwithyourpain?”

VoluntarycollectionofthepatientsatisfactiondatabeganinOctober2006,andresultsareexpectedtobepublishedontheCentersforMedicare&MedicaidServices(CMS)websiteinearly2008.ThereportingispartofMedicare’sbroadpay-for-performancequalityinitiative.Hospitalsmustparticipateiftheywanttoreceivethefull-marketbasketupdateforfiscal2008.Thosethatfailtoparticipatewillreceivetheupdateminus2.0percentagepoints.Thiscouldsliceahospital’sreimbursementincreaseinhalf,sincethemarketbasketupdatehasbeenaround4%inthepastfewyears.Hospitalsmustsubmitapledgeforminthesummerof2007statingtheirintentiontoparticipate.Inaninterestingtwist,theMedicarePaymentAdvisoryCommission,theagencythatadvisesCongressonMedicarepolicyandpayment,hasrecommendedthatthegovernmentreducesomeofthefundingforphysiciantrainingtopayforthequalityinitiative.

“Wehavefoundthatastablenursingworkforcewithexperienceatthefacilityaswellaswithspecificpatientpopulationscombinedwithgoodcommunicationswiththephysiciansleadstohighquality,”saysDr.DavidPryor,seniorvicepresidentofclinicalexcellenceatAscensionHealth.“Thedataiscleartous.Thereisacomponentofcommunicationandteamworkthatmustbepresentintheenvironmentinordertoprovidehigh-qualitycareandretainstaff.Nursesareprovidingfrontlinecare,andnurseturnoverisdirectlyrelatedtoeffectivecommunicationonthefloor.”Nursesatisfaction

Whatworks* 32

leadstostaffstability,whichleadstoimprovedclinicalandfinancialoutcomes.Onadailyoperationallevel,nurseshortagescanleadtodisruptionsofoperatingroomscheduling,diversions,andbedclosures,allofwhichhaveadirectimpactonphysicians.Ofcourse,physicianstaffinggapscanthemselvesleadtotheseproblems.Nursingandmedicinehavetoooftenoperatedinfunctionalsilos,buttheyareinfactcloselylinked,aswillbecomemoreevidentinthefuture.

Hospitalemployeeturnoverhasbeencorrelatedwithahigheradjustedmortalityindexandseverity-adjustedaveragelengthofstay,aswellasahighercostperdischarge.85PatientsinhospitalswithhighRNstaffinglevels(75thpercentile)hadlowerratesoffiveadversepatientoutcomes:urinarytractinfections,pneumonia,shock,uppergastrointestinalbleeding,andlongerhospitalstay,86accordingtoastudybytheAgencyforHealthcareResearchandQuality.HospitalswithhighRNstaffinghadsurgicalpatientswithlowerratesoftwoadverseoutcomes:urinarytractinfectionsandfailuretorescue.87AdditionalstudieshaveshownthatincreasingtheproportionofRNs,inparticular,couldbethemostcost-effectivewayforhospitalstoreducetheriskofadverseoutcomes.

Patientsatisfactionreportsalsomayunveilproblemsinnursingsupply.AccordingtoHoagHospital’sCNORickMartin:“Thenursingshortagedoesnotgettheattentionitneedsfromthepublicnorfromthepoliticiansoreducationalsystems;itseemstobeundervalued.Thepublicisnotfeelingthepainyet;theywillstarttofeelitwhentheynoticethenursingshortageimpactonthemedical/surgicalunits,diversionsfromtheemergencydepartment,andsurgerycancellations.”

Optimizing talent and investment

Healthcareexecutiveswanttoknowhowtobecomemoreproductive,worksmarter,andensuresustainabilityandsuccessovertime.Aswehavedemonstrated,variousproblemswithinthehealthcareworkplacearecreatingsignificantdissatisfactionthatispushingnursesoutoftheworkforceprematurelyandharmingtheproductivityandcohesionofthosewhoremain.Recentnursingandhospitalturnoverdataillustratethemagnitudeofthisphenomenon.

Ametric,suchashumancapitalreturnoninvestmentthatfocusesonfinancialmeasures,isrelativelyilldefinedinhealthcarewheretheoutputrelatedtoreturnoninvestmentis,ideally,healthierpatients.Inrecentyears,theuseoffacility-andsystem-leveldashboardsandscorecardshasincreased.Progressiveorganizationsareensuringthatmetricssurroundinghumancapitalgetmeasured,getreported,andreceivehigh-levelattentionsimilartothetraditionalfinancialindicatorsthatfacilitieshavemeasuredforyears.Giventhatlaborcostsconsumeapproximately49%ofthetotalorganizationalcostsformosthospitals,andthatanestimated30%ofhospitalemployeesareregisterednurses,keymeasurementssurroundingthenursepopulationshouldbeadopted.8889

Themajorityofnurseturnoveroccursinthefirstyearsofservice(Figure20).VHA’sCNOGelinassecondsthisnotion:“Nursesareleavingjobsafteronly24to36months.They’resaying,‘ThisisnotwhatIbargainedfor.’Theproblemisthatmosthospitalsjustaren’tgreatplacestowork.”Thespreadforthismetricbetweenthebest-andworst-performingorganizationsislarge,indicatingsubstantialimprovementopportunities.Perhapsthisfindingisnotsurprising,butitdoesreinforcetheneedforinnovativeretentioneffortsfocused

Figure 20. Selected hospital turnover metrics

Metricname N 10th 25th Median 75th 90th

Overallnursevoluntaryseparationrate

22 5.5% 7.0% 8.4% 10.5% 17.1%

%nursevoluntaryturnover1styrofsvc

23 13.0% 20.8% 27.1% 34.3% 40.7%

%nursevoluntaryturnover1-3yrsofsvc

22 18.4% 21.0% 28.1% 32.8% 37.2%

Voluntaryseparationrate(healthcare)

54 7.5% 9.1% 10.7% 13.6% 17.6%

Source:PricewaterhouseCoopersSaratoga90


onneweremployees,includingtakingstepstoensurethatappropriateorganizationalfitandhiringdecisionsaremadeinthefirstplace.

