Sleepless in the C-suite: Workforce, Part 2

Erika Grotto: Facing clinician burnout head on, today on HFMA’s Voices in Healthcare Finance podcast, sponsored by Red Dot. 

Hello, and welcome to the podcast. I’m Erika Grotto. A few months ago, I took my daughter to the dentist for a cleaning. On the front desk was a sign, much like the ones we’ve seen for the past few years asking us to wear masks or stay six feet apart. But this sign was different. It asked people to be patient, explained there was a staff shortage. On the bottom of the sign were the words, “This is the new pandemic.” I’ve thought about those words every time I’m in a waiting room in a healthcare facility or every time I see my neighbor, a CNA, looking exhausted when she comes home after a shift. Today, in the second part of our three-episode series on the healthcare workforce, we’re going to be discussing the difficult topic of burnout among clinical workers and how to address the mental health affects as well as contributing factors in the workplace. 

HFMA’s Chief Partnership Executive Todd Nelson is a former hospital executive who now develops collaborative relationships across all sectors of the industry. He’s known as something of a jokester around the office, but his tone becomes very serious very quickly when you ask him a question about the workforce. 

Todd Nelson: Clinical people are a special, wonderful breed of folks that I’m always impressed with what they do and the level of compassion and care that they have to do it.

Grotto: Media outlets around the world have written about physician and nurse burnout during the pandemic, but shortages have been an issue in the industry for years.  

Nelson: We’ve had clinical workforce shortages for a long time, so it’s not necessarily something that’s new, that’s just popped on the radar screen. We have been talking about needing physicians in all areas—rural areas, urban areas, certain specialties for decades. We’ve talked about the concern that as Baby Boomers retire that we’re going to lose them from the workforce. Many have been taking care of our family members and patients because they’ve been part of the clinical workforce. So from a clinical perspective, we’ve been talking about that for a long time, and it hasn’t gotten any better. And so we’re at that point where not only are people retiring, the job is more grueling. A job in the clinical workforce is not a cushy job. It is a job that creates a lot of stress, so it physically and mentally takes a toll on people, and we’re starting to see that as people not only near retirement age—those that are working—but we’re having more people to take care of.

Grotto: And if it wasn’t enough that the Baby Boomer generation is leaving the clinical workforce and adding to the patient population, they’re taking away valuable knowledge. 

Nelson: When you think about it, there is your clinical or operational knowledge—just how do you do the job that you’re tasked to perform—but it’s also the institutional knowledge, the understanding of how things work in the business of healthcare so to speak. And whether you’re a nurse, a physician, an accountant, a revenue cycle person, it’s losing that experience makes it really difficult because with experience comes understanding and the ability to make, in many cases, a faster decision because you can anticipate what the outcome is. You can anticipate the options quicker. And you’ve just seen more events, you’ve seen more disease if you’re a clinician. You’ve seen how people react to certain treatment patterns, and if you think about it from an operational or a finance perspective, you’ve seen patterns that you can then recognize much quicker so you can make a faster decision. And so you’re losing that experience not only in doing the work but experience training those that are new to the profession or new to the industry to also gain that knowledge so that they can come up to speed quicker.

Grotto: But the pandemic is much more than an elephant in the room when it comes to the clinical workforce, and the toll the past three years have taken is significant. 

Nelson: For all of us, a pandemic is a once-in-a-lifetime occurrence. And if we focus on the nursing shortage that had been there well before the pandemic, you’re used to taking care of patients that get better for the most part. So as a clinician, when you are taking care of a patient that you’re used to seeing—you know, you give them a certain treatment protocol, a medication or exercise or whatever to do and they get better and they go home, in the case of the pandemic, a lot of patients didn’t go home. And so you’re not used to the acuity level, the sickness that you see. You’re not used to the longer length of stay, having patients that just aren’t getting better. And that takes a toll on the clinicians who are forming a relationship with them and are there to want them to get better. I mean, they want to treat them. That is the purpose. That is the oath that they take, is to help patients heal, and the pandemic just changed that for a lot of people. You know, I think there is light at the end of the tunnel, but a lot of people have gone through a lot and are at their wit’s end to some extent.

Janae Sharp: A physician has to go tell someone bad news, and the family goes back and doesn’t work, but the physician has to keep going.

