November 10, 2021

Episode 65: Solving the “travesty” that is nurse scheduling

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Description

Our guest today for this episode is here to talk about an issue that is very close to our hearts here at Trusted Health: nurse staffing. Dani Bowie has built a career around solving this issue and cutting down the time that nurse managers spend creating schedules.

She earned her doctorate in Nursing from Yale with a particular emphasis on the issues of staffing and scheduling and is now the Vice President of Workforce Development at Bon Secours Mercy Health, where she is helping to build the nursing workforce of the future. At the center of this is a truly game-changing approach to scheduling, which takes the burden off of nurse managers and instead enlists a team of workforce professionals who are specially trained in this area. Today Dan and Dani talk about that program, what she’s seeing other health systems do in this area and what she thinks a truly flexible workforce looks like. 


Links to recommended reading: 

Podcast

Transcript

Dan:

Dani, welcome to the show.


Dani:

Thanks Dan. I'm excited to be here.


Dan:

I love it. So you have a PhD and it was focused in on workforce and staffing, which is a cool niche. My PhD was in innovation like no one's ever heard of a PhD in innovation. Very few people I'm sure have heard of a focus of a PhD in staffing and workforce. Tell me about your journey into this space.


Dani:

When I started, I actually, what was called a Providence Scholar. So Providence Health System, which is a large health system, it's now Providence St. Joseph on the west coast, actually paid for my last two years of my nursing education through the University of Portland if I would work for them for three years wherever their need was in the state of Oregon. So I actually was placed into a large metro hospital in the heart of Portland. So it was a great first step for me. So I really developed my practice there. And as I began practicing as a bedside nurse and improving my skill and understanding, I became more enticed with system management on a broader scale. So quickly I was moved into a charge nurse role and started seeing how the hospital operated. And as I started to understand how the hospital was operating and found that I had a bit of a niche for it, I reshifted my focus from critical care to actually wondering what would it be like to run or manage a unit or manage a hospital.


Dani:

So during my time as a bedside nurse, I actually entered into my master's program in health systems management through Vanderbilt, which was primarily online. So I was able to maintain my practice and then continue my education with a focus in health systems management. So once I finished my masters, I actually was approached to take over management of the unit that I had started on as a nurse. So that respiratory cardiology unit, step down unit, I was approached by the leader who was a director at the time. They had an opening, my manager who hired me retired. So they asked for me to consider managing that unit, which was quite unique because it required me to transition from those that saw me as a peer or even someone that they had trained into a manager, and that required some unique opportunities to show that I had their back.


Dani:

So took on a challenge. We came up with a solution together, leading that team together and really transformed that unit into a place of really great outcomes, nurse sensitive indicator outcomes, high engagement of our team, low turnover. So really turned the ship around after we addressed an issue that was going on that was related to a patient condition. So I did that work for about two and a half years as a manager.


Dani:

And it was really great to understand how does a unit function, how to lead teams and build that skillset that you just don't get unless you actually do it. As I did that work, I realized there was more I wanted to do and opportunities I wanted to pursue outside of managing a unit and I was managing the float pool at the time. Long story short, ultimately I decided to pursue the opportunity she presented and the reason I chose it, and this actually launched me into the world of staffing and scheduling, was because it was systems focused. And her desire and goal, the [inaudible 00:04:40] desire and goal was to transform their health system, to adopt new staffing and scheduling technology and help build their central management platform as well as better optimize the way that they're utilizing their system float pool of about 250 nurses.


Dani:

So we entered into this journey and through that time, we were very successful in leading this project. We saw great outcomes, both in our engagement scores at legacy for staffing and scheduling and effectiveness from the frontline nurses. It actually improved after we implemented our project. In addition to, we saw a decrease in agency use, we also saw a decrease in some of our incentive spend. So we were really seeing great outcomes associated with this work. And we had a dedicated team doing this that helped build a new outlook and professional view, I believe, for legacy in regards to staffing and scheduling. While I was finishing my doctorate, what I decided to focus in was, again, scheduling. So I looked at predictive scheduling and what existed for a frontline nurse manager and discovered there was a lot of gaps in that space. So I actually worked with an independent economist and built a predictive scheduling model so that we could help predict what needed to be scheduled on a nurse's schedule before the manager actually put it out there for self-scheduling.