Nurseswhoquitcarrysignificantcoststotheirorganizations—coststhatmaybedifficulttofullyquantify.Acomprehensivecostestimatewouldincludethefollowing:

Recruiting,advertisingandplacement

Learningandeducation

Humanresourcescosts(newhires,recruitingagency,etc.)

Training

Additionalovertime/pressuresonremainingstaff

Agencycostsduringvacancy

Opportunitycosts(delaysinexpansion,diversions,etc.)

Lostteamcohesion/productivity

Quality

Thetotalcostrelatedtothelossofanursecanequatetoasmuchastwotimestheannualsalaryofthatnurse.91HRIestimatesthatreductioninturnovercansaveanillustrativehospitalupto$3.6millionannually.Basedonanaveragehospitalof350full-time-equivalentnurses,everypercentinincreasednurseturnovercostsanaveragehospitalabout$300,000annually(Figure21).

Figure 21. Cost of nurse turnover for low-performing hospitals

Hospitalnurseturnoverperformance

Lowest10%

Lowest25% Median Top25% Top10%

Nurseturnoverrate

17.1% 10.5% 8.4% 7% 5.5%

Annualcostofturnover

5.4M 3.3M 2.6M 2.2M 1.7M

Source:PricewaterhouseCoopers’HealthResearchInstitute92

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Recommendations

Incentivize teamwork. Recognitionshouldbegiventotheimprovedoutcomesachievedwhenteamsareexperiencedandfamiliar,worktogethercollaborativelyandsharecommonincentivescenteredonefficiency,quality,andperformance.Entitiesshouldexaminetheirrewardstructurestoensurethattheincentivesarealignedtoallowforincreasedchancesofachievingthedesiredresults.Giventhefundamentalroleofphysicians,specificconsiderationshouldbegiventoaligningphysicianincentiveswithenterpriseincentivesthroughtheuseofvariouscollaborativemodels—includinggainsharing,co-management,andintegratedandjointventuremodels.93

Recognize the evolving incentives.Aspaymentisaffectedbypatientsatisfaction,anyproblemswithintheworkforcewillbecomenotonlymorevisiblebutalsofinanciallydetrimentaltotheunpreparedorganization.Inadditiontothefinancialincentives,participationinMedicare’spatientsatisfactioninitiativegivesahospitaltheopportunitytoidentifyareasofweaknessintermsofcaredeliveryandthestability,satisfaction,andcompetenceofitsworkforce.Aspartofthat,organizationsshouldbeproactiveincollecting—forbothnursesandphysicians—clinicaldatarelatedtoquality.Effectivelyimplementingpay-for-performancemodelscanresultinoverallprocessimprovement,betterqualityoutcomes,higherlevelsofpatientsatisfaction,andfewermedicalandadministrativeerrors.

Whatworks* 34

Connect quality outcomes to compensation.Organizationsshouldidentifyandmonitortheimpactoftheirnursingshortageonpatientoutcomesandimplementtheappropriatestrategies.Clinicaloutcomescanbeimprovedwithoptimalnursesupply—specifically,byincreasingtheproportionofRNs.Formallyrecognizingnursesasanintegralpartofthequalitychainandintegratingthenursingstaffinleadershipofqualityinitiativesaswellaslinkingcompensationandperformancecanyieldsynergy.Thoseorganizationsthatarerecognizedforoutstandingqualitywillattracthigh-performingstaffandphysicians.

Set benchmarks.Leading-edgeorganizationsaremeasuringtheirhumanresourcescapitalmetricsalongwiththeirfinancialmetrics,recognizingthecostsassociatedwithpoorandineffectivestaffingpractices.Considerationshouldbegiventotheevolvingimplicationsforcreditratingsaswellasthesignificantcosts(bothrealizedandopportunity)associatedwithpoorstaffingpractices.

Personal story. A higher calling

Forsome,healthcareistrulyacalling.RalphandDorisrunafamilypracticeasphysicianandheadnurse,respectively.Whiletheyviewhealthcareastheirministryofservice,theyareincreasinglyconcernedwiththeamountofadministrationandpaperwork.“Thereisasenseoffulfillmentwhentreatingpatientsandworkingwithpeople.Ilovethehumantouchandseekingsomewaytomakepatientssmile.”

The career

Tenure 30yearsasphysician/nurseteam

Educationfinancing Medicalschoolloans


“Istartedasanengineerbutneverfeltitwastherightcareer,soIswitchedcollegesandcareersandstartedmedicalschool,”saysRalph.

Dorisadds,“Ilovebuildingthepatientinteractionandbuildingthepracticeastheheadnurse.”