Grotto: That’s Janae Sharp, founder of the Sharp Index, a not-for-profit organization dedicated to improving physician mental health. If you click the word Mission at the top of the Sharp Index home page, you’ll see a banner photo of three children standing in a cemetery. Those are Janae Sharp’s children, and the grave they’re standing at is their father’s, a physician who died by suicide. It was his death, and the struggles of other physicians she knew, that inspired Sharp to found the organization. 

Sharp: Watching my kids go through that and watching people’s response—both individually, family and from the healthcare industry—was so frustrating that I thought we should make a change. And at first, I hesitated because I wanted to have the perfect answer.

Grotto: She said seeing what her children were going through, and the way she reacted to it, gave her a sense of purpose. 

Sharp: Part of the defining moment was, so after John died, my kids followed the coffin. Watching them was so traumatic. At the same time, I think one of the neighbors, their dad died from an aneurysm. I was jealous of how people treated their kids. That is not a good place to be. We don’t even think mental illness is a real illness, and my husband was just as dead as someone with a cancer death. When you look at funding, when you look at support, it’s way less, and a lot of it’s, like, survivors. So I feel like, looking inward and being like, jealousy comes from scarcity. Jealousy comes from me not having enough for myself. And in the end, it was all the same identical void, but the way that we’re supporting our children is different. I’m shocked that I’ve been able to talk to some of the people I have, to help some of the people I have, and also shocked just how easy it is to help. It’s a low bar.

Grotto: Sharp offered some advice to people who might see their clinical colleagues struggling. 

Sharp: Check on people you know. Don’t expect them to reach out. There are a few different things that happen when people are in crisis. Sometimes people try to get stronger, and they isolate. Don’t wait until someone who’s depressed and already overwhelmed has a nervous breakdown. Show up at their house and bring them something, or be friendly, which isn’t just saying, “Let me know if you need help.” It’s actually showing up and helping with something specific. We’re not going to be able to fix the nursing crisis until we get more nurses. This is a workforce issue. That’s gonna take school. That’s gonna take a bit of time. But, you know, we can check in on each other. We can try. We can save some people.

Nelson: If you see a team member that appears to be struggling, ask them if they’re OK.

Grotto: That’s Todd Nelson again. 

Nelson: It sometimes can be an uncomfortable conversation, but if you see someone struggling, and you care about them enough to notice that, to see that their behavior is different, then ask them how they’re doing. And if you’ve got an employee assistance program or some other, you know, hotline or something at your organization to help people that are having a rough time, so first, thing is approach them and ask them, but the second is encourage them to reach out to the resources that you have available.

Grotto: He also encouraged people to reach out to leadership in order to advocate for themselves and their coworkers, to effect change long term.  

Nelson: If there are opportunities at your organization to place your input—whether it’s suggestion box or whatever—those get listened to and read and acted on by leadership at the organization. Many times they go to the board level so they get acted on that way. And I think that it’s hard to folks. It’s hard to ask for help, and you know, I think it’s really the best approach or maybe the easiest approach is to watch out for each other and try to help and reach to each other.

Grotto: The mental health aspects of burnout are significant, but as Janae Sharp said, there are underlying workforce issues that contribute. We’ll discuss some ways to address those issues when we come back. 

Let’s take a moment now to get a word from our sponsor. Here is Michael Bumann from Red Dot. Welcome, Michael.

Michael Bumann: Thank you, Erika.

Grotto: In the last episode, we talked about how motor vehicle accident claims can be very difficult for a typical hospital revenue cycle person to deal with, and you mentioned that they take years to resolve. And I can’t help but think, that’s gotta be really tough on patients too. How can working with Red Dot help a hospital’s patients?

Bumann: Well, one of the main ways that we help the patient experience is by relieving the stress that they’re not in a debt collection activity. Oftentimes, patients see the worst possible outcome—often not accurate—they think they’ll get sued, they’ll have wages garnished, lose their car, lose their home, whatever kind of boogeyman that they can create. And when they hear from us that no, that’s not the case, that we’re going to work solely with the responsible liability policies, work with their attorney if they’re represented, the sense of relief that they get is enormous, because it does take years. Everything is pegged to the underlying claim being resolved between the parties involved in the accident, and for that self-pay patient, they don’t have the ability to pay that bill for the treatment they’ve received, so they need an understanding partner to work with them until it does resolve. That’s difficult for a hospital to do because they work days in A/R versus years in A/R. So when we come in and acquire on our arbitrage platform, we take the years part onto our shoulders, and the hospital has it days in A/R and then that patient knows that they’re not being hounded, they’re not dealing with collection calls, that they have a party that’s going to understand the predicament that they’re in and wait alongside them until that claim resolves.

