February 24, 2020

Episode 2: Lori Armstrong of the Armstrong Reliability Group

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Description

On this episode of The Handoff, healthcare industry veteran Lori Armstrong shares workforce insights from her 35 years as a clinician, a nurse leader and a consultant to healthcare leaders. She and Dan discuss the best way to incorporate flexible workers into your culture, why she thinks travel nurses are an untapped resource and how a travel nurse once stepped in to help when one of her hospitals was in the midst of a crisis. Lori also discusses trends from the conversations she’s having with hospitals around staffing and flexible work, why she advises her clients to treat flexible workers like family and why the idea that flexible workers cost more than staff clinicians is actually a fallacy. 


Lori is a transformational leader in the healthcare industry, and has been a healthcare executive and Nurse at several prestigious healthcare facilities around the nation, including Kaiser Permanente, Texas Childrens, New York Presbyterian and Stanford University. Today Lori is the CEO & Chief Clinical Officer of her own consulting firm, the Armstrong Reliability Group, where she helps to equip healthcare leaders and organizations with the skills to achieve and sustain change.

Podcast

Transcript

Dan:
Lori, great to have you.

Lori:
Thanks. So glad to be here.

Dan:
Lori, tell us a little bit about your background.

Lori:
Well, I've been a nurse for over 25 years and my original clinical background and training is neonatal nursing. So I started out with the tiniest, most fragile and vulnerable patient and I always share that because it was truly there that I learned the impact that frontline hands-on clinical nurses have on the outcomes of babies, but also on the outcomes of families. So that takes you from an episode of time to a lifetime of a patient and just thankful for that background. Then once I really learned the magic that happens at the bedside, I was hooked from then on and wanted to make a difference in a bigger, broader way. So going into leadership was a natural progression and I really, I think you'd say I rose through the ranks in a very traditional fashion. Assistant nurse manager, nurse manager, director, and then I always had my heart set on being a chief nurse. And I'm very grateful, for the past 15 years I've been a chief nurse at some mere organizations, most recently as chief nurse executive at Kaiser, Santa Clara in Northern California.

Dan:
That's great. So you did take more of the traditional path.

Lori:
Absolutely.

Dan:
Did you have any non-traditional roles in your experience?

Lori:
I think that although my leadership path when you look at it at a bit of a high level is very traditional, but I always took on different and varied opportunities. For example, when I was a director of a clinical service line, the opportunity became available to be a director of the nursing education department. So a little one traditional in the sense is I wasn't formally educated in being a clinical nurse specialist or educator, but I was very passionate about the role of preparation and leadership development of the entire nursing workforce. So when I was at Stanford Children's Hospital, Lucile Packard, I was given the opportunity to go into from an operational world to a more support role and lead their center for nursing excellence. And that was a great opportunity. But as I said, I was always open to other things but I guess you could summarize it's been primarily traditional.

Dan:
Well, yeah. And all those roles lead you into that chief nurse executive because you are managing the education, the frontline, the business and all those types of things. So I'm sure that was a added value to you.

Lori:
Well, added value because the support departments feel that operations always has more influence. And I learned in me director of center for nursing excellence role that the CNS, the educator support, are our frontline staff. And in terms of leadership development, 365 days a year, and may need input and may need support as well, not just inpatient.

Dan:
Right. You've had multiple roles in multiple parts of the healthcare organizations. One of the focus we have here is on what the flexible workforce or the flexible workforce of the future will have, the impact it will have on healthcare. Can you talk a little bit about your experience working with travel nurses over the course of your career?

Lori:
Sure. I can honestly say that 100% of the organizations that I've been a nurse or a nurse leader in, all had travel nurses and we have leaned on and really trusted the work and impact that travel nurses make. So views them frequently or unanimously at every organization. And as a nurse leader, quite honestly, Dan, we couldn't survive without the resources that travel nurses provide. And I've used travel nurses in many capacities, primarily frontline hands-on providers, frontline nurses. But I've also used travel nurses in the capacity of educators, clinical nurse specialists and nurse leaders, predominantly assistant nurse managers and nurse managers.