The profession

“Thereisfartoomuchtimespentonpaperwork,documentation,andprotectionsfromlawsuits.Preauthorizationfrominsurersfordrugsandtestscreatesaburdenaswell.”RalphandDoris’sotherthoughtsabouttheprofession:

ManydoctorsintheregiondonottakeMedicaidbecauseofpoorreimbursement

Theyspendtoomuchtimeontasksthataren’treimbursedbyinsurersandthegovernment

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Conclusion

Despitetheamazingadvancesinmedicaldiagnosticandtherapeuticcapability,themodelfortheeducationandpracticeofnursesandphysicianshasnotchangedmuchinthelast50years.Thereisverylittletechnologyusedintheprocessofcare.ThemanagementrevolutionthathassweptoverAmericanbusinessandindustryduringthaterahas—toalargedegree—bypassedthehealthcareworkplaces.Healthcareorganizationsmustembracethemanyknowneffectivestrategiesforhelpingpeopleworkindividuallyandasteams.Thiscanbeachievedthroughsharedgovernance,establishedandtransparentperformancemetricsinkeyareas,incentivealignmentacrossteamswithgainsharingforall,andunifiedmissionwithoutfunctionalsilos.Thetoolsareavailablebutmustbeimplementedthroughfocusedleadershipthatcanlookbeyondday-to-daypressuresandtowardafuturevision.

Movingfromtoday’sworkforcemodeltothefuturewillbedisruptivetostaffandtheorganization;however,astheindustrychanges,ahealthsystemororganizationmustchangewithit(Figure22).

Figure 22. Transitioning from today’s workforce to tomorrow’s will be disruptive

Payment

Venue

Records

Treatment

Today’s clinicians were trainedfor this environment

Today’s students need to be trained to work in this environment

Volume based

Hospital based

Paper

One size fits all

Performance-based

Integrated, outpatient

Electronic

Personalized

1990 2000 2010 2020

Source:PricewaterhouseCoopers’HealthResearchInstitute94

When hospital executives surveyed by HRI were asked which situations would be most likely to “get their attention,” hospital CEOs ranked revenue shortfalls and decline or loss of profitability as first and second, respectively, while CMOs and CNOs chose accreditation jeopardized and bed closures due to staffing shortages as their top picks. There is clearly a significant disconnect between hospital CEOs and clinician executives around prioritization of organizational strategy and resources. Ultimately, if clinicians want to gain stature in the hospital and public policy hierarchy, they will need to convince CEOs and other decision-makers that medical workforce issues are crucial for our health system’s success. After all, this is an industry running on people power.

Whatworks* 36

Appendix

Commonpractice Bestpractice Leadingpractice

Standardshiftassignments(shiftsassignedbasedonasetoffactors)

Flexiblescheduling(flexibilityworkedintoschedulingtomeetspecifichospitalandpersonalneeds)

Web-basedshift-bidding(nursesabletorequestshiftsthroughonlineprograms)

Ignoreworkplaceergonomics(littlethoughtputintodesignofworkstations)

Correctergonomicdesign(facilityconveniences,suchasergonomicequipment,implementedtomakeworkenvironmentmorefunctionalfornurses)

Personalizedergonomics(conveniencesbeyondergonomicequipment;facilityconveniencesthatsupportdailyfunctions)

Top-downmanagement(traditional,low-staff-involvementmodel)

Staffinvolvement(stilltopdrivenbutmorestaffinvolvement)

Sharedgovernance(staffinvolvedindecision-makingprocess)

Non-merit-basedcompensation(job-specificcompensation)

Merit-basedcompensation(individualachievementtakenintoaccount)

Rewardsbasedonachievedresults(performancemetricssuchasqualityoutcomesandachievinggoalstakenintoaccount)

Toleranceofabuse(abuseofnursesbyphysicians)

Policyandprocedureinplaceandwellcommunicated

(issuesnotignored;policiesonabusewrittenandstaffmadeaware)

Decisiveexecutiveactiontakenwhennecessary(consistentenforcementofprocessestodealwithnegativebehaviors)

Continuousqualityimprovement(CQI)handledthroughseparatequalityimprovement(QI)unit

(nointegration;CQIoperatesasseparatesilo)

NurseinvolvementwithCQIinitiatives(nursesgettinginvolvedwithqualityimprovement)

Nurse-ledCQIinitiatives(clinicalstaffdrivingqualityinitiatives)

Longevitynotrewardedwithcompensation(norewardfortenure)

Seniorityrewardedwithcompensation(compensationincentivetostaywiththesameorganization)

Retirementplansstructuredtorewardlongtenure(plansdesignedtoincentivizestafftostaywiththeorganizationuntilretirement)

FragmentedITinitiativeswithinadequatechangemanagement(recognitionoftechnologybutnoprocesschange)

FragmentedITinitiativeswithadequatechangemanagement(recognitionthatunderlyingprocessesmustchangetoutilizetechnology)

FullyintegratedITdeploymentwithexcellentchangemanagement(fullrecognitionofprocesschangeandimprovement)

Appendix A. Retention enhancement practices


B. Global migration of health professionals95

AsNewYorkTimescolumnistThomasFriedmanwroteinhisbest-sellingbook,wearelivingina“flatworld.”96Thefreeflowofcapitalandinformationislevelingtheglobalplayingfield.Similarly,theflowofpeopleisimpactingtheworldwidehealthcaremarketplaceinnewways.TheUnitedStates,theUnitedKingdom,Canada,andAustraliaarethelargestimportersofinternationalnursesandphysicians.Withinternationalmedicalgraduates(IMGs)makingup23%to28%oftheirphysicians,IMGshavebecomeanintegralcomponentoftheworkforceinthefourcountries.Language,cultural,andtraininggapscanmakethetransitiontoU.S.healthcaredifficult,butmanyU.S.hospitalsovercomethisthroughstructuredculturaltransitionprograms.

