Written by: Christina Flisram, MSN, RN; Jenny Jackson, MBA, RN; John Richards, MHI; Alicia Waletzko, RHIA, PMP
In the winter of 2021, leaders at Gundersen Health System in La Crosse very clearly saw the toll COVID-19 had taken – and was taking – on the organization. Staff were tired, frustrated, and leaving our workforce. It was time to tip traditional thinking on its head, discover and define the struggles and explore solutions to alleviate the burdens – all in the interest of retention and job satisfaction.
Overcoming obstacles and bridging gaps
At the heart of our organization, there is a lot of love. Our motto is Love + Medicine and when you walk the halls, you know it. Our staff provide great care every single day. They take pride in their work, in being problem solvers and in putting our patients and their families first. They know that being a patient is hard so they do all they can to make sure that the journey is as smooth and caring as possible. Our staff are creative. They have experience that helps them with the routine but are exceptional at problem-solving and adding a personal spin for each unique patient. They don’t let a bump in the road stop them – they find ways to overcome obstacles because they know that is what our patients need. And that is how life works, overcoming obstacles and bridging gaps, going the extra mile every day!
As the pandemic lengthened, we tired
But over time with our ever-full walls and the crushing weight that was COVID-19, the time required to bridge gaps and solve problems no longer existed, and the staff on the frontlines felt the effects the most acutely. The red tape that had provided a safety net for problem solving in the past now took a toll on staff autonomy. COVID-19 required our organization to act fast as a single unit while depending on centralized decisions. Burden after burden, we just had to make it through. As the pandemic lengthened, we tired. Authorities and experts still guided us, but there was no one to tell us it was time to begin taking care of ourselves. Giving energy to ourselves might mean we take it away from patients and that is counter to the way we are wired.
It was time to shift the tide and start tucking our staff in with the same care and effort given to each patient day in and day out. If we didn’t, we didn’t stand a chance. The hard times would consume us leaving only pain.
Just listen. Just hear.
Knowing that immediate action was needed, our Chief Nursing Officer and Chief Strategy & Innovation Officer directed our newly formed innovation team (Edge) to jump in. Their approach maybe seemed too simple at first, but it was powerful. Just listen. Just hear. Gather the stories through the voice of those on the front line. Staff and their leaders live in the chaos every day. Their voice is what brought understanding to life. To the average observer, strain on the supply chain takes precedence over the lack of drinking straws. Straws seem a luxury. To a nurse though, lack of a straw means a spill, a soaking wet gown and bed, and because of the strain on laundry service, hours of wasted time spent tracking down fresh linens, changing a bed, and moving the patient. The only way to understand this… Listen. Hear.
The opportunity to share ‘what it was really like to be a nurse surviving the day-to-day’
Edge’s original goal was to listen and to fix anything possible, as quickly as possible. The goal evolved. It was critical to hear the nurses in an environment that was safe. Edge did not interject, try to offer explanations, or deliver promises. The goal was to ensure staff were heard and could tell their story. To that effect, Edge held day-long open interviews with each inpatient unit over the course of two months covering day and night shifts. Nurses could pop in when it was convenient for them. Two hundred nurses (30% of those on staff in the hospital) shared their time over roughly 125 hours of interviews. Staff were asked for 15 minutes but many stayed longer and often left stating it ‘felt like therapy.’ Unit leaders were also included and played an essential role in supporting their staff by encouraging them to come and share their experiences – the good and the bad, the frustrations and needs. In general, just what it was really like to be a nurse surviving the day-to-day.
The time to solve problems no longer existed
The real value was the understanding and shared story the nurses told. Their stories revealed a list of 20 priority systemic issues staff needed addressed. The universal story revealed how the pebbles, rocks and boulders had become insurmountable. And most importantly, how no one was at fault. COVID-19 had laid us bare. The time once available to solve problems no longer existed. Just like everyone had been required to unite against the pandemic, now they were required to unite in order to heal.
New strategic priority added to the organization’s strategic plan
Edge heard stories of triumphs and devastating heartbreak – stories that no one would ever imagine. All that was required was the commitment to listen and truly hear. There were stories of missing linens, stories of equipment that was stuck overseas for months on end. There were stories of nurses staunching groin bleeds for hours on end, going physically numb with the effort, and of broken chairs that remained unfixed because the manufacturer was no longer in business. There was confusion because in every unit from critical care to obstetrics, patient complexity and needs continued to grow higher, and higher, and higher – even when covid was not directly responsible. And staff worked longer and longer hours as the staffing shortage became steadily worse.
An understanding was born, revealing just what we needed to do. That story was told and retold – and it was heard! Thirty days later, a brand-new strategic priority was added to the organization’s strategic plan: the People strategy! This strategy places focus on the people of Gundersen – the people who are the heart and soul of the organization.
As part of the new People strategy, two strategic work teams (the Recruitment and Retention Strategic Work Team and the Frontline Innovation Strategic Work Team) were formed and given responsibility for the 20 systemic issues the nurses described. Once the teams were developed, they partnered with leaders from Recruitment, Department of Nursing, Human Resources, and operations to transition the work they had already begun. This partnership has continued to increase the success of our strategic work teams in our new cross functional leadership structure.