Dan:
That's great. That's not a story we've heard consistently across the board. Sometimes we hear that travelers are given the worst shifts and treated as outsiders. So I'm wondering how you incorporated travel nurses into your nursing culture in the organizations you've led?

Lori:
Well, I think ideally that nurse leaders have to be very, very mindful about the travel nurses that you're bringing in. And I think I can say that my colleagues, you know that in your head, but in terms of ensuring operationally that travel nurses are welcomed, travel nurses are prepared to enter your organization seamlessly. You know what's best for the organization is that whoever pays the paycheck is transparent to the patient. Whether it's a travel nurse organization or the hospital or healthcare system itself, it doesn't matter. It should be transparent to the patient. Meaning that the nurse who's providing care, it doesn't matter who employs them. And to be able to accomplish that, you have to make sure that the travel nurse is treated just like one of the family. And that's not easy to pull off.

Dan:
No. Because they're there for 13 weeks and kind of in and out and yeah-

Lori:
Correct.

Dan:
... that must be a challenge.

Lori:
It is a big challenge, but one thing that I truly value about flexible nurses or travel nurses is their flexibility. I have found travel nurses and maybe this is because I was a travel nurse myself earlier on in my career, traveling locally within the city of Chicago when I lived there. You learn flexibility, you adapt and you're able to take what you learned from the last organization you were at or several organizations in your say, 13-week commitment, to your current location, your current organization. And the organization gets to benefit from that. I personally as a nurse leader like to introduce the whole leadership team, introduce myself as the chief nurse, ask them where they came from and what's different, what do they see and what do they miss about where they came from. Because that's how you get better.

Dan:
Yeah. Do you have any stories of anything that kind of popped out from a travel nurse that really made you think or change something in your role?

Lori:
Oh my God, I'm so glad you asked that question. We were having a central line associated bloodstream infection outbreak at a particular organization. The hospital had done really, really well for about two years. We had the lowest in the region and all of a sudden there was a spike. So I would say after the third or fourth infection within a six-week period, I thought, "Okay, something's going on." And we pulled the group of frontline nurses together, just put a notice out in an email out that said anybody interested from these departments that is interested in participating in the solution and really having a voice in what's going to change in care of patients with central lines, please attend the meeting. And we had a room full of people, which me as a chief nurse was just thrilled that frontline wanted to be engaged in that solution.

Lori:
And most frontline nurses, they want to have a voice in their practice. It's just that often a venue for them. So everybody was in the room and one of the travel nurses raised their hands, really truly like raised her hand and said, "Let me share with you what I learned at my last organization." And she spoke about different equipment and a different central line change kit that she was used to. And we took that information and we examined the central line kit and some tacts that we were using and we made some changes.

Dan:
That's amazing. That's a great story. One of the things that I've been thinking about and you mentioned this as well, is these nurses have been around multiple organizations, academic medical centers, community hospitals, and they learn all kinds of different practices and best practices. They're almost like a special operative that comes into an organization with this untapped knowledge a lot of times. And so that's a great story of how you can actually pull a best practice that makes instant clinical impact. I think there's a wealth of opportunity for nurse leaders to think about when they have travelers on their floors.

Lori:
Definitely an untapped resource if leaders are not doing that or thinking of the traveler nurses for sure.

Dan:
In your current role, you're doing consulting work and speaking and teaching around change management. How often does the topic of flexible work come up and what are some of those conversations like?

Lori:
Well, I would say staffing comes up 100% of the time, 100%. And when you get a few nurse leaders or chief nurses in the room, flexible staffing and scheduling and flexible or travel nurses, the conversation always ends up there so quite often. And what I would say is that, I guess my recommendation to my colleagues or people that I am supporting and consulting is in terms of temporary staff. Is beyond what we all ready talked about Dan, is that treat them like one of the family. Treat them like a full- time staff member. They want to feel engaged, they perform better when they are engaged and feel like one of the family. But beyond that, the number one thing that I try to teach them is that never budget for 0% flexible work travel staff. There's always the right percentage for an organization. And I've never been at an organization that did well with zero travel nurses or zero flexible staff. So find out what your number is.