Whiletheinternationalmigrationofphysiciansandnursesisalong-standingaspectofglobalization,newconcernsarebeingraisedaboutthebraindrainonexportingcountrieswiththeirowntenuoushealthcaresystems.Whilethereissignificantmigrationamongthefourbiggestrecipientcountries(exceptthatout-migrationfromtheU.S.isvirtuallynil),thelargestpercentageofIMGsoriginatefromlower-incomecountries.FortheU.S.,60.2%ofIMGscomefromlower-incomecountries;fortheUnitedKingdom(UK),75.2%;forCanada(CA),43.4%;andforAustralia(AU),40%.

Thetop12sourcecountriesofIMGspracticinginUS/UK/CA/AUareIndia,thePhilippines,Pakistan,theUK,Egypt,China,SouthAfrica,Germany,Mexico,Ireland,SouthKorea,andNigeria.IndiaandPakistantogetheraccountformorethanhalfofthetotalIMGssuppliedbythetop12“exporters.”However,someofthesecountriesdon’thaveenoughclinicianstotreattheirownpopulations.Forexample,theWorldHealthOrganizationrecommendsaminimumdensityforphysiciansis20perevery100,000people,andfornurses,500perevery100,00097(Figures23and24).

Figure 23. RNs per 100,000 by host/source country

Hostcountries

RNs/100,000

Physicians/100,000

Lifeexpectancy(M/F)

Sourcecountries

RNs/100,000

Physicians/100,000

Lifeexpectancy(M/F)

Australia 941 247 78/83 SouthAfrica

472 77 47/49

UnitedKingdom

847 230 76/81 Philippines 418 58 65/72

NewZealand

841 237 77/82 Zimbabwe 129 16 37/34

Ireland 804 279 75/81 China 99 106

UnitedStates

782 256 75/80 Nigeria 66 28 45/46

Canada 741 214 78/83 India 45 60 61/63

Pakistan 34 74 62/63

Source:UnitedNationsDevelopmentProgramme98

Whatworks* 38

Figure 24. RNs per 100,000 by source country

0

200

400

600

800

1,000

Recommended density level

500 RNs per 100,000 people

Australia UK NewZealand

Ireland US Canada SouthAfrica

Philippines Zimbabwe China Nigeria India Pakistan

Source:UnitedNationsDevelopmentProgramme100

Migrantsarealso“pulled”todevelopedcountriesbyvariousattractionssuchasmodernmedicalenvironments,betterpay,career-advancementopportunities,physicalsafety,andpoliticalfreedom.Industrializednations,withamplemedicalinfrastructureandhigherpay,havebecomemagnetsforphysiciansandnursesfrompoorernations,leavingmanyoftheworkforcedonornationswithincreasingshortages.Forexample,29%ofGhana’sphysiciansareworkingabroad.Ghanalost382nursestoemigrationin1999,equaltothatyear’sentirenursingschooloutputofgraduates.Zimbabwereportedlylost2,000nursespermonthin2003.One-thirdofallZimbabweannursesareworkingabroad.InSouthAfrica,thenurse’sunionestimatesthat300nursespermonthemigrate.Oncepeoplemigratetoanearbycountry,theyarebetterpreparedandmorelikelytomoveevenfartheraway.Mostsub-SaharanAfricannationsareconsideredbyWHOtohaveacriticalshortageofhealthcarepersonnel.101

ThehealthcareprofessionalshortfallinAfricaisfurtheraggravatedbytheHIV/AIDSepidemic,creatinggreatclinicalneedwhilealsodiscouraginganddisablinghealthcareworkers.ForAfricaasawhole,HIV/AIDSwillbethecausein19%to53%(pervariousestimates)ofallpublicsectorhealthcareemployeedeaths.102

Anotherwayoflookingatthisisthroughtheuseofanemigrationfactor(thepercentageofsource-countryphysicianslosttoemigrationtoUS/UK/CA/AU.)Byregion,thehighestemigrationfactorisforsub-SaharanAfrica(13.9%),whichcanleastaffordthisdrain.ThenexthighestistheIndiansubcontinent,at10.7%,thentheCaribbeanat8.4%,followedbytheMiddleEastandNorthAfricaat5.2%.

Inaddition,manymiddle-incomecountrieswithgoodmedicaleducationsystems—suchasFiji,Jamaica,Mauritius,andthePhilippines—enrollstudentswiththeintenttoemigrateforjobopportunitiesincountriesoftheOrganizationforEconomicCooperationandDevelopment.TheRepublicofthePhilippineshasbecometheworld’slargestexporterofnursesandanticipatesremittancesfromthoseexpatriatesasaboosttotheeconomy.Anestimated85%(164,000)ofemployedFilipinonursesareworkingin46countries,primarilytheU.K.,SaudiArabia,Ireland,Singapore,andtheU.S.103Inaddition,Filipinodoctors,frustratedwiththeirdomesticprospects,areretrainingasnurses.Comparedwithmedicine,nursingisseenasafasterandeasierpathwaytoemigrationandawell-payingjob.Since2000,3,500Filipinodoctorshaveretrainedasnurses,andanother4,000Filipinodoctorsareinnursingschool.104

One of the basic concepts employed to understand the dynamics of nurse and physician migration is the “push/pull factor.”99 Source country conditions such as inadequate resources, poor pay, lack of safety, and political oppression may act to “push” professionals to emigrate. Once a shortage develops, a vicious cycle is created because those who are left are overworked and may want to leave as well.