Dani:

So the nurse manager didn't need to figure out, "Hey, what do I need to schedule?" It was being evaluated for them with this model that took about three years of historical data, census, some other things to help guide that nurse manager and better management of their schedule when they created it. So then as you move into your staffing period, you're not dealing with over or under-staffing situations.


Dani:

So I did that work all together and finished, and then really felt like I needed to grow more. So actually was recruited to work for Bon Secours Mercy Health. So I'm their system vice president of nursing workforce development. And this is a unique role in that I think it's a new breed of nursing in my opinion. And what we're looking at doing is actually understanding our workforce. So a component of my work is staffing, scheduling, operations, making sure we're effective and efficient in that space.


Dani:

And I'll talk a little bit more about that, but we also look at other areas such as retention, turnover, vacancy engagement, our pipeline planning. So it's really the whole picture of our nursing workforce and how we need to both react to what we're experiencing today and plan for what we're heading into into the future. Or what I like to say is actually, what can we create in the future? So who do you want to be? And where do we want to go? I truly believe that nursing and nurses, professional nurses have the ability to carve that path out and make a journey for the workforce through leadership and opportunity.


Dan:

On a double-down on that piece, because that's something that's different I think for health systems. Before it's been, how many years of experience you have, and that kind of dictates how you put people into different scheduling models and talent profiles and that kind of stuff. And now we're starting to look at individual skillsets and maybe move beyond the sort of service line mentality of things where you can float nurses, talent across different places depending on patient need. You're thinking of it, less of that nurse is hired into four [inaudible 00:08:05] and they're going to work there forever and more about like that may be a home base, but they can also work in these five other places. Is that something that you're working on and do you see that as the future? Or do you think this service line kind of mentality of a med surge nurse [inaudible 00:08:18] we're going to work med surge is going to maintain?


Dani:

I think it shouldn't maintain. I believe that we enter into nursing because of the beauty of the profession and the versatility that we can experience throughout our career. If you want to do med surge and do that for 20 years, you can, but if you don't want to, there's so many opportunities out there and I believe health systems are recognizing that desire within nursing. The paths that we're creating is we want to build our pipeline. So how can we ensure that we're bringing in a workforce and keep that stream consistent? But also when we get a workforce, what do we need to do to engage that workforce to continue to develop them professionally? So we're developing programs, career pathways, where we're helping our workforce understand how to navigate. What do you want to do? Do you want to get a certification?


Dani:

Do you want to look at potentially informatics? Do you want to look at nurse management? Do you want to look at just changing from a med surge to an ICU position, or an OR position or women's? So we're working on creating those pathways and there's a lot of really smart people here at Bon Secours Mercy Health putting that together so that we can engage our workforce and say, "Hey, we're large. We have a large health system and we have a lot of opportunity here. And if you're not being satisfied in one space or you feel like you need to grow more, well, let's talk about what that really looks like and where else you can go."


Dani:

And I think that's what we need to be comfortable with too. I think that it also requires the support of our nurse managers. Nurse managers have a lot on their plate and they do a heavy lifting in hiring and training their team. So being able to give the tools and the support to our nurse managers to make them comfortable in that space of, you may hire this someone but really, this is the beginning of their journey in this health system and help guide them maybe to their next juncture or place in the journey, which could be to a different unit, could be into another area. So I know that's our mindset here and I do believe that is the shift that's coming into this profession.


Dan:

I think we're seeing that as well, this kind of idea of more flexible work and career pathing, not only in the same system, but even coming in, getting some skillset, trying other places out of their specialties, coming back, settling down for a little while and then moving through and up and around. And it's not following that kind of traditional thing we heard from our nursing instructors for so long, which is, "I did my diploma program and I stayed there for 20 years. And then I got promoted to a system next door. And I worked there for 20 more years." I don't think the workforce is going to do that. And they're looking for how do they make an impact and value and they know there's a shortage. So they can really write their own ticket wherever they want to go. How has that changed your idea of retention? How do you conceptualize retention with this kind of changing mindset of the workforce?


Dani:

Yeah, I think as I've looked at some literature about retention and what's important to the workforce, some key things that I think are fundamentals to our workforce that will continue to exist, I think it's cross-generational, I know it really applies to the millennial generation as well, but we want to build, I believe in multi-generational workforce is relationship with your leaders. So that is a key piece of someone's work environment, as well as flexibility around staffing and scheduling. So being able to help create or carve your path in regards how you schedule, how you staff and the work that you're doing. So we're tackling that head on here at Bon Secours Mercy Health in redesigning staffing and scheduling and ensuring that we're utilizing technology to the most optimal place that we can. There's always limitations within that. Redesigning how we're doing the work for our nurse managers so they're not spending 60% of their time doing this work.