A new team forms to assess threats, develop strategies and improve recruitment, retention
The Recruitment and Retention Strategic Work Team (R&R SWT) develops system strategies that improve recruitment and retention while assessing internal and external threats to the Gundersen workforce. This team – along with other strategic work teams at Gundersen – focuses on meeting the five system strategic priority areas: Digital Transformation, Population Health, Growth, Cost and People.
Focusing on People: Critical staffing index implemented
The R&R SWT is primarily focusing on the People strategy of Gundersen, but also has an impact on Cost Reduction and Growth. Initially the team worked to fill critical positions related to direct patient care and eased the burden due to the challenges in recruiting and retaining staff. A weighted critical staffing index was created to identify the departments/positions in need of the most assistance, which reinforced the need in our inpatient care teams. As more information was gathered and initial interventions were put into place the team has been able to expand its focus to ambulatory staffing needs and cost reduction strategies.
Within the last nine months the R&R SWT has implemented the following:
Compensation worked quickly to assess and implement wage adjustments to acute frontline positions
Partnered with Recruitment and Department of Nursing to launch MA and CNA training programs
Implement the Patient Attendant role on inpatient units to remove the non-patient care tasks from the direct patient care staff to ease workload when assignment ratios increased due to staffing challenges and to improve patient satisfaction
Change the requirements to our Weekend Only Employment policy to open the program up to more staff and assist with the increased challenges with staffing weekend shifts
Created the Extended FTE program to decrease the dependency on contracted staff by allowing GHS staff to temporarily increase their FTE at an increased wage
Adjusted our referral and sign-on bonus programs for more flexibility and to target critical positions while saving money for the organization
Our future work includes a focus on:
Review certification and education requirements determine if those requirements are creating any barriers and could be removed or altered to increase potential applicants/hires
Research and develop loan forgiveness programs
Review current tuition reimbursement program to improve retention of staff who wish to continue their education
Partner with local college, university, and tech schools to increase number of students accepted in programs and to meet with current students to promote GHS as a great place to work
Since much of this work is new, Gundersen is still determining the impact on recruitment, retention, and cost reduction. Initial assessments have shown a positive impact in terms of the number of staff participating in the programs and the projected cost savings. This work will require continual adjustments to keep up as the market continues to change.
Second strategic work team added to improve job satisfaction, company pride and employee vitality
In addition to the Recruitment and Retention Strategic Work team, the Frontline Innovation team was also created. Although the work for Frontline Innovation is different from Recruitment and Retention, they both have the same goal: To have a positive impact on the People, the frontline staff; to improve overall job satisfaction, company pride, and employee vitality. Frontline Innovation has developed innovative solutions that remove barriers. This team also created an avenue for frontline staff and leaders to continue to bring their ideas and feedback to the Frontline Innovation team.
First step: Identify immediate needs for frontline staff
After the creation of the team in early 2022, the first several months were spent having teams from facility operations and information technology and digital services round on nursing units to identify items that needed to be addressed, including broken equipment, broken or out-of-date technology and environmental concerns that needed to be addressed. The teams then spent two weeks on each unit addressing and fixing as many of the issues they could during that time. In October of 2022, the Frontline Innovation team transitioned to using the Scrum Framework to develop innovative solutions to broken workflows and barriers the frontline staff were facing.
Solutions have focused on:
Improving the reliability of technology that is used daily by nurses to deliver care to patients
Creating proactive approaches to managing technology and improving the environment
Expanding the hours valet parking is available having a positive impact on both employees and patients/visitors
Re-envisioning workflows that are cumbersome and ineffective
Identifying new technology that is being put into place that will improve efficiency and patient care
Gundersen recognized the importance of not only being innovative in how we provide care to improve the patient experience, but also of finding innovative solutions to improve the experience of providing care to patients. The focus of Frontline Innovation is on our number one asset within the organization, and that is the frontline staff.
Delivering value in increments, seeking feedback, building relationships, trust
From the Edge conversations came new priorities and strategies. Now, the new strategic work teams leverage an Agile Mindset and the Scrum Framework to drive action and solutions. Having an agile mindset changes the way we deliver change in the organization by delivering value in increments, continuously seeking feedback to improve the value that is delivered, building relationships, and building trust. The Scrum Framework has provided structure for our teams to be agile so that the solutions the teams create are valuable to the organization and to the staff, to improve staff satisfaction, retention of staff, vitality, and company pride.
The continuity and responsiveness of the agile mindset and the structure of the scrum framework are critical because they drive results. The best intentions fall flat if they end with only a report or summary. There is no real value until change is made, until a new product is put in place. Without action, there is waste. Staff understand that time given to change efforts takes away from time with patients. And if problems are being solved that is a valuable tradeoff. But without action, the costs are too high, and the front line has a responsibility to the patient first. Edge talked to several staff at several different times who put it most simply, “If nothing happens as a result of all of the interviews, we can’t talk to you again.”
That is why we strive to drive change and to value the understanding and stories entrusted to us through action… addressing the problems and removing the barriers staff encounter, every day. COVID laid us bare, it showed us where we need to improve. We can’t let that lesson go unlearned.