HealthResearchInstitute

Cater PatePartner,[email protected](703)918-1111

David Chin, M.D.Partner,[email protected](617)530-4381

Sandy [email protected](214)754-5434

Hindy [email protected](703)453-6161

Benjamin [email protected](214)754-5091

Paul [email protected](267)330-3460

Nicholas Korns, [email protected](860)241-7483

Jessica [email protected](267)330-3024

Ginger [email protected](865)769-2022

Shubha [email protected](678)419-1424

Kevin [email protected](720)931-7204

Health Research Institute Advisory team

Dianne Dismukes, R.N.Partner,[email protected](214)754-5170

Gerald McDougallPartner,[email protected](267)330-2468

Frances PennellPartner,[email protected](617)530-4780

Jack Rodgers, Ph.D.ManagingDirector,[email protected](202)414-1646

Deedie Root, Ph.D., R.N. ManagingDirector,[email protected](713)356-8532

Bill [email protected](678)419-1591

Janet [email protected](703)918-1408

Patricia Michaels, [email protected](314)206-8212

Nik [email protected](202)414-3866

Margaret [email protected](267)330-1379

Elizabeth Kaczmarek, [email protected](713)356-4107

Warren Skea, [email protected](214)754-5406

Linda Young, [email protected](813)222-5423

Deborah Allbach, [email protected](214)754-5481

Research Institute Contributors

HRIwouldalsoliketoacknowledgethefollowingparticipantsinthePwCThought-Wikiprogramandtheircontributions:

WilliamRosenberg,JeffreyShort,RyderSmith,MitchelHarris,JackieMazoway,KunbiOguneye,JonSouder,JudithCremeens,KristiKawamoto,JaniceFang,JulieEpstein,VanessaSam,andDanielCummins

Whatworks* 40

1MedicarePaymentAdvisoryCommission,ReporttotheCongress:MedicarePaymentPolicy,March2007,72.(RepresentsGraduateMedicalEducationandIndirectMedicalEducationexpenditurescombined.)

2VHAResearchSeries2002;7.TheBusinessCaseforWorkForceStability.

3Shepard,S.,“LaborPainsatTheMed:Last-MinuteDiversionsCreateHavocatOtherHospitals,”MemphisBusinessJournal,January19,2007.

4MedicarePaymentAdvisoryCommission,ReporttotheCongress:MedicarePaymentPolicy,March2007,57-58.

5ibid,54.

6AmericanHospitalAssociation,TheLewinGroup,TrendWatchChartbook2006:TrendsAffectingHospitalsandHealthSystems,March2006,chart5.6.

7PwCanalysisbasedoncompanywebsites,April,2007.

8HealthResourcesandServicesAdministration.TheRegisteredNursePopulation:Findingsfromthe2004NationalSampleSurveyofRegisteredNurses.II.TheRegisteredNursePopulation1980-2004.March2006.Accessed3/21/07athttp://www.bhpr.hrsa.gov/healthworkforce/rnsurvey04/.WhatIsBehindHRSA’sProjectedSupply,DemandandShortageofRegisteredNurses?II.NursingSupplyModel.September2004.Accessed3/21/07athttp://www.bhpr.hrsa.gov/healthworkforce/reports/nursing/rnbehindprojections/index.htm.Note:PastnumbersincludeRNpopulationwithalicensetopracticeintheU.S.ProjectednumbersincludethenumberoflicensedRNs.

9Auerbach,D.,Buerhaus,P.,andStaiger,D.,BetterLateThanNever:WorkforceSupplyImplicationsofLaterEntryintoNursing.HealthAffairs.2007;1:178-185.

10ibid

11ibid

12HealthResourcesandServicesAdministration(HRSA),What’sbehindHRSA’sProjectedSupply,Demand,andShortagesofRegisteredNurses?September2004,accessed4/2/07athttp://bhpr.hrsa.gov/healthworkforce/reports/nursing/rnbehindprojections/index.htm.

13ibid

14HealthResourcesandServicesAdministration.TheRegisteredNursePopulation:Findingsfromthe2004NationalSampleSurveyofRegisteredNurses.II.TheRegisteredNursePopulation1980-2004.March2006.Accessed4/12/07athttp://www.bhpr.hrsa.gov/healthworkforce/rnsurvey04/.Note:Public/CommunityHealthincludesschoolandoccupationalhealth.Othersincludepositionsininsuranceclaims/benefits,policy/planning/regulatory/licensing,correctionalfacilities,privateduty,andhome-basedself-employment.For2004,NursingEducationcollectivelyincludesRN,LPN/LVN,alliedhealth,medicalschool,andconsumereducationsettings.ThetotalnumbersofRNsacrossallsettingsofemploymentmaynotequalthetotalestimatednumbersofnursesduetoincompleteinformationprovidedbyrespondentsonsettingsandtotheeffectofrounding.

15AssociationofAmericanMedicalColleges,HelpWanted:MoreU.S.Doctors;ProjectionsIndicateAmericaWillFaceShortageofM.D.’sby2020.2006.

16AmericanHospitalAssociation,TheLewinGroup,TrendWatchChartbook2006:TrendsAffectingHospitalsandHealthSystems,March2006,Chart5.1.

17HealthResourcesandServicesAdministration(HRSA).PhysicianSupplyandDemand:Projectionsto2020.October2006.