Dani:

And looking at building flexible workforces so that there is the opportunity for whether it's hospital-hospital changes, or work environment, or system environment where we can help bring the workforce across our system. So there's a lot in the works that we want to bring to life here to help engage our workforce not only in attracting them to work for us, but to keep them working for us and to have a healthy and enjoyable career. And we know that work environment, staffing levels impact healthy work environment. So if we don't get that right, or we don't address that, or work towards a solution, then we're not going to create that environment that I think is enticing to our workforce. So there's a lot that goes into it in regards to retention, but I believe fundamentally in what I've seen in the literature and what I've experienced is your manager relationship, your team relationships are key, and then creating this environment that is flexible with your staffing, scheduling and ability to help grow your career is another key component for our workforce.


Dan:

Hey, there Handoff listeners. This is Dr. Nurse Dan. I hope you're enjoying today's conversation about nurse staffing and scheduling, which is a topic we're particularly passionate about here at Trusted Health. And in fact, we've just launched Trusted Works, the comprehensive staffing platform that will change the way hospitals predict their staffing needs, hire and retain talent. With Works, we've created a completely new model for clinical workforce management, empowering employers to create their own on-demand workforce by uniting internal and external labor sources into a single operating system, creating one source of truth for all of their staffing needs and ensuring that open shifts are filled in the most efficient manner.


Dan:

If you're interested in learning more about Works, please visit www.works.ai. There seems to be this push and pull within nursing specifically around the length of shifts. We love our 12 hour shifts because we get a few days off, but then we also hate our 12 hour shifts. Are you seeing a shift to more dynamic scheduling where nurses can pick up 2, 4, 6 hour shifts instead of 12 and actually being more dynamic in those things and what are some of the trade-offs there?


Dani:

Yeah. And that's absolutely where we're wanting to go. Some of our technology limits our ability with our flexibility. So the desire of the profession potentially as well, I want to schedule eight hours here, maybe 10 hours there. And what I found is in enterprise build of technology, it can be challenging to create that fluidity of desire and flexibility for the workforce. And I believe that we're on a journey. I think that the tech will get there, but I just think there's some limitations in some of the tech that I've worked with in this space. It's comfortable to build tech like, "Hey, everyone's 12 hours. They have the same start time and in time." And it makes it much easier to manage whether it's at a hospital level, enterprise level. However, it also does a disservice to the fluidity of what we need within our workforce have different start times, different shift lengths. So we're on a journey to get there and also make sure that we move away from paper scheduling to enterprise.


Dan:

Well, and I've worked in healthcare technology for a long time too. And it seems like the evolution has been, "Hey, we did this on paper and then we put in technology that makes that paper digital." But the process is exactly the same. Now it's just on a computer instead of a piece of paper. And now we're starting to see technology come out that's actually more flexible, is built with technology as the core, rather than the paper process as its core. But you're right. It's so easy to just build the system with these kinds of industrial models of widgets and things. And we know that the workforce is much more dynamic and there's a lot more data to be had to better understand these supply and demand signals.


Dani:

Yeah.


Dan:

So tell me a couple of the programs that you're working on at Bon Secours Mercy's that you would say kind of are leading edge that are pushing the industry to think differently about how you manage a clinical workforce.


Dani:

I always believe or stay this, it's a journey. So I think perfection is the enemy of progress. So we're definitely not perfect, but we're in pursuit of a journey to become better. And that really involves looking at, as I continue to describe organizational design. So who's doing the work today? What policies govern the work that we're doing? And then also what technology are we using or aren't we using? And that really then creates the lens at which we start to view, how are we managing workforce? So one of our biggest foundational programs that we're implementing across our ministry that I think is setting us up for future success with innovations and flexibility in our workforce is what we describe as the resource optimization center. The acronym for that is the ROC. And this resource optimization center was designed to help support our hospitals and our markets and operating with more efficiencies that look at who was doing the work.