Grotto: You said to me that a really common question when you work with a new organization is, how are you going to treat our patients. So tell me, how do you treat the patients that you work with?

Bumann: Medical care for a patient is always personal. At some point with a hospital, of course, it naturally flips to a transactional relationship. Working with us keeps it personal.

Grotto: Thank you for sharing these thoughts, and thank you for joining me today.

Bumann: Erika, thanks for having me.

Grotto: Red Dot is the best technology-enabled acquisition solution for hospital self-pay motor vehicle accident accounts. Hospitals can now leverage Red Dot’s solution to improve their bottom-line revenue while dramatically improving their patient relationships by avoiding debt collection activities. Red Dot: Good for hospitals, good for patients. To learn more, visit reddotmgmt.com.

Jonathan Wiik, the FinThrive vice president we heard from on last week’s episode, said the focus on clinical worker wellbeing could lead to a stronger workforce in the future. 

Jonathan Wiik: There is way, way more attention being paid to how valuable the nurses and the staff at the organization are than was paid before—not that it wasn’t valuable before, but it’s like, how are you doing, what can we do, let’s involve you in the decisions that are happening organizationally. We want you to stay here. What staffing makes sense to you? What shifts make sense to you? What benefits make sense to you? How can we keep you here for perpetuity to make sure that you feel this is a safe and healthy—I would argue—place to work going forward because we want to make sure we’re creating that and we value what you’re doing very, very much. Not that those conversations weren’t happening before, but they’re real now. There’s a lot of dialogue happening back and forth with that.

Grotto: Wiik pointed out—as did Nelson, Sharp, and everyone else I talked to for this series—that by and large, people want to do a good job at their jobs, and it’s important for leaders to recognize that. 

Wiik: Of all the people that took the brunt of Covid, the nurses took it the hardest. They worked triple shifts. They saw many, many of their patients die right in front of their eyes and just were done. And a lot of folks just exited the workforce, and it wasn’t fair to those that were left there—not that there is a fair with Covid—that were there kind of holding the bag saying geez, there used to be six nurses on my deck, there’s four now. I can’t handle that load. And so you’re starting to see organizations like, well, maybe we only need to operate half the deck because we need to keep our nurse/patient ratios because that’s what safe, that’s what good for our staff.

Grotto: Before the pandemic, HFMA put together a think tank with several other organizations including the American Organization for Nursing Leadership, American Nurses Association and Institute for Healthcare Improvement. The think tank focused primarily on nurse staffing, but Todd Nelson said their findings could be applied across the industry. 

Nelson: The priority areas that we looked at were things like healthy work environment. Well, when you talk about burnout and staff relations and culture, healthy work environment’s an important part of that for everyone, no matter where you work. So focusing on that part of it. Diversity, equity and inclusion was another priority area, so thinking of who’s on your team, who’s leading your organization. How do you interact with all the members of the team—in healthcare, the patients that are coming through the door. How do you support people for what they need? Thinking about, you know, work schedule flexibility. People have lives outside of work, so if you’re able to be flexible or think outside the box, how can you support your team whether they’re clinical or non-clinical, with some flexibility there. Whether that is working remotely or onsite or some digital-virtual part of that. Certainly, when we think about burnout, something called the “stress injury continuum” where really, whether that’s emotional intelligence, whether that’s physical violence, but thinking about the move toward burnout and the impact of environment and all these things on the staff. Gotta think, if you can’t hire more people, what kind of new care delivery model. So innovative care delivery models. Are there different ways to perform the tasks to deliver care, to meet patients where they are—in their home, at their church, wherever. So how do we redesign care, and who should be on the team, and what are some of the new models that could be a hybrid mix of remote versus on site? And last but not least, thinking about total compensation. If I’m in my 20s, my retirement may not be as important to me as a higher wage. So while I appreciate the fact that the organization is matching my retirement funds if I put it away or they’re offering me a fully paid health plan, maybe I really want a higher wage and I’ll not take those benefits. And so being flexible in how total compensation is delivered is really a key, and that comes with a lot of landmines to some extent, and it requires us to think outside the box. It requires a partnership with the human resource team and the benefits team and ensuring from a compliance and a legal perspective that you are doing equitable work that meets all those requirements and yet offering as much flexibility when it comes to total compensation certainly makes a big difference for a lot of people.