18Cooper,R.,“WeighingtheEvidenceforExpandingPhysicianSupply.”AnnalsofInternalMedicine.141,no.9(November2,2004):708.

19Wennberg,J.,VariationinUseofMedicareServicesamongRegionsandSelectedAcademicMedicalCenters:IsMoreBetter?”TheCommonwealthFund,December2005.

20HealthResourcesandServicesAdministration.PhysicianSupplyandDemand:Projectionsto2020.October2006.Accessed3/20/07athttp://www.bhpr.hrsa.gov/healthworkforce/reports/physiciansupplydemand/default.htm.Note:HRSASupplyincludestotalactiveMDsandDOs.Physiciansaged75andolderareexcluded.HRSADemandincludespatient-careandnon-patient-carephysicians.30%IncreaseinEnrollmentbasedonAAMC’scallforenrollmentincreasebyyear2015.A30%enrollmentincreasein2015equatesto5,000additionalenrollments.Itisassumedthatall5,000additionalenrollmentswillgraduatefrommedicalschoolin2019andgoontobecomeactivephysicians.Assumingtheincreaseinenrollmentcontinuesin2016andalladditionalenrollmentsgraduateandgoontobecomeactivephysicians,supplywillincreasebyanother5,000physiciansin2020.

21Starfield,B.,Shi,L.,Grover,A.,Macinko,M.TheEffectsofSpecialistSupplyonPopulations’Health:AssessingtheEvidence.HealthAffairs.2005;W5:97-107.

22Goodman,D.,etal.End-of-LifeCareatAcademicMedicalCenters:ImplicationsforFutureWorkforceRequirements.HealthAffairs.2006;25(2):521-531.

23Aiken,L.,AcademyHealthBellagioConference:InternationalNurseMigration,July5-10,2005.UnitedStatesPresentations.accessed9/20/06athttp://www.academyhealth.org/international/nursemigration/presentations.htm.

24NationalCouncilofStateBoardsofNursing.NCLEXexaminationstatisticsfor2005.NCSBN2005.

25Mullan,F.,TheMetricsofthePhysicianBrainDrain.NewEnglandJournalofMedicine.2005;353:1810-1818.

26AssociationofAmericanMedicalColleges.HelpWanted:MoreU.S.Doctors;ProjectionsIndicateAmericaWillFaceShortageofM.D.sby2020.2006.

27AmericanBoardofPediatrics.“2004-2005WorkforceData”accessed12/20/06,athttps://www.abp.org/ABPWebSite/;“FactsaboutFamilyMedicine”accessed12/20/06,athttp://www.aafp.org/online/en/home/aboutus/specialty/facts.html; “InternalMedicineResidencyPrograms,”accessed12/20/06,athttp://www.abim.org/resources/trainim.shtm.

28AmericanAssociationofCollegesofNursing(2005data).PersonalcommunicationwithRobertRosseter,associateexecutivedirector.

29GelinasL.,BohlenC.,Tomorrow’sWorkForce:AStrategicApproach.VHAResearchSeries2002;1.

30AmericanHospitalAssociation.Chartbook:TrendsAffectingHospitalsandHealthSystems,April2007.Chapter5:Workforce.Accessed4/23/07athttp://www.aha.org/aha/research-and-trends/trendwatch/2007chartbook.html.

31ThePerfectStorm:AnRxforEffectiveNurseStaffing.AMNHealthcare.November1,2006.accessedviawww.amnhealthcare.com.

32AmericanAssociationofCollegesofNursing.“Re:MedicalWorkforceResearch.”E-mailtoJessicaShure.12Dec.2006.

Endnotes


Endnotes

Note:A“qualifiedapplicant”isonewhomeetsallprogramentryrequirementsandwhotypicallyhasahighenoughundergraduateGPA,goodscoresonentranceexaminationssuchastheGMAT,andacompetitiveapplication/essay.Everyschoolisdifferent,soapplicationrequirementsdovary.TheAmericanAssociationofCritical-CareNursesasksschoolstosupplydataonthenumberofqualifiedapplicationsreceivedatnursingschoolsminusthenumberofapplicantsaccepted.

33InstituteofWomen’sPolicyResearch.NewStudyLinksNurseShortagetoNursePay.March2006.AccessedDecember2006athttp://www.iwpr.org/pdf/PressRelease2_ 8_06.pdf.Note:OriginaldatastatedasMedianWeeklyEarnings.PwCcalculatedtheMedianAnnualEarningsbymultiplyingtheweeklyearningsby52.

34AssociationofAmericanMedicalColleges.HelpWanted:MoreU.S.Doctors;ProjectionsIndicateAmericaWillFaceShortageofM.D.sby2020.2006.

35AssociationofAmericanMedicalColleges.AAMCStatementonthePhysicianWorkforce.June2006.

36SummaryReportoftheGraduateMedicalEducationNationalAdvisoryCommittee,September30,1980.DHHSPublicationno.(HRA)81-651.Washington,DC:U.S.DepartmentofHealthandHumanServices;1980.accessedviahttp://www.acponline.org/hpp/pospaper/health.htmon4/23/07.

37BureauofHealthProfessions.NationalCenterforHealthWorkforceAnalysis:U.S.HealthWorkforcePersonnelFactbook.Table102.NumberofActivePhysicians(MDs)andPhysician-to-PopulationRatiosbySpecialty,SelectedYears1970-2000.Accessed3/30/07athttp://bhpr.hrsa.gov/healthworkforce/reports/factbook.htm.