Dani:

So oftentimes if you look at literature and if you've lived in the practice environment long enough, typically nurse managers spend about 60% of their time doing staffing and scheduling work. And to me, that's just a travesty because often we require a nurse managers and leaders to be masters prepared, bachelors prepared. So they're trained in so many things such as evidence-base leading or programs that they should be implementing, managing complex workforce issues, are leading their teams. So if they're spending 60% of their time building a schedule, or trying to maintain a schedule, or trying to do staffing that doesn't give them a lot of time to build their teams or do some of these other areas that I think elevate the profession and get them practicing to the top of their license. So our goal here at Bon Secours was to help bring in a team to support our nurse managers.


Dani:

So we actually shifted the day-to-day work of building a schedule and doing staffing from our nursing team to a team that supports nursing. So these are not clinical nurses that are doing staffing and scheduling and building schedules, this is a group of professional individuals that have certain qualifications that we have hired and recruited to come in to help support our nurse managers, our directors, our CNOs, so that we have 24/7 staffing and scheduling for our health system. And we're building it out market by market. So a market could have, say, three hospitals, eight hospitals, two hospitals. It doesn't matter, we can build it based off of the size of their workforce. So we have set in place a new expectation of roles. And then we also look at our policies. So what's governing our practice? Do we have staffing and scheduling policies that are overlapping, that are confusing, that are very detailed, but maybe we don't need them to be?


Dani:

So we actually designed system staffing and scheduling policies for our health system. So seven states, multiple hospitals, so that nursing was speaking the same language and you keep it high level, your high level in what you're designing so that it allows for still some creativity and ability within the markets and the units to determine, "Hey, how do you do self scheduling? Are you going to have rotations in that? What is your weekend expectation?" Things like that. So we allow for creativity in that space, but still say, "Hey, you know what? You're going to open and close your schedule during this time. This is how our incentive policy works." So it allows us to start to speak that same language. And then what we bring in is our technology, so that we're moving from paper or moving from disparate processes to all using the same system and starting to build that database, so that actually, as we're using new technology and we're rolling that out right now, we are building what I believe to be a great opportunity to gather data, to build and forecast for the future as we look at our workforce.


Dani:

So that's one initiative that I believe is foundational to get us into the space of innovation so we can become more creative in our scheduling process and also have a greater understanding of our staffing and scheduling story so that if we're having a variance, we're overstaffed in one hospital, understaffed in another, how can we help shift resources? That's the first step. And then we are designing and looking at flexible workforces. So building a flexible workforce for our markets, so that now that we have the resource optimization center operating, able to see across markets, now we can then help place resources where they need to go.


Dani:

A new resources. So a new resource coming in where we would have a nurse being able to float between five hospitals for a certain specialty. And then we'll look at cross specialty floating and then ultimately we'll move it to system floating in opportunities there. So there's a lot of opportunity to grow and innovate and build and design that I think will help set us apart. But you got to get your foundations right. If everyone's doing their own staffing and scheduling, if everyone is using paper or pieces of the product, you're really going to struggle to bring this new vision into place if you don't really push for, I believe technology to be used and policy to be redesigned.


Dan:

Yeah. I think that system approach is huge. And I think it's always been... well, it hasn't always been, but in a lot of places technology's an option and the implementation of the technology is sort of underrated. And we don't do a good job of number one training, but also taking away some of the stuff that we used to do on paper and actually kind of forcing the hand into the technology. Because then you have the data, you have the system of record, you can manage these moving parts much better than the paper and pencil that I used to use when I was self scheduling in the ER. You just kind of put your initials on and then it'd go into some black hole and then I'd get an email that I was scheduled for X, Y, Z shifts. And there's so many better ways to do that now I think. COVID has obviously disrupted a lot of the workforce stuff from furloughs to shutting down entire units, ORs that kind of stuff. How has the COVID crisis changed your perspective on staffing?


Dani:

I think the COVID crisis actually accelerated what I believe needed to be happening in staffing and scheduling. So as we talked about the desire of the workforce to be flexible across specialty training or a workforce moving from one site to the next, not everyone likes that, but there is a desire for it and the need for it. So when COVID hit there was this new norm placed on us that now we needed to move our workforce and move our workforce from one place to the next, who was interested in it, who wasn't, who had the skill set. So up-skilling where we needed to, et cetera. So I live in this space, I believe in flexibility, I believe in pushing the limit to understand what we can accomplish in our health systems with our workforce. So COVID, I think just accelerated this understanding in a deeper way where different health systems maybe weren't set up to handle this because they didn't have the ability to see across our health system with the view of technology that's needed or they hadn't set up system policies.


