Great Retirement Leading to Continued Workforce Shortages

Paul Anderson: Welcome to Smart Healthcare Safety from ECRI, the most trusted voice in healthcare, committed to advancing effective, evidence- based care. I'm your host, Paul Anderson. And for more than 10 years, I've overseen our patient safety, risk and quality membership programs here at ECRI. Tens of thousands of healthcare leaders rely on us as an independent, trusted authority to improve the safety, quality and cost effectiveness of care across all healthcare settings worldwide. You can learn more about our unique capabilities to improve outcomes at www. ecri. org. Today, we're taking another look at shortages in the healthcare workforce. Healthcare has faced workforce shortages in the past, and even before the COVID- 19 pandemic made things worse, the American Nurses Association and the US Bureau of Labor Statistics forecast the retirement of more than half a million registered nurses by 2022. Our guest today is Tom McCormick, vice president of patient accounting at Penn Medicine in Philadelphia, Pennsylvania. Tom, what are some of the current challenges and issues related to your world, to the patient accounting world, that are really hitting healthcare right now?

Tom McCormick: Sure. Thank you, Paul. I will tell you that we're experiencing similar to the statistics you just mentioned, especially something that I'll call the great retirement. We've had a lot of people that have, I think, suffered from pandemic exhaustion. Some individuals that were not willing to make a transition for a different type of workforce during the pandemic. They decided that they were of age and they were going to retire and that would be the end of it. So, in our world, probably last year, we had 28 individuals retire from our workforce, mostly as a result of the changes that we made when we went 100% remote.

Paul Anderson: Would you say, I've heard some other people characterize it this way, and I'm curious if you feel the same, is this the most critical issue facing hospitals as we're here in the beginning of 2022?

Tom McCormick: I think staffing challenges are definitely the most critical thing facing hospitals. With the exhaustion that has come over from taking care of long stay COVID patients, the longer work hours, the shortage of staff that puts the pressure on the staff that are existing there, and the changes that we've had to make to meet those challenges is definitely one of the most critical things we're facing.

Paul Anderson: So, can you tell us a little bit more about Penn Medicine and what you're doing to navigate these challenges? And maybe just frame for our audience a little bit how many sites you have in Penn Medicine, what's your patient population that, and again, how are you trying to tackle these workforce challenges?

Tom McCormick: Yeah, absolutely. So, we're a six hospital health system and our flagship hospital is the Hospital of the University of Pennsylvania. We have three inter city hospitals in Philadelphia, and we have three kind of community hospitals. Although, I would consider Lancaster General, a major health institution in an area that's in our Western suburbs. Along with the flagship hospital, we have Pennsylvania Hospital, the first hospital in the country. We have Penn Presbyterian, which is our trauma center in West Philadelphia. We have Princeton Hospital in North Jersey and Chester County Hospital, which is a small community hospital just outside of Philadelphia. So, we have 24, 000 employees. We're an$ 8 billion revenue organization, so it's a fairly substantial health system.

Paul Anderson: So, you mentioned the number of retirements you had just in the last year, what are some of the initiatives you're putting in place to try to deal with all this workforce churn?

Tom McCormick: Yeah. So, I like to start off by telling what happened in the beginning of the pandemic. So, when the pandemic first started, we were challenged to create some social distancing just within our office space. So, in that whole January- February timeframe, we started to create different work schedules and those work schedules ran from four- day work week to three- day work weeks. Some people that still had a five- day work week. And our goal was no more than 50% of any one section would be in. So, we could spread employees out and not be on top of each other in that cubicle- type environment that we have in revenue cycle. Then come April, the governor started shutting everything down in the state, so restaurants and everything else was closing down. We took that initiative to basically say," You know," we could have come in as healthcare workers, but we said," Why make that chore, when we can actually create a more safe environment for our employees, by allowing them work from home?" And literally within 10 days, we had a 300 FTE workforce at home. In the beginning, they were working on their own computers. Then, we quickly within about three week timeframe got Penn computers out there just for better security, what have you. And even though, we're still working out technical difficulties, this was truly like necessity was the mother of invention. If somebody would've asked me pre- pandemic, am I ever going to have even a four- day work week, let alone 100% workforce? I would've said," No, that doesn't work for me. People need supervision, management by walking around," all of those theories. And I was stunned. I was stunned that we now have productivity increasing, a happier workforce, I mean, this satisfaction quotient was going up, people loved this whole idea of working from home and their own domestic flexibility improved as well. So, as we did all of that, all of a sudden we uncovered these little areas of the operation that were paper- driven and not only were they paper- driven, they really weren't necessary. So, that's kind of a long beginning to answer your question. We kind of started to rightsize our operation. And we took a look at some of these individuals who, quite frankly, were on our payroll for 45 years, some of them even longer than that, they were well over the retirement age, but they just didn't want to retire. These were the individuals that really had difficulty, even with the technology of working from home. I'm going to tell you, the biggest thing that stunned me was how many people, when we sent people to work from home, did not have Wi- Fi. That just was a foreign concept to me when I started thinking about the way everybody works in the world today. So, we started working with these individuals. Some of them, we just needed education on what it meant to be retired and how they could have a better lifestyle, how they really weren't going to be successful in the current environment. They totally agree with us. As I said, we basically started to rightsize our organization, engage more automation, scanning, electronic faxing, things that you would take into consideration when you wanted to have a more efficient operation regardless. Some of that was keeping us back was the fact that we had these people, that they were there and they were being employed. So, we kept the paper process just to keep them busy during the day.