Lori:
When I'm working with nurse leaders, I look a lot at historical data. I'll look at the historical utilization of travel nurses. I look at percentage of overtime, I look at vacancies, I look at turnover, and then I also look a lot at what the cost of benefit is, the benefit structure. Because of course it varies across the country, but where I am in Northern California, it's upwards of 30%, 30 to 40% benefit. And a lot of times when nurse leaders and our finance colleagues are calculating the cost of flexible staff or travel nurses, they don't always incorporate that into what I consider a strict mathematical model. So my recommendation is never to budget for zero and find your number, find your number because you need them.

Dan:
Yeah, that's great advice. One of the things that we're seeing as we talk to different healthcare organizations is that they'll never ever be fully staffed with their own FTEs.

Lori:
Never.

Dan:
And that you have to have that magic number, whether that's travel, whether it's per diem, whether it's some flexible on demand kind of structure. But nurse leaders, that's the new reality. And so it is impossible to completely build out your empty FTE count. We actually talked to one organization and they said, "If we filled all our FTEs up, we'd actually be an insolvent organization. We can't actually afford to have all the benefits and FTEs fully built out across this massive organization." So I think planning for the flexible workforce is key to the healthcare leaders out there.

Lori:
I agree and I think that we never really solved that issue of really knowing the number and really calculating the troll for ROI. So we have to do a better job. Nurse leaders and financial colleagues.

Dan:
You mentioned the nurse leaders and the financial colleagues. What are some of the biggest misconceptions you hear in the room with those folks when you're talking about flexible workers or travel workers?

Lori:
That's the easiest question you're going to ask me, Dan. What's the biggest misconception? The biggest misconception is that flexible work, travel nurses if you will, are too expensive that they cost so much more than benefited staff and that's actually not the case in many, many organizations. Obviously, I don't advocate for 100% temporary step. That's not how you run an organization. But when you do the math, and I always say this, some nurse leaders run away from the math. When you do the math, it's actually not the case when you look at the all in equation.

Dan:
Yeah. I think a lot of people forget that 30 plus, even some places 40% benefits on top of the the hourly wage -- it ends up being a wash sometimes.

Lori:
Really. Absolutely. I would also say, I think perhaps not financially related, but there is a link. Is that there is a very, very big misconception that flexible or temporary staff are inferior to your full-time benefited staff and that's not the case. When selected properly, oriented properly and utilized properly and welcomed into the organization properly, they're not inferior. In fact, I've had had the experience of having temporary staff that we really didn't want to go. Physicians would ask them if they could stay longer. The nurse nurse leaders on the units would ask them if they could stay longer. Just recently at Kaiser Santa Clara, we awarded the first Daisy award recognition to a travel nurse before I left.

Dan:
Oh, that's amazing.

Lori:
It's great.

Dan:
Trusted Health just signed up for the Daisy program this year as well, and we are awarding our travelers out there Daisy awards as they get nominated by their clinical placement leadership. That's a wonderful way to recognize good nursing practice no matter where they come from.

Lori:
Really good to hear that you all are doing that.

Dan:
As you think about how you incorporated travelers and their expertise into the clinical setting, what advice would you give other healthcare leaders? What policies would you set up? What structures or conversations would you set up to actually be more formal in extracting that expertise from travelers as they're on assignment with you?

Lori:
Well, I think some of the work is done pre on site. So, I just can't emphasize enough Dan, proper selection. I think some organizations are in reactive mode versus proactive, and I think putting a system in place and having a relationship with the temporary or flexible staffing or company that you are engaging with. I think having that relationship and making sure that you're selecting the right people is critical. Orienting them. Yes, we all want travel nurses to hit the ground running, but making sure they have proper orientation and have key people who can mentor or buddy with them when they do come on site. A number one critical. But when they do get there, reviewing the competencies that they have, making that great connection between competency. And assignment for the patient, yes, most important, but also competency in term of where their interests are in the professional practice.