Grotto: He also pointed to the importance of leaders being involved, visible and appreciative of the everyday work people are doing. 

Nelson: A simple, heartfelt thank you goes a long way. So being visible, being out there. When you come across someone that does something—it could be something that we take for granted such as helping a patient find their way to the area of the hospital for their next exam—just walking a patient down the hallway. And if you witness a staff member do that when it’s not, quote, their job, but they do it because they are caring and compassionate people, tell them thank you. I mean, it’s just amazing how much a simple thank you that is heartfelt goes such a long way. It does not always have to be when you’ve done something tremendous and heroic, but sometimes it’s just those little things, I think, that make a big difference.

Grotto: Janae Sharp said clinical workers can find solutions just by having conversations with one another. 

Sharp: Sometimes you’re actually getting strategies of how to make things better from your peers. They’re like way willing to support each other. They’re more willing to support each other than they are to like talk to leaders or talk to like press people or even speak at an event. They’ll support each other. And that’s nice. People still show up for each other. I’m finally finding the words again to talk about difficult things like during the pandemic and like with my kids and like with working mom stuff. People are still good. I still have a lot of hope for all these groups that are standing up and being like, we’re going to change things. Because I think it’ll work.

Grotto: If you are experiencing workplace burnout and want to reach out for help, here are a few resources. You can reach the National Suicide Prevention Lifeline at 1-800-273-8255. Reach the Crisis Text Line by texting the word HOME to 741741. And if you’re a physician in need of help, you can reach the Physician Support Line at 1 (888) 409-0141. 

Next week on the final part of our special series.

Stu Schaff: Average non-physician folks would have job description, would have SOPs, standard operating procedures, other things like that. We don’t do that really for physicians in the same way. What we do instead is say, “You’re a doctor. You know how to doctor. I’m not going to tell you how to doctor.” And physicians, for their part, are not really saying, “This is what I expect out of my job. This is what I need out of my job.”

Strategies for combating burnout among clinical workers

Workforce shortages and burnout exacerbated by the pandemic have left healthcare leaders scrambling for strategies. On a recent episode of the “Voices in Healthcare Finance” podcast, industry experts who are working on solutions discussed shortages of clinical workers and offering help to those who remain.

“We’ve had clinical workforce shortages for a long time,” Nelson said. “We have been talking about needing physicians in all areas — rural areas, urban areas, certain specialties — for decades.”

The retirement of baby boomers causes three problems, Nelson said. First, fewer people are left to do the work. Second, there are more patients to care for as the retiring population ages. Third, with their exit from the workforce, retirees take valuable knowledge.

“With experience comes understanding and the ability to make … a faster decision because you can anticipate what the outcome is,” he said. “You’re losing that experience not only in doing the work but experience training those that are new to the profession.”

The effect of the pandemic

Although shortages of clinical workers aren’t new, the pandemic has made them worse and contributed extra stressors.

“You’re used to taking care of patients that get better, for the most part,” Nelson said. “When you are taking care of a patient that you’re used to seeing … get better and go home, in the case of the pandemic, a lot of patients didn’t go home.”

Janae Sharp, founder of the Sharp Index, a not-for-profit organization dedicated to improving physician mental health, said what Nelson described takes a toll on clinical workers who don’t always have resources when suffering on the job.

“A physician has to go tell someone bad news, and the family goes back and doesn’t work, but the physician has to keep going,” she said.

Strategies for improvement

Sharp recommended healthcare leadership have in place a way to connect with clinical workers who are struggling and finding ways to help.

“Don’t wait until someone who’s depressed and already overwhelmed has a nervous breakdown,” she said. “We’re not going to be able to fix the nursing crisis until we get more nurses. This is a workforce issue. That’s going to take a bit of time. But we can check in on each other.”

Nelson suggested not only checking in on people but encouraging them to take advantage of resources at work, such as employee assistance programs or hotlines. Leaders also should work to improve conditions that contribute to stress and burnout, he said. Some strategies could be to implement more flexible work schedules, incorporate remote work, changing the way care is delivered and offering flexible benefits. He also pointed out the importance of leaders being involved, visible and appreciative.

“A simple, heartfelt thank you goes a long way,” he said. “It does not always have to be when you’ve done something tremendous and heroic, but sometimes it’s just little things that make a big difference.”