Paul Anderson: Yep. It's funny, you talk about that transition to home happening so rapidly. And I can remember when ECRI, because we're located just outside of Philadelphia. So, we're in the same basic area that you are. And I can remember the day or two when we made that decision to go home. We thought it would be for about three weeks, but it looked like the place was being looted as people carried out to their cars right there, their keyboards and their monitors and all those things. And right now it's been two years and a week or so and we're still here. So, besides working from home and you talked about a couple things that were different types of flexible work arrangements. So, changing the number of days, obviously shifting to location of work, what other kind of flexible arrangements did you find that staff were asking for on their own?

Tom McCormick: Yeah. So, I could tell you even before the pandemic, my staff wanted a four- day work week. Honestly, literally about 40 years ago, we actually tried something like that. It just didn't work out. Especially for the management team. Because it always seemed like the management team was never getting into that four- day work week that the staff was requesting. Other than that, there really wasn't a whole lot of other requests for that. I mean, I do think that working from home, if there were certain individuals who were a specific skillset and they weren't hourly employees and they would request to work from home. Some of it was just because they wouldn't have the distractions of the onsite work activity, and they could focus on what they wanted to do. In the past, we've actually found some people just take way too much advantage over that and we lost some context. And that's one of the reasons why a work- from- home strategy was kind of like something that we really weren't in favor of. Then, we went through that first year, that first year of all of our people working from home and we saw the increase in productivity. Paul, I got to be honest with you, the one thing that really went down is the irritating, interpersonal, some people call it the water cooler interactions that occur that suck up your management's time, because somebody doesn't like the cologne this person wears, somebody... The cleaning fluid that they wipe on their desk is aggravating their asthma. That whole interpersonal problem went away. I mean, and we could focus on more strategic things, at workflow operations, improving our efficiency, how we deal with payers. All of those things, I think, actually contributed to the improvement in our productivity. The way we measure productivity, particularly with a clerical hourly staff, it increased 28% over the last two years.

Paul Anderson: Wow. That's really meaningful. I mean that's not just a little bit.

Tom McCormick: Right. Then of course, after the first 12 months, we went to the CFO of the organization, my boss, and we made a proposal and he actually was all for it. We're on offsite space, you know downtown Philadelphia, you're in that Plymouth Meeting area. So, in downtown Philadelphia, we rent space right across the street from city hall. Then we had a lot of corporate divisions of which ours was one of the largest. So, we were able to reduce our footprint, patient accounting footprint from 65,000 square feet down to just under 10,000 square feet. Most of that is because we have servers that we still have to maintain. We have some onsite staff maybe that still, we still have to do the mail. We still have to do... There are some paper processing that still takes place. But that has gone down from an amount of about 300 full- time employees down to about, at any given day, we might have eight or 10 on site.

Paul Anderson: Well, I think something that's so interesting to me both when we talk about the healthcare workforce and, in particular, as we've gone through the pandemic and we talk about all these type of steps that you're taking. I think so often, in the public, our mind goes to direct caregivers, nurses, and a nurse for the most part can't work from home. But it takes this army of people to keep a health system running and to be able to make some of the changes on the fly that you're talking about, that reduces the burden all the way across the board, I'm imagining even onto the direct care providers. Because there's just fewer people in the building. There's more room. You are not getting sick as much and taking up healthcare resources, because you're at home just that trickle down effect I think is really interesting because it... You, in your role, and your immediate team, you're not touching patients. But by being offsite, you're still having an effect on the patient care capabilities of the health system.