Dani:

So I think that really pushed us in that space. And then I've seen it accelerated, I live in this professional space of staffing and scheduling, so I've seen it start to accelerate in large health systems, particularly of roles similar to myself, being developed by these health systems for workforce management. And it's titled things like logistics, or workforce, or integrated resource centers or whatever it is. There's a variety of health systems on a larger scale understanding now that if they come together, you can scale your resources more efficiently with better economies of scale essentially. And then it helps manage this workforce in an emergent situation. So I think a lot of places were caught off guard. Some were set up well and some were caught off guard.


Dan:

Yeah. I think it's forced us to rethink how we use talent more efficiently too, and the stories of in OR shutdown, you were able to move OR nurses into the ICU to help out and vice versa and thinking of nurses' individual skillsets, and people with career paths and desires and needs and helping them achieve those objectives through a flexible workforce, I think is really a cool concept. I feel like sometimes nurses, especially newer nurses feel like they're locked in to some sort of predetermined path. And I think the more we can create these opportunities, the more you can actually build the skills of your entire workforce to be more beneficial to patient care, but also, meet the needs of retention and people being really excited about coming into work every day.


Dan:

So that's super awesome. As we wrap up here, I would love to hear if you had like one nugget to give a nurse leader about how they should be rethinking how they manage their clinical workforce? What would be that nugget?


Dani:

There's a couple of nuggets. One, I believe in the power of human capital or people. I think this is an untapped potential. So I'd really challenge nursing as a profession to look within and for our leaders to also pull out those solutions that I believe exists within our workforce. So I think that there's so much possibility within people and the ability to solve problems, create new things. So I would really encourage us as a profession to work together and to really push ourselves to think differently. And in that same sense, as I ask us to think differently, I would really challenge us to think about what are the cultural norms as a nurse that have inhibited us from thinking differently. Like, "This is the way we've always done it. A nurse is a nurse is a nurse. Or only a nurse can do this." So I think that's the case.


Dani:

I think we need to think about is the work that's happening that actually isn't the top of license for a nurse? Is there technology that we need to really embrace and push forward and say, "It's not perfect now, but I believe if nursing really pushes in, we can make it better." And then also I would just say that, as I said before, perfection is the enemy of progress and that this is a journey and I don't think there's a final destination.


Dani:

I think that it continually iterates into better and more efficient ways of doing work. So I would just challenge our profession to own this space. I don't think that we need legislators to own it for us, we don't need technology to own it for us or even financial partners or others. We live it, we intuitively know it and it's challenging, but I would hope, and I believe that we can step up and say, "We can also solve it and make it better."


Dan:

Yeah. And I've been recently kind of giving some talks at different nurse leader conferences and the topic has been, this is a paradigm shifting moment, or we can go the way of blockbuster as a profession. And I think exactly what you said, we have to challenge some of the assumptions we have about the profession that have driven us to where we are. And we know that they're broken, they've been broken even more the last year and a half and the way out of this is to work together and innovate enabled by technology, but more just shifting the way we think about our entire work as nursing. So I love that. And that's a great message to end with. Dani, where can people find you if they're interested in your work, your dissertation? What's the best way to get them to get your message?


Dani:

I am on LinkedIn. So I do use that professional platform. So I think that would be the best way is just for them to connect on LinkedIn. I do have publications out there. You can just Google my name and they'll pull up the different articles that I have written in the past about staffing and scheduling and there's more to come. So more to come in the work we're doing at Bon Secours Mercy Health. So I'd love to share that. But LinkedIn would be probably the best place.


Dan:

I love it. And also, our book chapter will be out in the next couple months. So we'll keep an eye out for that too. That's a great resource to hit in on all of the work that frontline nurse managers can use as well. So appreciate you contributing to that. And thanks for being on the show. This was awesome.


Dani:

Yeah, my pleasure. Thanks for putting this together and being an innovative, inspiring leader yourself.


Dan:

Appreciate it, Dani. Thank you. Thank you so much for tuning into The Handoff. If you liked what you heard today, please consider leaving us a review and subscribing on Apple Podcasts or wherever you listen to podcasts. And for more information about Trusted, please visit trustedhealth.com. This is Dr. Nurse Dan. See you next time.


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