38AssociationofAmericanMedicalColleges.HelpWanted:MoreU.S.Doctors.Accessed3/27/07athttp://www.aamc.org/workforce/.

39ibid

40Blank,A.,OpeningNewMedicalSchoolRequiresPatience,Persistence.AAMCReporter:March2005.accessed4/24/07viahttp://www.aamc.org/newsroom/reporter/march05/newschools.htm.

41AssociationofAmericanMedicalColleges.Facts-Applicants,MatriculantsandGraduates.MatriculantsbyState.October2006.Accessed2/23/07athttp://www.aamc.org/data/facts/start.htm.

NewFacilities,NewPartnershipsMedicalEducationExpands.February2004.Accessed2/23/07athttp://www.aamc.org/newsroom/reporter/feb04/newfacilities.htm.

42AssociationofAmericanMedicalColleges.AAMCStatementonthePhysicianWorkforce.June2006.

43TheNewYorkCenterforHealthWorkforceStudies.TheUnitedStatesHealthWorkforceProfile.October2006.

44HealthResourcesandServicesAdministration(HRSA)..HealthProfessionalShortageAreas.Accessed4/24/07viahttp://bhpr.hrsa.gov/shortage.

45TheNewYorkCenterforHealthWorkforceStudies.TheUnitedStatesHealthWorkforceProfile.October2006.

46AmericanAcademyofFamilyPhysicians.2002PrimaryCareHPSAs.2007.Accessed4/26/07athttp://www.graham-center.org/x815.xml.

47Bodenheimer,T.,PrimaryCare—WillItSurvive?NewEnglandJournalofMedicine.2006;355:861-864.

48ibid

49AmericanAcademyofFamilyPhysicians.“AAFPAdoptsNewPhysicianWorkforcePolicy.”September28,2006.Accessed4/24/07athttp://www.aafp.org/online/en/home/press/aafpnewsreleases/200609pr/20060928workforcepolicy.html.

50AmericanAssociationofMedicalColleges.MedicalStudentEducation:Cost,Debt,andResidentStipendFacts.October2006.

51ibid

52AmericanMedicalAssociation.2003ReportoftheAmericanMedicalAssociation—MedicalStudentSectionTaskForceonMedicalStudentDebt.Accessedviahttp://www.ama-assn.org/ama1/pub/upload/mm/15/debt_report.pdf.

53AmericanAssociationofMedicalColleges.2006MedicalSchoolGraduationQuestionnaire.

54AssociationofAmericanMedicalColleges.MedicalSchoolGraduationQuestionnaire.AverageTotalEducationalDebtofAllStudents.Accessedathttp://www.aamc.org/data/gq/allschoolsreports/start.htm.BureauofLaborStatistics.NationalOccupationalEmploymentandWageEstimates.HealthcarePractitionerandTechnicalOccupations.Accessedathttp://www.bls.gov/OES/.

InflationCalculator.Accessedathttp://146.142.4.24/cgi-bin/cpicalc.pl. SallieMae.StudentLoanInterestRatesandFees.Accessedathttp://www.salliemae.com/get_student_loan/apply_student_loan/interest_rates_fees/#Stafford. U.S.GovernmentSecurities/TreasuryBills.Accessedathttp://www.federalreserve.gov/releases/h15/data/Business_day/H15_TB_M3.txt. Note:PwCanalysisofthemonthlydebtobligationinvolvedadjustingthedebtamountforinflation,performingafinancialcalculationusingtheStaffordLoaninterestrate,andassuminga10-yearpayperiod,withpaymentsoccurringmonthly.PwCanalysisofmonthlyincomeinvolvedtakingaweightedaverageofwagesacrossphysicianspecialties,adjustingforinflation,anddividingby12.

55InstituteforWomen’sPolicyResearch.SolvingtheNursingShortagethroughHigherWages.2006.

56HealthResourcesandServicesAdministration.TheRegisteredNursePopulation:Findingsfromthe2004NationalSampleSurveyofRegisteredNurses.Chart9.Actualand‘Real’EarningsforRegisteredNurses,1980to2004.March2006.Accessed3/15/07athttp://www.bhpr.hrsa.gov/healthworkforce/rnsurvey04/.Note:Onlythosewhoprovidedearningsinformationareincludedinthecalculationsusedforthischart.

57KellermannA.,CrisisintheEmergencyDepartment.NewEnglandJournalofMedicine.2006;355:1300-1303.

58PricewaterhouseCoopers’HealthResearchInstituteSurvey.

59Green,S,Pone,J,Cahill,C.,ReducingStaffingAgencyDependencyandImprovingReturnonInvestment.NurseLeader.October2004:42-46.


61ibid

62CitedinGelinasL.,BohlenC.,Tomorrow’sWorkForce:AStrategicApproach.VHAResearchSeries2002;1.

63ibid

64ibid

65ibid

Whatworks* 42

Endnotes

66NationalLeagueforNursing.NursingDataReview.AcademicYear2004/05.NationalCouncilofStateBoardsofNursing.NurseLicensureandNCLEXExaminationStatistics.2004.Accessed4/12/07athttps://www.ncsbn.org/462.htm.Note:Numbersarefromthe2003/04academicyear.


68PricewaterhouseCoopers’HealthResearchInstitute.

69“Tenn.toEncourageNursingInstructorsthroughLoanForgiveness,”Tennessean(Nashville,TN),January23,2007,http://tennessean.com/apps/pbcs.dll/article?AID=/20070123/NEWS07/70123011/, accessedonJanuary30,2007).