Tom McCormick: Yeah, you're absolutely right. And most of the people at Penn Medicine, they get their care at Penn Medicine. So, if I'm keeping my staff healthy by living at home or working from home, then I'm actually contributing to less pressure for patients coming in that need to be seen. I got to tell you, the instances of people on my team that actually contracted COVID going all the way back to January is very minimal, very small. We credit a lot of that for people just staying home, following their own protocols at home in terms of washing their hands and their inaudible. I'll never forget, we used to end every call, these virtual calls with staff by saying," Watch your hands, don't touch your face." It was just a constant reminder. The staff remained healthy. I mean, we really had very few inaudible of people that actually contracted it, and nobody who actually passed away from it. Thank God.

Paul Anderson: That's wonderful. So, that's their physical health. I know that you've also implemented an employee morale committee. It's funny, you talked about that lack of water... The interpersonal distraction of I don't like their cologne or... For me, it was always people with flavored coffee and I'm sitting inaudible that. But there is that other piece of, okay, what have we lost potentially by not being around each other? So, can you tell me about that employee morale committee? What did they do? What kind of interventions do they pursue?

Tom McCormick: Yeah, so we appointed people that we knew had that personality. I mean, you can imagine when you have 300 people and you say," Raise your hand who wants to be part of the employee morale committee." You'd probably get at least 150. And most of them are like," Man, I can get a couple hours off of work and not have to worry about productivity, sign me up." So, we tag people that usually do engage in departmental type of things, like the annual Christmas party or any other kind of celebration that we would run. And we tapped them for these ideas. And we formed this group that we would meet on a regular basis. And we would come up with typical things that we would do on site, but we would do them virtually. So, we had a virtual Christmas party. Now, under normal circumstances, you'd have 300 people wandering the floor for a half a day enjoying some snacks. And we gave out departmental prizes and things of that nature. But we moved that to be sectional. We used MS Teams, people would get onto MS teams. We still allocated gifts for the managers to give, we developed trivia programs. They would take some time off from work. We didn't make it a half a day, because I think that would be not... It wouldn't be feasible for you to have a half a day virtual meeting. But we told them they could take up to two hours, wish everybody happy holidays, create that sectional engagement. We also have contests that we did department- wide, the ugly sweater contest, the best Halloween costume contest, send in pictures of your decorated house for the holidays and whatever it was, internal, external, whatever you wanted to do, the employee morale committee are the judges. And we would give out awards for that. That took the place of, we used to have the best decorated cubicle. So, we translated this whole idea that we're working virtual into as many ideas as we could to just keep the people engaged. Even beyond the employee morale committee, engagement's important. Every manager, supervisor are required to meet with their team no less than once a week. It has to be an MS Teams meeting and cameras are on. We even developed our virtual dress code, which actually looks very similar to our original dress code, except that it's only from the waist up. We basically, same things, we say," Hey, just because you're working from home, doesn't mean that you can sit with baseball caps on backwards, or wear inappropriate T- shirts," those type of things. It's like," We want... Once you wear college shirts or at least a dress sweater or something presentable, you have to look presentable. You're still part of a professional organization. And I don't want you to feel like you can just roll out of bed and click onto your computer."

Paul Anderson: Yeah. I will say, I will admit that I, before I get dressed, I look at my calendar for the day and decide now just how much of a grownup do I actually look like today? It's on my to- do in the morning.

Tom McCormick: The first time we put that out, one of my direct reports showed up on a management Teams meeting in a hoodie with sunglasses and some kind of stupid saying across his sweatshirts inaudible.

Paul Anderson: One of the things I've heard a lot of organizations do, particularly in professional roles like patient accounting and your team is really doing more cross- training of staff and helping them to both cover for each other, because you don't know when you're going to have sudden staff shortages in different places. That applies again in the clinical world, as well as in the professional world. Have you found that as something that was a strategy that you employed and how did staff receive that?