Lori:
Some people may have examples in EMR optimization and technology. They have a passion for that. Some, which is this is where I focus on the most because of my work and research between a nursing care and patient outcomes. If they have an interest in a passion in quality improvement, put them on your committees. Most... I shouldn't say most. A lot of hospitals have shared governance. Ask them if they want to attend the shared governance committee. Make sure you're doing something, putting them into the organizational structure or committee structure so that they can hear their voice. The benefits to the organization are really invaluable.

Dan:
Yeah, it sounds like keeping them as outsiders is probably the worst piece of advice. So creating ways that they can interact even informally with the organizational culture, whether it's shared governance or a committee or even just a check in with the nurse manager. It seems like some formal connection regularly during their assignment would be very beneficial to organizations.

Lori:
Exactly, and I think that nursing departments across the country don't always do a very good job of that. Orientation is talking even for your own permanent staff, but when you're bringing on sometimes even large numbers of travel or flexible nurses during high census period, that connection or buddy that you have, whether it be a manager or an educator or CNS, just isn't there.

Dan:
As you have these conversations around the country with different organizations, what are some of the biggest workforce trends that you're seeing? We talked a little bit about the fact that you're always going to need some sort of flexible workforce, but are you seeing trends in the new nurses coming in, not wanting to stay with organizations for a longer period of time? What are some of those big trends that you're seeing?

Lori:
I think that definitely the trend that you referred to Dan is the newer nurses not having that... It's not that they're not loyal, they just might not be loyal to a particular organization. They're loyal to being a nurse. They're loyal to their practice, but they might not just be loyal for a long period of time to one employer. So keeping them engaged is critical, but because the turnover of those newer nurses, one, two, three years is rising, that presents new challenges for organizations and thank goodness that we have flexible and temporary resources that we can tap into.

Lori:
I think that we're also seeing that at the manager level as well. Contributing factor, separate and apart from the whole loyalty of the newer generation of nursing is violence, workplace violence that is leading nurses to leave traditional work environments in the hospital. And I think that burnout and stress of nurse managers is leading to a gaping, gaping hole that's only getting bigger.

Dan:
Yeah. Some of the numbers I've heard on that is 44% turnover rate year over year for nurse managers.

Lori:
That was actually the last number that I saw as well. It's scary and it's sobering.

Dan:
One other thing that we talked about before we started recording was around the interim nurse leader role. Do you see trends in that interim nurse leader role where that expertise is coming in and kind of fixing healthcare organizations or kind of riding the ship? What trends are you seeing in that area?

Lori:
Well, what I'm seeing is a more open-minded hospital leadership in considering the investment in a management travel assignments or interim placement. Again, it really is up to the chief nurse or the nursing leadership or a very informed chief financial officer to educate those about the cost of not having a dedicated leader in a unit that has vacancy. Overburdening an existing nurse leader into taking on example there, a nurse leader of the med surge unit, somebody, another manager leaves another with two units. And the negative impact in the cost on cost for the hospital to do that as opposed to bringing in an interim leader, you have to do the math. And the math 100% of the time is that it's more cost effective to bring someone in. Because if you think about it, the span of control of one nurse leader to 50 or 100 nursing staff, you just can't do that. You can't spend the individual time with each frontline staff that they require and deserve to give exemplary care. It's just, it's worth every penny to bring the interim leadership in and that's not always been the mindset. So I do see a more open-mindedness across the country and healthcare leaders are bringing in interim management.

Dan:
Yeah, it sounds like there's a shift moving towards more matching the right skill set at the right time, both at the travel nurse or a flexible workforce at the frontline, but also at the leadership level where before it was well we need them in our culture and they need to be our employees. But there definitely are situations where it may make more sense to have that expert come in at different levels to kind of fix the problem of the moment and then it allows you time to build the structure for a longer term solution.