70NationalCouncilofStateBoardsofNursing,accessedviahttps://www.ncsbn.org/nlc.htm on4/16/07.

71NorrisT,etal.,RegionalSolutionstothePhysicianWorkforceShortage:TheWWAMIExperience.AcademicMedicine2006;81:857-862.

72PerWebsiteaccessedon4/25/07,http://www.novahealthforce.com/about/index.html.

73PricewaterhouseCoopers,TheHealthCareWorkforceShortage:ExecutiveSummary,PreparedfortheNorthernVirginiaHealthCareWorkforceAlliance,January2005,http://www.novahealthworkforce.org,accessedon2/2/07.

74HealthResourcesandServicesAdministration(HRSA).TheRegisteredNursePopulation:FindingsfromtheMarch2004NationalSampleSurveyofRegisteredNurses.

75AmericanAssociationofMedicalColleges.2006MedicalSchoolGraduationQuestionnaire.

76BureauofLaborStatistics.November2004EmploymentandWageEstimates.HealthcarePractitionerandTechnicalOccupations.November2005.Accessed3/29/07athttp://www.bls.gov/oes/2004/november/oes_29He.htm.AmericanAcademyofNursePractitioners.DocumentationofNursePractitionerCost-Effectiveness.2004.Accessed3/29/07athttp://www.aanp.org/NR/rdonlyres/.

77Whitcomb,M.,TheShortageofPhysiciansandtheFutureRoleofNurses.AcademicMedicine2006;81:779-780.

78Daniel,L,etal.E-BiddingandHospitalAgencyUsage.JournalofNursingAdministration.2006;4:173-176.

79Davis,A,etal.,ImplementingaBiddingSystemforFillingOpenShifts.NurseLeader.August2004:46-49.

80Green,S,Pone,J,Cahill,C.,ReducingStaffingAgencyDependencyandImprovingReturnonInvestment.NurseLeader.October2004:42-46.

81Daniel,L.,E-BiddingandHospitalAgencyUsage.JournalofNursingAdministration.2006;4:173-176.

82Green,S,etal.,ReducingStaffingAgencyDependencyandImprovingReturnonInvestment.NurseLeader.October2004:42-46.

83AmericanNursesCredentialingCenter,accessedvia http://www.nursingworld.org/ancc/magnet/index.html on 4/19/07.

84AmericanNursesCredentialingCenter(asubsidiaryoftheANA).BenefitsofbecomingaMagnet-DesignatedFacility.ANCC2006.Accessed1/4/07athttp://www.nursingworld.org/ancc/magnet/benes.html.

85VHAResearchSeries2002;7.TheBusinessCaseforWorkForceStability.

86AgencyforHealthcareResearchandQuality.HospitalNurseStaffingandQualityofCare.ResearchinAction:Issue14.March2004.

87ibid

88PricewaterhouseCoopers’Saratoga,2006/2007HumanCapitalEffectivenessReport.

89U.S.DepartmentofLabor,BureauofLaborStatistics,CareerGuidetoIndustries,HealthCareGuide,http://www.bls.gov/oco/cg/cgs035.htm,(accessed2/16/2007).

90PricewaterhouseCoopersSaratoga.

91Atencio,B.,Cohen,J.,Gorenberg,B.NurseRetention:IsitWorthIt?NursingEconomics.Volume21,Number6,viahttp://www.medscape.com/viewarticle/465918,accessed3/15/2007.

92PricewaterhouseCoopers’HealthResearchInstituteanalysisbasedonahospitalwith350NurseFTEs,April,2007.

93Booth,J.,Hickman,B.,Matson,B.,“WorkingTogether:PhysiciansandHospitalsPartneringforQualityImprovement,”TheQualityConundrum,PricewaterhouseCoopersHealthResearchInstitute,2007.

94PricewaterhouseCoopers’HealthResearchInstitute.

95Mullan,F.,TheMetricsofthePhysicianBrainDrain.NewEnglandJournalofMedicine.2005;353:1810-1818.

96Friedman,ThomasL.,TheWorldIsFlat:ABriefHistoryoftheTwenty-firstCentury.NewYork:Farrar,Straus,andGiroux,2006.

97WorldHealthOrganization.TheWorldHealthReport2006—WorkingTogetherforHealth.

98UnitedNationsDevelopmentProgramme.HumanDevelopmentReport2006.Physicians(per100,000people).2006.Accessed4/17/07athttp://hdr.undp.org/hdr2006/statistics/indicators/58.html.

wwWorldHealthOrganization.Countries.Countries.2007.Accessed4/17/07athttp://www.who.int/countries/en/.

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100UnitedNationsDevelopmentProgramme.HumanDevelopmentReport2006.Physicians(per100,000people).2006.Accessed4/17/07athttp://hdr.undp.org/hdr2006/statistics/indicators/58.html.

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101WorldHealthOrganization:CountriesProfilesaccessed12/21/06,athttp://www.who.int/en/.

102ibid

103AcademyHealthBellagioConference:InternationalNurseMigration,July5-10,2005.Presentations(12)accessed9/20/06,athttp://www.academyhealth.org/international/nursemigration/presentations.htm.

104AcademyHealth2006HealthinForeignPolicyForum,2/8/06.MigrationandtheGlobalShortageofHealthcareProfessionals(transcripts)accessed9/20/06,athttp://kaisernetwork.org/health_cast/hcast_index.cfm?display=detailandhc=1622.

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