Tom McCormick: Yeah, absolutely. We did employ that strategy and I'll tell you something that was even a part of that, when I had all these people retire, it's one of those programs that you have to offer a variable separation program is what we called it. And we were giving them incentives to take their retirement packages, not early, but I mean, they were all of retirement age. Well, I had a significant part of my management team that saw that benefit and said," Wow, this is something I can't turn down." I wasn't necessarily looking for them to retire, but they did. So, again, we took that opportunity to rightsize. So, we shuffled the chairs around. We have a hospital side and a professional fee billing side. They are different in my organization. We have one central management team, but we started to combine elements that were easy to combine, recordkeeping, the scanning component of putting the paper stuff into a virtual environment. We started to say," We can consolidate these under a manager, not replace certain management people and really take advantage of this opportunity." And that did require cross- training. So, people had to learn the professional side and some had to learn the hospital side. There were data entry components that we could combine. So, most of the staff actually appreciated the opportunity to learn something different. A lot of them saw as an expansion of their opportunity. And a few of them said," Well, if I have to learn something new, do I get more pay?" And I said," Well, I'm not asking you to work more than eight hours a day. So, I'm still getting my eight hours out of you." For the most part, it was fine. I think the staff did appreciate the fact that they were still working. They still had this pretty great opportunity to continue to have flexible, what I call domestic flexibility, because we still have a lot of employees that have children. They're going to school. When the child is sick, they don't have to stay home. I mean, they don't have to go to work. They can stay home. When the water heater breaks and the plumber's coming, these are things they can manage. A lot of employees recognize the fact, they were saving substantial money. They weren't traveling, there's no cleaning bills or any of the other things, they're not buying their lunch somewhere. So, a lot of them recognize that in the place of," Do I get more money for training?" Or something along those lines, they recognize," Hey, I'm saving a lot of money in this new environment."

Paul Anderson: You mentioned a couple times the role that technology and automation played in the transition home and in allowing staff to be even more productive from home. You talk about e- faxing and some other things, but if you could elaborate on that a little bit more. What kinds of technologies did you use and what kind of supports did you have to have for your staff as they had to adopt new things and they couldn't come to a conference room to be trained, because they're all dispersed.

Tom McCormick: Yeah, absolutely. So, I mean, just to that point you just made, we did develop a virtual training program, since one of the things that are required to do this virtual environment we have is that everybody has to be proficient in MS teams. So, we get all the staff up on MS Teams, new employees that are coming in, we onboard them virtually, they still have to come in for a certain amount of things, but we try to limit that as much as possible. But the training is all virtual. We still have the opportunity to say," All right, if a person just isn't getting it, virtual is not working for them. Then we will bring them in." I mean, we still have space enough. We have what we call flexible space, so people can come in and they'll get that shoulder- to- shoulder thing until they are more proficient. Then we're able to send them back home. But we've used a whole host of other things. And one of the things I think has been very helpful to us, we're a very telephonic- dependent organization. We collect money. So, we're calling insurance companies, we're calling departments, everything, there's still that interaction that has to take place. People were using their home cell phones and blocking the numbers when they're trying to do this. And a lot of times that's difficult for that connection. If you're leaving a message, they're leaving it on their old work phone and we still maintain those voicemails. Well, we're now moving to an opportunity to use MS Teams better where you can actually use the telephone right through MS Teams. And it leaves a number. You can leave a message, they can call you back on that number. So, that's going to create a great deal of efficiency in terms of just that one operation of the telephone. But scanning, all the things that people used to do to get records and come back, we've turned all that into an electronic profile, which has really created tons of efficiencies throughout the whole department, particularly because we got rid of a lot of the people shufflers anyway. But even our collectors who are managing that process for medical records requests, it's made their life a lot easier as well. Because we've kind of centralized that. We still have some companies they'll say," Sorry, we can't take the inaudible, you got to mail to me." So we do. That's why we have that little onsite force. But taking it away from those people, that onsite capability, that onsite need that they had to have that paper record has made them a lot more efficient.

Paul Anderson: I'm thinking besides efficiency, you mentioned, there were maybe a handful of folks who either couldn't or decided they just weren't going to adopt some new technologies. But I'm thinking for the majority of your workforce, a lot of these must be big satisfiers, being able to... I know exactly what you're talking about with using the phone through Teams. Because we do that here at ECRI as well. And I tell you, that's made life a lot easier for me from a work perspective. So, I'm thinking you must have had a lot of positive feedback around those things too.

Tom McCormick: There definitely was. There was a lot of feedback on just making their life easier. They felt supported in terms of we're trying to make them more successful. When people are tracked on their productivity, the one thing that really drives them crazy is what makes them inefficient in terms of how they do their work. So, when they see management trying to support their efficiency for that, so that they can be more successful, that is a huge satisfier.

Paul Anderson: So, I always try to wrap up by asking for a first step. If I'm in another organization, probably not going to be able to fix everything at once, but I might know that I need to get started. And I'm thinking, particularly with this topic, across the country, we probably have folks in all different phases of this transition of workforce and some folks coming back and some folks are not going to come back. Where's a starting point to try to figure out how to approach this looking forward over the next months and years?