Lori:
Exactly. And your comments Dan, are spot on and what it made me think about was a couple things and I'll tie them together. I've said a couple of times in this podcast about selection, selecting the right person. And when you bring in a leader to a hospital as an interim assignment, the selection really has to be spot on. Do they match with the mission, vision and values of the organization? Do they have the clinical skills to oversee the unit properly during a vacancy, but also about leadership. I'm a proponent of... Well, I always say that there is an inseparable link between nursing leadership and patient outcomes. And that's no different with interim leadership. And when you bring in someone that has the ability to lead change, that has the ability to inspire the staff because they're so genuine and authentic, that's when you're not going to see a gap, even though you have a vacancy in leadership. It's when you select the right transformational and authentic leader and I've come across many of them even as interims.

Dan:
Yeah. I think just because you're not employed full time at a organization doesn't mean that you can't influence people, which is the core of leadership. And there's something about really excellent leaders that can take that skillset wherever they go.

Lori:
Right. We have to really let go in our mindset of the traditional legacy staffing models for nursing, else we're not going to be successful.

Dan:
Yeah, definitely. So I'd love to hear more about what you're up to now. I know you left the full-time chief nurse executive role and jumped into the world of consulting and teaching. Can you tell us a little bit about what you're up to?

Lori:
Yeah, great. I always share with people, it's such an exciting time for me professionally, but a terrifying time in the same aspect. I have spent over 25 years in traditional roles as we spoke of in hospitals and stepping out to really follow my passion. My doctoral research was on the link between nursing care, nursing leadership and patient outcomes. And once I completed my degree a few years ago, I decided it was time to take that leap and try to make a difference in a different way, in a broader way. So I teach in the master's program at Drexel University. I teach up and coming nurse leaders, just that about operations and the link between their leadership and patient outcomes. Love it. I spend a lot of time on strategic planning and change management. We as nurses don't always learn that.

Lori:
I also have had the opportunity and honor really the writing nurse executive curriculum for Dr. Louise Jakubik of Nurse Builders and I teach, I'm the first soul faculty to help nurse leaders become board certified in leadership at the nurse manager level and the executive level. So I spend a lot of my time in front of up and coming leaders, nurse leaders who are really going to lead the way in this current and next generation. So it's my honor to do that.

Lori:
And then I also do consulting helping organizations, nurse leaders particularly improve outcomes, patient safety outcomes. My specialty is high reliability and decreasing hospital infections.

Dan:
That sounds awesome. Yeah, no, I know you're definitely passionate in that and I know we worked together at Kaiser Permanente for a little while and was always impressed by your ability to build that culture and actually improve the outcomes. So exciting that you're taking it on a road show.

Lori:
Well, thank you. Thank you so much. I think we all know that 2020 is the year of the nurse and a year of the nurse midwife. I mean, it's self-imposed. I certainly don't have that big an ego, but I feel like this weight, we really have to do something this year. Like 2020, and I thought, "Hey, it's a new decade, let's take the decade."

Dan:
Love it.

Lori:
We usually have a week, now we have a year, and let's take it, Dan.

Dan:
That's right. Let's do it. Hey Lori, where can we find you? If some of the listeners are interested in connecting with you and learning more about what you're up to, where can they find you?

Lori:
Best way to find me or to contact me is Lori, L-O-R-I at Armstrong Reliability Group, or you can visit my brand new, still building out website, armstrongreliabilitygroup.com.

Dan:
So exciting. Lori, thank you so much for being a part of the podcast today. I think your insights will influence nurse leaders across the board and it's just a pleasure talking with you again. Thank you so much.

Lori:
Thanks, Dan. Have a great day.

Dan:
Thank you so much for tuning in to the Handoff. If you like what you heard today, please consider writing us a review on iTunes or wherever you listen to podcasts. This is Dr. Nurse Dan. See you next time.

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