Tom McCormick: Sure. Yeah. I have to say, I'll start this way, there's not one size fits all. A lot of people, my own colleagues that I have here in the Delaware Valley, some of them they're 100% supported in terms of having a remote workforce and others saying," Gee, I'd rather have a hybrid. I think I'd like to rotate people coming in." Some of them want to make it an incentive program. But you do have to start with a strategy. So, you figure out what works in your organization? What's your strategy? And if you have one, then you got to engage your management team. That's your first step, get your management team on board with your strategy. If you don't have one, make them part of it, get them as part of the design. But you start with your direct reports, you get them involved, you get them on board with what your vision is and your strategy or whatever you develop. And then you start to push that down through the organization, to the management teams. And when you have that all on board, everybody is in sync with the same strategy, then it's time to implement. So, that's where I would start. I'd start with your team.

Paul Anderson: So, Thomas, I think about a lot of the changes you described, eliminating some processes, changing work shifts, changing work environments. Obviously, your immediate team is not part of a clinical team, but I'm thinking that a lot of those changes probably could apply to folks providing clinical care. So, I'm curious, have you seen that in place and or could you at least envision how they might apply back to a clinical team?

Tom McCormick: Yeah, absolutely, Paul, that's a great question. And to tell you the truth, as we've been discussing, a lot of this is about how management can support the team so that they can be more successful. Some of those strategies we put in patient accounting certainly can apply in other areas of the institution. And if I was going to think about clinical directly and I sit in financial statement meetings, we talk about operations all the time and nursing turnover and what have you, they are applying some of those same types of management support strategies. So, what do I mean by that? Obviously, we could take a look at compensation and compensation's just only one component of that. One of the things that we've noticed is that, for them, it's not always just about compensation. Some nurses are leaving because they can work at agencies and have more flexible hours. So, we need to start thinking about that in terms of how do we support our nurses at the bedside so that they can feel like that they've got something that could be more flexible in their work to home life relationship, so that they're not going to be exhausted or get burned out or feel like they have to leave. Then, the other side of that coin is always that whole concept of the grass is greener. There's all these opportunities out there now, particularly in nursing agencies or even other clinical areas. They start to think," Well, maybe I'll try that out." We've actually seen some people coming back saying," It wasn't really that green on that side." And I think it was better that they were working in an organization that they felt more comfortable with and being supported. So, we're continuing to work on those types of things. Some of it is rightsizing staffing, can we get staffing in, like CRNAs, to support the nursing staff to take off some of the things so that they just don't feel like they're overwhelmed? These are a lot of strategies that are being considered. And it is about management trying to put those employees, clinical or nonclinical, into that place where they can be successful and feel supported. So, I do think that there are lots of the same string that can be implemented on the clinical side.

Paul Anderson: Tom, one of the questions that occurs to me that I wanted to ask you, we talked a lot about how your team made these transitions and the role of the employee engagement, the employee morale committee, and all those things. And I'm thinking about how has it changed your role in being at home? I'm sure your job must be very different today than it was two years ago, even if your job description hasn't changed. So, how has it changed your role? And have you found some of the same things that the rest of your staff have found in terms satisfiers or challenges?

Tom McCormick: Yeah, actually, it has significantly changed my role. You talk about your whole work- life balance. I think that I have more lunches with my wife now than I ever had before, because she also works from home, but I actually still go into the office once a week, because we have an onsite team, we've developed a schedule where every manager has to take a turn at least coming in. So, we have the first four days covered by senior management. So, I take a day, I have two direct reports that take a day, there's a manager who most of those people are on site, they take a day. So, it's a Monday, Tuesday, Wednesday, Thursday, that's all covered. And then on Friday, the rest of the management team takes a turn on a rotation basis. We have a schedule out there and in that schedule, they may have to come in once every two months. But it's a wonderful thing, Paul, when it's snowing outside and you don't have to jump in the car. I live an hour outside of the city, so I don't have to make that drive. I've become very proficient at Teams myself. And I usually try to light up every meeting I have with a different background that will make people smile inaudible. Trust me when I tell you that every meeting starts off with me in a Hawaiian shirt.

Paul Anderson: That I very much believe you. Tom, thanks so much for being with us today.

Tom McCormick: Paul, thank you. It was great being with you.

Paul Anderson: Learn more about equity and the ISMP PSO from the ECRI website at www. ecri. org, where you'll find our 2022 top 10 patient safety concerns report, which includes staffing shortages as the number one item on the list. You can learn more about Penn Medicine at www. pennmedicine. org. Be sure to subscribe to Smart Healthcare Safety on Spotify, iTunes, Google Play, or wherever you get your podcast to get our latest episodes. We welcome your feedback. Visit us at ecri. org or email us at ecri- podcasts @ ecri. org.